figure 1

Introduction

In 2004, I moved back to Cumbria for the summer during my time at university. The bank of mum and dad had plenished me throughout my studies but was well and truly closed for the season. This necessitated getting some summer employment, so through to Keswick I went, CV in hand, looking for a job that would enable my social life. It's a picturesque market town bustling with tourists and locals alike throughout the high season, and I distinctly remember a hefty number of cafes, pubs, bars and restaurants looking for summer staff, so I thought I'd have no problem. What I didn't bank on was the demand for jobs matching the supply; most were gone in a day or two. While I managed to bag one in a pub, it was only because the hours didn't suit the majority of the job seekers - they wanted to be free in the Lakes during the day and work in the evening. Looking back, the balance between supply and demand was just about right.

Fast forward 20 years, and I am constantly pondering whether that balance exists in today's market or not. It is a market unrecognisable from my youthful days due to a lengthy number of factors. For the dental profession, some of these factors are external, and some are internal. And so, in 2024, who holds the upper hand in the recruitment market - the recruiter or the job seeker?

figure 2

The landscape as seen today

In most - not all - conversations I've had with both job seekers and recruiters, the message is loud and clear: it is firmly a job seeker's market. Practices are struggling to recruit, and it is a now a problem that was once believed to be a rural and coastal issue which has migrated to almost all parts of the UK. To emphasise the point, in 2021, John Lewis wrote the following in BDJ In Practice: ‘Recruitment of dentists in rural areas has reached breaking point. It has always been difficult, and it has steadily got worse. A great destination for holidays but not for a permanent move, according to many young graduates who seem to want to stay in cities. The gender and cultural mix of graduates has changed markedly over the years and this has had an effect on rural recruitment. National recruitment for Dental Foundation Trainees (DFT's) can result in graduates being placed in areas they don't want to be in and national workforce planning seems not to have taken any of the above into account.

‘Practices are closing due to difficulties attracting staff, including in Cumbria where vacancies are abound. My local, award-winning practice recently advertised for a part time private associate. There were three applications: two requesting Vocational Training by Equivalence (VTE) (not possible in this practice) and thankfully the third is a superstar. This experience opened my eyes! Yet it is not all doom and gloom. From dentists who have moved to Cumbria, the overwhelming feedback has been that local people are very welcoming and the patients are accepting and easy to treat, with no awareness of racism from the general public.'1

‘ Practices are struggling to recruit, and it is a now a problem that was once believed to be a rural and coastal issue which has migrated to almost all parts of the UK.'

In 2023, Evans et al further discussed the problem and postulated the conversation relating to the recruitment crisis in UK dentistry was a slightly inaccurate way of framing the discussion and debate, writing: ‘The NHS dental crisis has been widely reported throughout the media, both dental and mainstream, as the dental profession, patient groups, Members of Parliament and patients have become increasingly frustrated with the apparent lack of progress in addressing the underlying issues. In England, there is widespread acknowledgement that the current NHS dental contract is one of the key issues affecting access to care and creating inequality of provision. Despite universal criticism of the contract and many years of discussions, negotiations, and the piloting of alternatives, the profession has little confidence that there will be any profound change in the near future.

‘This lack of confidence is undoubtedly impacting on the views and aspirations of the dental profession, which appears to be translating into challenges around workforce recruitment and retention (R&R). Until now, R&R of dentists within NHS primary care was ostensibly a geographical issue, with rural and coastal areas struggling to recruit, while urban dental practices experienced less of an issue. There are now a growing number of reports that problems of recruitment are more widespread, with both urban and rural practices affected. In rural areas, recruitment problems have also been reported within the private sector.

‘The most recent data from the General Dental Council (GDC) indicate that dentist registration numbers are relatively stable and over the last ten years we have seen an increase from 34,700 in 2011 to 43,292 in 2021. In contrast, according to data provided by the Department of Health and Social Care, more than 2,500 dentists across England and Wales ended their NHS roles in 2021. This would seem to imply that we do not have a recruitment crisis in UK dentistry, but a crisis within the NHS, with increasing numbers of graduates investing their future in the private sector.'2

