No future for NHS dentistry without reform, warns PAC, as Government efforts fail to halt decline
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Government's attempts to improve access to NHS dentistry have been
a complete failure. In a report on fixing NHS dentistry, the Public
Accounts Committee (PAC) warns that there is no future for NHS
dentistry without action from Government to go further in
supporting the dental workforce, as patients continue to suffer the
effects of a lack of access to care. The report finds that, at
best, only around half of the English population could see an NHS
dentist over a two-year...Request free
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Government's attempts to improve access to NHS dentistry have been a complete failure. In a report on fixing NHS dentistry, the Public Accounts Committee (PAC) warns that there is no future for NHS dentistry without action from Government to go further in supporting the dental workforce, as patients continue to suffer the effects of a lack of access to care. The report finds that, at best, only around half of the English population could see an NHS dentist over a two-year period under current funding and contractual arrangements. Just 40% of adults saw an NHS dentist in the two years to March 2024, compared to 49% in the two years pre-pandemic. The four initiatives of the Department for Health and Social Care (DHSC) and NHS England's (NHSE) February 2024 dental recovery plan, which the report finds was never actually ambitious enough to meet its stated aim of ensuring that everyone who needs to see an NHS dentist would be able to, have comprehensively failed:
On the current NHS dental contract, the PAC's report finds that it is not fit for purpose. A fundamental issue for improving access is the discrepancy between what a dentist can earn delivering NHS and private work. There were 34,520 dentists registered to provide dentistry in England in April 2023, but only 24,193 of these provided some NHS dental care in 2023-24. Without proper remuneration it is likely that even more will move exclusively to the private sector. In March 2024, there were over 5,500 vacancies across the NHS dental profession with many of these going unfilled for over 180 days. While scrutinising the issue, the PAC asked NHSE if it would be better to rip the contract up and start again. NHSE responded that this was exactly what they were going to do, and the PAC agrees with the DHSC when it says that fiddling around with the contract fails to address the real problem. While the new government has committed to fundamental reform of the dental contract, the report highlights there are still no details on when this will happen and what it will look like, and warns that further tweaks to existing arrangements will not be enough. The PAC is calling on NHSE and DHSC to be clear what the actual cost of delivering NHS dentistry is, without which any efforts at reform will fail to address fundamental issues around the affordability of NHS work. The PAC further calls on Government to work with the entire dental profession and wider stakeholders to design and deliver short and long-term changes to prevent further decline of the service. Sir Geoffrey Clifton-Brown MP, Chair of the Committee, said: “This country is now years deep in an avalanche of harrowing stories of the impact of dentistry's system failure. It is utterly disgraceful that, in the 21st century, some Britons have been forced to remove their own teeth. Last year's Dental Recovery Plan was supposed to address these problems, something our report has found it has signally failed to do. Almost unbelievably, the Government's initiatives appear to have actually resulted in worsening the picture, with fewer new patients seen since the Plan's introduction. “NHS dentistry is broken. The Government could hardly fail to agree on this point, and indeed I am glad that it is not in denial that the time for tinkering at the edges is over. It is time for big decisions. NHSE agreed that the current contract is not fit for purpose, and that it is time to rip up the aged contract through which dentists deliver their services, and start again. This was said over a month ago at the time of our public hearing, since when we have seen massive change, including the abolition of NHSE itself. “This gives the Government the opportunity to completely reconfigure the way the NHS is run. In particular, so that more resources can be devoted to the local health boards who commission dentistry services. At the same time, a new contract should be negotiated with dentists so that all in this country will have proper access to a NHS dentist for the treatment they need. Parliament, the dental profession and patients all now need to know, as a matter of urgency, what comes next.” PAC report conclusions and recommendations Minor changes to a contract that is not fit for purpose have failed to incentivise dental professionals to undertake sufficient levels of NHS work, and while more fundamental reform has been needed for decades there is still no sign of progress. The current dental contract is based on arrangements agreed back in 2006 and pays dentists fixed amounts for delivering contractually agreed levels of dental activity. Officials broadly accepted that the contract was not fit for purpose and needs urgent and fundamental reform. When we asked NSHE if it would be better to rip up the NHS dental contract and start again, following a consultation with dentists to establish what their requirements are from a new system, they told us that was exactly what they were going to do. The contract no longer meets the needs of the population, provides disincentives for practices to take on NHS patients (especially patients with more complex needs), and leads to a situation where under-delivery on contracts leads to significant underspends in the NHS dental budget. There has only been one set of changes to this contract since 2006 and more fundamental reform, along with a clear focus on prevention and overall oral health, is desperately needed. The new government has committed to delivering this reform, but DHSC and NHSE cannot yet give an indication of when this process will begin. Patients and the dental profession alike deserve to know when they can expect further details on reform. They also need clarity on how prevention will be at the heart of changes, and how DHSC and NHSE will consult on what patients and professionals need from the service in future. Recommendation 1.
