Policy paper

Faster, simpler and fairer: our plan to recover and reform NHS dentistry

Published 7 February 2024

This was published under the 2022 to 2024 Sunak Conservative government

Applies to England

Foreword

Victoria Atkins, Secretary of State for Health and Social Care

Dentistry is a priority for this government. As the newly appointed Secretary of State for Health and Social Care, who represents a rural and coastal constituency in Lincolnshire where there are challenges around access to dental services, I understand the need to deliver real and immediate improvements for patients.

The impact of the pandemic on dental services was devastating. While the data is showing that the situation has improved since the first year of the pandemic, there is much more work to be done - particularly to improve the provision of care across England.

I am delighted to announce this plan to make dental services faster, simpler and fairer. It aims to improve dental services by making them:

• faster for patients through our new patient premium to support dentists to take on new patients and a new marketing campaign to help everyone who needs one to find a dentist
• simpler for patients and for dental staff by streamlining and tackling bureaucracy, with a wider set of workforce reforms to maximise the skills across the entire dental clinical team
• fairer, particularly for our rural and coastal communities, by introducing new dental vans to bring dental care to our most isolated communities, offering ‘golden hello’ incentives to encourage dentists into under-served areas and supporting those practices with the lowest rates of payment for their work

This plan will fund more than 1.5 million additional NHS dentistry treatments or 2.5 million NHS dentistry appointments. A course of treatment can include more than one appointment for some patients.

Our plan has 3 components.

1. In 2024, we will significantly expand access so that everyone who needs to see a dentist will be able to. This will begin with measures to ensure those who have been unable to access care in the past 2 years will be able to do so - by offering a significant incentive to dentists to deliver this valuable NHS care. We are introducing mobile dental vans to take dentists and surgeries to isolated under-served communities.

2. We will launch ‘Smile for Life’ - a major new focus on prevention and good oral health in young children, to be delivered via nurseries and other settings providing Start for Life services, and promoted by Family Hubs. We will also introduce dental outreach to primary schools in under-served areas, and take forward a consultation on expanding fluoridation of water to the north-east of England - a highly effective public health measure.

3. We will ramp up the level of dental provision in the medium and longer term by supporting and developing the whole dental workforce, increasing workforce capacity as we have committed to do in the NHS Long Term Workforce Plan, reducing bureaucracy and setting the trajectory for longer-term reforms of the NHS dental contract.

This plan sets out a meaningful and practical set of actions that will help all of us look after our teeth now and in the future.

Andrea Leadsom, Minister for Public Health, Start for Life and Primary Care

Good oral health is essential for every one of us. Yet, since COVID-19 when most dentists had to close their doors, the recovery of NHS provision has been too slow, and many are still unable to access the treatment they need.

So, this recovery plan addresses the urgent need to boost access, and we aim to make sure everyone needing NHS dentistry will be able to access it. Not only that, but we are building capacity for the long term, supporting our excellent dental staff to work at the top of their training, and encouraging more hard-working dentists to those areas of England that are currently under-served.

But my real passion is for every baby to have the best start for life. And oral health begins even before birth. In our Family Hubs and settings that provide Start for Life services, we will promote the importance of good oral hygiene in pregnant mums. Parents-to-be will be offered guidance in how to care for baby gums and milk teeth to make sure good oral health is there from the start. In nursery settings, babies and toddlers will have toothbrushing as part of the daily routine, and it is our ambition that, by the time they reach primary school, every child will see toothbrushing as a normal part of their day. Supporting every parent to give their baby the best start for life is my top priority in my ministerial role.

Jason Wong, Chief Dental Officer, England (interim)

Good oral health is essential for good general health. Dental and oral health teams have been working hard to recover NHS services from the impact of the pandemic and meeting rising demand. However, we know that for some people it continues to be difficult to access NHS dental care. We know we must do more to help those who need access to our services, and I endorse the ambition of everyone who needs NHS dentistry to be able to access it.

The publication of this recovery plan is a significant step on the journey to improve and transform access to NHS dentistry and deliver care that meets the diverse oral health needs of people across England. 

The NHS dental service is an essential cradle-to-grave prevention service. The government’s launch of Smile for Life and the focus on early years is welcome, particularly for England’s most deprived communities. The consultation on expanding water fluoridation in some parts of England is an opportunity to improve the oral health of communities for generations to come.

New funding is being made available from government that will provide millions of additional treatments for patients and make the service more attractive to staff.

