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Evidence to the Review Body on Doctors’ and Dentists’ Remuneration for 2017/18

September 2016

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Contents Page Introduction 3

Response to last year’s report 3 Targeting Awards 4 Policy updates from UK countries 4

Review Body requests 10 General Dental Practice 11

Taxable income for GDPs in the UK 11 Morale and motivation of GDPs 16 Satisfaction with the NHS 22

Recruitment and retention of GDPs 22

Practice staff costs 26

Recommendations for UK general dental practice 26

Community dental services 27

Workforce data 27

Environment in which the CDS finds itself 29

Motivation and morale 32

Northern Ireland CDS update 33

Conclusion 34

Recommendations for pay in the Community Dental Services 34 Clinical academic staff 35

Overall conclusions 36

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1. Introduction 1.1 The British Dental Association (BDA) is the professional association and trade union for

dentists practising in the UK. Its membership is engaged in all aspects of dentistry including general practice, community dental services, the armed forces, hospitals, academia and research, and includes dental students. Every year the BDA provides evidence to the DDRB covering general dental practitioners, community dentists/salaried practitioners and clinical academic staff. References in this report to the NHS should also be taken to apply to the Health Service in Northern Ireland unless indicated otherwise in the text. NHS England now refers to salaried primary dental care services as ‘community dental services’ and the latter term is used in this evidence, except for Scotland, where the service is called the ‘Public Dental Service’.

1.2 In 2016/17 the Review Body recommended an increase of 1 per cent to general dental

practitioners’ income, net of expenses, and for salaried dentists, a base increase of 1 per cent to the national salary scales. Applying the Consumer Price Index (CPI) to the usual weightings for expenses equated to a 0.7 per cent uplift to the overall value of primary dental services contract payments in England for 2016/17. This meagre uplift and other inadequate uplifts across the UK have done nothing to address – let alone reverse – the significant decrease in general dental practitioner (GDP) taxable income that has occurred over the last five years. The continued erosion of dentists’ remuneration is having a devastating effect on the morale of the profession, the reinvestment in facilities and ultimately the care that NHS practitioners can provide.

1.3 In the year of the 10th anniversary of the GDP contract in England and Wales – a contract that has failed abjectly in its attempts to improve access and reward preventive work – the Review Body’s paltry pay uplift constituted a severe blow.

2. Response to last year’s report 2.1 The BDA and the profession in general was deeply disappointed in the recommendations

made by the Review Body in its 44th Report. We commented last year that acting within public sector pay policies gives the Review Body little room for manoeuvre to fulfil its remit for dentists and, as such, has little opportunity to respond genuinely to the evidence submitted. We were compelled once more to question our participation in a process that we have long believed to be of value.

2.2 We agree with the Review Body on the need for all parties to submit evidence to schedule in

order to allow sufficient time for them to digest and comment on each other’s evidence.

2.3 We expressed our disappointment last year over the abandonment of the formula and note that in its 44th Report the Review Body did not rule out a return to the formula. We hope that a robust data set will soon be found to support a formula-based approach for GDPs. We have attempted to engage the Department of Health (DH) and NHS England in discussions about expenses but neither party was able to engage formally prior to the issue of the DH remit letter. This lack of enthusiasm on the part of the DH and NHS England suits them in assisting the Treasury. A separate approach to obtaining data is being pursued in Scotland.

2.4 The DH has confirmed that it will use the CPI as its index for inflation in England. It is

important to note that when expenses are not remunerated, this has an effect on dentists’

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overall income. If dentists are underpaid on expenses, this means that the 1 per cent pay rise is not actualised.

2.5 Taking into account the above, the BDA continues to believe in an independent pay review

process.

3. Targeting awards 3.1 In principle we are opposed to targeting as we do not believe that it has any value in this

process. We note that the Review Body did not consider it appropriate to implement targeting this year. In the evidence provided to the Review Body for this round, all parties recommended against targeting for 2016/17. We are concerned that the Review Body has not precluded targeting in future years.

3.2 We strongly believe that the Review Body should recommend a pay uplift for all its remit

groups and that targeting would have a detrimental effect on morale, motivation and retention. We do not support the targeting of awards between countries. GDPs in all four countries have experienced similar reductions in taxable income and should receive the same pay uplift. There is no difference in recruitment and retention issues for community dentists and salaried practitioners in each of the countries and we do not wish to create any more differences in pay between the four countries.

3.3 NHS England is already able to target contracts and spending to areas where new dental

services are needed, so additional targeting of spending is unnecessary. Targeting rises away from dentists may also affect the numbers of dentists who tender for contracts, given that it will be clear where the priorities are. This issue also affects dentists in Wales.

3.4 If the Review Body were to target resources away from dentists and towards GPs in

England, for example, this would ignore the very significant resources put into GP services by NHS England and it would ignore the evidence of recruitment issues for dentists that we discuss in paragraph 6.27. Primary care dentists have the option to move from NHS to private practice and NHS practice owners themselves are increasingly opting to either sell their practices or terminate NHS contracts and convert to private practice. In England, from data published in relation to the NHS Friends and Family Test, we know that the number of NHS practice locations is falling; from 7,228 in June 2015 to 7,151 in June 2016 and we would expect this fall to continue.

4. Policy updates from UK countries

UK General Dental Council (GDC) increase in the Annual Retention Fee (ARF) 4.1 In December 2014 the GDC increased the ARF for dentists by 55 per cent, from £576 to

£890, despite the BDA’s judicial review having found the GDC’s consultation on the 2015 ARF unlawful. In November 2015 the BDA responded to the GDC’s consultation on the dentist and dental care professional ARF level for 2016, arguing for a reduction in the ARF and expressing concerns about the data provided. The BDA argued that the GDC should set the ARF for dentists in 2016 at a figure not exceeding £500, and then set about making further substantial reductions in 2017. However, the GDC decided that the ARF in 2016 would remain at £890, thereby continuing to stretch dentists’ already taut personal finances. We anticipate that the GDC will seek to maintain the fee at the same high level in

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2017. At £890, the dentists’ ARF is over double that of the doctors’ (£425). In addition to this colossal expense, one of the defence organisations informed us that in the UK indemnity fees for practice owners and associates had increased by 9.9 per cent from 2015/16 to 2016/17.

England and Wales

Dental contract reform 4.2 To commemorate the 10th anniversary of the GDP contract in England and Wales and to

ascertain the views of BDA members on the contract, a survey was sent out in February 2016 to all general dental practitioner BDA members in England and Wales. The results of the survey, to which 1408 dentists responded, highlighted the serious concerns held by dentists about the Unit of Dental Activity (UDA) system, in addition to showing dentists’ strength of feeling about working within the NHS:

93 per cent of dentists reported that chasing government targets was limiting their

ability to care for high-needs patients who required complex or repeat treatment 83 per cent said the system was holding them back from preventive work

Nearly 70 per cent stated that the contract was now limiting their ability to take on NHS patients

Over 85 per cent stated that the contract had restricted the time they could spend with patients.

