key: cord-0075482-7q5qr9b6
authors: Westgarth, David
title: The dental workforce: An assessment of the recruitment market
date: 2022-03-07
journal: BDJ In Pract
DOI: 10.1038/s41404-022-1066-7
sha: 99d5a4624cb522ae20e873288bbf3ecdba193f44
doc_id: 75482
cord_uid: 7q5qr9b6

nan

For a time, I was based at our publisher's office in London, which happened to coincide with the deconstruction of a vacant property and subsequent construction of a hotel. Besides the obvious noise that on occasions made concentrating an untenable prospect, it was rather fascinating. Amongst colleagues, tea and coffee breaks presented an opportune moment to catch up on the day's activity and dissect what we thought they were doing. I vividly remember being fascinated at the large machinery they brought in to smash through the ground to put in the hotel's foundations -right up until the point where it made bits of the office fall on my head.

Alas, this reminiscing got me thinking. Foundations are everything. They can mean a good relationship or, like the above, a hotel and property. For us, the foundation of the dental profession is the workforce, and after a tumultuous 24 months (and counting), I wondered what the recruitment market says about the foundations of dentistry.

As with most pieces of analysis, it comes with a pandemic-shaped caveat. Writing at the height of the pandemic in April 2020, Adrian O'Dowd highlighted that the BDJ Jobs website had seen its traffic fall by 26% from February to March of that year, and, prior to the virus and related government restrictions, in January and February of 2020, the website saw a 158% growth in job postings, 54% growth in job views and a 27% rise in applications when compared with the same months in 2019. 1 These figures suggest the market was trending in the right direction, but the truth is we will never know if these data would look this way had COVID-19 not swept the globe. The pandemic accounted for 48% of respondents in the BDJ Jobs Recruitment Whitepaper 2021 saying they had experienced difficulty recruiting, 2 so most signs point towards a bright future. And yet, many of the responses listed in Figure 1 relate directly to policies introduced long before.

It's difficult to know where to start. Ahead of the introduction of the current NHS dental contract in 2006, dentists left in their droves. A seismic policy with an equally sizeable epicentre, and yet the ripple effects are still being felt today. Too many examples of NHS contracts being handed back could point to many practitioners reaching their own personal tipping point. In May 2020, Chief Dental Officer England, Sara Hurley, wrote: 'The prospect of change has dominated our professional dialogue for years. In harnessing both past and present discussions, we have the opportunity to realise our profession's acknowledged ambition for reform; however, we need to decide and act fast to ensure that the COVID-19 disruption to 'business as usual' delivers the necessary and profound change in oral healthcare experience for our patients and our profession. ' 3 I highlight this because of its poignancy. Words like prospect and ambition in relation to contract reform are oxymoronic in nature, for despite numerous pilots and prototype contracts, pledges and words, we are yet to make significant progress. The result? In January 2022 the BBC Shared Data Unit reported around 1,000 NHS dentists left the profession last year -the equivalent of more than 2,500 posts across England and Wales.

The number of NHS dentists working in two English clinical commissioning group areas (CCGs) fell by more than a quarter in the year ending March 31, 2021, with the combined equivalent of 2,435 dentists leaving the health service. The worst-affected was NHS Portsmouth CCG, which lost 26% of its NHS dentists over 12 months. Meanwhile, 28 other English CCGs lost at least 10% of their NHS dentists.

In Wales, 6% of NHS dental posts were lost, with 83 fewer dentists working across health boards than the year before. The worst-affected area was the Swansea Bay University Health Board, which had 22% fewer NHS dentists compared to the year before. 4 In Scotland, the number of health service dentists remains stable, with 3,703 dentists on the books in March 2021, three more than there had been a year before. It is a similar picture in Northern Ireland, where there were 1,142 health service dentists in 2020/21, five fewer than the previous year.

It's worth noting it hasn't always been like this. As Table 1 shows, the last decade has seen more dentists joining the NHS in England than leaving. That hasn't stopped those already in the service considering their options; figures released by NHS Digital show that well-over half of GDPs said they were thinking of leaving general dental practice. This is highest among practice owners in Northern Ireland, where 70.4% said that they 'strongly agree' or 'agree' that they often think about leaving general dental practice, but even the lowest levels -among associates in Wales (53.7%) -indicate a significant dissatisfaction among dentists with their working lives. 5 What should concern the profession the most is these data cover 2018, 2019 and 2020 -the working conditions and low morale caused by the pandemic may mean these figures are even higher when updated.