Deploying dental vans, while longer-term solutions are established, will be welcomed by areas who are struggling with access, particularly our rural and coastal communities.

Offering dental teams a new patient premium to treat patients who’ve not seen an NHS dentist in over 2 years will help more patients access NHS dental care.

Changes such as uplifting the minimum unit of dental activity (UDA) value to £28 will make NHS dentistry provision more attractive and the service more sustainable. More importantly, it will make the NHS dental service fairer.

Growing the workforce so that more patients can access NHS dental care is critical in helping us improve and expand services. We will support government and the General Dental Council (GDC) in the introduction of provisional registration and making it easier for international graduates to work in England while maintaining our high standards. I have always been a strong advocate of the use of skill mix and look forward to further developing this in the provision of NHS care, and we will support the implementation of the NHS Long Term Workforce Plan. 

Dentistry is an important service for the NHS and the government. This plan ensures dental teams are better supported to provide high-quality NHS dental care, so we can deliver for our patients.

Summary

Between 2020 and 2022, at least 7 million fewer patients saw an NHS dentist compared with pre-pandemic levels (2022 data compared with 2019). As those patients have returned to dental practices, they have found it difficult to get the care they need.  

Our commitment is to improve access to NHS dental care for people who need it, especially in under-served parts of the country, and improve preventative care for the youngest children.  

We want everyone who needs NHS dentistry to be able to access it - wherever they live and whatever their background. And we want to embed good oral health habits across all parts of society - including a renewed focus on early years and our most deprived communities. Our hugely ambitious and far-reaching plan will tackle the different factors that make accessing dental care too difficult for too many patients.

We will support parents and families to protect the oral healthcare of babies and children, reducing the number of children having to go into hospital to remove their decaying teeth - a procedure that should be largely avoidable.

We will deploy new mobile dental vans into those areas where there are no NHS dental practices - bringing dental care directly to under-served, more isolated communities.

We will introduce a new patient premium for dentists treating new patients, because we know that if patients do not already have a relationship with a dental practice, they have struggled more to get appointments and treatment following the pandemic. 

We will offer a ‘golden hello’ to dentists who want to move to those areas that persistently struggle to attract dentists into NHS work and make it easier for dentists from overseas who meet our regulatory standards to work in the NHS. 

Our investment will deliver more than 1.5 million additional NHS dentistry treatments or 2.5 million NHS dentistry appointments for patients across England.

This plan takes bold steps to improve access for patients immediately and make changes so more dental therapists, hygienists, dental nurses and dentists can treat more NHS patients. We will support integrated care boards (ICBs) to improve care delivery, meaning more care for more people. Longer term, we will grow the workforce and work with dentists and other dental care professionals so that more people will want to deliver valuable, high-quality NHS dental care. 

We aim to make dental services faster, simpler and fairer for patients and the dedicated workforce.

Launch Smile for Life: a new ambitious programme to promote good oral health across the life course

Working to improve prevention, in particular for younger children, we will:

• support Family Hubs and other settings that provide Start for Life services across England to promote prevention initiatives to improve the oral health of pregnant mums, and guidance for parents about how to protect baby gums and milk teeth from decay

• support nurseries and other early years settings to incorporate Smile for Life good oral hygiene into the daily routines of infants and toddlers so that, by the time they reach primary school, every child sees daily toothbrushing as a part of their normal routine

• starting later this year, deploy mobile dental teams into schools in under-served areas to provide advice and deliver preventative fluoride varnish treatments to more than 165,000 children, strengthening their teeth and preventing tooth decay

• consult on expanding water fluoridation, initially to the north-east of England, so more people benefit from the prevention of dental decay

Make access faster and fairer for patients by investing in care delivered to new patients and rolling out new ways of delivering care in rural and coastal areas through dental vans

We will:

• increase access for new patients by immediately introducing a new patient payment of either £50 or £15 for each patient, depending on treatment need, in addition to the funding the practice would already receive for their care
• support dentists to treat around a million new patients and launch a new public health campaign to raise awareness of how to find and access a dentist when you need one. The new patient payment will be in place until March 2025
• launch a new dental van service for the most rural and communities, with the first vans up and running later this year
• raise the minimum UDA value^{[footnote 1]} to £28 this year, making NHS work more attractive and sustainable
• attract dentists into areas in need with ‘golden hello’ payments, starting with a first cohort of up to 240 dentists later this year
• apply a firmer ringfence on NHS dentistry budgets for 2024 to 2025 so ICBs can seek to improve dental access with this budget
• commence work this year to ensure that the funding provided to ICBs for NHS dentistry better reflects changing population demographics, such as ageing in coastal communities
• bring forward legislation early this year to enable dental care professionals to work to their full scope of practice

