Introduction

Access to NHS dental services in the UK is currently reduced, particularly in England, with demand massively outstripping capacity.1 Recruitment and retention (R&R) in NHS dentistry has been highlighted as an issue of concern2 and has been a chronic problem in certain areas for many years, exacerbated by the COVID-19 pandemic.3

It has been reported that staff morale dramatically declined during the pandemic,4 with high levels of stress and burnout.5 There is evidence that the impact has increased the number of dental professionals leaving the profession, through early retirement or a change in career.6 Workforce data revealed that more than 2,500 dentists across England and Wales ended their NHS roles in 2021.2

A report by the Association of Dental Groups has identified rural areas as a matter of concern, with Lincolnshire, Cumbria and the South West Peninsula experiencing specific challenges in NHS access.3 The Chief Medical Officer for England recently highlighted the health inequality which exists within rural and coastal (R&C) communities. Coastal communities are of particular concern because of the high burden of health inequalities and low levels of policy and research attention.7 Many factors affect access to NHS dentistry but the R&R of dentists is undoubtedly contributing to the problem.7 This is particularly challenging for R&C practices where recruitment is a longstanding issue.8

Most research into R&R in rural areas has been conducted in Australia, America and Canada. Remote areas of the UK are geographically less isolated and potentially face different challenges compared to those explored in the international literature international literature.

R&R in dentistry has been brought into focus within the UK recently due to severe problems of NHS access. General Dental Council (GDC) data regarding the number of dentist registrants are likely to be flawed,9 as they fail to reflect changes in working patterns, with increasing numbers of dentists working part-time.10

Immediate and long-term solutions are being widely discussed but there is currently a paucity of high-quality research. It is important to identify what evidence exists on R&R in UK dentistry to inform future workforce decisions.

Aim and objectives

The aim was to explore what is known or unknown about R&R in the dental workforce in the UK, with particular attention given to R&C areas. The objectives were constructed around five focused questions, used to guide the selection of results, the extraction of data and the presentation of the findings:

  1. 1.

    What factors affect R&R in the dental workforce in the UK?

  2. 2.

    What do we know about the current geographical distribution of the dental workforce across the UK?

  3. 3.

    What are the anticipated challenges to R&R in the dental workforce in the UK?

  4. 4.

    What strategies are there to assist workforce planning in the UK?

  5. 5.

    What is the extent of empirical research in this field?

In order to reflect the current situation, this review was limited to evidence from the past five years, as it would include recent external events, such as the COVID-19 pandemic and Brexit.

Methods

To answer these questions, we undertook a scoping review, a method of evidence synthesis used to explore broad topics across wide varieties of literature and studies. Scoping reviews address wider questions than systematic reviews and incorporate a wider range of evidence, such as reports and opinion pieces. For this reason, scoping reviews typically do not include a critical appraisal of the included items.11 Scoping review methodology has developed over recent years,12 and we followed the guidance by Peters et al.13

Protocol and registration

The protocol was developed a priori in accordance with the Joanna Briggs Institute guidelines for scoping review protocols,13 accessed at: https://osf.io/ctb7v/.

Eligibility criteria

All types of evidence, including empirical studies, secondary research, reports, opinion pieces and webpages, were considered. All categories of dental care professionals in primary or secondary care, privately or in the NHS, were considered. Inclusion criteria are described in Table 1.

Table 1 Inclusion and exclusion criteria
Full size table

Website searches

A number of websites were searched (see Box 1).

Literature searches

Three bibliographic databases were searched: Scopus (Elsevier), Web of Science (Clarivate) and Dentistry and Oral Sciences Source (EBSCOhost). The search strategy comprised terms for dental care professionals, recruitment and retention, and the UK. Searches were undertaken by an information specialist. Results were deduplicated in EndNote and transferred to Rayyan for screening.14

Selection of sources of evidence

All results were single screened against the eligibility criteria by the lead author (DE).

Data items

The following data items were extracted: author; year; type of evidence; factors affecting recruitment or retention; geographical distribution of dental professionals; future challenges to the workforce; and strategies, recommended or implemented.

Critical appraisal of individual sources of evidence

No critical appraisal was undertaken. Critical appraisal is an essential component of systematic reviewing, especially for clinical research into efficacy of interventions. This has less merit in scoping reviews, where the aim is to explore broad conceptual questions across a range of evidence types.15

Synthesis of results

The findings are synthesised narratively and presented to address each question in turn.

