The NHS Long Term Workforce Plan, at least in so far as dentistry is concerned, leaves me pondering. Is it a credible attempt at identifying issues and proposing solutions? Or a thinly veiled attempt to win the approval of a public largely unaware of the detailed reality?
As someone who spent the middle part of his career at the heart of Tony Blair’s attempts to reform the whole of the NHS, I appreciate the scale of the challenge. The complex web of interdependent relationships within the NHS was daunting when, in the mid-2000s, I was playing a part in trying to reduce waiting times.
At the time, it was hard not to be reminded of chaos theory and the butterfly effect as well intentioned initiatives yielded unintended consequences that solved some problems but created others. My return in 2008, to being fully focussed on dentistry was a massive relief for, to quote Winnie the Pooh, ‘a bear of very little brain’ like me.
However, while that experience has left me with a degree of sympathy for those wrestling with the conundrum that is the future of the NHS, I also can’t escape the feeling that the relatively self-contained nature of NHS dentistry lent itself to more substantial and robust proposals than was contained in the June publication.
Perhaps I’m being unfair. After all, there is a reference (singular) to an upcoming Dental Plan which promises more detail. However, it’s not entirely clear if that’s with reference to the entire workforce plan for NHS dentistry or just to the establishment of Centres for Dental Development.
There is an admission that “while the Plan’s model is founded on data, evidence and analysis, its projections are made with assumptions that are, by their nature, subject to a degree of uncertainty.” In such an unstable and unpredictable world, that seems fair. However, while the Plan is peppered with references to one of those assumptions, the number of current full-time equivalents (FTEs), the degree of uncertainty that needs to be attached to that assumption for dentistry dwarfs that of the various other healthcare disciplines within the NHS.
In the absence of an accurate baseline of the number of FTEs, it’s hard to attach any credibility to a workforce plan for dentistry. And it beggars belief that in 2023 there is not more accurate data on which to build a workforce model.
And so, to the Plan itself which is divided into three sections: Train, Retain and Reform.
Good intentions, but not enough
Given it is patently obvious to everyone, from seasoned observer to the general public, that we have a supply and demand imbalance within UK dentistry, it is not possible to argue against the intent to train more dentists, hygienists and therapists. The promise that by 2028, there will be a 24% increase in training places for dentists, therapists and hygienists sounds impressive enough until you realise that amounts to fewer than 300 individuals.
I know of a practice that recently handed back a £1.5 million contract that will now see, on a private basis, half the number of patients they were treating on the NHS. Just to cater for the half that don’t manage to become private patients at that practice will require four new NHS dentists. Or, to put it another way, 1.4% of the new training places. And that’s just to compensate for the loss of one practice. This also assumes the appetite to work at the frantic pace of the previous NHS dentists is matched by the new generation in the post pandemic world. As more dentists choose to leave the NHS the sands on which the Plan is based will continue to shift and defy any attempt to simply stand still, let alone improve matters.
Which brings us on to the Retain element of the Plan.
While we wait for the new recruits promised by the Plan to complete their training, thousands of patients from the practice mentioned above are being added to the waiting lists of those NHS practices in the nearby area.
Such displacement of patients, many loyal supporters of the practice, is not as a result of greedy, selfish or thoughtless behaviour on the part of the practice owner. Rather, the motivation to change reflects the reasons the Plan acknowledges are behind people choosing to leave an NHS trust. These are: “pay and reward, work-life balance, progression and continuing professional development (CPD), as well as health and wellbeing”.
That private dentistry offers the opportunity for such benefits is indisputable. On hundreds of occasions during my three decades working in the UK dental world, I’ve witnessed the transformation of practice owners and associates alike. Going from despondence and disillusion with their choice of profession to being reenergised, revitalised and, frankly, happy.
Fear of failure no longer justified
What has historically held many in the profession back from taking such a step is a combination of fears. First, that there will be insufficient patient loyalty to achieve financial objectives, and second, the sense that they are not only letting their patients down but being disloyal to the original ethos of the NHS.