Reducing bureaucracy and making NHS dentistry simpler for patients and all dental professionals

We will:

• as part of the NHS Long Term Workforce Plan, build a pipeline of new dentists for the future by expanding dental undergraduate training places by 40% to more than 1,100 per year by 2031 to 2032, with an initial 24% increase to 1,000 places by 2028 to 2029
• consult this spring on ‘tie-ins’ to NHS for dentist graduates
• increase the number of dental therapists and other dental care professionals, through a 40% increase to more than 500 training places per year by 2031 to 2032
• make it easier for NHS practices to recruit overseas dentists who meet the UK’s highest regulatory standards

This plan is a significant step on the journey to improve and transform NHS dentistry and deliver care that meets the diverse needs of people across England. We will evaluate the plan and report on its implementation. The NHS and government look forward to working with patients and our brilliant dentists and dental staff, taking into careful consideration their views and advice on implementing this plan. 

Smile for Life - taking action to prevent poor oral health

Prevent poor oral health, particularly in the very youngest children

Tooth decay is a significant, yet largely preventable public health problem in England. It affects people at all stages of life and is the most common oral disease affecting children and young people. Those in the most deprived 20% of areas of the country are 2.5 times as likely to have experience of tooth decay as those in the least deprived 20% of areas. Tooth decay can disrupt children’s learning and development as pain and infections from decayed teeth can result in school absences.

Tooth decay also has a considerable impact on the NHS. The costs to the NHS of hospital admissions for tooth decay-related extractions in children were £50.9 million in 2021 to 2022. Improving prevention is key to reducing the burden on other health services, such as visits to A&E and secondary care services, for tooth extractions. That is why we are taking a number of steps centred around children to improve prevention of tooth decay.

Support oral health improvement in Family Hubs and other settings that provide Start for Life services

Family Hubs bring existing family services together to improve access to and connections between families, professionals, services and providers, and put relationships at the heart of family support. They are a ‘one-stop shop’ that make it easier and simpler for families to get the support they need, including oral health support.

At the 2021 Autumn Budget and Spending Review, the government announced around £300 million to fund a 3-year Family Hubs and Start for Life programme, which will create Family Hubs across 75 upper tier local authorities in England and support the provision of services so that every family can give their baby the best start in life.

We have published guidance for all local authorities on rolling out Start for Life, which sets out the universal Start for Life services we expect them to provide. As part of our plan, we will also provide guidance on how to promote good oral health in pregnant mums and the very youngest children. This will aim to help families access oral health improvement information and support, both online and within Family Hub networks. Family Hubs and other settings that provide Start for Life services can also play an important role in signposting local oral health services.

We will promote a national universal offer of refreshed and new advice and education materials for all families to support and improve oral health in babies and younger children. We will work closely with local areas to share and promote good practice on oral health improvement support and learn from its implementation. We will ensure that the oral health prevention guidance can work effectively in a Family Hub or other setting providing Start for Life services, and consider how it can be strengthened and improved. We will work with local areas to explore the role that dental therapists and other dental health professionals can play to best support oral heath improvement for the youngest children and their families.

Improve oral health of children by providing oral health advice to parents and a Smile for Life programme into early years settings

Research shows that daily use of fluoride toothpaste reduces the incidence and severity of tooth decay in children. Several local authorities have already put public health grant funding towards supervised toothbrushing programmes. These have mostly been focused on school-age children, by which point the window of opportunity to embed behaviours for life in these children has narrowed.

We are keen to embed good oral health habits at an earlier stage, given the evidence that doing so later - for example, through supervised toothbrushing programmes in the later school years - will have less impact on outcomes but add administrative burdens to primary school teachers. To improve prevention for our youngest children, we will roll out support and education, targeting children aged 1 to 3 in a new Smile for Life programme. We will work closely with local areas to ensure our national advice and educational materials are tailored appropriately for nurseries and other early years settings.

Deploy dental teams to schools in areas of the country where oral health and NHS access is worst

We know that many, including children, still struggle to access dental care, and recovery of dental activity for children is not yet back to the same levels as it was pre-pandemic. We must go further to ensure that children can access preventative care. That is why we will be deploying dental teams to bring preventative dental services such as fluoride varnish directly to children.

