key: cord-0991924-v9wgvnak authors: Ashiti, Shoukat title: Nearly two years without the Overseas Registration Exam: what's next for internationally qualified dentists in the UK? date: 2022-03-11 journal: Br Dent J DOI: 10.1038/s41415-022-4001-8 sha: 99af269ff46946a56519ac46e883a8f90f799082 doc_id: 991924 cord_uid: v9wgvnak Due to the effects of the COVID-19 pandemic, internationally qualified dentists have been negatively impacted. This is due to the suspension of the Overseas Registration Exam (ORE) with no confirmation of any future dates. Similarly, UK dentistry was also affected by a significant increase in waiting lists all over the UK, with long waiting lists being present even before the pandemic. Due to these factors, many have highlighted and argued the need for internationally qualified dentists and urged the need to facilitate their registrations. Additionally, after Brexit, the government has introduced new immigration routes to attract overseas, highly educated human resources, so that they can contribute to different sectors in the UK. Considering these circumstances, there are a few alternatives to the ORE that could be introduced to facilitate the registration of internationally qualified dentists and to support NHS dental services. This paper suggests short- and long-term solutions to support the registration of internationally qualified dentists, considering that after two years, European-qualified dentists might need to undertake registration exams as well. Internationally qualified dentists (IQDs) need to pass the Overseas Registration Exam (ORE) in order to independently practise dentistry in the UK. This exam is run by the General Dental Council (GDC) and includes both a written and practical section to examine both theoretical knowledge and clinical skills. It is not mentioned how often it is conducted; however, both parts will usually have at least two diets a year. 1 On the other hand, the Licence in Dental Surgery (LDS) exam is run by The Royal College of Surgeons (RCS) in two parts and successful candidates will be able to register with the GDC. It is held less often than the ORE, with a lower number of candidates in each diet. 1 Similarly to the ORE, the LDS exam was suspended due to COVID-19 and in June 2021, RCS ran an online LDS Part 1 for those who were listed to sit LDS Part 1 in April 2020. Otherwise, no further dates for future exams have been confirmed. 2 Similarly, there was no ORE for the year 2021. ORE, besides the LDS exam, is considered the main, straightforward route for IQDs to register with the GDC and practise dentistry in the UK; however, both exams are suspended for the time being. [1] The last ORE exam was at the beginning of 2020, before the COVID-19 pandemic. On 8 September 2020, a freedom of information (FOI) request was submitted to the GDC asking about the number of candidates on the waiting list for the ORE. By 3 September 2020, it was reported that 880 candidates were waiting to sit Part 1 and 445 candidates for Part 2. The waiting lists have likely grown since then, as it was stated in that FOI that between 1 January and 31 August 2020, the GDC received 179 web form applicants directed to its customer advice and information team. Additionally, other inquiries have been made to other teams that are not stored electronically, which makes the real number of inquiries likely to be greater. Therefore, considering the significant waiting list, the number of candidates of each diet and the frequency of the ORE, this has made it increasingly difficult for overseas dentists to register in the UK and alternatives now might need to be considered. IQDs have always been welcomed in the UK and have been part of the UK dental force; however, over the last 20 years, IQDs started to present a significant part of UK dentistry, as it has been reported that the number of GDCregistered IQDs has spiked from 18% in 2000 to 28% by December 2019. 3 Furthermore, it was illustrated that about 11,000 new dentists have registered with the GDC and of those, about 3,500 dentists were registered through overseas registration exams. 3, 4 In 2019, 23% To raise awareness around the impact of COVID-19 on the overseas dentist registration process and dental NHS waiting lists. To shed light on the valuable healthcare workforce that can be utilised post-Brexit, especially after the government showed an interest in attracting overseas graduates. of the new registrants graduated from the European Economic Area (EEA) and 11% were registered through the ORE/LDS. 3 This demonstrates how the UK depends on IQDs and indicates that suspending the ORE will likely have a negative impact on dentistry in the UK. Although there have been many successful IQDs, there are also many barriers IQDs face during the process of registering in the UK. It was found that the main obstacles associated with the ORE are the significantly high exam fees, limited exam seats, reduced number of diets per year and the lack of certainty around the booking process. 5 Furthermore, these dentists needed to overcome social isolation, deskilling and discrimination. Regarding discrimination, first and foremost, IQDs experienced discrimination at an institutional level due to the difference in the registration process between EEA IQDs and non-EEA IQDs. 5 It was reported that it takes 3-6 months for EEA IQDs to register with the GDC, while it takes 2-6 years for non-EEA IQDs to register with the GDC using the ORE route. 