4.3 Free-text responses to the request ‘please tell us what the contract has meant for you and

your patients’ were overwhelmingly negative with respondents expressing great dissatisfaction and a desire for change. Variations of the word ‘stress’ appeared 116 times in responses, while variations of ‘unfair’ appeared 107 times. Other frequently used words were ‘treadmill’ and variations of ‘frustration’.1

4.4 Following a four-month roll-out period, the last of the eighty-two prototype practices in

England went ‘live’ in April 2016. Prototypes were allocated either blend A or B; variable blends of UDAs, capitation and quality payments. However, in December 2015 the DH confirmed that no financial adjustments would be applied in relation to Dental Quality and Outcomes Framework (DQOF) performance for the prototypes in 2016/17; DQOF performance would instead be reported on in shadow form. It was intended that financial adjustments would be applied in 2017/18.

4.5 Any roll-out of changes to the dental contract will not be in place until at least 2018/19

according to the current timelines set out by the DH. There is concern that wholesale change will not occur until after the next general election. The BDA remains fully engaged in the contract reform process but disagrees with the inclusion of UDAs in a dental contract that should be focussing on prevention, outcomes and improving oral health. A contract that puts prevention first is urgently required.

1 BDA survey of GDPs in England and Wales

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4.6 Two practices in Wales are taking part in a pilot/prototype on a new primary dental care contract. This is capitation-based around a deprivation index and with no activity component. The prototypes will run until the end of the financial year (March 2017).

4.7 We are concerned that the outcome of the EU referendum will lead to the demotion of

dental contract reform to a low-priority issue by the DH. We have been assured that the Department is still committed to the process.

English devolution

4.8 On 1 April 2016, responsibility for the health and social care budget in Manchester was

devolved from the UK Government to statutory organisations in Greater Manchester. There are a number of potential risks for dentistry under the proposals put forward by Devolution Greater Manchester. Concerns raised by local dentists include the impact of these new arrangements on the status and continued viability of businesses. There is uncertainty about what will happen to dental contracts; whether dentists may be forced to give up their GDS/PDS contracts and therefore lose NHS contractual benefits. General Medical Practitioners in Manchester will be able to take part on a voluntary basis from 2017 and it is likely that those who do will work on a Multi-Specialty Community Provider contract. If dentistry follows suit we may see practices federating to take on contracts, changes to remuneration systems and differing contractual payment methods. We are monitoring the situation closely and will report to the DDRB in more detail next year.

Changes to NHS sickness and maternity payments for GDPs 4.9 In late August the BDA was consulted on previously agreed changes to the SFE to impose a

cap on NHS sickness and maternity payments for GDPs. There will be a worsening of the terms and conditions for the dentists with the highest NHS commitments.

Seven day working in primary dental care 4.10 New dental services being commissioned by NHS England are tending to be open from 8am

to 8pm with some weekend opening. We are going to continue to monitor the prevalence of these services and any possible effects on dentists’ remuneration. We are constantly being told by NHS England and the DH that there is no more money for NHS dentistry, so any expansion of services must be done at a lower net cost, which will impact on dentists’ pay.

Spending on NHS general dental practice in England

Table 1 – Gross GDS/PDS spend in England including patient charge revenue

GDS/PDS Gross Spend in England (£m)

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

Nominal

2,386 2,568 2,752 2,814 2,813 2,844 2,740 2,746

Real

2,209 2,306 2,462 2,399 2,289 2,245 2,101 2,066

Source DH annual accounts

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4.11 As can be seen from Table 1 above, NHS dental spending in England is falling in real terms. Any decision by the Review Body not to award an increase in net pay will mean the dental spend continues to fall in real terms. In 2016/17 the Department of Health announced an increase in patient charges for NHS dentistry of 5 per cent with a further 5 per cent increase in 2017/18. This means that for some contracts with low UDA values, patients are paying more than the dentist is receiving for providing them with a Band 1 course of treatment. The NHS is effectively profiting from patient charges.

Northern Ireland 4.12 2016/17 uplift

On 19 September 2016 BDA NI was informed that the Minister for Health had accepted DDRB’s 2016/17 recommendation of a 1 per cent increase to net pay for General Dental Practitioners in Northern Ireland. In order to reflect a 1 per cent increase to net pay, the Department intends to apply a 1.13 per cent increase to all gross remuneration figures including gross item of service fees and capitation/continuing care fees. At the time of writing, BDA NI is examining the changes to the Statement of Dental Remuneration (SDR) and is providing the Department with comments before the SDR is introduced.

Timing and implementation of uplifts in NI

4.13 It is important to note that while the DDRB recommendation 2016/17 will be implemented,

there continue to be significant delays between the DDRB reporting, the Department of Health announcement and implementation (albeit backdated). For example, the DDRB recommendation for 2014/15 was only implemented in April 2015, backdated to April 2014, a full 12 months after the recommendation was published. The decision to deny an uplift to GDPs for 2015/16 was formally announced in January 2016 – 10 months after the publication of the DDRB recommendation. The uncertainty and delay creates anxiety and causes great distress amongst a profession delivering health service patient care in the context of falling incomes, rising expenses, and increasing administrative and regulatory requirements. The morale of dentists in Northern Ireland is at a low level, according to the government’s own figures2, and exhibits the lowest levels compared to dentists in the rest of the UK. The prolonged delays of 2014/15 followed by non-implementation of the pay award in 15/16, only serve to compound feelings of negativity within the profession and this cannot be understated.

Impact of zero uplift in 2015/16 and loss of commitment payments

4.14 In 2015/16 GDPs in Northern Ireland received no uplift. The reason cited by the then Health

Minister for rejecting the 15/16 DDRB recommendation of 1 per cent to pay net of expenses was affordability. However, continuous drops in GDS practitioner income and low awards are not affordable for dentists in the Health Service. No uplift to fees and concomitant payments delivered a ‘dual blow’ to health service dental services whereby net pay is eroded, and then further impacted by the increase in expenses needed to deliver

2 The HSCIC Dental Working Hours 2012/13 and 2013/14 Motivation Analysis, published August 2015, showed Northern Ireland to have the worst percentage in the UK for dentists who recorded their morale as ‘very high’ or ‘high’ (NI: 16.0 per cent for practice owners; Scotland: 21.9 per cent; England: 23.7 per cent).

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health service dental services. The costs associated with delivering health service dentistry must be recognised, funded sufficiently and met in full, through the GDS payment system.

4.15 A major concern to the profession is the impact of loss of commitment payments over the 3

years to date. The result is that those who are most highly committed to working within the Health Service are most heavily penalised. This is illustrated by figures from the NHS Digital 2014/15 report on expenses and earnings which shows that for all self-employed GDS dentists in 2014/15, those whose Health Service earnings accounted for at least 75 per cent of their gross earnings had the lowest taxable income from Health Service and private dentistry at £55,900 (compared to £57,600 in 2013/14). Those whose Health Service earnings accounted for 25 per cent or less and between 25 and 75 per cent of their total gross earnings had taxable incomes of £89,900 and £100,400 respectively.

