NHS Dentistry: Britain’s Dental Crisis, How We Got Here and What Needs to Be Done
In a departure from my usual history studies, I’ve decided to explore the history of NHS dentistry and its challenges today. This is a topic I follow closely in the news, as I believe the profession urgently needs support to survive within the NHS. To construct this week’s post, I’ve examined government reviews, surveys, and guidance from the British Dental Association and General Dental Council. I aim to summarise the key issues facing NHS dentistry and highlight potential solutions for its future.
Reading time: 12 - 15 minutes
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NHS Dentistry is struggling. Fewer appointments, a small number of dentists providing treatment, and not enough education institutes are just some of the problems facing our national health service today. As someone who has benefitted from the system, preserving this service is in our national interest. In the work below, I shall explore the history of the service and how the various challenges it faces today may impact its future. From this, it will become clear what our crisis state is and how we should fix it.
The History of Dentistry as A Field in Britain
Unlike medicine and surgery, Dentists did not have
qualifications until the 1850s. Their history as a ‘modern’ profession can be
traced to 1858 when the Dental Hospital of London and the Metropolitan School
of Dental Science opened their doors.[1]
This expanded to Edinburgh, Glasgow, and Ireland by 1879—a relatively fast
expansion for what is now a demanding course.[2]
The inclusion of Edinburgh is quite interesting, as today, the university only
focuses on post-graduate specialist courses (something I shall return to later).[3]
Dentistry, then, can be seen as a niche, requiring much time and support to
study. This factor is only affirmed by the requirement to study at both a
dental school and a medical school in the late 19th century.[4]
These requirements were later phased out; dentists today typically study a
Bachelor of Dental Surgery (BDS), the first of which was awarded at Birmingham
in 1906.[5]
The qualification development was relatively rapid; in a fifty-year window, the
nation went from not having qualified dentists to having schools producing
professionals. The development as such was remarkable, and whilst it could have
had a limited impact on the population – with dentistry being private at this
point, it established it as a ‘profession.’
The greatest asset of Dentistry in Britain was its
introduction to the National Health Service (NHS) in 1948. The NHS is the UK’s
medical service and was established in 1946 by the Labour Party’s Minister for
Health, Aneurin Bevan MP.[6]
The NHS was revolutionary at the time, founded on improving physical and mental
health and preventing, diagnosing and treating illness.[7]
At its introduction in 1948, NHS Dentistry was free, but this was only
short-lived, as charges were introduced in 1951. Charges are, to an extent,
necessary to ensure the payment of practitioners and materials, a theme that only
develops from the introduction. So, by the 1960s, charges were seen per item,
and a backlog in war-time issues and a development in dental technologies saw the
move from extracting teeth to restoring them.[8]
Kevin Lewis has coined this shift to restorative practices, which has seen a
‘heavy metal’ approach to the nation’s teeth.[9]
Like my parents, those who grew up in the 1960s – 1980s often seem to have many
amalgam fillings. This is, again, part of the restorative practice that was
brought in under the profession and implemented by the NHS. The profession focuses
more on restorative and preventative care than removing teeth today. As such,
the growth of the NHS increased the nation’s access to oral health provisions.
In essence, this was a positive thing.
NHS Dentistry Today
In 2023, approximately 23,577 dentists were completing NHS
work in England.[10] A
number nowhere near large enough to serve a population of 57 million.[11]
As Lewis shows, the NHS completed the work of those in the 1960s-1980s
generation, and realistically, there is less provision to support their
restorative work today. In addition to only 23,577 dentists practising, as of
June 2023, only 40.7% of adults had seen an NHS dentist, compared to 50.9% in
September 2019 and 51.7% in 2006.[12]
A reduction in service over the long term suggests we are heading for the end
of this subsidised care as we know it in England. The lack of provisions is
alarming. With a growing population, a reliance on restorations being
maintained, and a desire to prevent future generations needing said
restorations, something must be done.
This lack of provision is a concern as restorations have
lifespans. For example, the average lifespan for an amalgam filling is around
15 to 20 years. For example, if you had one placed on the NHS in 1990, by 2010,
the provision for NHS dentistry would have crumbled. The 2006 contract made the
provider (the dentist) agree to complete a set amount of dental activity annually.[13]
This was measured in units of dental activity (UDAs) and is problematic at
best. For example, dentists could only see so many patients on this, allowing
private practice to develop. By 2010 onwards, as per my example, a patient
would likely be required to pay a higher fee for more specialist work. Those
who aren’t dentally minded may not understand that more of the tooth's enamel
is removed when a restoration, such as a filling, is placed. This can lead to
teeth being overly filled and needing to be crowned/capped instead.