4 The significant impact of Brexit on IQDs is currently unknown, bearing in mind that, in 2019, 16% of dentists in the UK were EEA-qualified dentists; however, a survey by the GDC reported that up to 30% of EEA dentists may leave the UK after Brexit. Equally important, there may be a reduction in the number of UK students traveling to Europe to gain dental qualifications after the GDC announcement about the recognition of EEA dental degrees. Finally, up to now, there is no clear registration route for those who will graduate in Europe after 1 January 2023. 6 This makes the ORE and the LDS exam the only direct routes for GDC registration and they have several drawbacks; that is, limited seating, expense and being time-consuming. 1 On another note, COVID-19 has undoubtedly increased NHS dental waiting lists all over the country due to the cancellation of all elective procedures for three months in 2020. Yet, long waiting lists already existed before COVID-19. In April 2019, the Dentistry Online website published that in Cornwall there were 48,000 patients waiting to see an NHS dentist 7 and in Plymouth, in October 2019, there were 14,000 patients on the NHS dental waiting list. 8 Unfortunately the problem is worsening, for example in June 2020, The Daily Telegraph highlighted that the dental NHS waiting list was increasing by 40,000 patients a day. 9 In October 2020, the British Dental Association (BDA) published that the number of missed dental appointments in England had reached 14 million. 10 The situation is similar in hospitals, for example at the Eastman Dental Hospital the waiting period to receive treatment has doubled, from being about three months in October 2019 to more than six months at the end of August 2020. 11 The longest wait over the same period has spiked from about 14 months to 21 months. 12 Similarly, Birmingham Dental Hospital's waiting time tripled from about two months in October 2019 to six months by September 2020. 11 The longest wait at the hospital has reached 15 months, which means some patients will need to wait for more than a year to be seen. 11 More importantly, commenting on these long waiting lists, a general dental practitioner on the BDA website said, 'there's going to be a whole generation of children who've missed out, interventions are a lot easier and more effective for children [who are seen early] than it is to leave them until there's a massive issue and then they have to be referred for an extraction' . This is true as the increase in waiting times has affected children as well. 13 It was reported that the impact of COVID-19 will not stop at this point; however, there will be a lack in the dental workforce in the coming years and an increase in the build-up of waiting lists, which was already significant before the pandemic. 14 In December 2020, the Association of Dental Groups noted that 8 million people will be waiting for an NHS dentist by Christmas in the report 30 years of hurt. This report was authored by Richard Sloggett, a former aide to Health Secretary, Matt Hancock. The report highlights the issues that UK dentistry is facing and makes some suggestions on how to address these problems. One suggestion is about routes for overseas professionals to fill the workforce gaps in the short term. 14 Not only are dental waiting lists a problem, but it is also being compounded by the fact that dentists are opting to leave NHS dentistry. Paul Bristow MP highlighted this when he reported that across Britain, NHS dentist numbers are decreasing: 'Peterborough is seeing a decline of 2.5% in NHS dentists from 2018/19-2019/20. In other areas, the latest figures show dentist numbers dropping more dramatically and it is local people who are paying the price' . 15 Furthermore, a BDA survey has demonstrated that 75% of dental practices are facing challenges in filling vacancies and 59% of dentists have stated that they are thinking of reducing or leaving NHS dentistry. 16 Similarly to the Association of Dental Groups, MP Bristow has advocated that recruiting overseas dental clinicians should be made easier and the GDC is encouraged to look for a new examining and assessment system. 15 Furthermore, after Brexit, the government introduced a new visa route (the graduate route) which is aiming to attract talented and highly-qualified workforces from all over the world to help the government achieve its ambitions and goals. 17 However, with the current system of registering overseas dentists, I do not see how the dental workforce will benefit from this. Firstly, the consideration of the action plan mentioned in the 30 years of hurt report 14 suggests the following: 1) maintaining the recognition of EEA dental qualifications even after Brexit; and 2) extending the GDC recognition of dental degrees to cover non-EEA qualifications, that is, commonwealth countries, especially India. Where necessary, a temporary registration for a year under supervision can be used, which is a route that is been used by the GDC. 14 Secondly, there are approximately eight universities in the UK that deliver a threeyear taught Master of Science (MSc) degree in different specialties in dentistry, for example orthodontics and oral surgery. One