Results

What factors affect recruitment and retention in the dental workforce in the UK?

Factors affecting R&R in the dental workforce were widely discussed in the literature:

  1. 1.

    The NHS Units of Dental Activity contract was deemed the most common factor in England,5,16,17 including its associated workload.18The literature pointed to a relationship between stress-related R&R issues and the NHS working environment,19 reporting that stress and burnout commonly affects dentists across the UK.20 This was widely corroborated, with sources stating that dentists are 'deeply discontent with the NHS primary care systems' in England17 and are 'fed up with a system that is fundamentally flawed'.21 Ultimately, it was found that, in England, the contract is 'driving people out of the profession'5

  2. 2.

    Limited opportunities for career progression impacts retention, particularly NHS dentists and dental nurses across both NHS and private sectors.10 One study found that many dentists working for NHS dental services were keen to upskill,17 but are discouraged by the lack of financial incentives under the NHS contract22

  3. 3.

    Financial factors include the increase in the cost of expenses and indemnity23 and the long-term reduction in income.24 Remuneration was also identified as an important factor in attracting and retaining dental hygienists and therapists.25 Dental nurses report feeling 'underpaid and undervalued'24 and the feeling of being undervalued was commonly noted across the dental workforce.2 Many also expressed worries about costly and stressful litigation.21Financial factors were also found at the systems level.26 In England, government funding has reduced in real terms by 29% since 201027 and dentistry is the only part of the NHS now operating on a lower budget than previously28

  4. 4.

    Brexit and the pandemic were widely discussed, with issues including legislative uncertainty, the need for work permits and financial aspects.29 The number of European Union applicants entering the UK dental register fell from 1,249 in 2016-2017 to 686 in 2017-2018,29 the same year Article 50 was formally triggered.30 The decline continuing with only 357 applicants added to the register in 2020.31The situation deteriorated markedly in 2020 due to suspension of the Overseas Registration Examination (ORE) due to COVID restrictions.4 The ORE process was already under pressure and criticised for its effectiveness, capacity and laborious processes recognising overseas dentists2,32,33

  5. 5.

    Specific geographical challenges for rural and coastal areas have historically been more prevalent2 but some additional factors impact these locations:34

    • Poor transport links35

    • Urban prominence of dental schools, teaching hospitals and training opportunities23

    • The tendency for dentists to work within urban areas, where they have family ties36and personal connections23

    • Dentists often settle where they complete foundation training,35 coupled with a lack of R&C placements.37

What is the geographic distribution of the dental workforce across the UK?

An uneven geographical distribution of the dental workforceis highlighted within the literature and this maldistribution is not a new phenomenon.32,38 The National Audit Office reported that the UK has the fewest dentists per capita in Europe, with England having the fewest NHS primary care dentists per person.1 From 2020-2021, a fall in NHS dentist numbers was found in all regions in England,16 taking the headcount to its lowest level since 2013-2014.7 Further data suggest there are NHS dentist shortages across Wales.38 In Scotland, practice owners were unconfident staffing levels could be maintained and in Northern Ireland there is evidence dentists are leaving NHS dentistry.39

Workforce data and evidence submitted to the Health and Social Care Committee supports these findings, where nine in ten NHS practices across England were facing difficulties recruiting.2

Urban working preferences were noted and in 2018, an 'oversaturation of dentists in urban areas' was reported,18 particularly in London.40 A proposed explanation was that 22-23% of dental school applicants are from London41 and that students tend to return to their hometowns after graduating.42 Furthermore, 46% of speciality registrars chose London as their preferred location.

Locations with severe recruitment issues were Lincolnshire,21 Cornwall,43 Somerset,44 Scarborough, Hull and the Isle of Wight.45 Overall, the worst affected parts of the country were R&C areas.45 A practice in Barrow had permanent, unfilled vacancies for five years46 and a recruitment agency in Cumbria was unable to fill any vacancy in a 12-month period.47 There were many sources describing difficulties attracting the dental workforce to rural areas,2,24,38 and now major cities.7

A severe maldistribution of dentists across the UK was reported, especially affecting deprived and less populated communities.48

What are the anticipated challenges to recruitment and retention in the dental workforce in the UK?

Anticipated challengesto the future dental workforce include:

  1. 1.

    GDC data showed the number of registered dentists fell by 961 from 2021-2022.19 This impact is difficult to understand as the GDC does not collect information regarding how registrants work, for example, part-time, percentage NHS/private, or those on the register not currently practising clinically.49 This lack of workforce data was also discussed by Health Education England (HEE)50 and the British Dental Association (BDA)2

  2. 2.