Dental teams will visit state primary schools in under-served areas, and provide fluoride varnish treatments and advice. By offering vital prevention measures to reception-age children, we can give them the best chance at reducing dental decay and having a healthy smile for life. We aim to have every child see toothbrushing as part of their daily routine by the time they go to primary school.

Improve prevention of tooth decay through the first national programme of water fluoridation

Water fluoridation is a safe and effective public health intervention to reduce the incidence of tooth decay and oral health disparities. The UK Chief Medical Officers have concluded there is strong scientific evidence that water fluoridation is effective alongside other methods of increasing fluoride use. Around 1 in 10 people in England currently have fluoride added to their drinking water supplies, mostly in the West Midlands and north east, including Newcastle and Gateshead. The benefits are clear. The latest health monitoring report in 2022 showed that, if all children and young people in the most deprived 20% of areas with lower fluoride concentrations (less than 0.2mg/l) instead received water adjusted by a fluoridation scheme, 56% of tooth extractions due to tooth decay in these areas would be prevented. Lower levels of decay and fewer tooth extractions would also reduce school absences and the need for further dental treatment over time.

Despite these benefits, there has been no significant expansion of water fluoridation in England since the 1980s. Ireland and the USA both have fluoridation covering 73% of the population^{[footnote 2][footnote 3]}, while Australia’s covers 89% of the population.^{[footnote 4]} This compares with around 10% in England.

Under new legislation, we have made it simpler to start new water fluoridation schemes. Our long-term ambition is to systematically bring fluoridation to more of the country, with a particular focus on the most deprived areas, which stand to benefit most from fluoridation.

As a first step, we are taking forward proposals announced in autumn 2022 to expand water fluoridation across the north east into Northumberland, County Durham, Sunderland, South Tyneside and Teesside, including Redcar and Cleveland, Stockton-on-Tees, Darlington and Middlesbrough. The north east was chosen based on a combination of factors including the oral health needs of the region and water company experience operating schemes. Subject to consultation, this expansion would enable an additional 1.6 million people to benefit from water fluoridation. We will launch a consultation early this year.

Boosting patient access to NHS dentistry by increasing activity

Deploy dental vans in under-served areas while longer-term solutions are established

We know that there are some areas where patients struggle more to access the NHS dental care they need. We want to ensure that these patients can see an NHS dentist when they need to. To achieve this, we will deploy dental vans offering appointments to patients in targeted rural and coastal communities, starting later this year in the most under-served areas, while longer-term arrangements are set up.

These dental vans will provide care to patients in need, and patients will be able to have dental examinations and straightforward treatments, such as fillings. This builds upon the early successes with the use of mobile vans to boost access in Cornwall and other areas. The appointments offered in vans will rapidly enable more patients who have had to go without NHS care to have faster access to the treatment they urgently need.

Case study: Cornwall and Devon - Smiles at Sea UK

In Cornwall and Devon, Smile Together Dental community interest company (CIC) visits local fishing communities with its mobile dental unit every year to provide oral cancer screening and urgent or emergency dental care to fishermen and their dependent family members who can otherwise struggle to access traditional high-street dental care.

The service provides a range of dental treatment from oral health education, check-ups and x-rays to fillings and tooth extractions.

This service has helped to improve the oral health of fishermen who struggle to access a dentist due to their work and location. Funded by Smile Together and Seafarers Hospital Society and delivered in partnership with the Fishermen’s Mission as part of their national ‘SeaFit’ service, including their partner network of healthcare providers, it is an excellent integrated health initiative.

Offer ‘golden hello’ payments to attract dentists into new areas

We are committed to increasing the availability of NHS dentistry in all areas with low provision but know that recruitment and retention is difficult in certain parts of the country. To support practices in areas where recruitment is particularly challenging, we will launch a new ‘golden hello’ scheme.

We will implement schemes working with ICBs that are struggling to recover their activity levels and would significantly benefit. A ‘golden hello’ of £20,000 will be offered per dentist for up to 240 dentists. Payments will be phased over 3 years, requiring a commitment from the dentist to stay in that area delivering NHS work for at least 3 years. We will decide on locations in the coming months, and we will review the effectiveness of this scheme before considering whether to extend the scheme in the future.

