Dental deserts: The exception or the rule?

For a number of years the phrase ‘dental deserts' has been banded around to describe the paucity of NHS dentists and access available in certain areas. It's a phrase that conjures up images of mirages and desperate people having visions of an oasis, only to find they were actually dreaming. In films, these scenes have often been depicted as the exception rather than the rule, but in 2024, are dental deserts the rule rather than the exception?

Reality

In 2022, the British Dental Association teamed up with the BBC to assess the state of access to NHS care for patients across the UK. The results spoke for themselves, as shown in Figure 1.

Fig. 1

Proportion of dental practices contacted by the BBC not taking new adult NHS patients

The investigation found the problem was worst in the South West of England, Yorkshire and the Humber and the North West, where 98% of practices were not accepting new adult NHS patients. Conversely, access was best in London, where almost a quarter of practices were taking on new adult NHS patients.

For child patients, one in 10 local authorities did not have any practices taking on under-16s for NHS treatment, despite children in full-time education being entitled to completely free care on the health service; almost 200 practices said they would take on a child under the NHS only if a parent signed up as a private patient.

Not only did the research find that in many places routine dental care was difficult to access quickly, it found most practices did not even have waiting lists. For those that did, the majority reported waiting times were a year or longer or were unable to say how long people might have to wait. To highlight the absurdity of the problem, one practice in Norfolk told the BBC it had more than 1,700 people on its list, while another, in Cornwall, warned that it would take five years to be taken on as a patient.

Fast forward to 2024, with the pandemic in the rear-view mirror (but its outer ripples still being felt), a Dental Recovery Plan and investment in the service nowhere near levels required to right the ship, let alone improve it, it comes as no great surprise to hear these issues have failed to improve.

In February 2024, MailOnline created an interactive map shown in Figure 2 revealing how many patients there are per NHS dentist, laying bare the fact that ‘dental deserts' should perhaps be a phrase consigned to the past; the balance has shifted, and rather than patients being unable to access an NHS dentist as the exception, it has now become the rule.

Fig. 2

Number of patients per NHS dentist

Using NHS Dental Statistics, the map highlights the critical state NHS dentistry finds itself in. Nationally, there was one NHS dentist for every 2,342 patients in 2023, on average. NHS Gloucestershire recorded one dentist per 2,399 patients in 2022/2023, up from 2,011 patients per dentist in 2018/2019. It logged the biggest hike in the dentist-patient ratio out of the entire country (19.3%). But it is NHS Norfolk and Waveney that logged the largest disparity between dentist and patient numbers (one dentist for every 2,776 patients, a 17.1% increase). Seven of the 42 integrated care boards (ICBs) across England saw rates increase by at least 10%, and only 14 ICBs saw their ratio shrink.

However, a word of caution. The reality is, of course, different when you drill down into the figures. These statistics only record dentist headcounts, not how much NHS work they perform; a dentist who saw one NHS patient the entire year counts just the same as one who sought no private work.

This is why data gathering - described as ‘pioneering' by the BDA - on the dental workforce must provide the foundations for a serious plan of action for the service. The General Dental Council has asked registrants to account for their NHS/private split. It shows 19% of the workforce provide only private care, with no NHS, and a further 14% said they work predominantly (over 75% of their time) in private care. Only 15% of are fully NHS, with no private care, and a further 27% said they work predominantly (over 75% of their time) in NHS care.

These data would allow for analysis to provide the first credible estimate of the Whole Time Equivalent NHS dentist workforce, and for properly resourced long-term plans to be developed based around where the nation's real ‘dental deserts' are. While the response rate is strong (some 57% of registrants completed) it currently lacks granularity to look at local workforce challenges. While they provide a snapshot, they're a starting point. It will take time to build the body of data needed, and more time beyond that to break them down, but they could be the difference between real change and the continued efforts to rearrange the deckchairs on the Titanic.

Wider picture

These data might be England centric, but the problems don't stop there. In Wales, Senedd Research stated there appeared to be a ‘disconnect between what stakeholders and the Welsh Government are reporting in terms of the extent of the problems with accessing NHS dentistry', with the BDA previously urging the Welsh government to correct its claims surrounding NHS dental appointment availability after it stated that 112,000 extra dental appointments had been secured by recent reforms.

In Northern Ireland, a survey of high street dentists suggests impending doom. The survey revealed 75% of dentists in NI have reduced their NHS commitment since lockdown by an average of a quarter. A further 88% now say they intend to reduce - or further reduce - that commitment in the year ahead, while 49% say they are likely to go fully private. Only 20% of dentists report their practices as taking on new HS registrations.

In February 2023, figures from Public Health Scotland show participation rates - contact with a dentist within the past two years - had continued to fall. On 30 September 2022, just 50.4% of all registered patients had seen an NHS dentist within the last two years, still down on the 52.6% seen in 2021, and a considerable reduction from almost two-thirds (65.1%) in 2020. The participation rate among registered children was higher than for adults (65.7% compared to 47.2%). The gap between the most and least deprived areas in Scotland continues to grow, with the new data showing record inequalities in participation rates. In September 2008, the gap in child participation between the most and least deprived areas was three percentage points; this had increased to seven percentage points by 2010, 18 percentage points (55.3% compared to 73.1%) in September 2021. The figure then stood at 20 percentage points (55.9% compared with 75.8%).

So what's the solution? This perfect storm of patient access crises, recruitment and retention issues, practitioners reducing their HS/NHS commitments in due course, incorrect claims and misleading data does give weak to non-existent foundations for any decisions to be made on. Total overhaul? Perhaps. Whatever the answer, dentistry across England, Wales, Scotland and Northern Ireland needed it yesterday - it cannot wait much longer, for there may be no service left to save. ◆