Institutions like the NHS are essential to maintaining oral health and
preventing more complex work like crowns.
Whilst a blessing for the nation in its provisions, the NHS
only provides treatment with specific materials and in a banding system. There
are three bands, all providing a variety of treatments ranging from basic to
more complex. Under the current charges, Band 1 costs £26.80, Band 2 costs
£73.50, and Band 3 costs £319.10.[14]
These are much lower than the private comparison. For example, someone who
attends a basic check-up (Band 1) and is found to require one or more fillings
and likely have x-rays taken (Band 2) will only pay for Band 2. However, this
applies only if the treatment is carried out within two months of the first
appointment. By comparison, a private
fee for treatment like this would incur the initial appointment fee (anywhere
up from £49) and the fee for each filling (likely around £150 - £200+ depending
on material), and x-rays too (likely £20+). So, in total, the NHS patient pays
£73.50, whilst the private patient pays somewhere in the region of £200+ for a
single filling. The main pro of the NHS system is ensuring everyone gets access
to treatment at a price most can afford without neglecting problems. However,
the materials used on the NHS are solely amalgam (with very few exceptions,
i.e. you are under 15, you have deciduous (milk teeth), pregnant or
breastfeeding).[15]
This can be seen as unesthetic, so a patient has more choice with private
treatment—such as using white composite. Therefore, the NHS is limited in what
it can provide, but it benefits the patient financially.
The lack of provisions has led to the creation of ‘dental
deserts’, most notably in the East. As you shall see below in ‘The Current
State of Dental Schools’, most dental schools are centred in municipal areas,
predominantly in the North and some in the Midlands. As one consultant Oral
Surgeon put it, “It makes me so angry – daily, I see some of the most
vulnerable being abandoned. […] in a return to health outcomes of the 1940s.” Other
examples include Wisbech and Suffolk. In Suffolk, suggested plans for remote
dental care are being discussed with hopes of losing this tag by their health
board boss within 2 years.[16]
Much change is needed to achieve this. The NHS is underfunded and needs more
provisions to survive, such as schools, personnel, and funding. As such, the
lack of patient access currently leaves people in crisis.
With the limited scope of provisions established under the
2006 contract, can we call the Conservative Government’s plan a ‘recovery
plan’? The 2024 plan aimed to create 2.5 million additional appointments next
year and give dentists a ‘golden hello’ incentive to work in underserved areas.[17]
However, the 2015-2016 study found dentists often struggled to see 55% of the
nation annually.[18]
Increasing appointments won’t do anything unless we have the means to support
this. This would mean increased government funding in line with the approaches
in Scotland, and they would enjoy a very generous NHS treatment system at a
much lower cost. In their defence, they pay a little bit more in taxes. The
Labour government are tasked with the delicate balance of increasing taxes to
do this or face up to the fact that repairing the NHS may be too complex in its
current state. The state of NHS Dentistry is, therefore, in a precarious place.
The State of Britain’s Oral Health
The state of Britain’s oral health is currently relatively
good. According to a recent global health survey, Britain ranked second among
countries most likely to attend a dentist regularly.[19]
42% of participants reported that they regularly attend their appointments.[20]
This aligns with the number of patients who receive NHS appointments and is a
good measure of the number of people attending. However, the more pressing
matter is that a country can be seen as in good health, with only 42% of
respondents attending appointments. Whilst this is likely from a small sample
size, it is suprisingly low to rank second. Considering the points about
restorations needing to be maintained, we should aim to increase this number. In
this case, a system like NHS dentistry can be highly beneficial.
The case for increasing appointment attendance can be
further seen through the current state of adult’s teeth. The 2021 Adult Oral
Health survey highlights dentate adults having, on average, 25.4 natural teeth.
The survey also found that of those surveyed, 77% brush their teeth twice a
day, and at least half use an electric toothbrush.[21]
This is a good start and suggests that education in oral health programmes impacts
the extent of good habits. As part of the survey, 6,343 responses were recorded
between February and March 2021 from a representative selection of adults aged
16 and over across England. One part of the survey asked respondents to report
on the state of their teeth and count the number of restorations. These were
fillings (‘filled teeth’), crowns (‘crowned teeth’) and having had a ‘root
canal’. The proportion of adults aged 55-64 had the highest number of filled
teeth, with around 95% of respondents having filled teeth. This was the highest
of any other group. It also supports Lewis’ point about those who grew up
between 1960 and 1980 having more fillings under a restorative focus on
‘drilling and filling.’[22]
Being so common in this category alone, these restorations indicate the need
for increased appointment attendance. The NHS, as such, should be carefully
funded to help maintain the nation's health to a set standard.
