key: cord-0011667-f1n24rgm
authors: Eaton, Kenneth A.
title: Oral healthcare workforce planning in post-Brexit Britain
date: 2020-05-22
journal: Br Dent J
DOI: 10.1038/s41415-020-1579-6
sha: 2f118f7e72fe23727fd45b999be8dfcd963cb809
doc_id: 11667
cord_uid: f1n24rgm

The terms of the United Kingdom's (UK's) departure from the European Union (EU) are currently being negotiated. It is therefore uncertain exactly what effect they will have on planning the UK's oral healthcare workforce. Nevertheless, as 16% of dentists currently registered with the Genral Dental Council (GDC) have migrated to the UK from EU countries, this factor must be taken into consideration by workforce planners. However, it is far from being the only factor. This opinion piece therefore describes the current numbers of non-UK EU dentists and DCPs registered with the GDC and poses the question 'will they remain in the UK in the future'? It then comments on the current legislation on recognition of non-UK dental qualifications. It goes on to consider the Migration Advisory Committee's recommendation for dental practitioners, the oral healthcare needs of the population of the UK, who could address them and the implications for the Advancing Dental Care project

At the time of writing this opinion piece, the country seems to be far more concerned with limiting the spread of COVID-19 than the ongoing negotiations with the European Union (EU) over the terms of the United Kingdom's (UK's) withdrawal. These terms have to be agreed, and until they have been, opinions can be viewed as speculative. However, Brexit will almost certainly have an impact on the UK's workforce, including the oral health workforce. Two key issues are: will EU nationals who are currently working in the UK wish to remain, and will it become more difficult for EU citizens to come to the UK to work?

Health and social care in the UK has relied on numbers of EU nationals, in the relevant professions, coming to the UK to work. As far as oral healthcare is concerned, at the date of 31 December 2019, just under 16% of dentists registered with the General Dental Council (GDC) 1 were non-UK EU nationals, who had qualified from EU dental schools, other than in the UK. For reasons which will be explained later on in this article, the percentage of EU dental care professionals (DCPs) is far lower. For example, at 31 December 2019, just over 3% of registered dental hygienists came from the EU. 1 Furthermore, the consequences of Brexit for the UK's oral healthcare workforce will need to be considered by the Advancing Dental Care (ADC) project 2 and in a broader context.

Against this background, this article will consider the following aspects: • Current numbers of non-UK EU dentists and DCPs registered with the GDC • Current legislation on recognition of non-UK dental qualifications • The Migration Advisory Committee's (MAC's) prioritisation of professional groups • The oral healthcare needs of the population of the UK and who could address these needs • Will EU dentists and DCPs currently working in the UK remain in this country? • Implications for ADC.

On 31 December 2019, of the 42,470 (21,329 female and 21,141 male) dentists registered with the GDC, 6,725 were EU nationals who had qualified from EU dental schools. A further 36 were from Iceland, Norway or Switzerland, countries whose citizens have the same rights to work in other EU countries as EU nationals. Interestingly, in spite of the doubts for some years over the UK's membership of the EU, the number of EU dentists registered with the GDC was 54, higher than the number at 31 December 2018. Dentists from Poland (743), Spain (732), Romania (730) and Sweden (672) accounted for just under 40% of the 6,725 EU registrants. 1 Of the 70,953 registered DCPs, fewer than 1% (only 686) were from the EU. 1

As long as it is a member of the EU, under the terms of a European Commission (EC) directive (the Recognition of Professional

The UK's departure from the European Union (EU) seems highly likely to influence the number of dentists registering with the General Dental Council in the future. This factor will need to be taken into consideration by workforce planners.

Other potentially more important factors will include the oral healthcare needs and demands of the population, the extent to which many clinical tasks can be delegated by dentists to dental care professionals (DCPs) and the career aspirations of both dentists and DCPs.

At present, the terms for the UK's departure from the EU are being negotiated and, because of the current COVID-19 crisis, may not be clarified by the deadline of 31 December 2020. This makes any predictions of the impact of Brexit on the UK's oral healthcare workforce speculative.

The terms of the United Kingdom's (UK's) departure from the European Union (EU) are currently being negotiated. It is therefore uncertain exactly what effect they will have on planning the UK's oral healthcare workforce. Nevertheless, as 16% of dentists currently registered with the Genral Dental Council (GDC) have migrated to the UK from EU countries, this factor must be taken into consideration by workforce planners. However, it is far from being the only factor. This opinion piece therefore describes the current numbers of non-UK EU dentists and DCPs registered with the GDC and poses the question 'will they remain in the UK in the future'? It then comments on the current legislation on recognition of non-UK dental qualifications. It goes on to consider the Migration Advisory Committee's recommendation for dental practitioners, the oral healthcare needs of the population of the UK, who could address them and the implications for the Advancing Dental Care project Qualifications directive), 3 the UK is obligated to recognise the qualifications of EU dentists and, subject to proof of their good standing, register them. A different EC directive applies to DCPs and they have to prove that they have received equivalent training to UK DCPs and produce proof of good standing before they can be registered. This is possibly one reason why far fewer EU DCPs than dentists are registered with the GDC.

