‘Things need to be done differently and new ideas need to be brought to the table'

In June 2023, the government published the NHS Long Term Workforce Plan, designed to boost recruitment and retention across the NHS. In it, the report suggested one approach the government will consider is to introduce ‘incentives or other measures, such as a tie-in period, that encourage dentists to spend a minimum proportion of their time delivering NHS care in the years following graduation'.

The Plan, widely denounced by leading figures across the country, remains light on the detail, with some commenting it could have the reverse effect and drive more dentists out of the system than into it.

So what do students of today and dentists of tomorrow think? Will it drive them into private practice quicker? Will they leave clinical dentistry altogether? I asked Yaqoub Imran, 4th year student at the University of Birmingham, and Maryam Al-Dubooni, 5th year dental student from Peninsula Dental School, about their thoughts on the potential ‘tie in' proposal.

What do you think of the proposal to tie in new graduates to NHS dentistry for a period of time?

‘ I believe the main problem of dental professionals turning away from NHS work and going into private ultimately lies due to the NHS being underfunded and overstretched.'

YI I think the proposal is an interesting idea to say the least. On the one hand, I completely agree with the idea that as healthcare professionals in the UK we have a duty to support and play a role in the NHS. After all, the average cost to Health Education England of providing a Bachelor of Dental Surgery education to each student in the UK is estimated at £175,000. Therefore, if this amount of money has been invested into you as a student, it would only seem fair to give back into the system, right?

On the other hand, the concept of being ‘tied-in' doesn't quite sit right with me. At seventeen years old, I made a choice to study dentistry under the premise that I would be able to choose how and where I use my degree. After all, I would be the one spending five years working hard to pass rigorous exams whilst also staying on top of my clinical work. So, I say to myself is this really fair? I mean nobody likes to be forced into something, right? There are two sides to this proposal and unless the details are carefully considered, then its success may as well as be a flip of a coin.

M A-D As a final year dental student, the decision to consider working in the NHS or private sector is a thought I have every day. When applying for future jobs, I am applying to do a DFT year and this is within the NHS contract, however the way we are contracted makes the NHS seem a little more appealing (having a salary instead of being paid for UDAs). I believe the main problem of dental professionals turning away from NHS work and going into private ultimately lies due to the NHS being underfunded and overstretched.

Although the idea of tying new graduates in the NHS may temporarily solve the issue of fewer dentists within the NHS, it is not something that I would personally enjoy due to several factors. Our final year is funded by the NHS, and we receive a bursary towards our studies. If there is to be a tie-in period, I would expect in return to have all my years at university to be funded by the NHS and graduate with no student loan debts. However, the NHS bursary is not enough to purely live off, especially in this economic time, and I have found myself struggling for money, working outside of my studies, as well as having to ask my family for additional support. This would do a disservice to students from a more disadvantaged background, as they may find themselves struggling to pay rent alone and may need to drop out due to the financial difficulties. If the NHS does end up paying for the training of dentists, there should also be the option to refuse the bursary and pay for the degree yourself, leading to more discrimination against those from a more disadvantaged background.

This opens up a question of do dentists have a choice in where they want to work after the graduate, and will this deter students from applying to study dentistry in the first place? If the tie-in workforce plan is to be enforced, the plan needs to set out in a better way to retain dentists than forcing them to work for a system that is failing. The new workforce plans set out new actions that are to be taken for all NHS workers, however it seems like they vaguely specify how they intend to better the NHS dental workforce, with no real plans set in place other than tying them in and increasing the number of dentists being trained. This unfortunately is not a permanent solution in retaining dentists in the long term.

The way that NHS dentists are being paid in terms of UDAs means that some dentists end up not making money if providing lots of work, i.e. providing dentures, root canals, fillings, extraction, extra-coronal restorations. If some lab fees are being paid by the dentist, over the average of all the appointments, the dentist may end up making less than minimum wage, which is totally unacceptable.

In the current economic situation, and all things considered, I think the way that the NHS is currently funded, tying dentists into the NHS is not viable to sustain a healthy work-life balance.

‘ I believe the main problem of dental professionals turning away from NHS work and going into private ultimately lies due to the NHS being underfunded and overstretched.'

What do friends and colleagues in your cohort think?

YI Students, that I spoke to, weren't completely opposed to the tie-in as long as it was an optional scheme that offered an incentive. The idea of a compulsory scheme for students was heavily disliked. Choice was key. In addition to this, students also shared potential incentive ideas that would increase their likelihood of joining the potential scheme. As Maryam suggested, these could be financial with student loan forgiveness, bursary/grants as a student and extra cash at the end of each year whilst working in the ‘tie-in' scheme. There are also non-financial ones too, such as increased training and CPD opportunities whilst working in the ‘tie-in' scheme.

M A-D I sent out a poll to all final year dental therapy and hygiene students, as well as dentists and overall the results showed a 100% dislike to the new dental reforms of tying them into the NHS for a period of time after graduating. Overall, the comments were similar in the sense that tying dentists in does not fix the problem of the NHS.

Some comments:

“Trying to solve the NHS issue by forcing dentists to stay within the NHS means it is not fixing the problem of funding/resources to provide safe/good treatment. As well as this, by allowing more people to study dentistry may shift the focus to recruiting more underqualified people to become dentists.”

“When signing onto the NHS tie-in it may reduce the amount of people that apply due to the lack of flexibility the NHS may offer for work”

“If they made the NHS tie-in optional, it would put certain groups at a disadvantage.”