The implication that the workforce crisis is a crisis within the NHS specifically rather than within UK dentistry is a fascinating one, and one which frames the landscape upon which current discussions and debate rage on. It is an undeniable fact every year dentists leave NHS dentistry for a variety of reasons - to pursue private practice, to retire, to change careers or to take up further study - while others leave primary care NHS dentistry to work in hospital services or other areas of the profession. In 2019, the BDJ Recruitment Whitepaper identified that In England, from 2012/13 to 2016/17, 7,311 dentists left NHS primary care, but this was balanced out by 8,290 joiners - meaning an overall net increase of 979 dentists. However, nearly half of that net increase came in 2012/13 and the overall trend has been one of a gradually declining net increase over the period, with there being only 27 more joiners than leavers in 2016/17.3

In the 2021 version - with data and opinion impacted by the height of the pandemic - the BDJ Recruitment Whitepaper identified that in 2019/20 there were 31,003 dentists working on the NHS in primary care dentistry across the UK, a 0.5% increase on the previous year. While the number of NHS dentists increased slightly in England, Scotland and Northern Ireland, there was a small fall in Wales. In England, figures for 2020/21 showed a fall in the number of dentists, with the number reduced by 951 or 3.9%, reducing the NHS dental workforce headcount in England to its lowest level since 2013/14.4 It will be fascinating to see the next iteration of this Whitepaper now the pandemic has in-large washed out of the system - although political rhetoric still apportions a significant amount of blame on the pandemic for the problems the dental profession face today.

In fact, it was a point British Dental Association (BDA) Chief Executive Martin Woodrow mentioned in September 2023, when he said: ‘We've heard a lot since the pandemic about the difficulties patients have faced in accessing oral healthcare, and NHS dentistry in particular. To be fair, this was a problem brewing before 2020, but the recent access crisis has led to a widespread debate about the workforce in dentistry and whether we have enough professionals to meet the care needs of our population.

‘ The implication that the workforce crisis is a crisis within the NHS specifically rather than within UK dentistry is a fascinating one, and one which frames the landscape upon which current discussions and debate rage on.'

‘The reality is that we actually have more dentists and General Dental Council (GDC) registrants in total than we have ever had. What we don't know is what those registrants are doing, whether they are working at all, in general practice or elsewhere, full- or part-time, in NHS or private practice, or indeed, whether they are even in the UK.

‘We've heard all sorts of nonsense from the Westminster Government, including the Prime Minister, about an increase in the number of dentists undertaking NHS dentistry. But Rishi Sunak's repeated claim that ‘the number of NHS dentists has increased by about 500 over the last year' has been based on highly selective data. The reality is that NHS dentist numbers in the 2022/23 financial year were down 695 on the previous year, and over 1,100 down on numbers pre-pandemic. That reduction brings us to levels not seen since 2012.'5

He continued: ‘Having talked about what we don't know, there is nevertheless evidence of recruitment problems within general practice. The BDA undertakes regular research among practice owner members, and last year's work suggested that 57% of practice owners had a vacancy for an associate during the year (compared to 36% in 2021), and of those, 67% had not managed to fill that vacancy when completing the survey. An important point is that the difficulties were more significant for practices focused on NHS dentistry. The challenges don't just relate to dentists; 82% of practice owners were seeking to recruit dental nurses, and of these, 90% experienced problems recruiting.'5

Whichever way you cut it, these sources, authors and data all point in the same direction: NHS dentistry is struggling.

Factors, patterns and prevailing winds

Besides the (considerable) impacts of the pandemic and the UK's withdrawal from the European Union, it's worth having a closer look at some of the reasons for the problems within dentistry - both NHS and UK-wide, that shape the debate on who holds the upper hand in today's job market.

There is the not-so-small elephant in the room relating to NHS dentistry as a career - is it as appealing as it once was? Fewer dentists, more targets, limited to no additional funding and increasing patient demands doesn't exactly sound a desirable mocktail to enjoy, does it? All work and no play makes a dentist a dull person, comes to mind. One individual can only spread so far before thinning out to the point of being ineffective. Perhaps unsurprisingly, there are a plethora of data suggesting morale, happiness and satisfaction are at all-time lows. The 2019 Confidence Monitor Report6 found that a massive 86% of NHS dentists were unhappy or very unhappy across seven key areas. In contrast, the same survey found that 83% of private dentists were happy or very happy. The reasons for this stress? The perceived risk of complaints and litigation, as well as the ability to meet GDC standards. In 2022, Martin Kelleher drew attention to this in his paper How the General Dental Council and NHS UDAs crushed the compassion out of dentists, where he concluded: ‘Dentists are not saints and have never claimed to be. However, the combination of the government-imposed UDA contract, together with perceived fear of the GDC's draconian processes, have been highly effective at crushing compassion out of many NHS dentists. The GDC has helped to destroy patients' trust in dental professionals but has failed miserably to replace it with anything either measurable or worthwhile.

