Where have all the dentists gone?

Everyone knows more dentists are needed, and not only for NHS work. But will the Government’s plans make a difference? Jaimie Kaffash reports

It may be completely coincidental that, on the week the BBC revealed that £900m had been clawed back from dentistry by the NHS, the Government announced new plans to increase the number of dentists in England. The approach was double pronged: a change to clear the backlog in the overseas registration exams (ORE), and an increase in the number of medical school places.

These are the latest in a number of attempts to ensure England has a pipeline of dentists, especially to provide NHS work. Other attempts have included golden handshakes (to incentivise dentists to stay in dental deserts) plans for golden handcuffs, which would see dentists being made to complete a minimum stretch of service within the NHS, and encouraging skill mix.

Yet the figures suggest that nothing is really improving. As the population grows, the number of dentists per head providing NHS work – and the amount of NHS activity - is decreasing.

The standard explanation is that these dentists are deprioritising their NHS contracts in favour of private patients. But it isn’t as simple as this. The shortfall in dentists is affecting private practices too, and this is as a result of cultural and generational issues as much as the state of the profession itself.

So where have all the dentists gone? And, more importantly, what do we need to do to ensure the nation has the number of dentists it needs?

Workforce figures

‘We absolutely do need more dentists,’ says Neil Carmichael, chair of the Association of Dental Groups. ‘We have [almost] the lowest number of dentists per capita in the whole of Western Europe.’

The problems with NHS dentist workforce figures are well known. Mr Carmichael says there are almost 2,700 vacancies in NHS dentistry. This is even more acute when looking at the ‘dental deserts’, he says. ‘You could argue in broad terms, another 5,000 dentists are necessary to prevent the dental desert problem.’ For NHS dentists only, these regional differences are stark - there are twice as many dentists doing NHS work per 100,000 in London and south eastern ICBs compared with those in Norfolk, Lincolnshire and Northamptonshire.

But it is a mistake to think that this is just affecting NHS dentistry. According to the World Health Organization, the UK has 5.08 dentists per 10,000 patients - only Ireland and Switzerland have fewer dentists per capita and, in the latter case, this figure was from 2019. NHS England figures show that there are around 4.2 dentists providing NHS care per 10,000 patients – this tallies with a General Dental Council survey in March, which found that one in five dentists provided no NHS work whatsoever, while a further 14% spent more than three-quarters of their time on private treatment.

As always with recruitment, there are winners and losers, and right now it is a jobseekers’ market. Dr Victoria Holden, president-elect of the British Association of Private Dentists, says: ‘My dental practice is a fully private, multidisciplinary specialist practice. We do a lot of complex dentistry as well, taking referrals in from other practices. So we need experienced dentists, and it is a challenge finding them. Those kind of dentists want their own practice, and why would they not? It's not necessarily just about having numbers of dentists to churn through the patients.’

The current president of the BAPD, Dr Simon Thackeray, says the cost of living means practices are struggling with expenses, and the lack of dentists means that associates are demanding more. ‘Some associates are starting to get back to the idea that they should be getting 45%, 50% or similar. They are completely out of touch with the costs of running these businesses.’

Ministers have been trying to boost workforce for a number of years. The 10-Year Workforce Plan in 2023 said that there was a need for 23,000 full-time equivalent dentists and dental care professionals by 2036/37 – up from 8,800 FTE dentists and 500 dental care professionals in 2022. To achieve this, it proposed increasing training places by 40% by 2031/32, improving participation rates in NHS dentistry, and greater use of other skills within the practice, such as dental therapists and hygienists.

The Labour Government’s 10 Year Plan focused on NHS work. It committed to requiring all newly qualified dentists to work in the NHS for a minimum of three years. It also committed to ‘fundamental contract reform’, and dentists working within ‘neighbourhood teams’. It advocated the wider use of dental therapists, who ‘could undertake check-ups, treatment, and referrals, while dental nurses would lead individual and community oral health education efforts. The work therapists cannot do would be safely directed to dentists.’

Changes to the overseas registration exam

A lot of this is predicated on sorting out the NHS contract. But, in the meantime, the Government has reformed the ORE in a bid to unlock ‘thousands’ of dentists.

In an announcement on 10 March, the Government said that ‘thousands of fully qualified dentists from overseas who are often already living in the UK are unable to practise because of limited exam capacity’. It committed funding of £420,000 to enable the Royal College of Surgeons in England to increase ten-fold its number of final exam places, from 180 to 1,800. This would allow up to 1,350 overseas-trained dentists to join the GDC register annually by 2028 and be available to provide dental services in the UK.

The ADG campaigned for the change to the overseas exam, and Mr Carmichael is happy with the Government’s announcement, adding thanks to the GDC for their role. He says: ‘We're certainly delighted that our campaign landed so successfully. What we've got to make sure is that it actually happens. So the GDC have said what they're going to do and now we need to make sure that going forward we get the students in place and that the numbers are increased.’

Dr Holden says that she knows of a number of dentists who qualified overseas who are in limbo waiting for a space to sit the ORE, and are on the dental register as DCPs in the meantime. ‘As soon as exam places they're released, they're just gone, straight away. It's like some massive, terrible version of Ticketmaster where everybody's waiting in advance for them to come available, but it's just like luck of the draw who actually gets to take them.’

Yet there are still concerns. Whenever there is an attempt to increase the numbers of professionals in a short space of time, there will always be the suspicion that the bar to entry is being lowered. Dr Thackeray says: ‘It's got to stay quality assured, and I think that's the concern that a lot of people would have.’

