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The dental desert

A lack of NHS dentistry provision is causing people to neglect their oral health or perform their own procedures. Spotlight reports from the front line of a rapidly decaying sector.

By Harry Clarke-Ezzidio

Located one mile from Birmingham city centre, opposite a park through which a seventh-century river flows, the Edgbaston Dental Centre could hardly be described as “deserted”. Yet Edgbaston is one of many areas across the country termed “dental deserts”: places where there is either a shortage of dentistry practices to serve local people, or no more capacity in existing ones to take on new NHS patients. This leaves scores of people without access to vital dental services; some just need a simple check-up, others are suffering from tooth decay and gum disease – and many are dealing with excruciating levels of pain.

Edgbaston Dental Centre – a large, pearly-white, converted Victorian-era house, with a more modern, brown-brick extension – has practised for more than 20 years. It’s an anomaly in Birmingham: the practice is one of few in the city that is taking on new NHS patients. A 2022 BBC investigation found that 82 per cent of dental practices in Birmingham are not accepting any new adult NHS patients. The picture is worse for the whole UK: nine in ten practices aren’t taking on adults, and eight in ten are not accepting new child patients.

On a chilly Wednesday morning in March, I arrive at the clinic alongside Preet Gill, the shadow primary care and public health minister and MP for Edgbaston, who I’m accompanying on a shadow ministerial visit. An array of patients arrive at the practice. One local resident travels by foot, wrapped in a black puffer jacket to shield them from the cold, while another arrives in a sparkling white Porsche, dressed in a dark grey designer tracksuit.

Around 90 per cent of dentistry services are provided by high-street practices such as this one, which are independently owned and essentially operate as small businesses. These practices take on a combination of NHS patients, who pay subsidised costs based on the level of treatment they need, and private patients, who can pay up to three times more for the same services. Children, pregnant people and those on certain low-income benefits receive free treatment.

Inside the dental surgery, patients nervously twiddle their thumbs as they wait to be called into the treatment rooms. When I speak to them, the dentists themselves seem nervous, too. Many are worried about the level of decay (both literal and figurative) that their industry is dealing with. “Morale is very low,” Dr Anoup Nandra, the owner of the Edgbaston Dental Centre, tells me, perching on his dentist’s stool. “Dentists are overworked. Dental teams are overworked.” The practice is “super-stretched” and is now open from 8am to 8pm. “Covid was a big problem… patients were not coming,” he adds.

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Despite dental care being an essential part of population health, dentists were not deemed to be key workers at the start of the pandemic. Dental practices were forced to close between March and June 2020, and appointments sharply declined, causing a significant backlog. Dental treatments peaked at a record 39.7 million in 2018-19, then dropped to a low of 12 million in 2020-21. The number has since bounced back to 32.5 million in 2022-23, but this is still below pre-Covid levels. “We are, in many ways, still catching up on the backlog of care needed,” says Nandra.

One of Nandra’s patients, Steven, first started coming to the Edgbaston practice in 2022 because he was unable to get registered at any of his more local practices in the nearby district of Moseley and Kings Heath. “Getting into a dentist is virtually impossible in places,” he says. Treatment delays and poor oral health can cause a cascade of other health issues, beyond the well-known ailments of toothache, decay and gum disease. It can increase the risk of heart disease, stroke, diabetes and complications for pregnant people.

Steven is visiting the dentist to get “impressions” – a mouth mould – to replace two of his bottom teeth, which are rotting. “I’ve been in a lot of pain,” he tells Gill in a treatment room, prior to his procedure. “It’s ridiculous – we’re supposed to be a good country.”

Shortly before Gill’s visit in March, NHS dentistry made headlines when the police had been called to manage a huge number of people who were queuing outside a dental practice opening in Bristol, desperately trying to register for an NHS dentist. Consequently, 1,500 patients were registered for treatments in just two days. One in five Britons (22 per cent) are not registered with a dentist, according to a survey from YouGov, with the most common reason being that they can’t find an NHS dentist open to new patients. The research also revealed that one in ten people have resorted to performing “DIY dentistry” on themselves, including pulling out their own teeth or making their own dentures.