‘The perverse outcomes have been that many NHS dental clinicians are disillusioned and demotivated and many have run out of compassion. Sadly, they now don't trust the GDC, the government, or indeed, many of their patients, to be fair or reasonable or tolerant of even minor or unpredictable problems.

Having had the enforced downtime to reflect on things during the lockdown caused by COVID-19, is it any wonder that many dental professionals are reluctant to return to a hugely pressurised environment, involving many clinical difficulties, often unrealistic patient expectations, claustrophobic personal protective equipment and multiple personal risks, while having to watch their every step as they try to navigate a safe way through the dangerous GDC and NHS minefields?7

Next time say what you really think, Martin.

So the NHS working environment likely forces practitioners to consider alternative career pathways and directions. In this issue, the BDA's Ella Buckland assesses some of these trends, commenting: ‘But why are these [recruiting] difficulties arising? One of the main reasons cited by practice owners, was the reluctance among associates to work within the NHS/HS, with the proportion highlighting this as a difficulty when recruiting rising from 35% in 2018, to 72% in 2023. This shift among associates from NHS to private is mirrored by future career intentions and NHS commitment data, which found that over the last eight years, the proportion of associates wanting to increase the proportion of private work in the next five years increased from 34% in 2015, to 48% in 2023, and the proportion of associates in the sample treating 75% or more NHS patients, reduced from 67% in 2015 to 48% in 2023.'8

Allied to these BDA data, the GDC has asked registrants to account for their NHS/private split. Of the responding dentists, these data identified:

  • 97% are working in the dental sector. Less than 1% are seeking work

  • 88% are working primarily as a dentist, and a further 9% are working as a specialist

  • 52% are self-employed/agency or working as a locum. Only 26% are employees

  • 85% are working predominantly (over 75%) or fully in clinical roles, with a further 10% undertaking a mix of clinical and non-clinical work

  • 42% work 30 hours a week or less

  • Around 70% work in a general or specialist dental practice. 7% work in a dental hospital, 5% in a hospital and 5% in community dental services

  • 37% regularly work in more than one location, with 62% commonly working in one location

  • 19% provide only private care, with no NHS, and a further 14% said they worked predominantly (over 75% of their time) in private care

  • Only 15% of responding dentists are fully NHS, with no private care, and a further 27% said they worked predominantly (over 75% of their time) in NHS care.9

    ‘ One individual can only spread so far before thinning out to the point of being ineffective. Perhaps unsurprisingly, there are a plethora of data suggesting morale, happiness and satisfaction are at all-time lows'

It is the 19% of the workforce providing only private care with no NHS and the 15% providing only fully NHS with no private care that fascinates but perhaps shouldn't surprise. The most recent NASDAL (National Association of Specialist Dental Accountants and Lawyers) annual Benchmarking Report for the financial period, 2022/23 have shown:

  • Average associate remuneration is up for the second year in a row from £75,488 to £80,554, a 6.71% increase

  • A small increase in typical practice profits but smaller than inflation (from £172,291 in 2022 to £175,063 in 2023)

  • A reduction in private practice profit - a drop from £178,513 in 2022 to £175,800, but still returning to expected levels (2022 was higher due to the impact of the pandemic)

  • Differential of profitability between NHS and private practices - £17,893.

It is simply a more attractive place to work, financially and from a working pattern perspective. While data suggest the migration of the workforce from NHS to private is likely to continue, only time will tell whether this is sustainable, or perhaps be the final nail in the coffin for NHS dentistry.

Brexit, the pandemic, a less appealing career pathway precipitating a move to private dentistry (among others) - the challenges are stacking up. One of the future challenges any workforce planning needs to address is the apparent decision of practitioners to shift from full time to part time, essentially forcing those recruiting for roles to find two people per role. Whichever way you cut it, that's not sustainable.