Make it easier for patients to access NHS treatment by introducing a new patient premium

We want to make it faster and simpler for new patients to access NHS dental care. To help services recover from the pandemic, we will offer dental practices an additional payment for each new patient requiring treatment. The purposes of this scheme will be to support anyone who has not been able to receive NHS dental care in the preceding 2 years. The payment level, of £15 or £50 depending on the treatment required, is in addition to the NHS funding a practice would already receive for this care, and recognises the additional time that may be needed for practices to assess, stabilise and manage the oral health needs of patients who have not received NHS dental care for more than 2 years.

The new patient premium will be a time-limited scheme launching in March 2024 and ending in March 2025. Patients are able to see which practices in their area are accepting new patients via the NHS website or the NHS app, and the public will be provided guidance via the NHS app and website on eligibility and details of the scheme. We will issue guidance to practices and ICBs on the operation of this new incentive scheme. We will measure the impact of this new payment on the number of new patients accessing the system and on wider access to NHS dentistry. 

Uplift to UDA where rates are lowest

It can be harder for dentists to sustain their NHS work where the rates paid for each UDA are lowest. Having introduced a minimum UDA rate of £23 in 2022, we will now go further and raise the rate to £28. This will mean that almost 1,000 contracts will see an uplift to their UDA rate this year, supporting them and making treatment of NHS patients more sustainable.

We have also developed guidance to support local commissioning by ICBs, including how they can consider addressing UDA rates locally to support better delivery of dental care for patients.

Reform the contract to make NHS work more attractive

We have listened to concerns from dental professionals around how NHS dental care is funded and how the current contract and business models may not support the high-quality, personalised and prevention-focused care dental teams want to provide. While our new patient premium will support practices to accept patients who are struggling to access care they urgently need, and contract changes already delivered last year reward practices more fairly for complex care, we know that further change is still needed for care of some patients who require more significant and ongoing treatment to improve their oral health.

Building on our guidance to support ICBs who are seeking to develop local services, we are developing further recommendations for dental contract reform to properly reflect the care needed by different patients and more fairly remunerate practices. We will also review what further action we can take to support professional development and skill mix within NHS dentistry, to make NHS dental care an attractive career choice where all professionals can work to their full scope of practice.

We expect to develop options for consultation with the dental profession in advance of a further announcement later this year. Any changes would be phased in from 2025 onwards.

Enable practices to deliver more NHS care if they are willing and able

Prior to our improvements to the NHS dental contract in 2022, practices were only able to deliver up to 104% of the activity committed to in their contract, with the extra 4% of activity carried forward into the next year. This meant practices that wanted to go further and treat more patients were limited in doing so.

NHS England will work with ICBs over the course of 2024 to 2025 to identify opportunities to support contractors to deliver additional capacity beyond their existing contractual requirements (up to 110%).

Free up funding for practices that can deliver more by addressing persistent contract under-performance

Unfortunately, at present, not all practices deliver the full amount of activity they have committed to and been funded for in their NHS contract. The amount of care that was commissioned but not delivered was equal to around £150 million in 2021 to 2022. Even before the pandemic, there was a substantial volume of practices that failed to deliver their expected contracted activity, leading to a loss of NHS oral healthcare, which could have been available for patients.

We recently took the first step in enabling commissioners to tackle persistently under-performing dental contracts. Commissioners will be able to permanently and unilaterally amend NHS dental contracts that fail to deliver their contracted amount of dental activity over 3 consecutive non-COVID-19 years, releasing these UDAs to others to deliver instead. We will keep these new powers under review and consider whether further action is required.

Ringfencing NHS dentistry budgets for dental care

We currently invest more than £3 billion in NHS dental services each year. We are committed to protecting this funding for dentistry purposes and we will ringfence this funding in 2024 to 2025. We will issue guidance to ICBs shortly through NHS England’s 2024 to 2025 revenue finance and contracting guidance. To ensure compliance against this requirement, and to strengthen oversight of funding that is used to deliver access to NHS dental care, NHS England will meet with and collect monthly returns from all ICBs to establish current and planned spend against the ringfenced dental allocations budget.

Give local commissioners the tools they need

Since April 2023, ICBs have been responsible for commissioning dental services. This creates the opportunity for much greater local accountability about performance and service availability. To support this, we have started to publish monthly data on local NHS dental activity at the ICB level, including the proportion of UDAs being delivered in different places. We will also publish new workforce data early this year to support ICBs with their commissioning function, including employment and working trends. We will also consider publishing data on community dental services, which provide care to the most vulnerable patients, and we will explore opportunities to link to other community data sets and help join-up of local services.   