    The pandemic has had a large influence on the challenges to R&R, by exacerbating existing problems and raising new issues:

    • The recruitment of dentists from outside Europe is a challenge, as they may not be able to complete their ORE in time.51 This is reportedly due to inflexible legislation and the pandemic backlog.4 It is believed that due to its limited capacity,32 the ORE will be unable to process the 2,000 waiting dentists4 before the strict legal time limit runs out51

    • During the pandemic, many dental professionals felt dentistry was less secure. A number of hygienists, therapists and technicians believed they would not be in their current roles in the next 12 months and younger professionals were considering career changes.6 In 2020, it was suggested that the worst effects of the pandemic on the mental health of the dental workforce was yet to materialise.52 A more recent source reinforced this, stating dentists were 'exhausted and demoralised'53

    • Exacerbation of limited NHS capacity,54 along with financial and workload pressures,55 contribute to the perception that NHS dentistry is an unattractive and stressful working environment,2 particularly if there is a requirement to work longer hours.52 These factors act as a driver to reduce NHS commitments and to work in private practice instead,22 where it was reported dentists feel there is less pressure.56

  3. 3.

    Change to working patterns with dentists not working clinically five days a week57

  4. 4.

    R&C issues, including young dentists' concerns regarding stress and wishing to work in urban areas with a perceived better quality of life,42 and that those wishing to undertake further training and hospital jobs locate near to teaching hospitals,35 mainly in urban areas.23

What strategies are there to assist workforce planning in the UK?

Strategies to assist workforce planningwere reviewed. There were many suggestions; however, few had been implemented:

  1. 1.

    In England, the Advancing dental care review by HEE aims to support retention by restructuring education to fit trainees' preferences, via flexible training.50 The development of 'integrated centres for dental development' was promoted, with hubs providing additional training opportunities in areas remote from dental schools,50 as well as apprenticeships to promote a local dental workforce58

  2. 2.

    Train more dental professionals, particularly in areas with poor access,32 commonly R&C.50 A number of sources also highlighted the need for more dental foundation trainers23 and a change in the competitive dental foundation training application process, to address uneven workforce distribution50

  3. 3.

    It was recognised that work engagement could reduce dental nurses' intentions to leave,59 by creating avenues for career progression60

  4. 4.

    National strategieswere proposed by the BDA, who 'urged the government to factor dentistry into its NHS plan',28 and The College of General Dentistry, to 'support workforce retention through its career pathways programme'.61It was also noted that the NHS recruited 'thousands of reservists';62 however, no evidence shows these resources in dentistry

  5. 5.

    Contract reform was the most frequently mentioned factor in England for improving conditions across the dental team5 and addressing recruitment problems.61 Workforce retention is considered 'intimately related' to the NHS contract63 and if there are no 'significant changes' introduced, the drift to private dentistry will continue22

  6. 6.

    After Brexit, commentators called for an easier system for assisting overseas dental professionals to practise in the UK. This would involve extending the recognition of qualifications32 and reforming the ORE.51 This has been partially addressed by the Professional Qualifications Act 2022,64 allowing countries to mutually recognise qualifications

  7. 7.

    Local level strategies have been implemented across several regions, such as the South West, including recruitment campaigns35 and funding for post-graduate courses.35 Joint initiatives with various local dental networks and authorities65 were also identified.

What is the extent of empirical research in this field?

Of the 73 included sources, most were editorial and opinion pieces (n = 37), often in dental publications. The audience were assumed to be mainly dentists working across the NHS and private sectors. The second largest proportion came from official reports and documents (n = 21). There was a limited amount of empirical research (n = 15): 13 quantitative and 2 qualitative.

The quantity and type of evidence identified provides some indication of the level of interest around R&R, but, unfortunately, with limited empirical research and inadequate statistical evidence and workforce data to support these discussions.

Many sources highlighted most R&R issues were associated with primary care NHS dentists, followed by dental nurses working across both the NHS and private sectors.