Need and demand for dental services in Northern Ireland

4.16 Patient registrations continue to increase and the growth in the need for dental services is

continuing as the general population increases in size with significant increases in the number of older persons remaining dentate. GDS dentist numbers increased by 5 per cent from 2011 (1020) to 2016 (1076). Patients registered with a dentist under HS arrangements increased by 10.5 per cent over the same period (of particular note is the 21.5 per cent increase in HS patients registered over 65).

Table 2 – Patient registrations

Year Patients registered Over 65 June 2016 1,165,765 150,179 June 2014 1,154,472 142,771 June 2013 1,150,890 135,998 June 2012 1,126,484 128,252 June 2011 1,054,799 123,637

4.17 GDS workloads are set to increase as the dentate population rises. Alongside this, there has

been an increase in the proportion of time spent on non-clinical work and a decrease in the proportion of time spent on HS dentistry. Dentists are now required to spend increased hours on activity which is essential but not clinical in nature. This type of activity requires remuneration as it is necessary, but it prevents dentists from undertaking remunerative clinical activity.

4.18 GDS dentists are already working more hours and this has been shown to impact on morale

and motivation. The morale of dentists in Northern Ireland is at a low level, according to the government’s own figures3, and exhibits the lowest levels compared to dentists in the rest of the UK. Poor morale was linked to longer working hours, carrying out more Health Service and administrative work and taking less leave. The results for morale are significantly lower in practice owners, which is a cause for concern given the rise in expenses and the fall in income.

Contractual change in Northern Ireland

3 The HSCIC Dental Working Hours 2012/13 and 2013/14 Motivation Analysis, published August 2015.

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4.19 The new contract for the GDS is often cited as the solution to the exacerbating problems

associated with the current GDS. Until new contract arrangements are in place, dentists operate in a system largely based on fee per item with payments for patient registration and clinical care, with percentage payments (a proportion of item of service fees) making up a practice allowance, and other allowances. Item of service payments, by their nature must reflect the resources utilised in respect of professional time, materials and overheads in place. While negotiations on a new contract are continuing and pilots have ended, these will have to be evaluated and followed by negotiations. A new contract for the GDS is a considerable time away.

How to apply the uplift

4.20 In determining how an uplift should be applied, it is important to note the detail of the

payment system in place for dentists in Northern Ireland. The payment system has a series of elements which together form the total remuneration package for dentists.

4.21 Some elements such as item of service fees are expressed in gross terms and are inclusive of

elements of both expenses and net income. The Practice Allowance is an example of a payment in respect of expenses. Other items such as the Continuing Professional Development allowance reflect net pay. All payments are described and set out in the Statement of Dental Remuneration (SDR). Each payment must be uplifted in accordance with whether payments reflect gross or net costs or both. Table 3 sets out details of the payment system in Northern Ireland, the value of payments in 2014/15 and includes details of whether payments reflect gross or net costs.

4.22 The BDA requests that DDRB make a complete recommendation which refers to all the

elements referred to in the SDR.

Table 3 – Payment system for GDPs in Northern Ireland

Payment Detail 2014/15 Individual Payments £ Gross Net Expenses

Items of Service for treatment items £72,495,252.16

Patient Registration (Continuing Care & Capitation) £21787381

Sessional Payments for provision of emergency dental services £329,497

Seniority payments £279, 475

Commitment payments £2,226,614

Maternity/paternity/adoption leave £1,152,185

Long-term sickness pay £46,267

Clinical Audit Allowances

£325,539

Practice Payments Reimbursement of non-domestic rates £765,307 Practice Allowance

£9,480,673

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All figures provided by Department of Health September 2016

5. Review Body requests 5.1 The DDRB requested that the parties comment on particular general issues. This section

contains our responses to the questions that are relevant to us and are not answered in the community dental services and general dental practice sections of our evidence.

Pensions and other benefits 5.2 ‘The BMA said that the abolition of the State Second Pension and the ending of contracting

out would mean that members would pay full National Insurance contributions. The BDA said it would investigate the impact of increased contributions on recruitment, retention and motivation for next year’s evidence’ (p. 23).

5.3 The end of the contracting out of the additional state pension for defined benefit pension

schemes means that some members of the NHS Pension Scheme who have been paying National Insurance at a reduced rate will see their National Insurance contribution rate rise. We are concerned that the change might affect earnings and have a knock-on effect on the state pension of those affected. The change will also affect Foundation Dentists/Vocational Dental Practitioners who will pay an increased amount of National Insurance.

5.4 We have considered the effects of the reducing value of NHS pension benefits; the value of

the NHS pension for GDPs has been eroded. This is due to a combination of increased employee contributions, change from RPI to CPI in dynamisation calculations and pension increases, increased retirement age, and the introduction of the new 2015 scheme (and a switch to CARE from final salary in the case of employed dentists).

5.5 The Office of Manpower Economics (OME) 2014 report for the DDRB might suggest that

changes between 2010 and 2016 have potentially halved the value of the pension benefits built up by a GDP across their career, with this representing a reduction valued at around 10-15 per cent of NHS earnings. Significant actuarial work and expenditure would be required to confirm the actual reduction in NHS pension value for GDPs, and the figure quoted in this reply carries a large margin of error. We would like the Review Body to commission further OME work to derive accurate figures for typical GDPs, and that this should be considered in the light of the revised expenses formula which is currently being discussed.

5.6 Lifetime Allowance and Annual Allowance have very personal effects, which are very difficult to model, but we know that these are relevant to a significant number of GDPs, especially following recent reductions in the allowances.

Pay settlements 5.7 ‘… we would like all the parties to provide us with evidence on how the new models of care,

and new contracts, will affect our remit groups, and particularly any implications for their pay or job weighting’ (p. 76).

5.8 As we said in paragraph 4.8, there is considerable uncertainty around how new models of

care will affect NHS dentistry. In October we will be holding a joint event with NHS England to look at new models of care and the issues for NHS dentistry, devolution and NHS

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England’s sustainability and transformation agenda. All we can say at the moment is that this considerable uncertainty over funding streams for oral health care will likely have adverse consequences for pay.

5.9 ‘As recruitment and retention is a core part of our terms of reference, we ask all of the

parties to continue to keep us updated on any workforce planning issues, including any staffing targets that form part of such plans, and to explicitly consider whether any pay response is required to help shape future workforce plans.

5.10 A major concern to the BDA is the possible impact of Brexit on the dental workforce. We

have asked the Department of Health and NHS England to work with us to monitor the situation as we go forward. Currently about 16 per cent of registered dentists qualified in the European Union. Most of these dentists will work in general dental practice, many as associate dentists. If we are able to obtain data on the current rate of recruitment and retention of NHS dentists from Europe, we can then monitor the situation going forward. The situation has the potential for profound changes in the recruitment and retention of dentists, which will have an adverse causal impact on services to patients.

Expenses

5.11 ‘The parties in all four UK countries have the option to make the provision of expenses data

a mandatory requirement of new GMP and GDP contracts’ (p. 56). 5.12 For dentistry it is too early to look at the detailed elements of any reformed contractual

requirements; however, we would be opposed in principle to any requirement for dental contractors to provide expenses information.