The dental recovery plan was never going to deliver its headline ambition that everyone who needs to see an NHS dentist would be able to, and has failed even to deliver the hoped for 1.5 million additional courses of treatment in 2024-25. The plan's initial promise to expand access in 2024-25 so that everyone who needed to see a dentist would be able to was never aligned to its actual target of an additional 1.5 million courses of treatment. Even this target would have left overall delivery still around 2.6 million courses of treatment short of pre-pandemic levels. The dental recovery plan has failed to deliver the promised additional courses of treatment, the number of new patients seen is actually falling, and slow or no progress has been made on other initiatives. At least £88 million has already been spent on the new patient premium, but 3% fewer new patients have been seen since it was launched in March 2024. Given the public money spent on initiatives that have yielded little or negative results, it is important that NHSE and DHSC produce a transparent evaluation of what government spent on the plan and why it has not had the desired impact on access to NHS dentistry. Recommendation 2. DHSC and NHSE must publish their evaluation of the dental recovery plan and what was spent on it. They should write to the Committee as soon as is practical to confirm their final analysis of the plan's performance in 2024-25, including details of:
DHSC and NHSE's modelling of what might be achieved, and how much this would cost was wrong and it took too long to identify the error, raising wider concerns about the quality assurance processes in place for such plans. DHSC and NHSE only identified an error in their assumptions about the cost of the new patient premium during preparation for our evidence session, a year since the publication of the plan in February 2024. While they assured us that the error was not material to the delivery of the plan, we were concerned that something as fundamental as the cost of the plan, and the number of appointments it could deliver, was based on flawed analysis. The NAO report in November 2024, and the Health and Social Care Committee's inquiry into NHS dentistry in March 2024, had previously raised concerns over how robust this modelling was. We heard that DHSC and NHSE have now designated dentistry a "business-critical model", and that additional resource and quality assurance will be available in the future, but they have yet to make clear what this change will mean in practice. Recommendation 3. In their Treasury Minute response to this report DHSC and NHSE should set out how they are strengthening their own analytical capabilities in dentistry, and explain what will change in practice as a result of dentistry being designated as 'business critical'. The dental recovery plan relied on centrally planned and imposed initiatives that ultimately failed to positively influence the amount of care delivered by dental practices. The dental recovery plan set out national initiatives that relied on take-up and delivery at a local level, hoping to influence the behaviour of individual dental practices. This approach ultimately failed, with the example of mobile dental vans particularly illustrative of a nationally-planned idea failing to address issues on the ground. Going beyond this national plan, it is imperative that regional disparities in access to NHS dentistry are resolved - access to NHS dentistry ranged from 382 courses of treatment delivered per 1,000 people in Somerset ICB to 800 delivered per 1,000 people in South Yorkshire ICB in 2023-24. NHSE and DHSC must support ICBs to use what flexibilities they have in their commissioning powers to deliver improvements that will work for their particular areas, and where necessary there should be clear lines of accountability for how ICBs manage NHS dental services under their responsibility. Commitments like the new government's proposed 700,000 urgent appointments will rely on NHSE and DHSC's ability to work with the people who deliver the service to translate that national priority into a local reality. Recommendation 4. NHSE and DHSC must in their future plans for NHS dentistry:
DHSC and NHSE have not undertaken the analysis needed to understand the actual cost of delivering NHS dental care, without which any efforts at reform will fail to address fundamental issues around the affordability of NHS work. The discrepancy between what a dentist can earn delivering NHS work and private work is a fundamental issue for improving access. The current NHS dental contract, and its reliance on Units of Dental Activity (UDA) rates that were set nearly two decades ago, is unfit for purpose. Recent attempts to address disparities in what practices can earn for delivering NHS work by increasing the minimum UDA value first to £23 and then to £28, and to better reflect the different costs of treatments of greater complexity, have failed to deliver any identifiable improvements. We agree with DHSC when it says that fiddling around with the contract fails to address the real problem. In April 2023, there were 34,520 dentists registered to provide dentistry in England, but only 24,193 of these provided some NHS dental care in 2023-24. Without proper remuneration it is likely that even more will move exclusively to the private sector. However, it does not appear that NHSE and DHSC yet have a sense of what level of funding would provide a realistic incentive for dentists to prioritise NHS work. Until there is a clear and evidence-based proposal for remuneration that reflects the true costs of dentistry, that issue is unlikely to be resolved. Recommendation 5. DHSC and NHSE should commit in their Treasury Minute response to conducting and publishing analysis of the actual costs of providing NHS dental care as part of any future work on reforms to NHS dentistry, reflecting the full range of complexities of treatments that patients might need. This should include an explanation of how the current structure of payments to dentists, in terms of the range and complexity of treatment, has different impacts depending on the deprivation of the community served. Without a workforce sufficiently supported to deliver NHS dental care, there will be no future for NHS dentistry and DHSC and NHSE have not yet done enough to address workforce issues. The total number of dentists delivering some NHS dental care is in decline and NHSE data showed that in March 2024 there were over 5,500 vacancies across the NHS dental profession with many of these going unfilled for over 180 days. Whether the issue is a lack of dental professionals altogether, or a lack of dental professionals willing to take on NHS work, it is clear that there is a need to go further on efforts to support the dental workforce. This is particularly true for deprived, rural and coastal parts of the country where challenges in attracting dentists to work are particularly acute. The dental recovery plan included some measures to address this challenge, such as a consultation for a dental graduate "tie-in" to the NHS, expanding training places and helping patients access care from a variety of dental professionals. The results of the consultation on the dental graduate tie-in is still outstanding, and work by DHSC on the other measures is ongoing. The success of these measures will depend on buy-in from all members of the dental team, and a clear sense from DHSC and NHSE of what the barriers are to attracting professionals to NHS work. Recommendation 6. DHSC must:
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