northern university, for example, graduates approximately 24 postgraduate dentists per year who have undertaken these programmes. Most of the postgraduate trainees on these programmes are overseas-qualified dentists. These dentists are being trained by NHS dentists (consultants/academics/specialists and speciality dentists) among NHS trainees, in NHS hospitals and treating NHS patients. Over the three years, these dentists become familiar with the NHS system, become fluent in the English language and become accustomed to UK culture and the way of life. Therefore, following the government's plan for the 'graduate route' and the need for NHS dentists, the following can be considered as alternatives for the ORE for these IQD's with a UK-based postgraduate degree, to register with the GDC: approximately four months to reach a decision. This assessment route is currently being offered to overseas-qualified dentists who fall into the 'exempt person' category under the Dentists Act 1984. 18 A similar assessment route is currently available for overseas-qualified dentists to register as dental therapists or hygienists. This route is only given to those dentists who are married to EEA citizens only; 1 however, what about modifying this to be offered to those dentists who are married to UK citizens, especially since after Brexit this scheme may no longer exist? Some could argue that UK citizens should be the ones that benefit from this exemption, not EEA citizens. I believe that a significant number of IQDs have married or are in a relationship with a UK citizen; however, due to the uncertainty of the ORE and GDC registration process, these relationships can suffer from instability and stress 2. A one-year, supervised post under temporary registration in an NHS practice/ hospital/community dental service, where the dentist has to meet certain competencies. Following this, the dentist can be registered with full registration. It would be the dentist's responsibility to secure a job offer; however, it does not need to be a Health Education England training post, that is, it does not have to be a dental foundation training or a dental core training post from national recruitment. Again, this method is undertaken by the General Medical Council (GMC) 14 3. Registration with a limited scope of practice until fully passing the ORE. The practice scope will depend on the speciality the overseas dentist has taken at university, that is, if the overseas-qualified dentist has undertaken a three-year MSc in oral surgery they could work as a dentist in the UK, but would need to limit their practice to oral surgery only. These three-year, MSc-taught programmes are recognised by RCS as speciality training programmes that qualify the graduates to undertake speciality exams, that is, Tricollegiate membership in oral surgery or membership in endodontics etc. 19 Thus, it might be worth suggesting that if RCS can offer a special training year for those graduates that they qualify them to be registered with the GDC. Furthermore, what about cooperation between the NHS and RCS to establish dental care centres, where these dentists can undertake this training year under supervision and during said year will provide treatments for NHS patients? Maybe this is something the newly-formed College of General Dentistry (England) could consider thinking of to utilise these dental workforces for the short term. If the dentist is registered via options one, two or three above, these dentists should then have a commitment to work within the NHS for a specific period, in order to help reduce the shortage of NHS dentists. For example, the dentist needs to work for 2 years at an NHS practice or hospital for about 30 hours a week at least, which is a similar approach the UK army takes when offering student bursaries to undergraduate dentists. Regarding concerns of whether these alternatives are feasible, as mentioned, the GDC already has a team responsible for the assessment routes. Thus, with the addition of specific criteria based on the syllabus of these three-year courses, option one can be utilised. On the other hand, option two can be based on the same concept of dental foundation training (previously called 'vocational training'), which aims to improve the clinical and administrative skills of newly-graduated dentists so they are able to have a career in dental practices. However, it might require the involvement of the deanery to approve this training year, similar to that which is done through the Performers List Validation by Experience route. 20 In 2007, a pilot study offered temporary registration for non-EEA IQDs, which allowed them to work in primary care under supervision and demonstrated that these dentists received good feedback from both patients and staff. 21 Thus, such a scheme can be a good model to follow. Similarly, option three, despite it possibly being the least favourable for overseas dentists, would offer them the chance to have a job within their scope in a specialised department, keeping their skills up and allowing the NHS to utilise these workforces. It is worth mentioning that the GMC currently has several routes for overseas-qualified doctors to be able to register, including sponsorship, approved postgraduate qualification and specialist registration. 