Perhaps -for those in England -they bought into the 'prospect and ambition' contract reform promised, before turning that 'thinking' into 'doing' . It's like waiting for a bus. You commit to it, because the COVER FEATURE second you decide to walk away, invariably a bus would tear down the hill, flying past your stop the very moment you vacate it. It may well be that the figures presented by the BBC reflect a culmination of poor policies heaped onto political decisions with a dollop of pandemic, and it's a dish that just isn't palatable any longer. There is only so much one can take before leaving, and I' d wager that figures released next year will show a similar pattern.

In February's issue of BDJ In Practice, I discussed tribalism and divisive political questions. The very mention of Brexit has the potential to turn a pleasant conversation amongst friends into a full-blown heated argument. Whichever side of the 52:48 you found yourself, from a recruitment perspective, the entire healthcare profession has felt the repercussions, albeit to varying degrees.

According to Christie & Co's first annual report on the dental market published in 2018, they highlighted that although the number of UK qualified dentists had grown year-on-year since 2014, the overall number of registered dentists who qualified in the EEA or overseas had decreased over the same period. Additionally, in 2017 the number of new registrations by dentists who qualified in the EEA dropped by 19% compared to 2016 and 39% over two years. 6 From a longer-term perspective, the proportion of EEA qualified dentists actually increased very slightly from December 2019 to December 2020.

So, a mixed picture, and one further blurred by the pandemic. The ORE had been suspended from January 2020 until as recent as late February 2022, with as many as 2,000 waiting to sit their examination. In a statement, BDA Chair Eddie Crouch said the delay and inaction on restarting the exam left 'highly skilled clinicians waiting tables and stacking shelves while millions struggle to get an NHS appointment' .

Uncertainty over the UK's new immigration system and the long-term validity of European Economic Area (EEA) qualifications after Brexit, coupled with a backlog of millions of missed dental appointments caused by the pandemic created a 'perfect storm' in some areas of the UK. According to Neil Carmichael, chair of the Association of Dental Groups: 'The dental workforce is set to face a crisis in 2021 as overseas recruitment could dry up. As mutual recognition [of qualifications] and freedom of movement fall away at the end of the [Brexit] transition period, the UK could look a much less attractive place for EEA dentists to practice' . In a statement, Carmichael went on to add the ending of free movement of people when the Brexit transition period expired on 31 December would put pressure on the healthcare industry more broadly. Dentists from the EEA currently make up 17% of all registered UK dentists but in some more deprived parts of the UK up to 30% of NHS dentists are drawn from Europe, notably Poland, Spain and Romania.

Besides the immense intricacy and degree of uncertainty, there's the human element. Blogs, forums and social channels -none of which are verifiable -are starting to see claims and examples of qualifications no longer being recognised due to loopholes. Practice owners are increasingly voicing their concerns about vacancies they're unable to fill. It puts pressure on them to find solutions to treat patients, let alone have the capacity to take any more on, all at a time where the BDA reports close to 40 million fewer courses of treatment have been delivered since March 2020 when compared to prepandemic levels. In the five years prior to the pandemic, average volumes delivered sat at 39.4 million. The government's recent offer of a time-limited £50 million 'treatment blitz' designed to cover 350,000 appointments, which must be used by 1 April 2022, simply won't cut it. If £50 million is designed to cover 350,000 appointments, by the same logic it would take in excess of £5.7 billion to tackle the missed appointments due to COVID-19. It's fair to assume dentistry won't see that money, and so the service will carry on in a self-defeating spiral.

If dentistry doesn't rein in the number of missed appointments, address the access problems and make the profession an appealing career, these problems will eventually lead to the total depletion of the workforce. Yes, Brexit and COVID-19 have affected the recruitment market and the availability of dentists, but the pandemic has also worked those already in the profession to levels approaching burnout, against a backdrop of targets many view as unhelpful and disheartening. In a paper assessing how 'long COVID' could impact the profession and its workforce published in August 2021, authors Agar, Morgan and Lee wrote:

