The question many are now asking is, if NHS dentistry is languishing in its sick bed, could a new General Dental Services (GDS) contract be the remedy to breathe life into the system?
Back to the Future
In January 2023 we wrote an open letter to the Chief Dental Officer warning that if there was not a fundamental shift in the approach by Government, we could not see a future for NHS general dentistry in Wales. Several aspects we raised two years ago about contract variations under the reform programme remain on the critical list. Whatever new contract may be heralded in 2026; the Government needs to urgently consider the current state of dentistry now so that we have a viable service in the future.
"Members of Senedd are increasingly disillusioned with the official narrative, questioning the spin"
Government officials have claimed repeatedly that a new contract will put dentistry on a new and better path, and that skills mix will be a welcome salve. However, Members of Senedd are increasingly disillusioned with the official narrative, questioning the spin. Llyr Gruffydd MS conducted a survey of practices in his constituency, concluding the Government is in denial about the crisis. Sioned Williams MS is also an outspoken critic of the Government’s inaction in dealing with the dentistry crisis.
Signs and symptoms
Our 2024 UK survey has revealed some shocking truths about the negative impact of ongoing contract reform on the Welsh dental workforce. Associate recruitment levels have halved in comparison with UK-wide figures, yet all the positions are difficult to fill. More than a third of practice owners who responded identify contract reform as a barrier to recruit – double the UK average. A similar picture of difficulty in recruiting Dental Care Professionals is observed.
Around 80% of associates view the NHS service in Wales negatively or very negatively. Of concern, 42% of Welsh respondents rate their job as very or extremely stressful, compared with a third in England. Nearly half (46%) of Welsh associates score their current morale as low or very low, in comparison with just over a quarter (27%) in England.
Welsh practice owners’ (POs) work-life balance scores are the lowest across the UK, with four fifths disagreeing it is good. Job security of Welsh POs is also the lowest at 50%, contrasting sharply with two thirds of POs feeling secure in England. Morale of Welsh POs is the worst in the UK with 72% stating it is low or very low, in comparison with 47% in England.
This bleak picture of the NHS dental workforce is reflected in an independent report by Bangor University which ties in the increased stress levels and very poor morale arising from reform conditions with an increase in contract hand backs.
The latest dental services data release shows that 189 dentists left the workforce in 2022-23, which is 13.2% of the total NHS dental workforce. The figure of leavers for 2023-24 will not be available for another year but the likelihood is the trend will continue with more dentists withdrawing from NHS provision than entering it. Analysis shows that both Betsi Cadwaladr and Hywel Dda have significantly fewer dentists at 4.0 per 10,000 of the population compared with the other five Local Health Boards averaging 5.5 dentists.
Russell Gidney, Chair of the Welsh General Dental Practice Committee (WGDPC), commented “The workforce has borne the brunt of a decade of living off measly gruel and is showing significant signs of anaemia. Instead of ‘Please Sir can I have some more?’ perhaps the time has come to throw down the bowl and walk away.”
Is reform malaise contagious?
All four primary care groups in Wales - optometry, pharmacy, dentistry, and general practice - are dealing with very similar contractual issues. The four groups fall under the umbrella of primary care reform which is supposed to improve services for patients, but the reality is causing mounting stress and financial hardship for all contractors involved.
"Importantly, there is increasing evidence that a new contract by itself has only limited efficacy in reviving an ailing system"
Importantly, there is increasing evidence that a new contract by itself has only limited efficacy in reviving an ailing system. In January 2023, the new unified General Medical Services (GMS) contract was announced with great fanfare yet the annual GMS uplift contract negotiations broke down this autumn. As a result, the BMA’s Welsh General Practitioners Committee are currently undertaking a referendum of GPs. Earlier this month independent community pharmacies voted to take action for the first time ever in protest against the inadequate funding of their contracts. The question is, could dentistry be next?
Dan Cook, Vice Chair WGDPC, reflected “We have done everything in our power to negotiate a better GDS contract, but by itself this cannot reverse the trends we have seen in the last few years, signified by a great many contract hand backs. The new annual uplift negotiations are increasingly becoming a Sisyphean task. The fiscal constraints that practices are being squeezed by are becoming unworkable.”
Impact of contract reform on patient care
Healthcare watchdog Llais has just published a damning report of how patients in Wales are struggling to access even the most basic dental care. The report paints a picture of patchy access and diminished dental activity in some areas where contract hand backs continue apace.
This picture is borne out by recent official statistics showing treatment rates remain significantly depressed in comparison with pre-pandemic figures. The 12-month figures for adults and children treated in 2023-4 are still hovering around the 1 million mark or 32% of the population. Pre-pandemic it was circa 46%. The reduction is particularly notable for adults (from 43% down to 28%) and number of children seen has also reduced (from 60% down to 46%).
Patients who manage to see an NHS dentist may question what that dental care looks like under reform conditions. The report from Llais is not flattering on that issue either. Indeed, POs in Wales score the lowest (54%) for feeling satisfied with the standard of patient care under the variation volumetrics, compared with 64% in England which is still operating the widely discredited UDA system. Welsh POs who hand back their NHS contract always cite one of the reasons for converting to wholly private practice as being able to offer the standard of care patients deserve.
"No amount of government rhetoric and spin can change the reality that NHS dentistry in Wales is ailing and, in some parts, becoming ischaemic."
The claim by First Minister Morgan that “The UK government will take inspiration from NHS Wales on dentistry, where reforms have unlocked almost 400,000 more appointments in the last two years” is not only grossly misleading, it is an insult to the intelligence of professionals and public alike. No amount of government rhetoric and spin can change the reality that NHS dentistry in Wales is ailing and, in some parts, becoming ischaemic.
Can a new contract revive the system?
It has been a long hard road to persuade Government and NHS officials that a new dental contract cannot rely on using the crude volumetrics and unverified targets we have been subjected to under several years of contract variation. We proposed an alternative model which seemed to gain traction. However, Government officials terminated negotiation discussions early because of their legislation timetable. All parties are bound still by confidentially and cannot divulge details.
Our mandate from the profession and our principles for a new contract have been our north star. We did not compromise on these throughout the last year, and we upheld our core values to support the profession and our patients.
Our seven principles for a new dental contract
We aim towards a contract that is evidence-based where:
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Forthcoming commentary
Over the next few weeks, we will be updating you on the state of the GDS uplift negotiations, and providing commentary on the 2025-6 contract variation offer from Welsh Government. We anticipate that the elements of the new contract will be released by Government in a public consultation soon and when that happens, we will be ready to respond in public.