Figure 1.
A copy of Figure 6 from the Adult oral health survey showing respondents aged
16 to 75+ and their restorative work. (accessed via: https://www.gov.uk/government/statistics/adult-oral-health-survey-2021/adult-oral-health-survey-2021-self-reported-health-of-teeth-and-gums)
Furthermore, the case for the mean number of filled teeth in
each age group demonstrates the need for observation. According to the survey,
adults aged 16 – 24 had around 1.4 filled teeth, while adults aged 55 -74 had
an average of 6.5 and 6.6. Again, this asserts the need to improve the NHS
system to maintain all completed treatments. Of those with filled teeth, around
80% of respondents attended their appointments regularly (i.e., every 6-9
months), and 70% went occasionally – a slight decrease – before rising to 75%
of those with filled teeth who only went when having issues.[23]
This slight increase in those who only attend when experiencing issues should
implore us to find ways to increase access and ensure that people actively
engage with their oral health by attending these appointments. It cannot be any
more urgent than in the cases of dental deserts where people have extracted
their teeth. Dangerous practices risk increasing if we do not offer more
appointments and, most importantly, encourage people to use them.
Figure 2. A copy of
Figure 9 from the Adult oral health survey showing respondents’ attendance at
appointments (accessed via: https://www.gov.uk/government/statistics/adult-oral-health-survey-2021/adult-oral-health-survey-2021-self-reported-health-of-teeth-and-gums)
Some individuals may also have unreported dental anxieties,
preventing them from attending regular appointments. This also needs to be
tackled so anxious patients don’t lose access to an NHS dentist under the
current 24-month rule – in which if you do not attend, you are removed from the
practice books. Whilst the overall appearance of Britain’s oral health seems to
be good in the short term, we should be more concerned with long-term planning
to maintain this. Therefore, the current system's state needs to change for the
better – both for the professionals and the patients.
The Current State of Dental Schools
The number of dental school places is an issue. As of this
writing, there are 11 dental schools in England, 2 in Scotland, 1 in Northern
Ireland, and 1 in Wales. These schools had a combined entry projection for
2024/2025 of 1,107 spaces (see Tables 1 and 2). By comparison, 35 institutions
alone in England offered 7,048 Medicine spaces.[24]
Medicine spaces are thereby almost 7x higher than dentistry spaces. Whilst
future doctors are essential to the NHS, as the majority will work here, there
should be a further focus on the number of places offered to study dentistry,
too.
In addition, dentistry is often seen as an elitist subject
where fewer places can harm its applications. Today's average applicant is 19.7
years old and female; over half of applicants are from minority ethnic groups.[25]
The high entry requirements of AAA to A*AA often mean those of a lower
socioeconomic background are unlikely to gain the grades needed for entry. While
around 15% of applicants are graduates (applying for their second degree), the
lack of spaces and high entry requirements may indicate an issue with school
spaces.[26]
The average age being past 18 – the age of sitting A-Levels – indicates
significant demand for this degree, and more should be done to accommodate
those wishing to study it. More spaces are needed to widen the sector and help
overcome the issues facing the NHS today.[27]
One way to achieve this is through opening more dental
schools. The University of East Anglia in Norwich is set to open its first
dental school later this year.[28]
Located in the East of England, a school here could retain graduates to help in
its dental ‘desert’ of both Norfolk and Suffolk.[29]
As shown in Figure 3 and Figure 4, the distribution of dental schools
across the country is primarily centred in London, the north and north-west,
but the development of a dental school in East Anglia would further oral health
provisions in the area. Students would be required to undertake clinical hours
within the local community, which could help to reduce the waiting list for the
NHS. Furthermore, this would increase the number of dental school places in the
UK and likely add between 50 and 70 new dentists to the UK’s health service each
year.[30]
UEA already has a medical school, which would align it with the other
universities and could inspire other institutions with medical schools to
follow suit. This, however, is a slow process which must be supported by the
General Dental Council for the University to gain the relevant statuses to
teach and award degrees. It can, however, be hoped that examples such as UEA
will inspire more universities to consider developing adjacent dental schools
to help ‘fill’ (pun intended) the situation. This way, more dentists will be
trained and, therefore, can be recruited by the NHS.
Figure 3: A map
showing the distribution of medical schools only (blue) and medical and dental
schools (red). Created via Google My Maps.
Figure 4: A map
showing the distribution of medical schools only (blue) and medical and dental
schools (red) in London. Created via Google My Maps.