'We cannot, and must not, overlook the potential catastrophic impact long COVID could have on our dental workforce. The COVID-19 pandemic has been devastating 

for dentistry and those who work tirelessly to provide its services. There is no question about the severe financial impact on dental practices and professionals, many of whom are self-employed and therefore unable to access government support, such as furlough schemes, when practice closure was forced in March 2020. Furthermore, the continuing need for infection control measures will continue to constrain capacity as well as budgets and limit the pace of recovery. The Dental Defence Union reports that almost 70% of dental professionals feel they are experiencing higher stress and anxiety levels because of the pandemic, stress levels that are likely to continue to rise as we continue to carry the burden of COVID-19. Now, let us consider the added stress, strain and debilitation that long COVID would add to an already stressed and burnt out profession. ' Access to dental care has been severely affected and this is likely to continue for some time; dental professionals told the General Dental Council of their uncertainty about the demand for services and their ability to meet it. This is complicated by long COVID, with the debilitating symptoms meaning that impacted staff members simply won't be able to keep up with the demanding conditions they now face trying to evolve with the pandemic. Symptoms of extreme tiredness, shortness of breath and chest pain or tightness are likely to be exacerbated by the wearing of FFP3 masks or equivalent, meaning provision of simple aerosol generating procedures would likely feel like a marathon to the wearer. Employers should consider phased returns to work for long COVID sufferers and modification of duties if required; this may include shorter working days and altered working patterns. This will of course leave gaps in available staff to provide ongoing services as part of dentistry's attempts to recover normal service, which undoubtedly will put additional stress and strain on those still able to work clinically. There will also likely be more of a demand on locum dentists and bank dental nurses.

'Mental health of our workforce cannot be taken for granted either and we all have a responsibility to recognise the huge toll COVID-19 will have taken on all of us, be it for those who have suffered from it, are in a process of recovery, or those still working on the frontline to continue providing dental services. Long COVID therefore has the potential to impair not only the dental workforce who are currently living with its debilitating symptoms, but also those who are

What the BDA says about dentistry, Brexit, the workforce and recognition of qualifications 7

With regard to future registration of EU/EEA graduates, the arrangements for the immediate future have been clarified. For up to two years (until December 2022), the GDC will recognise dental qualifications obtained in EU countries while it considers a new approach. The arrangements will apply not only to EU nationals, but also to non-EU nationals who qualified in an EU country. The same arrangements apply for Swiss nationals until 2024 under a separate agreement.

With regard to EU citizens coming to work in the UK after 2022, the process for the recognition of their qualifications is unclear at the moment. The TCA includes provisions for further discussion and agreement on recognition procedures should there be a wish to hold such discussions. The Government also envisages the option of mutual recognition agreements between countries, but nothing is decided yet.

In the UK, there is a wider review of healthcare regulation ongoing. It is expected that provisions for the recognition of non-UK qualifications will be an important theme within this. It is currently unclear what approach will be taken. The GDC and other healthcare regulators are now involved in such considerations with Government. We will contribute to the discussions wherever possible. Whatever the future system for recognition, there is already a waiting list for registration exams, which has been further exacerbated by the pandemic since 2020. We believe that significant additional numbers of sittings may be difficult to arrange. Government information for health professionals on current arrangements is available, and the GDC has advice mirroring this information.

While the GDC has introduced application fees, the creation of a new or changed system is likely to have to be funded, or at least cross-subsidised initially, by existing registrants via the GDC's Annual Retention Fee (ARF).

It is also possible that EU nationals will have to do a more formal process of Performers List validation by experience (PLVE/VT equivalence) in the future as their current exemption from the formal programme is unlikely to continue indefinitely. This, in turn, would necessitate higher numbers of practices being willing to provide the training, and could also affect employment status (see more below). We have repeatedly asked NHS England for information on its considerations in this area, but have so far not received a response. Currently (December 2021), the system has not been changed in this respect.

We do not know what impact a more hostile environment (whether perceived or evidenced) might have on EU citizens who have lived in the UK for some time, and may have trained here, but hold citizenship of another EU country -some may choose to leave the UK, and there are some indications in the GDC's registration numbers that this is the case. The changes, and a less favourable exchange rate for Pound Sterling, may also make the UK a less attractive place to work for dentists in the future and have an impact on the dentist workforce in the UK.

While most of the attention around dentist workforce issues in relation to Brexit is often focused on general dental practice, it is important to point out that dentists in the community dental services, in hospitals and in academic and research roles, are affected in the same way, and that shortages in those areas are also of concern to us 1. 

left in its wake, trying to continue providing to patients with reduced human resources.

