1. Workforce and recognition of qualifications
EU dentists working in the UK
Under existing law, EU citizens with a dental degree from an EU country benefit from automatic recognition of qualifications based on the principle of free movement for EU citizens across the European Union.
This means that dentists qualified in the EU can come to work in the UK, as long as they have relevant language knowledge; registration is straightforward.
Around 16-17 percent of the UK dentist workforce is registered on the basis of an EU/EEA degree; this includes UK citizens who have studied in Europe. The registration of those currently registered should not be jeopardised by Brexit.
With regard to EU citizens coming to work in the UK in the future, the process for the recognition of their qualifications is unclear at the moment. The draft withdrawal agreement foresees some general continuation of current arrangements, but this is only relevant to December 2020; the situation thereafter is unclear as it depends on government negotiations with the EU on the ‘future relationship’.
In case of no deal, legislation has been passed making dental qualifications obtained in the EU eligible for registration for up to two years from exit day, while changes to the system are considered. It also provides the GDC and other regulators with the right to decline registration to some dentists if their EU degree has been identified by the GDC as a cause for concern, for example where there is evidence that minimum training standards have not been reached.
Whatever the future system for recognition, there is already a waiting list for registration exams, and significant additional numbers of sittings will be difficult to arrange. With an already existing workforce shortage, this is very much a recognised issue for UK dentistry for the future. Any changes to the registration system would likely have to be funded by existing registrants via the GDC's ARF income.
It is also likely that, in the longer term, EU nationals would have to go a more formal process of performers list validation by experience (PLVE/VT equivalence) as their exemption from the formal programme would also cease.
This, in turn, would necessitate higher numbers of practices being willing to provide the training.
UK dentists working in the EU
The same EU freedom-of-movement rules have also enabled UK dentists to work in other EU countries.
As UK citizens will not be EU citizens in the future, post-Brexit, they will no longer be able to benefit from free movement and automatic recognition; instead, recognition is most likely to depend on the arrangements for third-country nationals in any given country, subject to the negotiations of the ‘future relationship’.
2. Immigration arrangements
Currently, EU citizens do not need a work visa to work in the UK. This, in combination with automatic recognition of qualifications, has made the UK an active recruiter of dentists from the EU/EEA.
This is particularly true for the dental corporate sector, but also for more traditional practices. In the future, the UK government has indicated that EU citizens will not be treated differently to citizens from elsewhere.
The implication is that they will have to compete for work visas, where only the person who obtains the job is given the permission to work in the UK, for a defined time, after which they might apply for indefinite leave to remain.
Practices and their owners would take on the role of 'sponsor' for dentists from abroad as they currently do for those from outside the EU, and pay the associated costs.
As work is undertaken on the basis of a Tier 2 visa usually needs to be on the basis of an employment contract, practices may need to work with more employed, rather than self-employed, dentists.
While the government has removed the immigration cap for employed doctors and nurses, this exemption does not currently apply to dentists, so visas may or may not be difficult to obtain. The Migration Advisory Committee has recommended to the Government that the limit on the number of Tier 2 visas be relaxed, and there will an earnings threshold.
However, we do not yet have clarity around the Government's precise approach and we are keeping a close eye on this issue. A new immigration system based on an “Australian points-based system” is in development but the detail is as yet unclear.
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.
The GDC has published research into the intentions of EU qualified registrants working in the UK.
While most of the attention around 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.
The Government has set up the EU settlement scheme for EU/EEA nationals currently living in the UK. Dentists and their members of staff need to apply for settlement before December 2020 in order to remain in the UK without the need for future visa status, unless they have obtained citizenship. This includes individuals who have previously applied for residency in the UK; their status will be converted to the new scheme.
3. UK economy
There are many commentators on the state of the negotiations process and its impact on the UK economy.
Pound Sterling has suffered significant losses at several points since the referendum, the UK credit rating was downgraded in September 2017, and the economic growth prediction was downgraded by the British Chambers of Commerce in September 2018.
Any economic downturn after Brexit particularly in the case of a 'no-deal scenario' and continuing acrimony, could lead to higher prices and may impact on people's standards of living.
Research suggests that economic downturns can affect patient behaviour in seeking dental treatment, and we are concerned that this could affect dental practices' incomes – for both NHS and private dentistry.
We are keeping a watching brief on this issue and discussing it at appropriate stakeholder meetings.
4. Medicines and medical devices
UK medicines and medical devices have been subject to a central EU system of accreditation.
While the UK Government seems intent to stay within the realms of the existing regulatory framework, it is questionable whether this can be achieved without participation in other frameworks that the government has explicitly stated it will leave. If the UK leaves without a deal, then its participation in all current systems will stop and it will be treated as a third country by all EU member states.
If the process cannot continue as it is at the moment, there are questions over the timely provision of medicines, including those used in dental practice, and the rules for importing medical devices.
In addition, there are questions around the speed and efficiency of importing medicines and medical devices if there are border controls that could significantly delay transport. The Government is in contact with suppliers and has put in motion processes for the supply of medicines and devices in a no-deal scenario; these are reliant on relevant companies following government guidance.
It has published FAQs for healthcare providers if they are asked about Brexit by their patients.
In September 2019, the National Audit Office provided a report on the Government's work to deal with the issue of medicines and medical supplies.
Over time, it might be possible for the UK to establish its own processes mirroring existing ones going forward, but as it will have to pay to do this rather than being integrated in an agreed system, these costs will likely need to be passed on to those who use, and need, medical devices and medicines.
5. The Irish border issue
One of the main issues of the Brexit negotiations is the problem of a potential return of border checks of people and goods between Northern Ireland and the Republic of Ireland.
Within medicine and dentistry, there is a flow of workforce into both directions at the moment – registrants living in the Republic and working in Northern Ireland, or vice versa; and the same also applies to patients, who might seek care in a different part from where they live.
A potential hard border has implications for patients, workforce, service provision, data transfer, availability of medicines and other goods.
As mentioned above, BDA Northern Ireland is participating in a Department of Health working group on Brexit and we will keep members updated on discussions.