6. General dental practice 6.1 This section covers general dental practitioners throughout the UK. Where there are issues

specific to each country, these are noted. This year the BDA undertook two pieces of research to support our general practice evidence:

a survey of BDA associate members a survey of BDA practice owner members.

6.2 We have weighted the responses where necessary but have included un-weighted numbers

in the tables.

Taxable income for general dental practitioners in the UK 6.3 The NHS Digital Dental Earnings and Expenses Report 2014/15 once again showed an

overall decrease in general dental practitioners’ average taxable income, with the exception of practitioners in a Personal Dental Services (PDS) agreement. There was a decrease in the average taxable income for all dental practitioners working under a General Dental Services (GDS) contract, which constitutes the vast majority of general dental practitioners.

England and Wales 6.4 Mean average taxable income from NHS and private dentistry in 2014/15:

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For all providing-performer dentists (those who own a practice and also provide NHS dental care personally) the mean average taxable income as above was £117,400, compared to £115,200 in 2013/14, a 2 per cent increase.

For all associate dentists the mean average taxable income was £59,900, compared to £60,600 in 2013/14, a 1.1 per cent decrease.

For all self-employed primary care dentists the mean average taxable income was £70,500, compared to £71,700 in 2013/14, a 1.6 per cent decrease.

None of the increases or decreases were statistically significant. 6.5 Real terms average taxable income:

Using the retail price index (RPI) as the measure of inflation with 2008/09 as the base year, we obtain real falls in taxable income between 2008/9 and 2014/15 of 25 per cent for practice owners and 26 per cent for associates.

6.6 Median average taxable income from NHS and private dentistry in 2014/15:

For all providing-performer dentists the median average taxable income as above was £99,100, compared to £96,700 in 2013/14.

For all associate dentists the median average taxable income was £55,100, compared to £56,000 in 2013/14. For all self-employed primary care dentists the median average taxable income was £59,200 in 2014/15, compared to £60,300 in 2013/14.

Northern Ireland

6.7 Mean average taxable income from both Health Service and private dentistry in 2014/15:

For practice owner dentists the mean average taxable income as above was £111,700, compared to £112,500 in 2013/14, a 0.7 per cent decrease.

For associate dentists the mean average taxable income was £54,000, compared to £54,200 in 2013/14, a 0.4 per cent decrease.

For all self-employed dentists the mean average taxable income was £70,500, compared to £71,400 in 2013/14, a 1.2 per cent decrease.

None of the decreases were statistically significant. 6.8 Using the RPI as above, practice owners’ real terms average taxable income fell by 27.8 per

cent and that of associates by 32 per cent between 2008/9 and 2014/15. 6.9 Median average taxable income from both Health Service and private dentistry in 2014/15:

For practice owner dentists the median average taxable income as above was £80,000, compared to £87,300 in 2013/14.

For associate dentists the median average taxable income was £48,500, compared to £51,000 in 2013/14.

For all self-employed dentists the median average taxable income was £54,800, compared to £55,400 in 2013/14.

Scotland 6.10 Mean average taxable income from NHS and private dentistry in 2014/15:

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For practice owner dentists the mean average taxable income as above was

£102,900, compared to £98,400 in 2013/14, a 4.5 per cent increase. For associate dentists the mean average taxable income was £55,000, compared to

£56,200 in 2013/14, a 2.1 per cent decrease. For all self-employed dentists the mean average taxable income was £67,000,

compared to £68,000 in 2013/14, a 1.4 per cent decrease. 6.11 Using the RPI as above, practice owners’ real terms average taxable income fell by 27 per

cent and that of associates by 31 per cent. 6.12 Median average taxable income from both NHS and private dentistry in 2014/15:

For practice owner dentists the median average taxable income as above was

£93,100, compared to £87,400 in 2013/14. For associates the median average taxable income was £53,400, compared to

£54,200 in 2013/14. For all self-employed dentists the median average taxable income was £57,900,

compared to £58,500 in 2013/14. 6.13 The following graph shows the continued reduction in taxable income for GDPs in the four

countries. Scotland continues to have the lowest taxable income.

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

England and Wales £96,135 £89,062 £89,600 £84,900 £77,900 £74,400 £72,600 £71,700 £70,500

Northern Ireland £86,500 £78,900 £75,800 £71,600 £71,400 £70,500

Scotland £79,300 £73,300 £71,700 £68,600 £68,000 £67,000

60000

65000

70000

75000

80000

85000

90000

95000

100000

£

Figure 1. Mean average taxable income from NHS/HS and private dentistry for all self-employed general dental practitioners

England and Wales Northern Ireland Scotland

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6.14 Average gross earnings for practice owners are rising in England, Wales and Scotland, but Northern Ireland experienced a decrease of 2 per cent in 2014/15.

Table 4 – Practice owners’ gross earnings

Practice owners’ gross earnings (£)

Country

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

England & Wales

345,651 366,500 370,900 364,300 358,400 368,000 375,000 385,600

N. Ireland

311,227 333,700 344,600 331,000 318,600 316,000 335,600 328,700

Scotland

343,900 337,000 334,700 332,900 319,600 330,300 347,200

Source: NHS Digital

280000

300000

320000

340000

360000

380000

400000

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

£

Figure 2. Average gross earnings for practice owners in the UK


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Table 5 – Practice owner expenses to earnings ratios

Practice owner expenses to earnings ratios (%)

Country

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

England & Wales

61.9 63.3 64.3 65.5 67.8 68.5 69.0 69.3 69.6

N. Ireland

61.1 61.2 64.3 65.5 64.7 64.9 66.5 66.0

Scotland

65.5 66.2 69.8 69.1 69.5 70.2 70.4

Source: NHS Digital

56

58

60

62

64

66

68

70

72

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

%Figure 3. Average expenses to earnings ratios for UK practice owners


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Morale and motivation of GDPs 6.15 The Review Body noted the BDA’s intention to conduct research into GDPs’ morale and

motivation in 2016 and commented that ‘new motivation evidence will provide a helpful benchmark’ (pp. 47, 52).

6.16 Dentistry is a difficult and stressful job and dental students possess top A level grades.

Graduates leave Dental School with high levels of debt compared with other students and, ultimately, falling incomes will affect student recruitment. We asked both associates and practice owners whether they would recommend a career in dentistry and a large proportion of respondents would not. The majority (51 per cent) of associates said they would not recommend a career as a dentist and 51 per cent of practice owners said the same. This unwillingness to recommend the profession was particularly pronounced in Northern Ireland and Scotland, where only 42 per cent of associates said they would advise others to pursue a career in dentistry. However, it was practice owners in Northern Ireland who felt the most negatively about the profession; only 38 per cent said they would recommend a dental career. This is a damning indictment for members of a caring, vocational profession.