In the 2019 Recruitment Whitepaper, data revealed from July 2017 to June 2019 across the UK the majority of the roles posted on BDJ Jobs were in mixed practice. Purely NHS roles had the fewest jobs posted and the response rate was highest for wholly private jobs. More part-time private associate jobs are posted than full-time whereas the opposite is true in NHS and mixed practices.3

In the 2021 Recruitment Whitepaper, response rates for roles advertised on BDJ Jobs were described as proof of anecdotal reports that dentists are increasingly looking for part-time work were true.4 Even prior to the pandemic, response rates for part-time roles were significantly above those for full-time positions. This became even more pronounced in the six months from June 2020, when part-time job response rates became even higher. In July 2020, the response rate was nearly double for part-time jobs compared to full-time. These trends that followed the resumption of routine dentistry have calmed, but part-time roles remain favoured. In 2023, there were 9,431 more full time positions advertised than part time positions. However, the part time roles received as many job views and applications, which demonstrates they're more popular with job seekers and a sustained pattern of career choice, either by design or default. The recent GDC work pattern data show 42% work 30 hours a week or less - an incredible section of the workforce.

Perhaps one of the predominant factors in this shift is the demographic changes to the dental profession. The number of female dentists has exploded in the past several decades. According to the GDC's most recent Registration Report of March 2024, 21,003 male dentists and 23,470 female dentists were registered.10 Looking at their 2022 Registration Statistical Report,11 you can see in Tables 1 and 2 the changing percentage of male to female dentists throughout the years.

Table 1 Female dentists and DCPs added to the register 2019 to 2022
Full size table
Table 2 Male dentists and DCPs added to the register 2019 to 2022
Full size table

While data may suggest that female dentists are more likely than their male counterparts to work part-time, society is changing, and with it so are parental leave laws. As the industry approaches parity between men and women dentists, domestic roles are generally becoming more egalitarian; men are becoming more actively involved in parenting and benefit from reducing their work hours.

Similarly to the demographic shift toward more female dentists, data indicate that the dental workforce is ageing. A higher proportion of older dentists remain at work relative to previous decades. This also means more semi-retired workers, who reduce their hours and fill the production gap with a part-time associate.

At the other end of the career spectrum, the shift toward more part-time dentist jobs may come from more than just the applicants. As new dentists graduate and enter the workforce, they may have an easier time landing a part-time position than full-time. Some practices offer part-time work to avoid providing the benefits that come with full-time positions, and today's generation are more aware of the risks of burnout and the necessity of a work/life balance than ever before. It truly is a myriad of reasons and factors.

Any answers available?

So, what's the answer? The NHS Long Term Workforce Plan seeks to expand dentistry training places by 40% so that there are more than 1,100 places by 2031/32, and to explore measures such as a tie-in period to encourage dentists to spend a minimum proportion of their time delivering NHS care in the years following graduation.12 Set against what the BDA describes as a backdrop of over half of dentists saying they have cut their NHS commitment since the pandemic - and many more state their intention to reduce - or further reduce - their NHS work, one questions these pearls of wisdom. In fact, I have yet to encounter any positivity about the Plan's visions for dentistry.

And then there's the recent NHS Dental Recovery Plan.13 Entitled Faster, simpler and fairer: our plan to recover and reform NHS dentistry, like its workforce predecessor, I am yet to encounter any pleasantries towards the Plan. Chair of the General Dental Practice Committee Shawn Charlwood has described it as ‘not really ‘Faster, Simpler or Fairer' and not worthy of the title, which tickled me, but is also a sad indictment on the political playing field dentistry finds itself in. Exaggerations, misdirection and plain untruths a plenty from the Government have all been met with strong rebuttals from the BDA, and this document is no different. Recently Chair of the All-Party Parliamentary Group on Dentistry and Oral Health, Yasmin Qureshi MP, exposed Secretary of State Victoria Atkins for misleading the House with inaccurate claims that the Plan is funded by £200m in ‘new' money.

When launching the NHS Dentistry Recovery Plan, Victoria Atkins repeatedly assured the House that the Plan was backed by £200m of new funding. ‘There is £200 million on top of the £3 billion that we already spend on NHS dentistry in England', she said. Qureshi then quoted Atkins in the House during a debate, stating: ‘She made it very clear, adding: ‘This is additional money. I have prioritised dentistry across the board, but this is £200 million of additional money - in addition to the £3 billion that we spend in England.'

Under questioning, Minister for Primary Care Andrea Leadsom MP told the Health and Social Care Committee that the Plan was not, in fact, backed by any additional investment. Leadsom also told the Committee that the modelling behind claims on ‘millions' of new appointments the Plan will supposedly generate had ‘quite a high likelihood of not being reliable.'