22, 23, 24 The abovementioned suggestions are based similarly to the approaches taken by the GMC. Finally, recently, the University of Central Lancashire is offering a Bachelor of Dental Surgery (international student route), where IQDs will undertake an 18-month course that makes them eligible to register with the GDC. The course is full-time, costs £68,000 and has certain entry requirements. 25 It is mentioned that the GDC has 'provisionally accepted' 25 the course, which shows the potential of flexibility regarding the routes of IQDs registration. Undoubtedly, it is a great opportunity for those who can afford the cost and have the time to undertake the course; however, maybe in the future we will see more universities offering the same course with reduced fees or being part-time, depending on the circumstances of the applicant, that is, nationalities, portfolios or country of graduation. In the UK, the registration of dentists is only processed by the GDC, which has two offices; one in London and the other in Birmingham. Therefore, these centres need to cater to UK dentists, EU dentists and overseas dentists, as well as dental therapists, hygienists, technicians and nurses. Compared to Germany, for example, each state has its own regulatory body that works in sync with others to make sure that new dentists are spread across the country. The UK consists of four countries and nine regions. Thus, if each country had its own branch that follows the GDC and regulates its own exams and registrants, this could increase the number of exams each year according to the demand of the area. In return, the dentist needs to work for 'x' number of years in the area of registration before changing to another. This will make overseas registration more feasible and available, as well as spreading dentists all over the country. Especially that, according to the GDC website, due to Brexit, after 31 December 2022 European-qualified dentists might need to undertake registration exams. It is very important to note that this paper is not suggesting IQDs should be able to register with no assessment of their skills or compromise patient safety. However, it is looking for a quicker way to utilise these highly trained dentists. The registration process has become even more difficult now because of the cancellation of the registration exams which were already limited. A valuable human resource is being wasted at a time when COVID-19 restrictions have resulted in long waits for patients to access NHS dental care. Since Brexit and the pandemic, there have been a lot of changes in the UK and maybe it is time to consider reviewing the way overseasqualified dentists can register with the GDC. It is a highly appropriate time to rethink the temporary and long-term workforce solutions suggested in this paper so as to acknowledge the contributions of internationally qualified dentists working in the UK. The author declares no conflicting interests. [1] Editor-in-Chief 's note: The GDC has just announced a full re-start of the ORE. (22 February 2022) . Brexit -information for dental professionals Cornwall demanding action with 50,000 patients on waiting list for an NHS dentist. Dentistry (Hertfordshire) Plymouth's NHS dental waiting list is continuing to grow. Dentistry (Hertfordshire) Exclusive: Dental waiting list growing by 40,000 a day and could exceed one million by autumn Dentists facing uphill struggle, as missed appointments top 14m COVID-19: spike in waiting times for NHS dental care. Dentistry (Hertfordshire) Patients face two-year wait to see a dentist: Thousands of Britons are left in agony as waiting times for NHS treatment double Coronavirus: dental care 'timebomb' leaves Britons unable to have teeth checked Association of Dental Groups. 30 years of hurt: The urgent need to rebuild our dentistry workforce Ministers must make it easier for the NHS to recruit dentists from overseas NHS Dentistry: 4 million fail to get care they need as access problems go Englandwide Available at https:// www.gov.uk/government/news/graduate-routeto-open-to-international-students-on Dentists Act 1984 -53 Interpretation (F258) Tri-Collegiate Membership in Oral Surgery (MOral Surg) Available at https://heeoe. hee.nhs.uk/dental/performers-list-validationexperience-plve#:~:text=Since%20April%202006%20 dentists%2C%20who Temporary registration in primary care for dentists moving to the UK from outside the EU: an evaluation of a national pilot scheme Full registration for international graduates who completed F1 Apply for registration Full registration for doctors with sponsorship Bachelor of Dental Surgery The journey of an overseas dentist in the UK Profiles of registrant dentists and policy directions from Written evidence from Ms Latha Sanjay Davda The migration and professional integration experiences of international dental graduates in the United Kingdom. London: King's College London Correction to: How did COVID-19 impact on dental antibiotic prescribing across England?The original article can be found online at https://doi.org/10.1038/s41415-020-2336-6Author's correction note: Research article Br Dent J 2020; 229: 601-604.When this article was originally published, an incorrect version of Figure 1 was displayed. The correct figure is presented here, in which the y-axis has been updated.The authors apologise for any inconvenience caused.