By David Westgarth, editor, BDJ In Practice

Introduction

According to the Trussell Trust, between 1 April 2020 and 31 March 2021, food banks in their UK-wide network distributed 2.5 million emergency food parcels to people in crisis, a 33% increase on the previous year.1 While many were furloughed and businesses fought to keep their heads above water, the Trust also says that compared to this time five years ago, the need for food banks across their network has increased by a staggering 128%.1

There can be little doubt that these figures are troubling, and yet there are some rare occasions where such data have been praised and welcomed. This reminded me of the time when, during local elections in 2021, a man from Hartlepool was asked why he voted Conservative, to which he replied that under their government they now had nine food banks in the area compared to one under Labour. A curious take, and one I feel has been mirrored in our profession.

There is something profoundly bizarre about the praise heaped upon charities operating in the UK by those in positions of power with the ability to rectify the need for these charities to exist. And yet, charitable presence in UK dentistry is increasing, and has been for some time. For years, a group of dental professionals have had letters published in The Daily Telegraph admonishing UK dentistry for being unfit for purpose, akin to the third world and in crisis. In 2018, one such letter, authored by Tony Kilcoyne, stated 'It is a terrible situation when you have got charities looking at Britain and seeing there is a desperate need to provide basic care'.2

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Reasons for the current landscape

So, why exactly are dental charities increasingly picking up the slack in the UK? Natalie Bradley, UK Clinical Director of Dentaid, said while it wasn't a new issue, the pandemic may have exacerbated the need for charitable support.

'Charities providing services alongside and working with NHS organisations isn't a new concept within healthcare or other government services', she said. 'Many aspects of healthcare such as care in hospices, cancer services or air ambulances are provided by charities. In the NHS Long Term Plan the NHS commits continuing to commission, partner and champion local charities and social enterprises providing services and support to vulnerable and at-risk groups. What has become more apparent over the past few years and especially since COVID-19, is that these vulnerable and at-risk groups are increasing and accessing dental care has become a challenge.

'With up to 14 million missed NHS dental appointments during the pandemic, this backlog together with dentists leaving the NHS or the profession altogether and difficulties in recruitment, so many areas of the country are now facing long waiting times to get an NHS dental appointment.

' For years, a group of dental professionals have had letters published in the Daily Telegraph admonishing UK dentistry for being unfit for purpose, akin to third world and in crisis'

'At Dentaid, we are able to provide dental care in communities who really struggle to access care and while we first started activities seeing people who experience homelessness and social exclusion, as they have always faced serious difficulties in accessing healthcare, over the past two years our work has expanded to care for other vulnerable and excluded groups. We provide clinics for fisherman, head and neck cancer patients, looked after children, refugees as well as public access clinics. Because we work outside of an NHS organisation, we can focus on our unique model of dental care, taking care out directly into communities and we can adapt quickly to the expressed needs of each of our patient groups. Previously, patients who we now care for may have accessed other services such as general dental practice or the community dental services; however, getting an appointment with a GDP is incredibly difficult at the moment and the CDS have long backlogs they are having to manage. Since the pandemic, the slack within the system and flexibility has dried up.

'Many of our patients struggle to attend at a fixed appointment time because of their varying immediate needs such as mental health, addictions or having to attend other appointments. With changes in infection control measures and social distancing, some services that they had previously accessed such as walk-in/drop-in services, no longer operate in the same way and this can be a big barrier to care. We aim to continue to be as flexible and adaptable as possible in order to break down these barriers to enable access.'

Linda Greenwall, founder of the Dental Wellness Trust, also suggested the pandemic was a leading reason for the current need.

'The COVID-19 pandemic saw unprecedented changes in dentistry and in the oral health of the country. The March 2020 lockdown meant that dental practices were forced to close and could only attend to emergencies. Children who were home schooling and out of their routines started snacking on sugary foods. Since their parents were preoccupied with the stress of the pandemic, many stopped supervising children with their normal daily toothbrushing. This also included adults as well who were out of their normal routines in the office.

'The general public's oral health deteriorated and, as a consequence, their long-term oral health also suffered. NHS patients were unable to get an appointment with their dentists and obtain relevant treatment due to a massive backlog of patients.

'This dire situation led to charities stepping in to fill the gaps in the service and to help the most vulnerable in the community. Dental Wellness Trust has responded to the crisis in the UK by expanding their programmes. We expanded our LiveSmart Oral Health Supervised Toothbrushing Programmes in schools to reach 11,000 children throughout England. All training is undertaken online so that the teachers get the needed training quickly and effectively and get started quickly once parental consent has been given.