The British Dental Association broadly welcomed the move. Answering a question from GDPUK at an event by the All Party Parliamentary Group on Dental and Oral Health, BDA chair Dr Eddie Crouch said ‘without doubt, we need more dentists’, and added that it was good that the Government was returning to the workforce plan. However, he added: ‘It doesn't matter whether you qualify in Manchester or Mumbai, if the system isn't very good, why would you stay in it?’

This policy also highlights long-term failures in workforce planning, Dr Crouch added: ‘It's ironic that a government who is concentrating the medical workforce on homegrown travel is actually looking for overseas recruitment of industry. It seems odd to me.’

Increasing dental school places

Alongside the changes to the ORE, the Government announced the expansion of dental school places. It was that an ‘extra 50 dentists will be trained in England every year from 2027, with the Office for Students having been asked to prioritise these new training places in so-called dental deserts that do not currently train dentists, for example in rural and coastal areas, where getting an appointment has long felt like mission impossible’.

Again, in isolation, this was broadly welcomed, but many were quick to point out that we are talking relatively small numbers. As Dr Crouch put it, ‘25 new dentists in Norwich is a great thing, but it isn’t going to be anywhere near enough to solve a problem that you've got in the East of England’.

Most people agree that the presence of a dental school will with workforce in the region. But there is also no guarantee. The Peninsula Dental School was opened in Plymouth in 2006, yet the South West is held up as one of the most arid dental deserts – to the extent that the APPG event was opened by a patient from Devon telling the story of having to take out her own teeth.

Dr Elizabeth Fynn-Famodun, founder of the Budding Black Dentists (BBD) group, was brought up in London, but went to Peninsula Dental School. Like many of her peers, she ended up coming back to London because that is where her support network was. For her, it is not just a case of opening dental schools, but attracting local students too. ‘We should be trying outreach in those dental deserts – for example, dentists giving talks in schools - and exposing local younger children to a career in dentistry because they would be going to university around their hometown with family and friends around them.’

Relatedly, many of those younger people would be put off by the glass ceiling in the profession, says Dr Fynn-Famodun’s colleague at BBD, Dr Dara Akioye. Most notably is a barrier to dental schools in the form of work experience requirements. ‘Work experience was already hard before Covid and it is even harder now. Unless you know someone, you have a family member or a friend or your personal dentist wants to take you on, you are calling up practices and asking to shadow - you're more likely to get a no or no reply. Many dental schools insist on two weeks’ work experience and that’s understandable – you need to understand what it is about. The dentistry that I am doing now and what I thought I'd be doing at 16 is two different things.

‘I get dental applicants messaging me, asking whether they could shadow me - and they have the grades.’

What is needed?

Although there are gripes, there is an acceptance among profession leaders that these policies are at the very least baby steps. But there is also a belief that training more dentists is only one part of the puzzle to increase access for both NHS and private patients. Unfortunately for the Government, this involves improvements to pretty much the whole infrastructure around dentistry, including improving skills mix. But the commitment to this has often waned.

‘Before you look at workforce, I think that what really needs to be understood is the dental estate – dentists need surgeries to work in,’ says Martin Skipper, head of p olicy at the LDC Confederation. ‘What is the actual capacity of dentistry in this country to see any number of the population – ie, how many dental surgeries are there? If you've only got one chair, you can only see one patient.’

The even more important ‘crunch point’ is dental nurse recruitment, he says. ‘They need to understand how to boost incentives for dental nurse recruitment and retention.’ In terms of the NHS, there is an easy way to help this, he says. ‘Dental nurses don't get access to the NHS pension despite providing care for NHS patients.’ This leads to a contradictory approach, he says, citing plans in the April contract announcement for dental nurses applying fluoride varnish, alongside the Government’s overall support of skills mix. ‘On the one hand they say “we'll make more use of skill mix”, but on the other they’re saying “we won't give anyone who's involved in skill mix NHS benefits”.’

At the APPG event, Dr Shiv Pabary, chair of the BDA's General Dental Practice Committee, cited the example of NHS pilot schemes that were introduced after the GDC allowed direct access from 2013, which involved patients seeing hygienists every three months for interim care management, for which the practice was paid. These provided ‘flexibility’ within the NHS contract, that was ‘really popular with the practice, popular with the team members, popular with patients. Guess what? It costs a little bit more money, and therefore the pilots were all scrapped because they wanted more for less.’

All these dental professionals – including general dental practitioners – need to be trained, and there is an issue around the recruitment of educators, too. Speaking about dental school expansions, Dr Crouch said academics are in short supply. ‘I know in my own dental school in Birmingham, if they lose a professor, they have to pinch another from another dental school.’

But, perhaps more than anything, what is needed to get on top of the GDP workforce problem is a great understanding of what younger dentists want from their career. Within general medical practice, there has been a move towards portfolio working, locuming and salaried roles and away from full-time partnerships. Such a move has not yet happened in dentistry.

‘I think this is one of the things also where behind medicine as well,’ says Dr Akioye, who herself has a portfolio role in health tech. ‘There all of these other roles within medicine, and you see it's very well documented. When I started to look at health tech, I couldn't find any dentists. I'm making my own path and trying to figure out like what I can do. Based on speaking to my friends, I think a lot of people would like a portfolio career.’

Dr Fynn-Famodun agrees about the inflexibility around ways of working within dentistry. ‘If there were salaried roles as general practitioners, or you were just paid a certain amount daily and it's not a case of completing a certain amount of UDAs, I would definitely want something like that. But those roles are not easy to come by in dentistry.’

Of course, neither dentist speaks for their whole generation, but this way of working, with flexible careers, is becoming more popular throughout healthcare and even wider society. Perhaps offering the next generation of budding dentists careers they can shape themselves is the way forward. But that is a long-term shift in culture and will not help current access issues. The Government will be hoping that their sticking plaster solutions will work, but maybe we shouldn’t hold our breaths.