6.17 This reluctance to recommend the profession is perhaps, in part, explained by low morale

levels. Only 10 per cent of associates said they considered their morale to be ‘very high’, while 11 per cent said they would rate it as ‘very low’. On the whole practice owners had higher morale than associates. The percentage of associates who responded either ‘very high’ or ‘high’ was 38 per cent and for practice owners was 42 per cent. A significant

50,000

100,000

150,000

200,000

250,000

300,000

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

£Figure 4. Expenses comparisons across UK practice owners


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proportion of both practice owners and associates considered their morale to be ‘low’ or ‘very low’ at 29 per cent and 32 per cent respectively. For associates, those numbers expressing ‘very high’ or ‘high’ morale were consistently low across UK countries – at between one-third and two-fifths – with the exception of Northern Ireland, where just 25 per cent stated that they had ‘very high’ or ‘high’ morale.

6.18 As well as around a third of the profession having low morale, there are also significant

levels of job dissatisfaction. A third of all associates were either somewhat, mostly or completely dissatisfied with their current job. For practice owners, the percentage was even higher; nearly two in five (37 per cent) said they were somewhat, mostly or completely dissatisfied with their current job. Only 4 per cent of associates and 7 per cent of practice owners stated that they were completely satisfied in their present job. There were no associates in Northern Ireland who considered themselves ‘completely satisfied’; for England and Wales there were fewer than one in twenty and only 7 per cent in Wales. Among practice owners in Northern Ireland and Scotland 5 and 4 per cent respectively were ‘completely satisfied’ with their job, in Wales 6 per cent and England 8 per cent.

6.19 Despite these low job satisfaction levels, more than half of both associates and practice

owners agreed that they have opportunities to develop their skills, feel supported at work, have opportunities to undertake challenging and interesting work, feel able to deliver patient care to a standard with which they are satisfied, and feel secure in their job. However, the proportion who believe that they are fairly remunerated for their work is below 40 per cent for associates and 42 per cent for practice owners. This is perhaps not surprising given the substantial fall in net incomes over the last 10 years. For those who spend more than three-quarters of their time on NHS work, only around a quarter felt fairly remunerated.

6.20 We looked at whether there was a relationship between morale and satisfaction with pay

for both practice owners and associates. GDPs who think they are remunerated fairly for the work they do are far more likely to have a high level of morale. Among associates who agreed with the statement “I am fairly remunerated for my work”, 54 per cent reported having a high level of morale. In contrast, just 26 per cent of associates who did not agree with this statement had a high level of morale. Among practice owners the “effect” of perceived fair remuneration was even greater. 63 per cent of POs who agreed with the statement “I am fairly remunerated for my work” reported a high level of morale compared to just 27 per cent of practice owners who did not agree with this statement.

18

Table 6 – Associates - Would you recommend a career as a dentist?

Yes No N

Nation England 49 51

Northern Ireland 42 58

Scotland 42 58

Wales 60 40

NHS personal commitment

>75% 45 55

<75% 55 45

All 49 51

BDA Associates Survey 2016

Table 7 – Practice owners - Would you recommend a career as a dentist?

Yes No N



Scotland 49 51

Wales 54 46


>75% 41 59

<75% 54 47

All 49 51

BDA Practice Owners Survey 2016

19

Table 8 – Associates - How do you rate your morale in your work as a dentist?

Very high

High Neither high, nor

low

Low Very low

N

Nation England 11 28 30 20 11

Northern Ireland 2 23 39 29 8

Scotland 5 28 31 22 15

Wales 4 36 29 26 6


>75% 7 24 31 25 14

<75% 13 34 30 15 8

All 10 28 31 21 11


Table 9 – Practice Owners - How do you rate your morale in your work as a dentist?

Very high

High Neither high, nor

low

Low Very low

N


Northern Ireland 4 26 34 23 13

Scotland 7 25 30 25 13

Wales 7 32 23 23 14


>75% 9 22 26 27 16

<75% 13 37 30 13 7

All 11 31 28 19 10


20

Table 10 – Associates - How satisfied or dissatisfied are you in your present job overall?

Completely

Satisfied

Mostly satisfied/ Somewh

at satisfied

Neither satisfied,

nor dissatisfied

Mostly dissatisfied/ Somewhat dissatisfied

Completely

Dissatisfied

N


Northern Ireland

0 61 6 30 3

Scotland 2 57 6 30 4

Wales 7 56 6 24 7


>75% 3 53 7 34 4

<75% 5 61 9 25 1

All 4 56 8 30 3


Table 11 – Practice Owners - How satisfied or dissatisfied are you in your present job overall?

Completely

Satisfied

Mostly satisfied/ Somewh

at satisfied

Neither satisfied,

nor dissatisfied

Mostly dissatisfied/ Somewhat dissatisfied

Completely

Dissatisfied

N


Northern Ireland

5 42 6 45 2

Scotland 4 53 7 33 4

Wales 6 48 5 35 6


>75% 4 39 9 42 6

<75% 9 55 7 26 3

All 7 49 7 33 4

21


Table 12 – Associates - Percentage ‘Strongly agree’ or ‘Agree’

All England NI Scotland Wales NHS

>75% NHS

<75% There are opportunities for me to progress in my career

54 55 44 50 58 50 61

There are opportunities for me to develop my skills

76 76 70 74 76 70 85

I get support from my colleagues at work

68 68 70 65 67 64 74

There are opportunities for me to do challenging and interesting work

63 63 67 62 62 56 75

I am fairly remunerated for my work

39 40 30 30 51 26 60

The practice I work in is well managed

44 43 52 55 47 44 45

I am able to provide patient care to a standard I am satisfied with

69 70 74 62 62 60 84

I feel secure in my job 58 57 58 62 64 52 66


Table 13 – Practice owners - Percentage ‘Strongly agree’ or ‘Agree’

All England NI Scotland Wales NHS >75%

NHS <75%

There are opportunities for me to progress in my career

48 49 41 38 38 55 51


79 79 71 77 75 69 85

I get support from my colleagues at work

67 67 68 69 64 63 70

There are opportunities for me to do challenging and interesting work

76 77 63 75 62 60 87

I am fairly remunerated for my work

42 44 24 29 40 28 52

I am able to provide patient care to a standard I am satisfied with

65 68 42 55 61 43 80

I feel secure in my job 62 63 42 60 59 51 69


22

Satisfaction with the NHS 6.21 Of those GDPs with a significant personal NHS commitment – both practice owners and

associates – only slightly more than two-fifths would recommend a career in dentistry. Those with a greater private commitment were more likely to recommend a career as a dentist; accounting for 55 per cent of associates and 54 per cent of practice owners. Similarly, morale and job satisfaction were lower for those with a significant NHS commitment. 43 per cent of practice owners and 39 per cent of associates who spend more than 75 per cent of their time on NHS commitments stated their morale was ‘low’ or ‘very low’. Nearly half (48 per cent) of practice owners with a significant NHS commitment were somewhat, mostly or completely dissatisfied in their current job and for associates the equivalent figure was 38 per cent. Only four per cent of practice owners and three percent of associates who commit more than three-quarters of their time to NHS work considered themselves to be completely satisfied. While for those with a larger share of their time spent on private practice there were higher satisfaction levels. Almost two-thirds, whether associates (66 per cent) or practice owners (64 per cent), with a lower NHS commitment stated that they were somewhat, mostly or completely satisfied in their present job.