'Through the generous support of Colgate UK, the Dental Wellness Trust provides toothbrushes for each child in the programme. Children keep their toothbrushes at school and get a new toothbrush issued each term. Children are educated to brush their teeth effectively and through fun. A song is played during brushing so the children associate the group activity as a fun and healthy part of the day. There has been a positive response to this programme. Teachers, children and parents love this programme as it's a proactive approach to improving children's oral health in the UK.'

Mhari Coxon, President of the Oral Health Foundation, pointed to a pattern of continuing unmet need.

' The COVID-19 pandemic saw unprecedented changes in dentistry and in the oral health of the country. The March 2020 lockdown meant that dental practices were forced to close and could only attend to emergencies'

'Charities - and charitable initiatives like National Smile Month and Mouth Cancer Action Month - are having to step in to fill unmet needs in the population. We know that around 50% of population can self-fund and regularly visit a dental professional, which means the other half cannot. They do not - or cannot - go for many reasons, and one of those reasons is access. Charities - not just in dental, but across healthcare - are plugging these access gaps.

'The Oral Health Foundation's National Dental Helpline receives calls that are by and large about not being able to access an NHS dentist and trying to understand what they can do next. Dentists are struggling to meet the targets given to them by government as activity is ramped up because they're snowed under with addressing problems developed throughout the pandemic. What does this mean? They can't actually treat and offer preventive advice because they're having to get the patient out of pain. All this means is discussions about prevention are pushed further down the line, which is far from ideal.

'Dentistry is faced with numerous problems, and this 'emergency crisis' is another that charities - free from the shackles of UDA targets - can connect with the public on. Dentaid do a great job, but how can you fit prevention into that? You can't, and so it becomes a cycle of failure in people's oral health, which has long-term implications.'

Increase in need

There is little doubt COVID-19 has decimated what was already a struggling service. The unmet need Mhari described, allied to the missed dental appointments Natalie highlights and the deterioration Linda mentioned is a cacophony of problems facing dentistry. But do these issues mean charities will take a greater role in the treating of patients in the UK?

'There will be more oral health services', Linda suggested. 'Reduced funding and funding cuts from the NHS due to expenses during COVID-19 means that there may be a reduced NHS service in the future. Charities will step in to fill the need.'

Mhari agreed.

'Given health inequalities are very much a hot topic alongside the government's levelling up agenda, you would hope not. However, like Linda, I feel charities will need to step in to meet the needs of the population.

'I have not seen dentistry being captured in the discussion about levelling up, nor the inequalities that exist across the country. One of the mottos I have heard is we need to 'put the mouth back in the body', but if anything I think the mouth has been taken out of the body. I have also heard some people say the government is almost glad dentistry is on its knees and dentists are walking away because they can't cope with the stress, which is quite surreal. It feels like there isn't a clear solution for how we're going to tackle the problems charities are addressing, so yes, in all likelihood their need will increase.

'Like food banks, why is this being normalised? We're normalising these for working people, as well as those below the breadline. We have a duty to bring discussions about the extreme social and health inequalities back to the table to make sure dentistry is being included and heard. The NHS Long Term plan, for example, talks about your life being shortened by 10 years if you experience such inequalities, and we know oral health is linked to systemic health, so where is the integrated approach to improving this message? It's about connecting the dots, and whether charities - mostly focused on pain relief and immediate treatment - have the time to do that with their patients is questionable.'

Natalie highlighted the need for adaptable and accessible dental care, adding: 'As the cost of living is increasing, the need for affordable dental care will also increase. In some areas of the country, there are reports of people only being able to access private dental care, or otherwise having to wait long times or travel long distances to get an NHS appointment. While some people will be able to go for these options, for some patient groups these are not possible. Many cannot afford private dental care, or wait with agonising toothache, or travel miles to get to an appointment. This needs to be addressed, otherwise patients will present in places where they won't get the care they need such as their GP or turn up at A and E departments.'

A targeted approach

With cost a significant driver behind patients attending A and E, their GP or pharmacist - and anywhere else but their dentist - you may be forgiven for thinking governments and their departments of health would know exactly where the problem lies and be able to do something about it. Alas, such common sense is missing when it comes to the integration of dentistry in healthcare services, which, according to Mhari, leaves those without a voice vulnerable.

'Dentistry is serving those who already see the dentist, not those who aren't. We as a dental profession have a job to do to open our eyes to the wider problems across healthcare, but dentistry has to be included in levelling up discussions for us to do that.