“I ain’t got the bottle to pull them out myself,” Steven tells Gill, half joking. She doesn’t laugh.

“That is not what NHS dentistry should look like in the UK,” the shadow minister later tells me in a vacant treatment room.

If there is such a thing as a “utopic” dental clinic, then it is perhaps located in the affluent London districts of Marylebone and Chelsea.

Happy Kids Dental, which has two separate practices in the capital, could aptly be described as a “dental Disneyland”, rather than a dental desert. The children’s clinic could be mistaken for a playground: photos on its website of the Chelsea clinic feature hippo shaped sinks, floor-to-ceiling sea-themed rooms with floating plastic fish, and a giant elephant-crewed toy ship, complete with a slide. The two clinics offer private treatment with a “full mouth oral health assessment” for children aged three to 16 costing £215-235 – nearly ten times the cost of an NHS check-up.

The existence of such premium clinics might add to an assumption that dental practices – and dentists by default – are all affluent. The government has leaned into this belief – perhaps to distract from the decline in service it has presided over. Earlier this year, the Health Secretary Victoria Atkins told Good Morning Britain that the “dental market” has “radically changed” in recent years. She suggested that dentists are increasingly choosing to perform more “cosmetic treatments”, which “tend to be rather lucrative for dentists, and a lot of dentists… are attracted to that”. But “not all” prioritise private work over their NHS patients, she added when challenged.

The dentistry industry wholly rejects this suggestion. Eddie Crouch, chair of the British Dental Association (BDA) and a practising dentist in Birmingham, tells Spotlight via video call that the opposite is true. “Colleagues are having to actually provide more private treatment… to cross-subsidise [the costs of performing] NHS treatment,” he says.

The current “NHS contract” between the government, the NHS and dental practices was first introduced by the last Labour government in 2006. Bar a few marginal improvements, it has barely changed since. This means that, rather than being paid for each piece of NHS work they do, dentists are paid per course of treatment. Dentists in England receive a “block contract” from their local integrated care board (ICB), which commits them to conduct a set number of “units of dental activity” (UDA) per year for a set fee, paid for by the NHS. If they don’t complete 96 per cent of that work, they have to pay back some money.

Treatments are categorised into three “bands” based on complexity, which are worth different numbers of UDAs and different patient charges. A check-up or examination is in band 1, accounting for one UDA; fillings and root canals are in band 2, accounting for three UDAs; and the most complex treatments such as crowns and dentures are in band 3, accounting for 12 UDAs. Patient charges range from roughly £25 to £320, and have risen by 12 per cent over the past year.

Patients are only charged a single cost per band (rather than per treatment item), and this payment also covers all treatment within lower bands, meaning dentists are doing more work for less money. For instance, one filling would cost an NHS patient the same as three fillings and an examination. Similarly, several treatments within one band only equals one UDA value, making it harder for practices to meet NHS commitments.

Crouch calls it a “broken contract”. He says that alongside poor monetary compensation, the multiple appointments and many hours of work involved in complicated cases do not accurately count towards their NHS quotas. Many practices “struggle” to fulfil these, especially as they are increasingly losing staff to other industries.

“Some of our dental team can earn far more money going to work in a supermarket,” Crouch adds. “When you can’t recruit dentists or… other ancillary staff to help you fulfil a contract, it’s really galling to hear a minister say that we are choosing to do that.”

The BDA is calling on the government to urgently prioritise reforming the NHS contract, and how dentists are paid for NHS work. The union’s other demands include building a sustainable workforce, establishing a national agenda for prevention, and giving dentistry a voice in integrated care systems. But while the sector is facing a workforce shortage (more than 2,000 dentists have left the NHS since the pandemic), contract reform needs to be the starting point for policy change, says Crouch. “Most MPs believe that this is a workforce problem,” he says. “They believe that if they train more dentists, or they import more dentists from around the world, the system will actually be better. But… if you come and work in a system that’s poor, you won’t stay.”