Dental schools and their fees should also be considered for
the future of NHS dentistry. Currently, all home students pay the same fee
regardless of their cost. However, students studying dentistry in a 5 – 6-year
course are eligible for funding from the NHS Bursary scheme. Here, they can get
their fifth year of tuition fees paid by the NHS.[31]
The UK government estimates that it costs £292,000 to train a dentist from the
beginning of dental school to graduation.[32]
In repayment terms, students owe £94,000 in tuition loans to the Student Loans
Company. As such, dental students benefit from training supported by their
universities and the government over their fees. It seems fair to tie in their
training to an NHS post. The government believes that as part of the NHS long-term
working plan (LTWP), there is a need for this as it is estimated that by 2031,
1,100 dentists will be being trained each year, up from 810 (approx.).[33]
There is currently concern that many practising dentists aren’t giving NHS
treatment. This needs rectification, and graduates should be encouraged to participate
in the NHS service. It does not need to be an extended policy but should aim to
secure an investment return, for example. This can be seen as helping to
‘balance’ the difference between their funding and the fees they pay, therefore
offering services to the NHS, which desperately needs to increase the number of
patients being seen.
As such, dental schools and their challenges can be a good
place to focus on the NHS recovery plan. Schools should expand and provide stronger
links for graduates to join NHS contracts. Through this, we can help secure the
investment in each undergraduate and strengthen the NHS’s future workforce.
How should we fix it?
To conclude, the problems of NHS dentistry are unlikely to disappear overnight. Careful planning is needed on all levels, from the government to the dental schools themselves, and collaboration with today's and tomorrow's dentists is essential. I believe this is necessary to maintain Britain’s oral health. An abundance of restorative work in some generations means careful observation and minor maintenance may be needed. This work was likely placed under NHS, and it seems only right to maintain it. Expanding dental schools will provide new training opportunities and widen participation in local communities after graduation. Government initiatives will increase student places and ensure we have a capable dental workforce for the future. These measures will ensure the survival of elements of NHS dentistry, but only if we act now.
What do you think, can NHS dentistry be saved? If so, how far can these measures help that?
Table 1: UK Dental Schools, their regions served and the
number of places available
|
Dental School /
Affiliated University |
Region Served |
Number of Home Places
for Entry (Y1) |
|
Queen’s University Belfast |
Northern Ireland |
45 |
|
University of Birmingham |
West Midlands,
England |
67 |
|
University of
Bristol |
South West, England |
67 |
|
University of
Cardiff |
Wales |
74 |
|
University of Dundee |
Scotland |
135 |
|
University of
Glasgow |
Scotland |
67 |
|
University of Leeds |
West Yorkshire,
England |
72 |
|
University of
Liverpool |
North West, England |
68 |
|
King’s College
London |
London, England |
141 |
|
Queen Mary
University of London |
London, England |
67 |
|
University of
Manchester |
North West, England |
67 |
|
University of
Newcastle |
North West, England |
67 |
|
University of
Plymouth |
South West, England |
55 |
|
University of Sheffield |
South Yorkshire,
England |
67 |
|
University of Aberdeen |
Scotland |
20 |
|
University of Central
Lancashire |
North West, England |
28 |
Key:
|
|
Post-Graduate
Entry Only |
|
|
Undergraduate
& Post-Graduate Entry |
Table 2:
|
Medical
School |
Region
Served |
Number of
Home Places for Entry (Y1) |
|
Anglia Ruskin
University |
East of
England |
100 |
|
Aston
University |
West Midlands |
100 |
|
University of Birmingham |
West Midlands |
372 |
|
Universities
of Brighton and Sussex |
South East
England |
193 |
|
University of Bristol |
South West England |
251 |
|
Brunel
University London |
London |
50 |
|
University of
Cambridge |
East of
England |
291 |
|
University of Central Lancashire |
North West England |
50 |
|
University of
Chester |
North West
England |
50 |
|
University of
East Anglia |
East of
England |
195 |
|
Edge Hill
University |
North West
England |
50 |
|
University of
Exeter |
South West
England |
208 |
|
Universities
of Hull and York |
Yorkshire
& the Humber |
220 |
|
Imperial
College London |