For those who don't like it, could you see them turning away from dentistry because of it?

M A-D I can see a large proportion of students turning away from dentistry if these tie-ins are to be enforced. Although considering this, this is all dependant on the amount of time that dentists are expected to be tied into the NHS. Part of becoming a dentist is helping those in need for dental care, and this is ultimately our job. I imagine some students would still be interested in becoming dentists regardless of the workforce plans, with the future intent of doing mixed private and NHS dentistry.

If, however, dentists are to be expected to work in the NHS in a tie-in period, I imagine the amount of student strikes, and dental strikes would go up, as they turn from self-employed to employed by the NHS.

YI I do believe this could be a possibility. Certain individuals who don't favour the idea of being obligated to work in a specific setting will undoubtedly clash with the scheme. Their expectations of having the autonomy to choose their own career path within dentistry for the first few years won't be able to be met. The expectations could stem based on their priorities and personal circumstances. Subsequently, it is imperative that the balance between the individual expectations of prospective dental students and fulfilling a degree of commitment to the NHS is found otherwise turning away from dentistry could be a reality for some.

For those who do like it, could it save the dental workforce?

M A-D No students were for the dental workforce plan; however, I can imagine that for some students this may be quite appealing. Some students may perceive the NHS to be a reliable and stable job and want the sense of security that the NHS can offer. For other students wishing to specialise and work within hospital or community, NHS years prior is a necessity.

YI I don't think this single proposal is enough to save the dental workforce, but it could be a step in the right direction. I say this because the current system is quite frankly not working. Many dentists have shared this sentiment. So, it begs the question - how do you fix it? An argument is to start with radical change. Things need to be done differently and new ideas need to be brought to the table. This proposal is an example of just that. Perhaps, it's too unconventional but this type of innovative thinking may be exactly what is needed to save the dental workforce.

How do you see the balance between NHS and private dentistry from an undergraduate perspective?

‘ I sent out a poll to all final year dental therapy and hygiene students, as well as dentists and overall the results showed a 100% dislike to the new dental reforms of tying them into the NHS for a period of time after graduating'

YI From an undergraduate perspective, our primary goal is rooted in the commitment to providing the best care to all patients. For students, the prospect of working within the NHS holds significant appeal, given that many have been touched in one way or another by the Service. However, a real concern arises from the perceived time pressures and financial constraints associated with the current UDA system.

On the other side of the spectrum, the private sector presents an appealing alternative. Here, time management appears less restrictive, potentially offering an environment conducive to delivering a higher standard of dentistry. Nevertheless, it's essential to acknowledge that a substantial number of students grapple with feelings of inadequacy about their readiness to meet the demands, expectations, and stresses inherent in private practice.

In essence, the balance between NHS and private dentistry revolves around a fundamental question for undergraduates — which sector can consistently ensure that I deliver the best care for all of my patients?

M A-D As an undergraduate student, I am aware of the balance between NHS and private dentistry that a lot of practitioners have. The majority of dentists, especially in the Southwest find it financially unsustainable to work solely in the NHS and generally supplement their income with multiple days of solely private care. However, bearing that in mind, a large community of dentists in the Southwest tend to lean towards joining the Navy or Army, which offers a much more attractive work-life balance and pay.

‘ I sent out a poll to all final year dental therapy and hygiene students, as well as dentists and overall the results showed a 100% dislike to the new dental reforms of tying them into the NHS for a period of time after graduating'

The perspective from an undergraduate student is that we are taught the “gold standard” of dentistry, by providing treatment best suited for the patient. The reality, however in NHS dentistry is different. The treatment provided does not fit the gold standard, rather what is economically viable to be provided within the NHS.

From my point of view, the number of dentists working purely in the NHS is far stretched, but this may be due to the demographic and the area that I am in. In larger cities, there are a lot more dentists who work purely in NHS as it gives them job security.

If the proposal becomes legislation, will it impact your chosen career pathway?

M A-D At this moment in time, I am quite uncertain on what I would like to do with my future. I have an interest in either specialising in something like oral surgery or endodontics. At the same time, something that appeals to me is doing implants. With the specialism pathway, being in a tie-in has its positives and its negatives.

Being in the NHS for a period of time prior to starting the specialist training pathway is crucial and would be more advantageous. However, if I chose to go down the MClinDent route, funding this would be near impossible on an NHS salary, without additional income from private work. This would mean the time taken for me to specialise in those would take longer due to financial complications.

If I chose to go down the implantology route, being tied becomes less of an issue. After being tied-in, I would be able to pay for the course to become an implantologist and find a mentor. The financial implications become less of an issue due to the cost of those courses compared to the MClinDent. Although implants are not typically offered on the NHS, those years working in the NHS would be able to build my knowledge of holistically treating the patient before embarking on something more specific within the private sector.

Overall, tying dentists into the NHS for a few years wouldn't make a huge difference to my chosen pathway, however students wishing to study dentistry would need to be aware of future plans and a more detailed plan. Undergraduate students should also be given a choice and the ability to refuse to sign a contract when starting dental university.

YI As of now, the proposed legislation wouldn't significantly influence my chosen career trajectory. My current aspirations involve completing both DFT and DCT training, and I envision working within the NHS for a few years post-graduation. However, it's essential to acknowledge that, as a fourth-year student, my clinical exposure remains relatively limited, and there exists the potential for my professional direction to undergo adjustments and ultimately change. ◆