6.22 There is a stark difference in the proportion who agree that they are satisfied with the level

of patient care they are able to provide depending on their level of NHS commitment. Those who spend the vast majority of their time on NHS work are far less likely to agree that this is the case than for those who do more private work. For example, less than half (43 per cent) of practice owners with significant NHS commitments agree that they are able to provide patient care to a standard with which they are satisfied; for those with a greater share of private work it is 80 per cent.

6.23 Given these findings, it is unsurprising that only 2 per cent of associates and 1 per cent of

practice owners were considering increasing the amount of NHS/HS work they do over the next five years, whereas a significantly higher percentage were considering increasing the amount of private work that they do (see Tables 14 and 15 below). These findings are reflected across all UK countries; only 1 per cent of practice owners in England intend to take on more NHS work whereas 46 per cent of practice owners in Northern Ireland plan to increase their proportion of private work.

Recruitment and retention of general dental practitioners 6.24 The Review Body asked parties to provide evidence on the extent to which they considered

pay to be a relevant factor in any recruitment or retention issues (p. 35). 6.25 A significant proportion of associates intend to leave the profession through retirement

(13 per cent) or working in a different sector (9 per cent) or to reduce their hours (26 per cent) in the next five years. The same was true of practice owners with nearly a third intending to retire in the next five years and a similar proportion looking to reduce their hours. There is also a large proportion of associates that intends to change their work within dentistry in some way; either by becoming a community dentist (2 per cent), a hospital dentist (4 per cent) or a practice owner (18 per cent), or by developing new specialist skills (29 per cent).

6.26 In addition to those questions asked about the career intentions of associates, practice

owners were also asked specific questions about their career plans and businesses. While a significant number were planning to sell their practice(s) – to become an associate or retire – there were also those looking to expand their practice, recruit dentists and acquire

23

additional contracts and practices. A third of practice owners had sought to recruit new dentists in the last financial year. However, 47 per cent of practice owners reported having experienced difficulties in recruiting new dentists over the same period and these difficulties were even more pronounced for those with significant NHS commitments.

6.27 Recruitment is a significant problem across all UK countries, with at least a fifth of BDA

members reporting this as an issue and reaching a peak in England with 49 per cent saying they had experienced this difficulty. Outside London, our members are reporting difficulties recruiting associates in the North East, South West, East of England, Yorkshire, Manchester and other areas. Pay is a relevant factor in the recruitment of dentists and where practices are having recruitment difficulties they will have to offer higher levels of remuneration.

6.28 The BDA has also received separate evidence of significant and sustained recruitment

difficulties from mydentist, the largest dental corporate in the UK, with over 600 practices. Mydentist’s survey in 2016 of its practices across England and Wales indicated widespread associate vacancies in: Cumbria; Lincolnshire; South Shields; Yorkshire; Somerset; Cornwall; Dorset; Devon; Welsh Borders; North Hants; Norfolk; Suffolk; Cambridge; Kent; and Hampshire. All of these areas were experiencing vacancy gaps of more than three months, all apart from one had gaps of more than six months.

Table 14 – Associates - What are your career intentions for the next five years? Select all that apply.


>75% NHS

<75% Become a community dentist 2 2 12 6 2 3 2

Become a hospital dentist 4 4 0 4 4 4 3

Become a practice owner 18 17 15 23 22 18 16 Continue working in my current role

44 44 52 38 46 47 42

Develop new specialist skills 29 29 14 28 29 34 21 Increase the proportion of NHS/HS work I do

2 2 0 1 2 2 2

Increase the proportion of private work I do

33 34 30 33 31 40 24

Leave dentistry to work in a different sector or industry

9 9 3 9 7 10 6

Leave the UK to work overseas 5 6 3 7 0 5 5 Reduce the number of hours I work

26 25 35 31 26 28 23

Retire from general dental practice

13 13 3 14 7 10 17


24

Table 15 – Practice Owners - What are your career intentions for the next five years? Select all that apply.


>75% NHS

<75% Acquire additional practices or contracts

10 11 5 4 7 10 10

Become a community dentist 0 0 0 0 2 0 0

Become a hospital dentist 0 0 0 0 3 1 0 Continue working in my current role

41 41 42 43 44 37 44

Develop new specialist skills 13 13 19 11 14 11 14 Increase the proportion of NHS/HS work I do

1 1 5 3 2 2 1

Increase the proportion of private work I do

27 26 46 22 26 35 21

Leave dentistry to work in a different sector or industry

5 5 5 5 5 5 4

Leave the UK to work overseas 3 3 1 3 3 3 3 Reduce the number of hours I work

31 30 34 34 32 31 31

Retire from general dental practice

30 31 22 33 19 28 31

Sell my practice and become an associate

18 18 22 12 19 18 18

Expand my practice 16 16 19 11 17 12 18


Table 16 – Practice Owners - Do you have any plans to sell your practice or practices in the next 12 months?

Yes No



Scotland 15 85

Wales 26 74


>75% 26 74

<75% 27 73

All 26 74

25


Table 17 – Practice owners - Did you seek to recruit any dentists during the last financial year?

Yes No



Scotland 31 69

Wales 35 65


>75% 39 61

<75% 29 71

All 33 67


Table 18 – Practice owners – Did you experience any difficulty recruiting dentists to your practice(s) during that year?

Yes No



Scotland 34 66

Wales 44 56


>75% 54 46

<75% 41 59

All 47 53


26

Practice staff costs

6.29 Dentists are paying more in staff costs in England than they were given in the expenses payment. Any pay increase to dentists is therefore lower because they have to factor in staff costs. In addition, the introduction of the Government’s National Living Wage on 1 April 2016 has meant that dentists are forced to pay more than 1 per cent in pay uplifts. Pension auto-enrolment costs, national insurance costs and the national living wage have amounted to a substantial rise in staff costs.

6.30 A majority of 53 per cent of all practice owners sought to recruit dental nurses during the

last financial year and, of these, 53 per cent experienced difficulties in doing so. The problem of recruiting dental nurses was particularly pronounced in Northern Ireland, with 60 per cent of practice owners who had sought to recruit dental nurses experiencing difficulties in doing so; in England the figure was 55 per cent.

Associate under-employment

6.31 The BDA associates survey revealed that 6 per cent of associates providing more than 75

per cent NHS work on the NHS met the criteria set by the International Labour Organisation for under-employment. This is a fall of 9 per cent since 2013 when we first measured it. This is another indication that an associate recruitment problem is growing.

Recommendations for UK general dental practice 6.32 From our evidence regarding general dental practice it is clear to the BDA that UK GDPs

should receive at least the full targeted one per cent increase in pay as a minimum. 6.33 In summary, GDPs should receive at least a one per cent increase in pay:

We now have evidence of an associate recruitment problem in many areas. GDPs are expecting to receive at least the full one per cent increase in their pay. Public confidence in NHS dentistry is high and must remain so. Practices are focusing their finances on retaining highly prized practice staff to

underpin the dental workforce; with clear recruitment issues now for dental associates, practice owners will have to increase the remuneration that is offered from NHS contract values that are not rising with NHS inflation.