'From a dental perspective, children, the elderly and those in care homes have much of the attention on them, purely because in their case the ability to pro-actively visit the dentist isn't theirs - they rely on others.

'I believe we have a gap in the Delivering Better Oral Health toolkit. That piece is designed to help dental professionals deliver better oral health to the population, but if you're only treating half of the population, the people who are left out are those who can't make the choice themselves, and that's this cohort of patients. DBOH is measured on how many fluoride applications we deliver, so who are we serving?

'There's some great work going on to improve oral health in care homes, but again, rather than being government-funded, it's being run by individuals and not-for-profit charitable organisations. It brings me back to connecting oral and systemic health not being of the importance it should be.

'If we're in a system where we're not being paid for the work we do, we're effectively delivering charity. National Smile Month is essentially National Smile Year - almost every dental professional in the NHS is delivering charity in some form or another. Again, it's the normalisation of this that alarms me, especially at a time where the healthcare community in general is really strapped for cash and low on morale. I would go as far as saying money isn't the real issue anymore - there's enough money that isn't necessarily going to the right places, but there's not enough resource to carry it out because so many are leaving the NHS and the profession.'

From Dentaid's point of view, Natalie believes the targeted approach does have its value.

' Reduced funding and funding cuts from the NHS due to expenses during COVID-19 means that there may be a reduced NHS service in the future. Charities will step in to fill the need'

'The cohorts of patients we see face significant barriers to healthcare. Many will have sporadic attendances due to disruptive lifestyles, often have high levels of disease and have other compounding medical and social problems such as mental health issues or lack of a fixed address. All these factors result in challenges treating these patients under the current NHS contract, as these patients often need multiple appointments to stabilise their disease, they may miss appointments or need longer appointments to manage their anxiety and additional needs. Practitioners might also lack the confidence in caring for these patients and many will hold stigma around certain patient groups.

'At Dentaid we support all our volunteers with caring for these patients so they feel confident in providing non-judgemental, friendly and patient-centred dental care and these skills can be taken back to their usual place of work.'

Linda also pointed to the lack of NHS provisions for the Dental Wellness Trust's patients.

'Many patients are unable to obtain NHS dental care', she added. 'The growing number of immigrants to the UK and asylum seekers has resulted in a great need for dental care. While asylum-seeking children and their families are eligible for NHS dental care, few dental practices are in a position to take on this extra work load due to extensive waiting lists and capacity. These families stay in temporary accommodation around the UK and are moved without much notice to different parts of the country. Dental Wellness Trust has teamed up with the respond team in Barnet Camden to help provide free dental care for these children with our Live Smart Dental Care programme. We are expanding this programme to reach more children with our two mobile dental units which will be stationed in Camden.'

The unease of normalising

It's probably worth noting at this point I do not have an issue with the work charities do - far from it. I cannot help but admire their quite brilliant work. My issue is that it is needed, and the continued growth of their services merely highlights the normalising - like food banks. So, do they provide the government and departments of health with a free pass, absolving them of responsibility to address the underlying causes?

Linda explained: 'We've had many discussions with relevant NHS bodies to help complement services which may be lacking and share the burden of oral disease. This can be achieved by improving oral health inequalities which exist throughout the UK, especially for those living in the most vulnerable communities.

The pandemic has shown that dental charities are even more essential now than before. There are currently over 200 dental charities in the UK all doing excellent work to make a difference and help more people attain better oral health. This includes helping - and educating - people to reduce their salt and sugar intake (especially fizzy drinks) and encourage snacking on more healthier foods, both problems that were prevalent throughout lockdown.'

Natalie added: 'As a charity we are able to fund our projects from varying sources and this does include local authorities and governmental sources. We have projects where local councils have identified a need in their area, and we can meet this in a quick and targeted way that meets the needs of the patient and statutory providers can address a particular need in their local population. For example, we work with the Home Office, Rough Sleepers Initiatives and local CCGs for several of our clinics. We are able to supplement this with fundraising and corporate support in order to extend the reach of the work we do and rely on our clinical volunteers who want to give something back to their communities. This means we are able to provide valuable and quality dental care for the patients we look after.

'As Linda highlighted, COVID-19 has shown how crucial accessible dentistry is for the entire population. For our head and neck cancer clinics, partnering with MacMillan has enabled us to provide timely dental treatment for patients prior to starting their cancer treatment, ensuring their treatment is not delayed. Our public access clinics in Suffolk have been overwhelmed with people in need with long queues of people desperate for care, often suffering with toothache and not being able to get to a dentist. NHS dentistry has been a regular in the news and spoken about in the House of Commons because so many people are struggling to get the simple, essential healthcare that they need. Our UK activities as a charity have never been so busy with requests for new clinics and expanding our fleet of mobile dental units and this in itself demonstrates the need for our work.'