On to the actual detail of the Plan, and it's no better. Take the 240 golden hellos available to dentists willing to work in areas where there are the worst recruitment issues, for example. The areas where they have been offered have not yet been set out at the time of writing, and that 240 number is around 1% of the NHS headcount in England. While they will be worth £20,000, it is the BDA's understanding that these will be paid over three years, with £10,000 in year one and £5,000 in the second and third years. Funds may be clawed back if the dentist does not continue to work on the NHS in the given area for three years.

Speaking of funds, the Plan commits to ringfencing the dental budget. Given the track record on such a statement, it's worth taking that with a pinch of salt. In all likelihood, no answers there. What about elsewhere?

In 2021, Health Education England's Advancing Dental Care (ADC) Review Report was published.14 The culmination of a three-year review to identify and develop a future dental education and training infrastructure that produces a skilled multi-professional oral healthcare workforce, which can best support patient and population needs within the NHS, the report made a number of proposals, including:

Skills development

  • Giving trainees diverse experience of managing complex care, co-morbidities, and a stronger understanding of the communities they serve in changing care models and pathways

  • Better use of the skill mix of the dental workforce and multi-disciplinary team working

  • Options for qualified dentists and dental care professionals to increase their knowledge and skills and develop new capabilities and competence, including leadership, management and research.

Widening access and participation

  • More flexible entry routes into training, to widen access and participation and develop more dental professionals in areas of greatest need

  • Supporting the development of apprenticeships to diversify and promote the concept of a local dental workforce approach

  • Co-ordination and distribution of postgraduate training posts, so that it is better aligned to areas with the highest levels of oral health inequalities.

Flexible working

  • Flexible models of Dental Core and Specialty Training to support workforce retention and career progression and an equitable distribution of postgraduate dental training places

  • Digital and blended learning opportunities to deliver dental education and training

  • Options for less than full time training and career breaks, which can support differing lifestyles and wellbeing of trainees.

The Report's aim in 2021 was to work across a four-year period to develop and deliver these recommendations. Well, 2025 isn't far away, and it will be fascinating to see how far and to what extent any of these proposals have been a success.

Maybe the answer lies in the Health and Social Care Committee's report into NHS dentistry, published in 2023.15 While eerily similar to recommendations made in a previous iteration, it was described as ‘being an instruction manual to save NHS dentistry'.16 The report called for fundamental reform of the failed NHS contract - not seen in the Dental Recovery Plan, placing greater emphasis on prevention and moving away from the discredited target system to a one of weighted capitation whereby dentists are rewarded for maintaining and improving their patients' oral health - also not seen in the Dental Recovery Plan. The report did call for permanent ringfencing of the dental budget, which is in the Plan, but the discrepancies between the Committee's report and the Plan put forward by Government are stark.

Conclusion

It is incredibly difficult to see past Evans et al's belief that the problem lies within NHS dentistry, not UK dentistry. This distorts the question posed here about where the balance of power lies in today's recruitment market, to an extent. There is no clear indication that job seekers looking for roles within the private sector encounter any or many of these issues; there is, however, a clear indication that practitioners making the transition from NHS to private are doing so as a result of these problems. If I'm a job seeker and I'm on the hunt for a new role, an NHS role would have to offer me too-good-to-be-true-esq terms in order for me to accept. Would an extra £20,000 over three years do that? Maybe, maybe not. Would systematic reform of NHS dentistry do that? Yes, that's more likely, for it would be a more appealing environment in which to operate. There is no point in beating around the bush here - private roles will likely see the balance of power lie with the recruiter, while NHS roles will likely see that balance tip the other way. Some of the solutions put forward to address and redress this balance on the face of it seem to be wild geese chases where you're more likely to see one of said geese lay a golden egg. Yes, there is no silver bullet to make these problems disappear, but dentistry deserves better than the bronze medal attention to detail it has received to date.

If more and more practitioners seek part time work, reduce their NHS commitment to move to the private sector - or leave the profession altogether - there may be no such thing as NHS dentistry left to discuss. ‘Oh David, come on, you're finishing on such hyperbole', I hear you scream. Maybe, but what's the alternative path? How does this story end? NHS dentistry is always likely to be here, but there's no escaping the fact these problems discussed - and a whole host not discussed - are precipitating a squeeze on Health Service provisions. Whispers in quiet corridors and in dark corners suspect the squeeze is a deliberate tactic. If that is the case, the recruitment market balance of power will most definitely mirror the provisions of dentistry in the UK, split between NHS, mixed and private, each with their own unique dynamic, each draining from the other. ◆