Taxable incomes continue to remain at significantly lower levels than in 2008/9. Dentists’ morale and motivation continue to be very low across the UK. Pay continues to be a motivating factor for GDPs. Dentist retention rates are not as good as they could be and 33 per cent of

associates intend to increase the amount of private care they provide. Almost a third of practice owners plan to retire in the next five years and nine per

cent of heavily NHS-committed associates want to leave dentistry and work in another sector within the next five years.

Dentists have been compelled to pay excessive fees by the GDC and indemnity services.

Practice owners will inevitably be subjected to further excessive expenses through the introduction of the auto-enrolment of pensions and the national living wage.

6.34 GDPs have tried to maintain high standards of patient care in spite of our clear evidence in recent years that their morale and motivation are much reduced; however, this cannot be sustained indefinitely. Inevitably patients will begin to see a deterioration in the quality of

27

service. NHS dentistry is far too important to patients for this to happen, as evidenced in the patient feedback data such as the Friends and Family Test data in England.

7. Community dental services 7.1 We are aware that pay restraint remains the primary approach of the government in

regards to public sector workers. As a result we accept as a matter of fact that there is no willingness to consider amendments to the basic Salaried Primary Dental Care Service (SPDCS) contract of employment in England. Similarly we recognise that the government considers formally negotiated and locally approved incremental progression to be a form of pay rise and not an appropriate reflection of increased responsibility and skills. In previous responses we have highlighted our fundamental disagreement with this governmental approach and those concerns remain apposite.

7.2 It is unfortunate that the well-respected independent process for setting dental salaries has

been circumvented for political expediency. For the sake of consistency we continue to provide information on community dentist/salaried practitioners in the UK. Indeed, we would welcome the DDRB continuing to offer comment in relation to the position of all community and salaried practitioners across the UK. Where issues are country specific this is noted in the evidence. The services are referred to by different names in the countries of the UK and in Scotland the name is the Public Dental Services, our collective name for all of these practitioners in this submission is ‘community dentists’ or ‘the CDS’.

7.3 This year we have submitted Freedom of Information requests to 93 community dental

services providers, 10 of which are social enterprises. Of these 93 85 responded, four of which were social enterprises. Alongside this we surveyed all BDA members working in the community dental services. As such we are able to present data on not only the structure of the CDS workforce but also the direction of travel of services, the climate in which they are operating and the motivation and morale of the dentists therein.

Workforce data

7.4 We identified 93 community dental service providers in the UK. That is, services employing

staff on the established community dental contracts. Broadly stated the grades within the CDS are established as Band A/Dental Officer, Band B/Senior Dental Officer, Band C/Specialist clinician and clinician service manager.

7.5 We received responses from 85 providers. 7.6 In the tables below, we present figures provided to us from our Freedom of Information Act

requests on the demographics of the community dental service workforce.

28

Table 19 – CDS Workforce by percentage of headcount and whole time equivalence

7.7 Dentists working in the CDS have traditionally considered such posts to be a vocation and

as such have displayed loyalty to the services in which they work. As a result, 74 per cent of CDS dentists have now reached the top of their salary scale with no opportunity for progression unless successfully applying for another post at a higher grade.

7.8 This loyalty to the service is evidenced by the overall age of the workforce. If we assume an

average career of 40 years (ages 25-65), then clearly over half of the workforce is over the half way point of their careers with a quarter of the workforce in the likely final stages of their careers.

Table 20 – Age distribution of community dentists

Source BDA Community Dentists Survey 2016

0 10 20 30 40 50 60

Band A / Dental Officer

Band B / Senior Dental Officer

Specialist clinician

Clinical service manager

CDS workforce (%)

Wte Headcount

0 5 10 15 20 25 30 35 40

25-34 years

35-44 years

45-54 years

55-64 years

65 and over

CDS workforce by age (%)

29

Environment in which the CDS finds itself

Pressure on staff 7.9 Last year we highlighted an ongoing trend of a noticeable number of posts being unfilled.

As a result staff are now being asked to cover the gaps in services left by these unfilled posts either through general increased working or as direct cover.

Table 21 – Amount of extra work reported by CDS staff

Source BDA Community Dentists Survey 2016 7.10 The median average of this extra work is approximately four hours per week. Given this, it is

not surprising that respondents are reporting increased workloads.

0 5 10 15 20 25 30 35 40

Never

Rarely

Occasionally

A moderate amount

A great deal

Extra working (%)

Been asked to work beyond weekly contracted hours Been asked to cover for colleagues

30

Table 22 – CDS dentists’ perceptions of their workload

Source: BDA Community Dentists Survey 2016

Pressure on patients 7.11 Despite this extra work provided by CDS dentists, a significant number of them do not

believe they are afforded sufficient time to treat their patients appropriately. Only 68 per cent believe that the default position is that they would generally have enough time to treat their patients.

7.12 Furthermore these appointment times show significant signs of tracking a decrease.

0 10 20 30 40 50 60

Very high

High

About right

Low

Very low

Perceptions of workload (%)

31

Table 23 – Change in length of appointments

Source BDA Community Dentists Survey 2016 7.13 Our members are thus concerned as to the impact these pressures are having on the overall

treatment level provided to patients, with almost 40 per cent believing that their service no longer meets patient need.

Table 24 – CDS dentists’ views on whether their service is meeting the needs of patients


0 10 20 30 40 50 60 70

Increased

Stayed the same

Decreased

Don’t know

How have the length of your appointments changed over the past year? (%)

0 5 10 15 20 25 30 35 40

Strongly disagree

Somewhat disagree

Neither agree, nor disagree

Somewhat agree

Strongly agree

Don’t know

"My service is meeting the needs of patients” (%)

32

Motivation and morale 7.14 Our research again highlighted that for many members the nature and scope of CDS

dentistry captivates them, with a significant number reporting that as their primary motivation. While the patient and treatment mix of the CDS remains a strong motivational tool, an increasing number of our members are reporting significant concerns in the following areas. More than 40 per cent of respondents did not agree that their pay was fair.

Table 25 – Dentists’ issues with their employment


7.15 It is therefore of little surprise that our members are hence displaying high levels of job satisfaction coupled with low morale.

Table 26 – Job satisfaction in the CDS


0 10 20 30 40 50 60

There are opportunities for me to progress in mycareer


I feel that my pay is fair

I feel secure about my job

Disagree Strongly disagree

0 10 20 30 40 50 60

Satisfied with job

Neither satisfied, nor dissatisfied

Dissatisfied with job

Job satisfaction (%)

33

Table 27 – Morale in the CDS


7.16 Furthermore only just over half of our members, for whatever reason, see themselves practising in the CDS in 5 years’ time.

