Two differing schemes, one a skilled worker visa and the other provisional registration, are designed to facilitate a wider range of candidates for hard-to-fill jobs; Caroline Holland reports.

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The employment of overseas qualified dentists and dental care professionals (DCPs) is complex. On the one hand, government wants to limit migration, on the other, there are services and industries where recruitment is a problem, not least in dentistry.

The option of applying for a skilled worker visa is an established scheme widening the pool of dental hygienists and dental nurses in the UK. Dental practices can obtain a sponsor licence1 which enables them to issue certificates of sponsorship visas for appropriately qualified professionals. Hundreds of DCPs have already been sponsored to move to the UK. As health and care workers, they must be guaranteed a minimum income which depends on the level at which they are being recruited.

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©SiberianArt/iStock/Getty Images Plus

Kim Day, founder of the Sheffield-based agency White Rose Visas, believes the scheme is a great option for tackling the recruitment crisis in dentistry; her agency is advising dental practices all over England and Wales, primarily in the South of England and the Northwest. She estimates that for every one dentist, nine DCPs are being sponsored, mostly dental nurses, but dental hygienists too.

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Kim Day

An electronic certificate, the C-o-S, has a unique number which authorises the chosen candidate to apply for a visa as a Skilled Worker in the Health and Care Worker category. To obtain a sponsor licence, businesses must pay a one-off fee to the Home Office - £536 for smaller businesses. The sponsor licence is then valid indefinitely with the only ongoing cost being £239 per C-o-S issued plus the immigration skills charge of £364 per year of visa sponsorship.

White Rose Visas has helped three dental groups as well as at least 50 dental practices who have recruited staff from countries such as Greece, Hungary, South Africa, Pakistan and India. Kim says: ‘Dentistry is a good area to work in because of the shortage of staff since Brexit. We enjoy working with dentists because they are used to compliance and run their businesses well.'

But, she says, dentists are short on time and need support or they risk getting into difficulty. The Home Office carries out regular audits to check that licence holders are complying with all requirements and will withdraw a licence if the sponsor breaches any rules.

Some practices rush into sponsorship and struggle with the paperwork, according to Kim, and everything has to be unpicked by her team. It is far better to put matters right with the Home Office, rather than having non-compliance spotted in an audit.

Dental nurses working as trainees

All candidates must be registered with the General Dental Council (GDC) with the exception of dental nurses in training who may be able to work under supervision prior to achieving their qualification. Employers must ensure the dental nurse is receiving the training so that they will become qualified and registered with the GDC.2

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Ikram Malik

Ikram Malik, a specialist immigration lawyer with Brabners, described the benefits of the scheme at the most recent meeting of NASDAL, the association of dental specialist accountants and lawyers, which advises dental practices. Being able to recruit overseas widens the pool of candidates, he says, and because sponsorship is for a five-year period, it helps with staff retention.

Nathan Poole, of business advisors and accountancy firm Ross Brooke Dental, said the C-o-S was worth considering in areas where dental practices are struggling to recruit.3 Dentists with NHS contracts have to do everything they can to fulfil their contracts and finding candidates from overseas to fill posts might be the only option.

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Nathan Poole

Provisional registration

The issue of provisional registration is equally topical but more complex and is currently geared to dentists. The government's policy document ‘Faster, simpler and fairer: our plan to recover and reform NHS dentistry'4 is an attempt to sort out the challenges of access to NHS dentistry by, among other things, making it easier for dentists to work here.

Provisional registration will allow dentists with overseas qualifications who have not yet passed the ORE (Overseas Registration Examination) to work under the supervision of a GDC registered dental professional until they achieve full registration. A Department of Health and Social Care consultation5 suggests that the minimum entry requirement for provisional registration would be an overseas dental diploma, but that the GDC could specify additional requirements as conditions of entry.

The consultation received mixed responses with most organisations broadly welcoming the move, but some with caveats. For the GDC, Stefan Czerniawski, Executive Director for Strategy, said: ‘The government's proposal for provisional registration represents the most substantial change to dental regulation in many years. It is essential that it is introduced in a way which protects patient safety and provides effective support and supervision for the internationally qualified dentists who become provisional registrants.

‘Putting the enabling legislation in place is the essential first step, but there will then be a great deal more detailed work to be done, in close collaboration with other organisations across dentistry, to design, develop and implement a system to deliver provisional registration in practice.'

Collaboration appears to be a theme. Earlier this year the General Dental Council (GDC) shared the view that responsibility for the problems in NHS dentistry can only be solved collaboratively. In an eloquently worded report6 on immigration, outlining the pressure on international registration routes, the GDC stated: ‘Sustained work is needed across the dental sector by everybody involved in the provision of dental services to ensure that capacity and need are better aligned than they are today'.

The GDC is under pressure from all sides since dentists and DCPs who move to the UK must be on their registers and those who move here from anywhere except the Economic European Area (EEA) need to pass the Overseas Registration Examination (ORE), for which there has been limited capacity, which has now been addressed.

The British Dental Association (BDA) Chairman Eddie Crouch said the BDA welcomes the concept of provisional registration, but it will need extensive work to ensure the safety of patients and the dental teams involved in future implementation. He said the association was not convinced that it was the answer to all the problems facing NHS dentistry - nevertheless the BDA was looking at ways to widen its offering to dentists moving to the UK.

The BDA Chairman Eddie Crouch said the BDA welcomes the concept of provisional registration, but it will need extensive work to ensure the safety of patients and the dental teams involved in future implementation.

