Agenda item

Update on NHS Dental Services

Dental services was added to the committee’s work programme on 16 February. NHS England & Improvement will provide an update to the Committee.


Terry Chikurunhe, Senior Commissioning Manager for NHS England and Improvement (NHSE&I) provided a verbal update to the committee covering the following areas:


  • The change in commissioning arrangements, moving from NHSE&I to the new Integrated Care System (ICS).
  • Key messages to address public confusion of dental services and the difference in patient lists when compared to GP doctors. Contractually, dentists provided treatment and then retained responsibility for that patient for two years afterwards, unless the patient had periodic ‘check ups’. 
  • The challenges for dentists throughout the Covid pandemic, the loss of services other than some urgent dental care.
  • Dentists continued to receive NHS funding throughout this period, providing they maintained services at a level set nationally. NHSE&I had a contractual monitoring role. 
  • Oral health promotion and work with the new ICS for Coventry and Warwickshire.
  • There were 65 dental practices within Warwickshire and five specialist orthodontic practices for children. South Warwickshire Foundation Trust provided secondary care for patients in the County, with George Eliot Hospital providing community dental services. Specialist and complex procedures were undertaken at the Birmingham dental hospital and children’s hospital. 
  • Dental services in Warwickshire performed well when compared to other areas of the Midlands region. However, there were some areas of the County with significant challenges for dental access, with Nuneaton and Rugby referenced. There were challenges in attracting dentists and nurses to work in rural areas. Reference to the work to promote NHS dentist services to practitioners. There were workforce challenges and some dentists chose to treat patients privately, even if the same premises were used for NHS services.
  • The planned strategic review of dental services. This would be based on population growth and tackling inequalities in current services.
  • Prior to the pandemic, 50 percent of the population accessed NHS dental services, with the other half either using private services or not having access to a dentist.
  • The pandemic impacted significantly on access to dentists, mainly due to infection control. Data was provided for Warwickshire. In December 2021, dental access was just below 44% of pre-pandemic service levels. Now the lower threshold for services was 62% of normal service levels, with one in 10 dental practices not achieving this level currently. 
  • Oral health improvement. Targeted work was taking place in Nuneaton, Bedworth and Rugby to address high incidences of children with tooth decay. A joint approach was taking place to encourage children through programmes like ‘brushing for life’ where education and toothbrush/paste were supplied. Reference also to training for care home staff so they could look after their residents. A move to more integrated services.
  • Fluoridation of water supplies. This was not preferred by all but was beneficial in preventing tooth decay.


A lengthy debate followed with the following contributions and themes:


  • The Chair requested that a written summary of the data be provided.
  • Further discussion about dental registration and the contractual obligations. After two years of initial treatment, a dentist was not contractually obliged to keep the patient registered. This was not widely known. People were classed as a dormant patient, unless they attended for a regular check-up. It was confirmed that people would not be removed from registration where they had become dormant through not being able to attend their dentist ,due to the pandemic. Reference also to the NICE guidance, work on the dental contract and through patient groups to ensure that patients were not deregistered unnecessarily.
  • A concern about rising living costs and people not attending dentists because of the costs. Whilst NHSE&I was not aware of this issue, some people had not visited their dentist for two years due to the pandemic. Dentists were reporting an increase in the number of more complex cases. From a financial perspective this was causing some dentists to cease providing NHS services.
  • Due to the pandemic, the equivalent of a year of dental activity had been lost. Addressing this backlog would take considerable effort and time. There were recruitment issues and staff fatigue too. Programmes were being run to increase capacity.
  • The follow up report would include the fee structure for NHS dental services. Some people were exempt from paying NHS fees, including for dental services, subject to meeting specific criteria.
  • Alarm that only 50% of Warwickshire’s population were using NHS dentists, which implied that the rest were forced to use more expensive private services. This was challenged and patients should not be forced to use private services. If NHSE&I became aware of such activity, contractual sanctions were taken. Some people chose to access private services, but it should be a choice. It was requested that a further report be provided to give a breakdown of data for the 50% of people that were not accessing NHS dentist services.
  • A view was sought on the financial viability of dentists in Warwickshire, with reference to the feedback received from some dentists.  This was a national issue and was based on the national contract and financing in place since 2006. NHS dentists had continued to receive full funding throughout the pandemic despite the reduction in operational activity. The subsequent report to members would include details of the incremental increases in operational targets for them to continue to receive this funding. It was NHSE&I’s view that dentists had been supported through the pandemic. It could be argued that there was a need to revisit the financing due to work and additional costs for infection control. This was an ongoing discussion and had significant financial implications. 
  • Chris Bain of HWW reported that dentistry was the NHS service which caused patients most confusion. The dental contract was described as impenetrable. Feedback from patients evidenced a reluctance to use NHS services during the pandemic, to reduce pressure on services, but this had actually resulted in lost appointments. HWW undertook a survey of dentistry, and the findings were published on its website. It showed a ‘postcode lottery’ in terms of NHS dentist services, with a lack of access to NHS services in both Rugby and Stratford at the time. The survey was being repeated this year and its findings would be reported to the committee. Private appointments were available at the time in both Rugby and Stratford, which evidenced the exploitation of confusion by some dentists. Referrals to the NHS 111 service did not result in satisfactory responses especially for urgent dental matters. These findings were also available via the Healthwatch website. Enquiries to HWW continued to include many related to dental services. The plans to increase services to address the backlog were not realistic and posed a risk of dentists leaving the service. The points about workforce challenges were known. The reports and assurances from NHSE&I differed from the lived experiences reported to HWW. Chris Bain offered to have further discussions with Mr Chikurunhe after the meeting. There was a need to tackle both inequalities and the postcode lottery. Some people in Rugby had not had dental appointments for over two years and there were concerns especially for children.
  • Mr Chikurunhe welcomed the opportunity to work with HWW. He acknowledged the access problems in Rugby and spoke of plans for more investment in dental services for this area. It was known that newly qualified dentists wanted to work privately, rather than provide NHS services. NHSE&I was aware that some practices offered both NHS and private services, offering faster appointment times and treatment privately. Further points about the differing fee structures and dentists wanting to work on a part time basis.
  • A comparison to NHS doctors who could also work privately but had obligations to see NHS patients. There were different contractual requirements and funding mechanisms for GPs and dentists, with dentists required to fund their own premises for example. The degree of influence for NHSE&I was much less for dentists than it was for GPs. NHSE&I provided a contract payment to dentists who then configured their services. Chris Bain responded that the funding did include an aspect for facilities.
  • A request that HWW provide feedback to the committee following its discussion with NHSE&I. It was suggested that the committee could revisit this topic at a future meeting.
  • Some specialist services were only available on a private basis and at significant cost. It was questioned why such treatment could not be provided as an NHS service. Mr Chikurunhe responded that especially where a patient was in pain, they should not be required to pay for treatment privately. Cosmetic procedures were not available via the NHS. An offer to look into a specific case reported. He also outlined the secondary care services available for more specialist procedures. Some people may elect to pay for private treatment, if there were waiting times for treatment on the NHS.
  • Members welcomed the plans for training of care home staff speaking about the importance of oral hygiene. This project was being led by dental Public Health colleagues and data would be provided as part of the report back. Reference also to the domiciliary visits which took place for people unable to visit a dental practice.
  • A question about the proportion of private dental services and when this became a concern. There was no easy way of measuring this, and it was more about responding to complaints from patients directed to private services, instead of being offered treatment on the NHS. Such dentists were reminded of their contractual obligations. Some patients may choose to pay for private dentistry, but they should not be forced to use private services due to a lack of NHS service. NHSE&I had no right to information held by dentists about their private work.
  • Councillor Cooke gave an outline of previous roles as a councillor serving on the health authority and spoke about the charging structures introduced for both dentist and optician services. Issues with NHS dental services had existed for some time and examples were provided to demonstrate this, as well as personal experience of a practice moving to provide only private services paid for via a monthly dental plan.  He spoke about the comparative costs for NHS treatment and was concerned at the lack of NHS dental services for children. He considered that the NHS dental contract required updating.
  • A question about dentists choosing to provide only private services and the impact for dormant patients who had not visited the dentist for two years. It was confirmed that such dentists were required to give a minimum of three months’ notice and to complete the treatment of current NHS patients. The councillor considered this a contributor to the 50% of people unable to access an NHS dentist as many preferred to stay with the same dentist.
  • The Portfolio Holder Councillor Bell commented on obligations of dentists whose training was paid at least in part by the public purse. There should be an obligation to treat children on the NHS, free of charge. An update was sought about the infection control requirements, also referring to the impact of the pandemic in limiting the number of patients who could have appointments. Addressing the service backlog would not be achieved if there were the same requirements for infection prevention measures. She also asked about the transfer to the ICS and what controls it would have, such as to revisit the dental contract.
  • Mr Chikurunhe considered the comment about training to be fair and this was an area for Health Education England, which was responsible for dental training. Like other students, most newly qualified dentists had a significant debt to repay. On infection control, he confirmed the additional risks for this service and the measures that were imposed to protect patients and staff. A detailed response would be provided on the rules now in place as this changed frequently. The transfer of dentistry and other services from NHSE&I to the ICS would include additional funding for the ICS. It was a question of how to reconfigure services at both the place and ICS level. However, the current issues would transfer to the ICS. He also spoke about an unsuccessful pilot scheme to align dental contracts to be more like those for GPs. This had actually impeded access to NHS dentists.
  • Nigel Minns added that the current problems would transfer to the ICS and would need addressing. There was considerable interest in dental services locally and it would be a clear focus for the new system to address as best as it could within the national framework.
  • It was questioned if dentists were required to offer a minimum proportion of NHS appointments. Mr Chikurunhe confirmed that dentists received a payment based on contractual terms, for the provision of NHS services. He outlined the services and the additional challenges due to the pandemic, making it difficult for new patients to receive NHS dental care.


In closing the item, the Chair made a number of points. The dental contract was not helping residents or dentists, who were given a binary either/or choice. The contract dated back to 2006 but there had been significant changes since that time, so it required update. She referred to the contractual requirement to deliver 65% of usual service levels during the pandemic. To address the known backlog, dentists would be required to work above normal service levels. If they chose to cease providing NHS services, it was questioned if the monies provided during the pandemic could be clawed back. She asked if there was a view about the contract review and ministers could be lobbied about this. Reference had been made to a strategic review for Warwickshire and the Chair asked for the timeline for this review. Reference also to the dental education provided previously in school settings. It was questioned if this service was still in place, as a reliance purely on parents may have an impact for some children. The Chair asked about emergency NHS dental treatment requesting that a pathway be provided to show how patients may access the services.  These points would be communicated to Mr Chikurunhe after the meeting for the follow up briefing note. He was thanked for his attendance and responding to the Committee’s questions.




That the Committee notes the update from NHS England and Improvement on dental services and that a further briefing note is sought on the follow up areas outlined above.