While ‘golden hellos’, the increase to the minimum UDA value and the new patient payment will support practices with existing contracts to deliver more access for their local populations, we recognise that some commissioners will also be looking to commission new dentistry capacity to support under-served areas. We will support ICBs to ensure they understand how commissioning teams can encourage development of their local provider market, and to identify what further support they may need to develop new capacity, where they would otherwise be dependent on existing contractors and facilities to deliver improvements in access.

The distribution of funding across England for NHS dentistry has historically been set in line with contractual commitments and activity from 2006 (when the current NHS dental contract was first introduced) and then grown and carried forward. Work has been commissioned to understand the relative distribution of need for dental services. This will inform future decisions about dental allocations to ICBs across England.

Reduce bureaucracy in NHS dentistry

There are clear opportunities in NHS dentistry for increasing efficiencies and improving digital capacity to make the system simpler for the dental workforce and for patients. To reduce unnecessary bureaucratic burdens for the profession and enhance patient experience, we will establish and work with a new stakeholder reference group for dentistry and oral health to identify the changes that would make the greatest difference to practices providing NHS care and their patients.

Supporting and developing the whole dental workforce

Expand dental undergraduate training places by 40%

As set out in the NHS Long Term Workforce Plan, we will grow the dental workforce in England by expanding undergraduate dentist training places to a record-breaking level. We will expand dental undergraduate training places initially by 24% to 1,000 places by 2028 to 2029. We will then expand training places by 40% from current levels to over 1,100 places by 2031 to 2032. making access to NHS care faster and fairer for patients.

We recognise that a significant proportion of dental graduates are likely to live and work near their dental school after graduation. Therefore, we wish to undertake this expansion in a way that is targeted to improve provision in areas of the country where it is most needed. We will set out further detail on how we will allocate places. If required to deliver our ambitions on workforce expansion, we will explore the creation of new dental schools in currently under-served parts of the country.

Consult on mandating NHS service for dentistry graduates

Having more dentists is not the sole solution to current workforce challenges in NHS dentistry. We have a large number (35,232) of dentists registered with the General Dental Council in England as of January 2024. However, only 24,151 of them delivered at least some NHS care in 2022 to 2023. We need dentists to do more NHS work alongside, or instead of, their private work.

Most, but not all, dentistry graduates develop their career in the NHS by taking up postgraduate dental foundation training (DFT). We are concerned that a proportion are opting to go straight into private practice after graduating, or are choosing to deliver little to no NHS work shortly after completing their foundation training.

The taxpayer makes a significant investment in the education and training of dentists in England. It is fair that the public expects this investment to be reflected in access for patients to NHS dentistry. We will launch a consultation this spring on introducing a ‘tie-in’ for graduate dentists. This would ensure that graduates spend at least some of their time delivering NHS care in the years following the completion of undergraduate training.

Subject to consultation, we will consider the impact of these measures and explore whether we need to go further - for example, tie-in periods related to specialty training or a tie-in for other dental professional groups.

Increase the number of dental care professionals

Dental care in England could not function without the vital contribution of its dental care professionals, including dental therapists, hygienists and nurses. As set out in the NHS Long Term Workforce Plan, we will expand dental therapy and dental hygiene undergraduate training places by 28% by 2028 to 2029, and expand training places by 40% from current levels to over 500 places by 2031 to 2032.

Dental therapists’ scope of practice means that they can deliver much of the routine care that dentists provide^{[footnote 5]} so more therapists means more care for NHS patients. In addition to dental therapists and hygienists, we will also encourage greater numbers of dental nurses and clinical dental technicians into relevant education and training programmes.

Enable patients to access care from a variety of dental professionals

Enabling dental care professionals (DCPs) to work to their full scope of practice would improve access to NHS dental care for patients and allow dentists to focus on delivering more complex care, which only they can provide. However, there needs to be a shift in mindset to change the current ways of working.

To encourage this culture change, we have published guidance clarifying how skill mix in NHS practice can be used within existing regulations. This guidance confirmed that dental therapists and dental hygienists can open and close NHS courses of treatment and provide direct access to NHS care. We have also removed administrative barriers that prevented dental therapists and other dental professionals from opening courses of treatment. We are also developing a national return to dental therapy programme, to support dental therapists who have been working as hygienists to refresh their dental therapy skills.