However, with waiting lists growing thanks to every early retirement, reduction in clinical hours and dentists “going private”, the NHS can no longer rely on fear to retain dentists. And when it comes to acting in the interests of those loyal patients, there is a tension between striving to achieve ever greater levels of productivity demanded by the NHS while meeting, as the London Federation of LDCs put it several years ago, ‘the gold standards of the GDC’. This creates a level of stress that, in far too many cases, compromises patient outcomes and safety, as well as dental careers.
For many, the appeal of private dentistry is the chance to see fewer patients, spend more time per patient and so affording the potential to better manage expectations in this increasingly litigious world. The fear of a fitness to practise investigation as a driver to leave the NHS should not be underestimated.
Glimmer of hope for regulatory reform
In this regard, there is a vague glimmer of hope with a restatement of the government’s commitment “to reforming the system of regulation for healthcare professionals, making it faster, fairer, more flexible and less adversarial”. Scaring the living daylights out of the profession is hardly the best way to go about protecting patient safety and maintaining public confidence in dental services, so change is sorely needed.
Although used in the context of dental education and training, the reference in the Plan to “seeking better value for the investment the taxpayer makes” raises the spectre of ever more pressure being heaped upon beleaguered NHS dentists. In which case an empathetic, supportive regulator would be essential. Undergraduates are not exclusive in their need for compassionate leadership and workforce psychological wellbeing considerations, as mentioned elsewhere in the Plan.
An idea the Plan floats to attempt to combat the appeal of private dentistry is to explore measures “such as a tie-in period to encourage dentists to spend a minimum proportion of their time delivering NHS care in the years following graduation”. As I have found during chats in pubs, to the average person in the street, such an idea sounds reasonable and has an immediate appeal in the current climate. However, unless job guarantees and considerable additional funding miraculously become available, such a proposal does not stand up to scrutiny. And, given all the other challenges that dominate the content of the Plan, this seems a stretch.
In truth, for the NHS to successfully retain the services of dental clinicians, it must face the reality that tactics relying on the big sticks of fear and tie ins are doomed to failure. What is needed are the carrots of work life balance and professional satisfaction.
No sign of contract reform
The Reform section of the Plan opens with the paragraph “Growing the NHS workforce, on its own, is not enough to ensure the NHS can meet the changing needs of patients. We need staff to work in different ways, including with each other and with patients, and for clinicians to be able to spend more time with patients providing high quality care.” Hear! Hear!
However, in the 111 paragraphs that follow are just four brief references to dentistry. None of them relate to the universally acknowledged need to reform the current dental contract in England. There are interesting references to robotics, artificial intelligence, remote monitoring, ICBs and ICSs. There are mentions of bringing people, including those from the EU and further afield, into the workforce more efficiently; as well as talk of educating and training the workforce differently. However, nothing about dental contract reform.
Along with the pledge to “equip the NHS workforce with the right skills and knowledge to shift care towards prevention and early intervention”, perhaps undertaking to equip NHS dentists with the right contract to facilitate such a shift and make working in the NHS more appealing might also be a good idea?
And therein lies the problem. NHS dentistry in England, though the picture is similar across the UK, is simply not as appealing as the increasingly viable alternatives, whether they be private dentistry or a completely different career. Unless dramatic changes are made to NHS funding and contractual arrangements, the steady stream of dental professionals currently taking back control of their professional and personal lives and, most importantly, the way they deliver patient care, by leaving will quickly become a torrent, then a flood. And that would leave the good intentions behind this workforce plan overwhelmed.
The “upcoming Dental Plan” has a tall order to fill.
If you are looking to gain more independence from the NHS, call 01691 684165 or visit www.nhs.practiceplan.co.uk
Nigel Jones is Sales and Marketing Director at Practice Plan, and has been working in the dental sector for over 30 years. He has a special interest in the development and future of NHS dentistry in the UK.
His knowledge and passion for dentistry has led him to become a trusted voice, offer invaluable advice on how to strategically and successfully run a practice.