The key will be having regular contact and team meetings involving all team members, inviting suggestions for improvements in service provisions, and opening discussions regarding stress and strains being felt within that service. Having an overall action plan that is well communicated with honesty and empathy will help create certainty and alleviate fears for all members of the practice. ' 8 The fragility of the workforce is a point further reinforced by recent survey data from Dental Protection highlighting concerns of young dentists and their wellbeing. More than a third (37%) of dentists who qualified in the last five years in the UK said they were worried about the impact of COVID-19 on their wellbeing, with a further 49% going on to say the backlog in patient treatments due to COVID-19 is impacting on their mental wellbeing. A further 35% said the backlog had resulted in them working additional hours, and just under half (49%) said they feel positive about their future in dentistry. 9 These concerns were also raised by the BDA, who said survey data collected suggest over 40% of dentists indicate they are likely to change career or seek early retirement in the next 12 months given the current pressures on the service. Two thirds (66%) indicate they will reduce their NHS commitment, with more than a third (34%) stating they plan to go fully private in the next year, and less than half (48%) are confident their practice will continue to provide any NHS services from April 2022. Dentists now face financial penalties for failing to hit imposed targets of 85% of pre-COVID-19 activity during the Omicron wave, amid high levels of staff sickness and patient cancellations. As the government recently announced plans to effectively live with COVID-19, there is no telling what impact this will continue to have on the profession. While reform has been pledged to the dysfunctional targetdriven NHS, it is unclear if there is sufficient ambition and resources to secure meaningful change. The BDA have said reform is a matter of urgency, given any reform of the service will fail if there is no workforce left by the time it is finally introduced.

For all the talk of a recruitment crisis, it's important to note much of the discussion focuses on where the majority of patients access dentistry: through the NHS. That doesn't mean the problems aren't being felt elsewhere -they are. In November, Paul Mottram, Chair of the British Dental Association's Private Practice Sub-committee, said an increasing number of private practices had to cease accepting new private patients as they were overwhelmed with their own cohort of patients and have no capacity to see additional private patients. As appointments become rarer than a golden ticket to Willy Wonka's Chocolate Factory, a significant number of patients, unable to access their own dental practice, sought dental care from the private sector, which will obviously lead to maximum and eventually over-capacity. Mottram added: 'The recruitment and retention of all dental personnel is at a crisis level. If this is not attended to the situation will be even more acute and the practices who rely on the majority of their income stream will be left with no alternative but to increase their fees in order to offset their increasing costs. A tipping point may occur where private practices are providing care for those who can financially afford it. ' We must recruit and retain our colleagues, particularly newer graduates in the profession (the future of our industry) in the NHS sector or there is a real risk that they will be lost to the private sector. There is becoming a significant sea change in movement from NHS to private service delivery. ' 10 It is the mention of this sea change that highlights an important trajectory of the recruitment market. Analysis in the Recruitment Whitepaper shows a preference for private roles over those in NHS and mixed practices, as Figure 2 shows. Perhaps more poignantly, these data do not appear to be influenced by the pandemic or anything other than an appetite for the better working environment private practice offers, and the foundations for longevity in the profession. Can you blame them?

It will take years for the effects of the pandemic to wash out of dentistry. We may truly never ben rid of it. Like an old, ancient burial ground discovered during the construction of a high-rise building, the pandemic has shaken the recruitment market to its core and is no basis to build upon while present. New foundations are needed, but there is real danger these will not come in sufficient number. As always, it will be patients who suffer, and the profession left to shoulder the burden. Too often we have collectively called for action, for change, for something to be done, and seen no results. If the recruitment market is an indicator, it may be too late to provide any, and I fear for the very foundations of the profession. ◆

Available online at: www.bdjjobs.com/article/ will-dental-recruitment-market-survivecoronavirus-pandemic

Why re-invent the wheel if you've run out of road?

News release: Patient 'glued own teeth' as dentists drop NHS work

NHS Digital. Dentists' Working Patterns, Motivation and Morale

Available online at: www.christie.com/news-resources/ publications/the-dental-industry

Brexit and its impact on dentistry

A further plot twist: will 'long COVID' have an impact on dentistry and the dental workforce?

Available online at: www.dentalprotection.org/uk/articles/ young-dentists-raise-concerns-about-impact-ofcovid-19-on-their-wellbeing

Addressing the backlog of patients: A view from across the profession