On the issue of dentists taking on supervisory roles, there were potential pitfalls, said Eddie, and it was important for dentists to understand the challenges that came with the role. Colleagues trained abroad might have enjoyed a very different training from their own and need support in adjusting to working in the UK, from the regulatory structure to patient communication.

Stephen Henderson, an independent dental advisor and former head of dental, MDDUS [Medical & Dental Defence Union of Scotland], also stressed the challenges that might lie ahead when advising clinicians whose training and cultural mores might vary greatly. In particular, he said that the expectations of patients giving consent in the UK were likely to be very unfamiliar to dentists who have trained overseas where a more paternalistic approach is normal. He predicted a lot of work still needed to happen to make provisional registration a reality.

He referenced research7 commissioned by the GDC examining Fitness to Practise data and carried out at the University of Plymouth; it found that male dentists from overseas were statistically more likely to face disciplinary procedures than other registrants. While more research needs to be done in this area, it could illustrate that encouraging overseas dentists to work here under provisional registration is not the quick solution that the government is looking for.

The Association of Dental Groups (ADG) is positive about provisional registration; CEO Neil Carmichael pointed out that the UK had the lowest number of dentists per capita in the developed world, commenting: ‘We need to recruit from abroad and we always have done. We need to make it easier.'

He said dental groups are exactly the right place for supporting provisional registration because they have the structure and framework. But he expressed his frustration with the process, saying the consultation was simplistic and there needed to be another consultation to understand how provisional registration might work. ‘In fairness to the General Dental Council, I do not think they thought that provisional registration would be thrust upon them so quickly.

‘We have to recruit at every level of dentistry. We are short of dental therapists, hygienists and nurses and they are key to the care of patients.'

The indemnity organisations have also identified potential problems with the scheme, warning that it should not be rushed through. John Makin, head of the Dental Defence Union (DDU), said: ‘Our chief concerns centre on the practicalities of adequately assessing the capabilities and any learning needs of overseas colleagues seeking provisional registration and securing sufficient appropriately trained supervisors and mentors with adequate time (particularly if they themselves are endeavouring to meet NHS targets) to oversee and sign off the period of provisional registration.'

He said that the DDU had a number of members who are GDC registered DCPs, many of whom are overseas qualified dentists. This route to registration was closed in March of last year which resulted in a surge of applications ahead of the deadline. He said that two thirds of the 3,300 applications from dentists wanting to work as a dental therapist or hygienist in 2023 were received in the week before closure of that route.

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John Makin

John Makin continues: ‘Clearly, well organised and properly constituted programmes of support, mentoring and supervision can and do meet the learning needs of the mentee. The skill set required to be an effective mentor is not something necessarily possessed by all registrants, even those with long-standing clinical experience. The educational “train the trainer” programmes such as those run over many years in Foundation and vocational training programmes UK-wide show the level of educational input required to produce an effective mentor.

‘It was disappointing to see that in April 2023 the PLVE schemes (Performers List Validation by Experience), many of which were well run and highly effective, were replaced by a “structured conversation” with a dental adviser leading to the offer of an educational/clinical support plan (ESCP). It is too early to determine the impact of this change.'

The DCP representative organisations I spoke to are also wary. Debbie Hemington, President of the British Association of Dental Therapists (BADT) pointed out that there is no shortage of dental therapists (DTs) looking for a job, but there is a shortage of DTs willing to work in high street NHS dentistry.

Not all countries train dental therapists, she said, and the scope of practice can vary from one country to another. DTs recruited from overseas might face additional requirements. While BADT now has a commitment that DTs will be allowed to supply and administer some medications and be able to open a course of treatment, there is no offer yet of a NHS pension, despite DTs being able to do 80% of the Band 2 work that is in a dentist's scope of practice.

Lesley has concerns for any dental nurses recruited from overseas with expectations of what working in this country might entail. They might feel very isolated and may need support and mentoring to adjust.

Lesley Redman, Chair of the Society of British Dental Nurses (SBDN), says there are more than 62,000 dental nurses currently on the GDC's register. Perhaps recruitment would not be such an issue if working conditions were better, she says. The SBDN regularly surveys their members and until last year, most respondents said that the reason they intended to leave dental nursing was because they weren't valued, closely followed by being poorly remunerated. Last year, there was a shift, the top reason was remuneration. What she would like to happen is for all high street dental practices to have appropriate levels of pay for dental nurses and to value what they do.

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Lesley Redman

Lesley has concerns for any dental nurses recruited from overseas with expectations of what working in this country might entail. They might feel very isolated and may need support and mentoring to adjust.

Meanwhile dentists who move to the UK from overseas need to be appropriately trained to understand the role and responsibilities of the dental nurses who work alongside them. Without the overseas dentist being adequately inducted and the dental nurse being appropriately trained, patient care might be compromised.

Joan Hatchard, Honorary President of the British Association of Dental Nurses (BADN), said: ‘The GDC have confirmed to me that dental nurses from non-EEA countries will have to undergo independent assessment of their qualification. Registration (requiring individual assessment) as a DCP with an overseas qualification costs a total of £549.09, comprising £36.33 for processing and a £512.76 assessment fee.'

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Joan Hatchard

The schemes outlined here do not appear to address the profound challenges at the heart of the current recruitment and retention crisis. Those I spoke to were categorical that changes to the NHS contract need to happen and were hopeful that the 4 July general election, announced while I was writing the article, will ensure that in the future, there will be a system that works for patients and the profession, with consideration given to the role and needs of the whole dental team.