After the UK's negotiations with the EC have been completed, it will no longer be obligated to adhere to the EC directives. The question therefore arises as to how the GDC will assess EU dentists who wish to register. In future, one possibility is that in order to be registered they will have to pass the Overseas Registration Examination (ORE). However, as the registrar of the GDC has pointed out, this would have financial consequences. 4 A system of mutual recognition of dental qualifications is operated by Australia, Canada, New Zealand and the Irish Republic. 4 Such a system might provide a mechanism for the GDC to recognise dental qualifications gained in other countries, including those of the EU. However, negotiations with the countries concerned and appropriate legislation would be required before this could happen. A third but perhaps unlikely scenario is that, although no longer a member of the EU, it would still accept the Recognition of Professional Qualifications directive. 3

The MAC has been established to advise the UK government on which groups of workers who wish to migrate to the UK should be given priority. Those in 'shortage' professions and trades will be given priority of entry to the UK. Disappointingly, in a review of its shortage occupations list (SOL), performed in May 2019, the MAC stated: 'We do not recommend including dental practitioners in the SOL, despite evidence received from stakeholders, as the relative vacancy rate is below average and the ranking of the shortage indicators is middle of the range' . 5 The evidence received by the MAC included a survey of EU registrants, performed for the GDC, which suggested that as many as a third of EU qualified dentists were considering leaving the UK in the next five years 5 and a statement from the BDA which included that many providers of dentistry are having trouble in recruting and that participation rates appear to be dropping in all four countries of the UK and the ageing population has an increased need for complex treatment. 5 The oral healthcare needs of the population of the UK and who could address these needs Logically, workforce planning should consider present and likely future population needs and demands. Reliable, up-to-date, representative data are therefore a prerequisite. At present, in the UK, only Scotland has such data. In England, Wales and Northern Ireland, the last Adult Dental Health Survey (ADHS) took place in 2009, 6 and the last Child Dental Health Survey in 2013. 7 A new ADHS is at the planning stage. However, with the current COVID-19 crisis, it seems unlikely that it could begin before 2021 at the earliest and, judging by previous ADHSs, unlikely that the results would be published before 2023.

Previous UK dental health surveys and treatment patterns in the general dental services (GDS) of the NHS have shown an overall improvement in the population's oral health over the last 50 years. It has been estimated that in 2011/2012, 73% of clinical time spent in NHS GDS practice was spent on tasks which were in the scope of practice of DCPs. 8 Much of this work could be performed by dental hygienists and therapists, leaving dentists time to carry out more complex care and treatment. Such task sharing is currently common in countries such as Denmark, Finland, Sweden and the Netherlands, where the ratio of registered dentists to dental hygienists is around 2:1. 9 In the UK, at 31 December 2019, the number of dental hygienists registered with the GDC was 7,535, just under 3,000 of whom were also registered as dental therapists. 1 Thus, in the UK, the present ratio of dentists to dental hygienists is 6:1.

The answer to this question is far from clear. As previously mentioned, there are relatively few EU qualified DCPs working in the UK and they represent less than 1% of all DCPs. On one hand, a survey performed for the GDC in 2018 suggested that as many as a third of EU qualified dentists were considering leaving the UK in the next five years. 10 On the other hand, between 31 December 2018 and 31 December 2019, the number of EU dentists registered with the GDC increased from 6,672 to 6,725. After the current interim arrangements with the EU have finished, it may well be more difficult for EU dentists and DCPs to register with the GDC, so their numbers may decline. However, other factors such as the economic situation and employment opportunities in their own countries will come into play. Overall, the probability seems to be that the number of EU dentists registered with the GDC will decline and that this will have an impact on oral healthcare workforce numbers.

The ADC 2 project seeks to advise on training the UK's oral healthcare workforce for the future. In particular, they advise on who could provide care and treatment and how they should be trained. It is currently in the middle of the second phase of its three-year programme and has recently examined evidence from the UK and other countries. The evidence from treatment trends in the NHS GDS and from other countries suggests that there will be an increased need for disease prevention and relatively simple treatment. However, due to the ageing population, many of whom have underlying medical problems, there will also be a need for more complex care and for an oral healthcare workforce which can address this need. Much of the prevention and relatively simple care could be provided by DCPs in general, and dental hygienists and therapists in particular. However, given the relatively small numbers of dental hygienists and therapists at present, it would require a considerable expansion in the number of training places before significant numbers were qualified, and it would take many years for the numbers of UK dental hygienists and therapists to match those of dentists. The current system of payment within the GDS would also need revision, as it does not recognise dental therapists and hygienists as providers. Furthermore, in 2011, for those working in general dental practice in England, over 80% of dental hygienists' income came from private fees, rather than the GDS. 11 It seems unlikely that this has changed since then.

A further factor in oral healthcare workforce planning is the consideration of how much time per week individuals are prepared to work. It has been suggested 12 that over their professional careers, female dentists work for fewer years than male dentists and that many young dentists do not want to work as clinicians five days per week. 13

Once the current negotiations with the EU have been completed, the consequences for oral healthcare workforce planning in the UK should become clearer. However, as described in this opinion piece, Brexit is only one factor which should influence the UK's oral healthcare workforce planning in the future.

Advancing Dental Care Review

/36/EC: Recognition of professional qualifications

Implications for the dental workforce

Migration Advisory Committee. Full review of the shortage occupation list

Office of National Statistics

Child Dental Health Survey

Alternative scenarios harnessing mid-level providers and evidence-based practice in primary dental care in England through operational research

Dental hygienists' professional education, numbers and independent practice in the European Union and European Economic Area

A survey of dental hygienists in the United Kingdom in 2011. Part 1 -demographics and working patterns as dental hygienists

The provision of dental care by women dentists in England and Wales in 1985: a ten year review

A question of value: a qualitative study of vocational dental practitioners' views on oral healthcare systems and their future careers

Report of dentist and DCP registrations