In February, shortly after the queues seen in Bristol, the government announced its £200m Dental Recovery Plan. The plan centres around two themes of action and prevention.

Dentists will be offered a “patient premium” of either £15 or £50 (depending on the level of treatment) to take on new NHS patients; the minimum UDA rate (the level of compensation that dentists receive) will be raised from £23 to £28 to make “NHS work more attractive and sustainable”; and a public health campaign encouraging good oral health will target those who are pregnant, as well as infants and toddlers. To help those living in “dental deserts”, the government is offering dentists “golden hellos”: a £20,000 payment to set up new practices in under-served areas.

The most striking aspect of the plan is to introduce “mobile dental vans” to provide more immediate support in dental deserts. But, in reality, this idea is not new at all. The charity Dentaid has provided free emergency dental treatment to vulnerable groups since 2016, and began operating its first mobile dental vehicle – a large truck, with a rectangular unit attached where procedures are conducted – two years after. It now has nine mobile dental units and ran 422 clinics in 2023. “It’s quite devastating to think that this is what it’s come to,” Natalie Bradley, Dentaid’s clinical director, tells Spotlight.

Bradley says the government’s dental van plan is “not a long-term solution”, and will be expensive: buying and modifying vans for dentistry costs in excess of £250,000 per vehicle, she estimates, based on her charity’s own costs. At best, 12-15 people could be seen a day, she thinks. It’s a drop in the ocean compared with overall need: according to a survey of GPs, 11 million people were unable to get an NHS dentist appointment in 2022.

Labour has also released a plan to “rescue” NHS dentistry, which it says will cost roughly £111m per year. It was originally going to be funded by scrapping the non-domiciled tax status, but as the government has since taken this policy, the funding will need to be generated from another source, which has not yet been confirmed.

Similar to the government’s plan for “golden hellos”, Labour would also offer a £20,000 incentive for dentists to open new practices in dental deserts, if elected. But is this enough to encourage a dentist to uproot their life? “Just to set up a dental practice will cost you many, many more thousands,” Anoup Nandra tells Preet Gill in his Edgbaston practice.

On first glance, you could be forgiven for confusing the opposition’s dentistry plan with that of the government’s. Both commit to treat those in urgent need (Labour is pledging to deliver 700,000 “urgent appointments”), reform the dental contract, and focus on prevention. Labour is also planning to introduce “supervised toothbrushing” in its new, proposed school breakfast clubs. “Our plan is absolutely different,” Gill tells me. “[The places] where parents were getting support no longer exist. That’s why the toothbrushing scheme – delivered in parts of early years and in schools – is so important, because we’ve got to make sure it’s a public health priority.”

As the shadow minister concludes her visit in Birmingham and is picked up by her driver, I speak with people on the street about their experiences of the NHS. “I had to go for private treatment in the end,” Harry, who was on his way to Birmingham New Street station, tells me. He had waited a year to register at a local dental practice that was taking NHS patients near his home, just outside of Liverpool: “I was at a point where I nearly overdosed on painkillers, because I was in pain every day.”

Harry lives with depression, which impacts his ability to brush his teeth as often as he’d like to. He ended up paying nearly £600 for private root canal treatment. He’s currently on an NHS waiting list for further treatment, and has been for two years. Unable to afford more private work, Harry believes that by the time he’s seen, his teeth may have deteriorated to the point where “it’ll have to be a full-on tooth extraction”.

“I can understand why people are doing dentistry on themselves,” he says. “I’m sure [dentists] must feel so guilty and get a lot of flak, but it’s out of their power. It’s through policy [where solutions come]. It’s through politicians.”

This article first appeared in a Spotlight print report on Healthcare, published on 17 May 2024. Read it in full here. .

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