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Deborah Evans

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© SDG icon credit: https://www.un.org/sustainabledevelopment

Continuing with our cover series on the UN's Sustainable Development Goals (SDGs), we reach SDG 8: Decent Work and Economic Growth. On this issue's cover, we attempt to illustrate the ongoing wariness surrounding the NHS dental contract, as more and more practices are withdrawing from the NHS altogether and time is running out to close on a solution. Deborah Evans, Ian Mills and Sally Hanks discuss SDG 8 via the debate surrounding whether the NHS Long Term Workforce Plan can deliver the necessary improvements in dentistry required to address current oral health inequality and provide decent working conditions for the dental workforce.

The United Nations Sustainable Development Goals (UN SDGs) project,1 in particular SDG 8, calls for a future promoting inclusive and sustainable economic growth, as well as full and productive employment with appropriate work for all.

SDG 8 sets out a series of admirable and ambitious goals, and highlights serious concerns in relation to forced labour, slavery and human trafficking. The UK is not unaffected by such issues, but it is important to maintain a sense of perspective, particularly when discussing workforce challenges in dentistry.

Recruitment and retention (R&R) of the dental workforce has been identified as a critical factor in sustaining a viable NHS dental service, and the government has recently published the NHS Long Term Workforce Plan (LTWP).2

This paper reflects on the LTWP and how this might align with the UN SDG 8.

NHS recruitment and retention

Evidence suggests that the required improvements in R&R of the dental workforce are intrinsically linked to dental contract reform.3,4,5 The existing contract does not currently align with the notion of 'decent' working conditions from the dental workforce's perspective, with sources stating that dentists are 'deeply discontent'5 and that the contract is 'driving people out of the profession'.3

An increase in the number of dental care professionals, as suggested by the LTWP, is to be welcomed, but is likely to have minimal impact unless it is developed in conjunction with contract reform. If the dental contract along with its associated problems are not fixed,6 then the dental profession will no doubt continue to walk away. This will impact the vulnerable and disadvantaged in society who often find it most difficult to access dental care, thus exacerbating existing oral health inequality.

Other major problems impacting R&R within NHS dentistry include the level of government funding, which has reduced in real terms by 29% since 2010.7 Financial remuneration is important; however, there are other important factors in maintaining a motivated and committed workforce. Members of the dental team need ultimately to feel valued, have personal and professional fulfilment, job satisfaction and support8 - as per the vision of the UN SDG 8.1

These are areas which have become increasingly difficult to achieve within NHS dentistry, largely due to the lack of investment.7 The private sector has greater flexibility in terms of staff investment, and this advantage is highlighted by dentists continuing to leave the NHS to work privately.3

The LTWP must be operationalised to ensure that as well as increasing the numbers of dental training places, the NHS provides a decent working environment which supports the needs of the profession and their patients.

Within this context, how can the LTWP begin to be effective?

Decent work and inclusivity

The LTWP includes a proposal of an NHS 'tie-in period to encourage dentists to spend a minimum proportion of their time delivering NHS care in the years following graduation'.2

However, any attempt to force new dental graduates to work within the current unpopular NHS system8 could have negative consequences, unless the underlying issues are addressed through contract reform to create improvements in working conditions. The British Dental Association has been highly critical of the 'tie-in' plan, and has described this as 'the Government's last attempt to fill a leaky bucket'.9

An increase in the number of dental care professionals, as suggested by the LTWP, is to be welcomed, but is likely to have minimal impact unless it is developed in conjunction with contract reform...

The motivating factors which influence the dental workforce to remain within the NHS have become increasingly tenuous. Financial stability, NHS pensions, and long-term security have been lost, with the fear of private conversion markedly reduced.8 Should an NHS tie-in be introduced for new graduates, it is likely to require significant benefits to make it attractive; for example, embedding training opportunities and professional development, in addition to service provision.

Should the NHS wish to embrace the UN's call to action, careful thought needs to be given as to how to recruit and retain the workforce through voluntary means. A voluntary form of enlistment for dentists post-graduation, including enhanced financial support throughout training, may be an attractive prospect and may support inclusivity in initial recruitment into the profession.

An alternative plan for recovery

The Advancing Dental Care Review published by Health Education England makes many excellent recommendations10 in line with, and in addition to, the LTWP. These include supporting the retention of trainees by restructuring education via flexible training; establishment of integrated Centres for Dental Development to provide training opportunities in areas remote from dental schools; and apprenticeship schemes to promote a local dental workforce.10 These recommendations have the potential to align more closely with SDG 8 and improve patient access to dental services.10

Further recommendations include simplifying the recognition process for overseas dentists,11 increasing overall funding within dentistry for new and established dental schools,12 and utilising the skills of our existing workforce effectively.8 This will not only increase productivity and patient access, but will also provide more fulfilling opportunities for the whole dental team.13

The contractual changes introduced in July 2022 in England included an element supporting more effective use of skill mix. However, this appears to have had limited impact on NHS access, oral health inequality, or improvement in R&R of the NHS workforce.8

Conclusion

The LTWP has the potential to positively influence the future of NHS dentistry with a substantial increase in the number of training places for dental professionals. However, the potential effectiveness of this strategy will be undermined unless it is aligned with radical dental system reform.

Dental system reform needs to enable development of a decent working environment which supports and values the dental team, so aligning with SDG 8. Pursuance of a tie-in for graduates needs to be carefully considered and, if adopted, might focus on a voluntary model with significant benefits, to encourage long-term commitment and retention within the NHS.

We have highlighted areas where the LTWP could support more closely the UN SDG 8, enhancing sustainability and productivity of the workforce. This could ultimately improve patient access, standards of care, and lead to a reduction in oral health inequality.