Promote therapist-led models of care

Current regulations prevent dental therapists from administering medicines, including certain antibiotics and local anaesthetics, without a written direction from a dentist, even though this is within their current professional expertise. In August to September 2023, we consulted on the potential to enable dental therapists to deliver these medications to patients with fewer unnecessary administrative barriers. Removing these barriers would enable practices to fully utilise the skill mix of their teams, improving access for patients.

Make it easier for overseas dental professionals to work in the NHS

Patients receiving NHS dental care benefit greatly from overseas-qualified dentists and dental care professionals. Around 30% of all dentists on the GDC register qualified outside of the UK and, in 2022, 46% of new additions to the register were trained overseas. However, we are concerned that a lack of flexibility in international registration processes can create unnecessary delay to overseas-qualified dental professionals who meet the UK regulatory standards providing NHS dental services.

We have already passed legislation that enables GDC to amend and expand its registration processes for international applicants and will continue to work with GDC on further expansion, making sure that overseas-qualified applicants who meet UK regulatory standards can join the GDC’s register as easily and as quickly as possible so they practise NHS dentistry at the earliest opportunity. We expect GDC to play its part fully in helping open up the profession to suitably qualified professionals.

Increase exam capacity for overseas-qualified dentists

To practise in the UK, dentists that have trained and qualified overseas (outside of the European Economic Area (EEA) or Switzerland) are required to take the GDC’s overseas registration exam (ORE) or the Royal College of Surgeons’ (RCS) Licence in Dental Surgery (LDS) exam. This is to ensure that applicants meet the high clinical standards required. However, limited exam capacity restricts the number of overseas dentists joining the register. The candidate list for the ORE has also increased in recent years, in part due to sittings being suspended during the COVID-19 pandemic.

We welcome GDC’s decision to expand capacity of the ORE exams in 2023 to 2024, creating an additional 1300 places. We also welcome GDC’s action to expand the size of its registration casework team. We will work with GDC to explore if exam capacity can be further expanded and consider ways to further reduce registration processing times and clear the registration backlog of dentist and DCP applicants.

We are working with the RCS to explore expansion of the LDS. We will support the RCS to develop and provide resources to prepare candidates, improve the pass rate and maximise the number of dentists eligible for GDC registration.

Introduce provisional registration to streamline the registration of overseas dentists

We will work to introduce legislation that creates a new provisional registration status, providing a new route for overseas-qualified dentists whose qualifications are not currently automatically recognised by GDC to join the register and practise in the UK faster.

Under this model, individuals holding provisional registration would be able to work as a dentist under supervision of a fully registered individual, while working to demonstrate that they are of the required standard for full registration. We will work with GDC and other stakeholders to ensure that the sector uses this new route, once it becomes law.

Explore automatic recognition of international qualifications from outside the EEA

To be entered onto the dentists’ register, an individual must hold:

• a recognised UK dentistry qualification
• an EEA or Swiss qualification recognised under EU exit standstill arrangements
• a qualification from one of the overseas universities recognised by GDC before 1 January 2001

or they must sit the ORE or LDS exams.

Under legislative changes that came into force in March 2023, GDC has greater flexibility to recognise additional qualifications that it deems sufficient for registration as a UK dentist. We will press GDC to ensure it is making full use of its new legal flexibilities so that more qualified dentists can practise in the UK.

Continue to improve the dental performers list (DPL)

Once registered with GDC, all dentists wanting to provide dental care for the NHS in England need to apply to join the DPL. Dentists do not have to join the DPL to go into private practice, meaning the DPL could be a barrier to providing NHS work.

We have already made improvements to streamline and improve the DPL. We amended regulations so that experienced dentists can be swiftly accepted onto the DPL and abolished the fees linked to applying to the DPL. There is more that we can do to improve the DPL. We will aim to ensure that dentists that have the necessary skills and qualifications can deliver NHS dental activity within 3 weeks after their full application to the DPL has been received by NHS England, and work to prevent applicants waiting longer than 6 weeks.

We will undertake a review of the DPL, including considering whether it could be streamlined further. This review will also consider whether commissioners should be able to use dentists working only in the private sector as a ‘provider of last resort’ - for example, to support access to dentistry for a short period in circumstances where there is short-term pressure on NHS supply.

Evaluation of this plan

We will track local experience as the plan is rolled out and keep its impact for patients under close review. We will look to evaluate elements within the plan, working closely with stakeholders including the British Dental Association and Healthwatch England.