London |
321 |
|
Keele
University |
West Midlands
|
154 |
|
Universities
of Kent and Canterbury Christ Church |
South East
England |
100 |
|
King’s College London |
London |
346 |
|
Lancaster University
|
North West
England |
125 |
|
University of
Leeds |
Yorkshire &
the Humber |
259 |
|
University of
Leicester |
East Midlands
|
80 |
|
University of
Nottingham: Lincoln Medical School |
North West England
|
309 |
|
University of Liverpool |
North West England |
369 |
|
University of Manchester |
North West England |
341 |
|
Newcastle University |
East Midlands |
346 |
|
University of
Oxford |
South East
England |
186 |
|
University of Plymouth |
South West England |
150 |
|
King’s
College London: University of Portsmouth Branch |
South East
England |
54 |
|
Queen Mary University of London |
London |
347 |
|
St George’s
Hospital Medical School |
London |
260 |
|
University of Sheffield |
Yorkshire & the Humber |
288 |
|
University of
Southampton |
South East
England |
243 |
|
University of
Sunderland |
North East
England |
100 |
|
University
College London |
London |
310 |
|
University of
Warwick |
West Midlands
|
180 |
|
University of
Worcester |
West Midlands
|
50 |
Key:
|
|
Also has a
dental school |
|
|
Medical
school only |
Sources for Table 1:
https://www.bda.org/advice/career-hub/how-to-become-a-dentist/dental-schools/
https://www.sfc.ac.uk/publications/university-intake-targets-for-dentistry-2024-25/
Source for Table 2:
[1] Gelbier,
S. 125 years of developments in dentistry, 1880–2005 Part 5: Dental education,
training and qualifications. Br Dent J 199, 685–689
(2005). https://doi.org/10.1038/sj.bdj.4813002
[2] Gelbier,
S. 125 years of developments in dentistry, 1880–2005 Part 5: Dental education,
training and qualifications. Br Dent J 199, 685–689
(2005). https://doi.org/10.1038/sj.bdj.4813002
[3] https://www.bda.org/advice/career-hub/how-to-become-a-dentist/dental-schools/
[4] Gelbier,
S. 125 years of developments in dentistry, 1880–2005 Part 5: Dental education,
training and qualifications. Br Dent J 199, 685–689
(2005). https://doi.org/10.1038/sj.bdj.4813002
[5] Gelbier,
S. 125 years of developments in dentistry, 1880–2005 Part 5: Dental education,
training and qualifications. Br Dent J 199, 685–689
(2005). https://doi.org/10.1038/sj.bdj.4813002
[6] https://www.parliament.uk/about/living-heritage/transformingsociety/livinglearning/coll-9-health1/health-01/#:~:text=1946%20NHS%20Act&text=and%20Northern%20Ireland.-,The%20first%20Minister%20of%20Health%20was%20Aneurin%20Bevan%20MP.,diagnosis%20and%20treatment%20of%20illness.
[7] https://www.parliament.uk/about/living-heritage/transformingsociety/livinglearning/coll-9-health1/health-01/#:~:text=1946%20NHS%20Act&text=and%20Northern%20Ireland.-,The%20first%20Minister%20of%20Health%20was%20Aneurin%20Bevan%20MP.,diagnosis%20and%20treatment%20of%20illness.
[10] https://commonslibrary.parliament.uk/research-briefings/cbp-9597/#:~:text=NHS%20dentistry%20workforce,their%20NHS%20commitment%20in%202023.
[15] https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2018/08/cdo-letter-amalgam-08228.pdf
[18] https://commonslibrary.parliament.uk/research-briefings/cbp-9597/#:~:text=NHS%20dentistry%20workforce,their%20NHS%20commitment%20in%202023.
[18]
https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates
[19] https://www.bakerstreetdental.com/blog/uk-performs-well-in-recent-global-dental-health-survey/
[21] https://www.gov.uk/government/statistics/adult-oral-health-survey-2021/adult-oral-health-survey-2021-report-summary#:~:text=The%20main%20findings%20of%20the,natural%20tooth%20(were%20dentate).
[23] https://www.gov.uk/government/statistics/adult-oral-health-survey-2021/adult-oral-health-survey-2021-self-reported-health-of-teeth-and-gums
[24]
See table 1 and table 2 for sources
[25] Booth,
A., Hurry, K. & Abela, S. The current dental school applicant: an overview
of the admission process for UK dental schools and the sociodemographic status
of applicants. Br Dent J 232, 172–176 (2022). https://doi.org/10.1038/s41415-022-3927-1
[26] Booth,
A., Hurry, K. & Abela, S. The current dental school applicant: an overview
of the admission process for UK dental schools and the sociodemographic status
of applicants. Br Dent J 232, 172–176 (2022).
https://doi.org/10.1038/s41415-022-3927-1
[30]
Calculated from data in Table 1 (not including Post-Graduate Entry Only
universities and universities located outside of England.)
[31] https://www.nhsbsa.nhs.uk/nhs-bursary#:~:text=Tuition%20fees,eligible%20course%20in%20Northern%20Ireland
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