Table 28 – Career intentions of community dentists within the next five years


Northern Ireland CDS update 7.17 A new contract for CDS dentists in Northern Ireland has been agreed. The new contract

came into effect on 1 April 2016, although the pay element is backdated to 1 April 2015 and represents the culmination of nearly seven years of discussions. The BDA was informed in January 2016 by the Department of Health, Social Services and Public Safety Northern Ireland (DHSSPSNI), now the Department of Health (DoH), that funding had been secured to fund a new deal and negotiations restarted with work being done to revise the Heads of Agreement provisionally reached in 2014 when funding was not available. Progress on this

0 5 10 15 20 25 30 35 40 45 50

High morale

Neither low nor high morale

Low morale

Job morale level (%)

0 10 20 30 40 50 60 70

Continue practising as a community dentist

Continue working as a dentist, but in a different field ofpractice

Leave dentistry to work in a completely different sectoror industry

Retire from working as a dentist

Other

Further career intentions (five years) (%)

34

was extremely quick, leading to agreement to ballot on a Summary Agreement on the main changes within the proposed new contract including revised pay scales and annual leave entitlement. There was an agreement that a full set of revised Terms and Conditions would be worked on during and indeed after the ballot period. This was made clear as part of the ballot documentation. The new contract finally allows CDS dentists in Northern Ireland to have modernised terms and conditions, to align them with colleagues in the rest of the UK.

7.18 The ballot of all community dentists in Northern Ireland on the proposed new contract

closed on 14 March 2016 and an overwhelming majority voted in favour of the new contract as outlined in the Summary Agreement.

7.19 Regarding the 1 per cent non-consolidated uplift as recommended by DDRB for 2015/16,

the Department had suggested that staff would not receive this, as is customary for the first year of a new contract. Although this is not our experience, and we believe that staff should receive this recommended 1 per cent, we have reluctantly accepted this proposal, to prevent delaying the agreement of the final terms and conditions any further.

Conclusion

7.20 The research we undertook into the CDS has revealed the worrying statistic that in the

majority of questions we asked that had a subjective qualitative element, approximately a third of respondents provided responses that equated to either negative or very negative. The breadth of the questions asked would make it unlikely that these responses were being provided by the same respondents each time. There is a sizeable core of high dissatisfaction within the CDS.

7.21 When the above dissatisfaction is viewed alongside the future career intentions of CDS

dentists it is clear that the service is at risk of a serious retention problem. A problem that will be exacerbated in impact by the fact that 74 per cent of the workforce are at the top of their scale and hence are the most experienced members of staff, most best-able to handle more turbulent times and to provide guidance and mentoring to younger and less-experienced colleagues.

7.22 If the government wishes to maintain high quality dental services for vulnerable patients

and for those services to have a coherent and ongoing strategy to provide that care, the increasingly loud and repeated concerns of our members must be addressed.

7.23 We believe that a 1 per cent increase for all staff is the necessary minimum in ameliorating

these concerns. Without it, it is quite likely that the almost 28 per cent of members who intend to retire within five years will see no reason to postpone such a decision given that they are already likely to be at the top of their scale and hence in effect enduring a real-terms cut.

Recommendations for pay in the Community Dental Services 7.24 We believe that at least a one per cent consolidated increase for all staff is necessary to

reflect the experience and expertise of the CDS/PDS workforce and the very low morale they have. As demonstrated, the majority of the workforce are already at the top of their scale and retaining them is a necessity if the CDS/PDS is to remain able to provide the care it does as well as accepting more complex referrals from General Dental Service colleagues.

35

7.25 While we have in the past reported that CDS/PDS dentists are not primarily motivated by financial reward, it would be inappropriate for the DDRB to use that as a reason for ignoring our claims this time around. With no opportunity for increased earnings, a financially stagnating CDS/PDS is at grave risk of enduring a significant retention problem generating all too obvious problems for the most vulnerable patients.

8. Clinical academic staff Information on workforce 8.1 As in previous years, we are providing evidence on the retention and recruitment of clinical

academic staff. Although clinical academics are outside the formal remit of the Review Body, staffing levels among this group have a profound influence on the quality of the education received by dental undergraduate students and so impact the recruitment of young people into the profession. Clinical academic staff play an essential role within dental schools and perform high quality teaching and research, with clinical skills which should be rewarded. It is vital to ensure a steady intake and progression of clinical academics to maintain high standards of research and teaching. We thank the Review Body for considering our evidence on clinical academic staff.

Table 29 – Vacant Posts by Academic Grade

FTE clinical

academic dentists

FTE vacancies

Total available

posts

Vacancies as a

percentage of total

FTE posts

Professor 117.0 6.6 123.6 5.3% Reader/Senior

Lecturer 120.7 14.2 134.9

10.5% Lecturer 106.3 2.0 108.3 1.8%

Total (P+SL+L) 344.0 22.8 366.8 6.2%

Senior Clinical Teacher 68.6 1.4 70.0

2.0%

Clinical Teacher 159.6 12.5 172.1 7.3% Clinical Researcher 11.0 2.9 13.9 20.9%

Total (SCT+CT+R) 239.3 16.8 256.1 6.6%

Grand Total (all grades) 583.2 39.6 622.8

6.4%

Source: Dental Schools Council, A Survey of Staffing Levels of Clinical Academic Dentists in UK Dental Schools, as at 31 July 2015, page 14

8.2 The Dental Schools Council data shows that the level of vacancies as a percentage of total

Full Time Equivalent (FTE) posts is 6.4 per cent on average. While this masks a variety of experiences, from less than two vacancies in Senior Clinical Teacher to over one in ten vacancies in Reader/Senior Lecturer, overall the picture remains one of a significant number of vacancies. The vacancies in Reader/Senior Lecturer are particularly significant, as these

36

are equivalent with NHS Consultants and therefore if pay parity is not maintained the vacancy rate is likely to rise further. Overall the vacancies in the areas of research active staff are likely to make it more difficult over the long term to maintain the current world class levels of oral and dental research.

8.3 In addition to the vacant posts, the Dental School Council reported that almost half of

Schools (8 out of the 18 dental schools) commented on the difficulties in recruiting to a particular specialty or grade; these respondents specifically stated that they felt there was a national shortage of academics in dentistry from which to recruit. There is a concern that vacancies in certain specialties are worsened by the fact that certain specialists prefer a full time clinical practice to having to juggle their clinical career with academia. The issues of recruitment and vacancies are in the context of a higher education system where higher fees have led to expectations from students of more direct contact with their teachers, which in turn results in more pressure on staff. If remuneration levels do not increase to make academic dentistry a competitive career there is a danger that the number of unfilled posts could grow. This in turn would have an impact on teaching and the student experience.

9. Conclusion 9.1 In conclusion, dentists are continually being asked to do more with less. Since the financial

crash in 2008 both practice owners and associates have seen large falls in their real incomes and these cuts have consequences. Patients suffer when the profession is left incapable of investing in new equipment, coupled with ever increasing reams of red tape placing additional burdens on practitioners. The priority of dentists is the delivery of high quality patient care as we have demonstrated; however, ten years of sustained cuts makes it more difficult to deliver the care that patients deserve. All dental practitioners are expecting an increase in pay this year and will be appalled and deeply disillusioned if they do not receive it.

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