According to Mhari, the dento-political landscape has helped to normalise something that shouldn't be normal.

'Charities are formed because there's a need that's not being provided for by the state', she said. 'As a supporter, you join because you believe in their cause. The Oral Health Foundation identified a historical unmet need; patients lack oral health advice in a manner that's easy to understand. The work we do has a positive effect on those who need it, but could the profession challenge the government more on why we're providing these resources? Yes, probably.

'You only need to look at oral health throughout the early stages of the pandemic. The reduced access and habit forming built up over time could have dropped off fairly quickly. Anecdotally, I have spoken to clinicians who say there were two extremes: those who lost their routine completely, and those who had improved their routine because there were aware they couldn't get access and so did something about it. The historic lack of NHS access means that now - more than ever - those who offer private dentistry are booked out solid and can't see enough patients, purely because appointments aren't available on the NHS.'

The future of dental charities

With governments across the UK at different stages in the post-pandemic dentistry revival, it's difficult to turn into Mystic Meg and predict what happens next. Yet, and with more than a tinge of sadness, you can bet your bottom dollar the immediate future of dental charities will not change. Their need remains, and remains more necessary than ever.

Or is it? Charitable work - by and large - means time out of the clinic. Is that realistic - for dentists and for dental care professionals - when there's such a hefty backlog created by the pandemic?

'Good question. There are many dentists within the caring healthcare profession who want to do more to help and give back to those less fortunate', according to Linda. 'Despite the busy dental schedule in practices, there are some dentists, dental students and dental teams who go beyond. I have met many of these amazing people. I call them angels. They volunteer with the Dental Wellness Trust and are the kindest, caring and most giving people within our dental profession. They make the world a better place and contribute to humanity in this way. The giver receives gratitude in so many different ways and this puts everything into perspective.

'Oral health inequality is a global issue which needs to be tackled by reaching out to one person at a time. There are so many positive ways to improve oral health inequalities. Together we are stronger and we all need to work together in this post-pandemic era to improve humanity and make the world more caring.'

'There's a wider quality of life perspective to consider here', Mhari suggested. 'I've never seen so much need for self-care within the healthcare system. I've never felt so sad to see how relentless and joyless things have become. GPs have been given a really bad press during this time, and dentists didn't do much better. I can assure you we didn't want to sit around making banana bread all day while NHS services were closed! Burnout is a real concern. We know from talking to those who get involved that National Smile Month is so important to the practices who give back to the communities they are serving and the sense of wellbeing it creates within the team. Closing that access was troublesome for some.

'What it did provide was a need to be innovative. National Smile Month was a huge success digitally when access to patients was closed off. It was a real positive to show that in the digitally aware world we live in there's so much you can do, even when you think there are limitations. We saw some brilliant, innovative ways to help people and provide them the crucial oral health information they needed.

'I'm an eternal optimist, so I hope that by continuing to show how successful National Smile Month is - and the other charitable work done across the country - that one day the government will plug the gaps we fill. I'm also a cynical healthcare professional, so I know that there isn't enough funding to address the problems that exist, and have existed for a long time. Until we're measured by something other than money and levels of investment, charitable acts will be required to pick up the slack.'

For Natalie and Dentaid, they rely on the generosity of the profession - even in the face of multiple challenges.

'Our kind volunteers come from varying backgrounds where many do take some time out of the clinic to give their time on the mobile units', she added. 'We have volunteers who do not work full time but see the need for our work and choose to give a regular day in their diary to work on the mobile unit. Others do ad hoc days when they can as it isn't just about giving back to the community, but also a learning and educational experience that they can take back to their practice. We have projects where foundation dentists and trainees spend time on the mobile units with supervision, as caring for these patients who often have a lot of dental needs and have comorbidities that need to be taken into account is a valuable training experience for the next generation of dentists and dental care professionals.

'We are passionate about shouting about the oral health inequalities we see every day on our mobile units and the need to address these inequalities in a sustainable, responsible and inclusive way. We see our place as a charity not to replace NHS or private dentistry, but to be another organisation at the table where we can bring our expertise at providing adaptable and accessible dental care for seldom-heard-from communities. Dental care will never be a one size fits all solution - there is a role for dental charities to work in partnership with governments, local authorities and the health service in providing care for people who really need it.'