A summary of the evidencesources based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process is in Figure 1.66

Fig. 1
figure 1

PRISMA flow diagram showing the sources of evidence included in the review66

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Discussion

In 2019, it was stated that 'dentistry faces existential crisis'. Three years later, it is reported that only 'urgent change can save NHS dentistry'.60 This scoping review has focused on identifying current workforce R&R challenges facing UK dentistry, with a particular focus on R&C areas. The R&R of dental staff is critical in maintaining a viable dental service and failure to act quickly and decisively will cause irreversible damage to NHS dentistry.27

Escalating problems could be envisaged if more dentists move into private practice, with the impact felt by NHS patients and practices. NHS access for patients will be further compromised, and practices will have increased vacancies or may close completely.36 Issues such as Brexit, the pandemic and financial pressures, affect both NHS and private practices, but the latter has greater control in adapting. This is likely to lead to greater opportunities within the private sector, thereby accelerating the transition of dentists from the NHS.

This could further negatively impact how new graduates view the NHS,2 meaning they may migrate earlier in their careers to the private sector.56 Increased demand on private practices, due to the lack of NHS patient access, will then place additional pressures. The challenges of R&R may not be isolated to NHS practice and problems of recruitment within the private sector in rural areas has already been reported.1,45

Priority for rural and coastal areas will aid deprived communities with access to dental care and address inequalities.48,50 It was reported in Australia that to develop a stable healthcare system, the factors that influence R&R of dental practitioners in rural areas must be better understood.67 Although rural Australia is geographically more isolated than the UK, strategies there could still be explored in the UK,28 including: increased financial remuneration; the development of social bonds and an enjoyment of the rural lifestyle, achieved by integration via the rural placement of dental schools; placement programmes; and increasing career opportunities.67 The proposed 'integrated centres for dental development' by HEE,50 located in areas remote from dental schools, could provide training opportunities within R&C areas.50 This would obviate the need for dentists to locate themselves in urban areas23 and could increase the number of dental professionals in R&C and deprived communities.48,50

Government actions will be key to initiating and assisting the strategies found to improve R&R of the dental workforce in the UK.

Firstly, increasing overall funding within dentistry, as well as towards new and established dental schools, could prevent the falling projected numbers of the future workforce and 'increase reach and training in underserved areas'.19

Furthermore, altering the legislation to enable more overseas dentists to complete the ORE4,32 and simplifying the recognition process33 would ease this barrier to recruitment.

Undoubtedly, the most common factor affecting R&R of the dental workforce is the NHS working environment,19 in particular, the NHS contract in England.5,16,17 Contract reform would directly address many recruitment problems61 and aid retention of the existing workforce.63

The reform would also be an opportunity to improve professional fulfilment and retention. Dental therapists63 and nurses with additional qualifications are not recognised as 'performers' under the current contract. This is a barrier to NHS access, undermines team-working and compromises the provision of preventative oral health care.

Future research is necessary to inform long-term strategic decisions, but this must be supplemented by urgent action. Research should include an exploration of the influences on graduates' decisions, in particular, location choices, to better understand the barriers, drivers and facilitators informing career choices. This is particularly relevant in R&C areas to address geographic inequalities.67

Secondly, there is a 'need for reliable contemporaneous workforce data', to allow full understanding of the problem50 and help predict the future workforce numbers needed.

Addressing these knowledge gaps, gaining more qualitative data and performing longitudinal studies would ensure that future R&R interventions can be more effective and target areas with the greatest needs. Ensuring collaboration across multiple stakeholders and joint working would produce both short- and long-term strategies that are paramount in improving the R&R of the dental workforce in the UK.

Limitations

Inevitably, reviews are constrained by the extent and nature of the literature. In this instance, there was a limited amount of empirical research, with most documents being from grey literature sources and with a lot being commentaries or similar. In addition, while the five-year timeframe we chose for the review ensured a focus on current workforce issues, it may have limited our access to longer-term concerns. It was also found that many evidence sources discussed R&R issues affecting dentists only and not the rest of the dental team, as well as a number of evidence sources discussing issues within England and not the rest of the UK. Finally, the review focused on workforce issues across the whole UK and it is acknowledged that there may be specific issues or initiatives at local levels that merit further attention.

Conclusions

This review has identified the key current challenges for the R&R of the dental workforce in the UK. Within the literature, the perilous state of NHS dentistry is widely acknowledged; although there appears to have been little progress in addressing the underlying issues. Further delays will undoubtedly impact on patient care, leading to a deterioration in oral health and unnecessary suffering for many. This will predominantly affect the most vulnerable in society, resulting in greater oral health inequality.

Our review also found that the situation appears to be particularly acute within R&C areas, but data needs to be collected and analysed to provide a better understanding. Well-informed, evidence-based decisions are essential in mapping out the future of dentistry in the UK, but this must not delay immediate action at a local, regional and national level.