Neil Carmichael: Levelling-Up Oral Healthcare in England

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ADG Chair Neil Carmichael discusses oral health inequalities in England

Public Health England’s report “Oral Health Inequalities in England”, published last month, is the first time that epidemiological data, NHS data, and academic research, have been brought together to confirm the oral health inequalities that have persisted in England over the past decade.

Its findings are stark. For example, relative inequalities in the prevalence of dental decay in 5-year-old children have increased from 2008 to 2019. These inequalities will only now be deepening as the impact of the pandemic becomes clearer – NHS dental statistics revealed in February that only 29.8% of the child population has been seen by a dentist during 2020 – a fall of nearly 50% from pre-pandemic figures.

The closure of schools and nurseries also meant the loss of many community supervised programmes. The report confirms a north/south divide that exists in so many policy areas, (together with pockets of deprivation in London and coastal communities in the south). Prevalence of tooth decay for 5-year-old children is highest in the North West, Yorkshire and Humber.

This regional divide was confirmed again with more data in the PHE 2020 oral health survey showing that 3-year-old children in Yorkshire and Humber were twice as likely to experience dental decay as the East of England. The challenge for a Government so committed to “levelling up” is clear. There is no one simple explanation for this divide.

Over the last 10 years, government net spend on NHS dentistry has been flat with no increase with inflation, which in real terms represents a cut. More money is never the only answer and given the myriad of calls on the Treasury during and beyond the pandemic, it is an unlikely one. However, current NHS spending can be used more wisely.

It is now widely accepted, all the way to ministerial level, that the current NHS dental contract of UDA activity does not incentivise preventative care or reach those most in need, and the time has clearly come for more local flexible commissioning for hard-to-reach groups such as children and care homes.

There have also been significant challenges in recruiting dental professionals to deliver NHS treatment for many parts of the country such as the Yorkshire and Lincolnshire coastlines, but also the South coast around the Isle of Wight, Portsmouth and in Cornwall.

During my period as Chair of the Education Select Committee (House of Commons) I saw the same challenges for recruitment into the teaching profession. It is now time for a serious look at long-term workforce planning by the NHS which incentivises dental and other health care professionals to raise outcomes where need is highest.

A model to emulate is the “London Challenge” launched by the Blair Labour Government – which successfully turned around educational outcomes in London – and apply this elsewhere.

In some parts of the country dental recruitment challenges have been met through overseas professionals coming to work in the UK. This will remain part of the solution for dentistry and healthcare as a whole. Post-Brexit we still need to attract the best clinicians from the rest of the world.

The General Dental Council itself acknowledges it operates within outdated and restrictive legislation and modernising recruitment pathways is another part of the puzzle.

Finally, nearly a decade has been lost while responsibility for water fluoridation stagnated at local authority level. Deep cuts to local authority budgets were one reason that this never received the priority it should.

However, with the Government now taking powers directly to roll out fluoridation, time is of the essence. It is estimated by the British Society of Paediatric Dentistry that water fluoridation could reduce tooth extractions in children by as much as two thirds in the most deprived areas.

Whole population fluoridation is a clear recommendation from Public Health England and the ADG has recommended that a “fluoridation” czar be appointed to co-ordinate consultation and drive forward roll-out. This has to be a priority for the new Office of Health Promotion.

Turning to structures, the ADG welcomes the “Integrated Care Systems” approach. Integration is obviously the right way forward – oral health is not a separate and distinct part of the human body – so we must place dentistry properly within the system while facilitating commissioning at the more local level to address inequalities within a national framework.

Taken together, these changes could begin to narrow the gap of inequality and “put the mouth in the body” across the whole country.