Annex: recent dentistry reforms

In March 2021, health ministers asked NHS England to lead on dental system reform, to start to address some of the underlying concerns about operation of the NHS contract and its impact on access by patients. 

As a result, the first major changes made to the contract since 2006 were announced in 2022. These included the following.

To support dentists to treat patients with higher needs, we increased the payments for more complex or high-volume treatments within band 2, meaning fairer remuneration for dentists where 3 or more teeth require filling or extraction, or complex treatment is needed. We saw this as a first step in a series of changes to ensure that remuneration more fairly reflects the treatment that patients need.

To reduce the number of clinically unnecessary check-ups and free up capacity for those that need treatment, we made changes to the FP17 form used to claim payment for NHS care delivered. The changes support adherence to NICE guidance around personalised recall intervals, which indicates that adults at low risk of poor oral health can wait up to 2 years, and children up to a year, for a check-up.

For those practices receiving the lowest rates for their NHS care, we established a new minimum UDA value of £23. This was a start to addressing historic variation between practices.

We addressed misunderstandings around use of skill mix in NHS dental care by publishing new skill mix guidance, supporting DCPs to work within the NHS. We also removed some of the administrative barriers in FP17s to support recording of the work of DCPs and facilitate dental therapists and hygienists, not just dentists, to open courses of treatment within their scope of practice.

We enabled willing and able practices to deliver up to 110% of their contracted activity, where this was agreed by commissioners.

We made regulatory changes to improve information for patients about where to go for NHS dental care. The changes mean that dental practices with an NHS contract are now required to regularly update the NHS website to state whether they are accepting new NHS patients.

This initial package was designed to support NHS dentistry as the wider healthcare system emerged from the pandemic and began its recovery. The changes therefore focused on supporting practices to return to usual activity levels and maximising care using existing resources. This, and further detailed engagement with a wide range of stakeholders in the sector, has also informed the development of the policies and changes outlined in this plan.

Patients also need to be well informed about how NHS dentistry works and the care they are entitled to. NHS England has created a new group of patient and public voice (PPV) partners and is working to raise awareness of how often patients should go to the dentist and how non-dentists (for example, dental therapists and hygienists) can be used to deliver patient care. 

It is also now a contractual requirement that all dental practices must review and update their NHS website profile information every quarter, which includes what services they offer and whether they are accepting new NHS patients. NHS England has recently put in place additional measures to monitor and improve this.

18 months on, the NHS continues to commission a similar amount of activity across the country compared with before COVID-19, and delivery against contracts has slowly increased. These initial signs of recovery are encouraging - however, delivery of NHS care is still below pre-pandemic levels overall and we know there is a great deal more to do. We have always recognised that the changes announced in 2022 were the first step in an important process of reform, which needs to tackle a series of long-standing challenges facing NHS dentistry.

In June 2023, we published the first ever NHS Long Term Workforce Plan to help ensure that we have the right numbers of staff with the right skills to transform and deliver high-quality services fit for the future. In the workforce plan, we committed to expanding and supporting the NHS dental workforce by:

• expanding training and education to record levels, including dentistry training places by 40%, to over 1,100 places by 2031 to 2032. To support this ambition, we will expand places by 24% by 2028 to 2029, taking the overall number that year to 1,000 places
• increasing training places for dental therapists and hygiene professionals by 40%, to more than 500 places by 2031 to 2032
• exploring 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
• exploring opportunities to support the professional development of dentists and dental care professionals, promoting fulfilling career paths and use of full scope of practice, while considering how to minimise the bureaucracy around starting to practise in the NHS
• reforming contractual arrangements to encourage more dentists back into NHS practice and make it easier for therapists and hygienists to provide NHS care directly

References

1. Payments for primary care dentistry are made for UDAs up to a maximum negotiated annual contract value agreed in each dental provider’s contract. ↩

2. Powell N. ‘Ireland reviews water fluoridation.’ Canadian Medical Association Journal 2014: volume 186, issue 10, pages E343 to E344. ↩

3. Centres for Disease Control and Prevention. Water Fluoridation Data and Statistics.  ↩

4. National Health and Medical Research Council. Public Statement: Water Fluoridation and Human Health in Australia. 2017.  ↩

5. Gallagher JE, Lim Z and Harper PR. ‘Workforce skill mix: modelling the potential for dental therapists in state-funded primary dental care.’ International Dental Journal 2013: volume 63,pages 57 to 64. ↩