© National Audit Office 2024

Investigation into the NHS dental recovery plan

Department of Health & Social Care and NHS England

Session 2024-25
27 November 2024
HC 308

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Ordered by the House of Commons

to be printed on 25 November 2024

This report has been prepared under Section 6 of the National Audit Act 1983 for presentation to the House of Commons in accordance with Section 9 of the Act

Gareth Davies
Comptroller and Auditor General
National Audit Office

20 November 2024

Investigations

We conduct investigations to establish the underlying facts in circumstances where concerns have been raised with us, or in response to intelligence that we have gathered through our wider work.

This report covers the dental recovery plan, which was published in February 2024 and aims to support NHS dentistry after the impact of the COVID-19 pandemic, with its headline ambition to deliver more than 1.5 million additional courses of treatment. This report aims to provide clarity on the current state of NHS dentistry, how the plan was developed and whether it is on track to meet its objectives.

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015445 11/24 NAO

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The National Audit Office study team consisted of:

Andrew Ellis, Rosemary Hill and Tom Tyson, under the direction of Lee Summerfield.

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Key facts

What this investigation is about

1 The dental recovery plan was published in February 2024 under the previous government and aims to increase access to NHS dentistry services. The £200 million plan was intended to deliver more than 1.5 million additional NHS dentistry treatments (or 2.5 million appointments) in 2024-25 and has three components:

expanding access in 2024 so that “everyone who needs to see a dentist will be able to”, beginning with incentives to dental practices to deliver NHS care and introducing mobile dental vans for under-served communities;

launching Smile for Life, a focus on prevention and good oral health in young children alongside a consultation on water fluoridation in north-east England; and

supporting and developing the dental workforce through measures in the NHS long-term workforce plan, and setting the trajectory for further contract reforms.

2 The additional courses of treatment in 2024-25 (at least 1.5 million more) were intended to come from the first of these components, through four headline initiatives:

a new patient premium, in which participating dental practices receive a credit of units of dental activity (UDAs) equivalent to £15 or £50 (depending on the course of treatment) for eligible new patients;1

‘golden hello’ recruitment incentives of £20,000 (phased over three years) for 240 dentists to work in areas with recruitment and retention challenges in NHS dentistry;

an uplift to the minimum value of a UDA to £28; and

mobile dental vans to deliver some dental services to targeted communities.

3 Smile for Life is not intended to deliver additional courses of treatment, and it is expected to have an impact over a longer time frame than 2024-25, as will initiatives to support and develop the dental workforce. Some progress was made on these aspects of the wider plan before the 2024 general election, including consultations on a dental graduate tie-in and water fluoridation in the north-east of England. Beyond that, these aspects of the plan are now awaiting decisions by the new government on its priorities for NHS dentistry.

4 We decided to investigate the dental recovery plan because of a widespread perception among the public, parliament and media that NHS dentistry is in a state of crisis. Because of the longer-term preventative focus of Smile for Life, and the uncertain future of some of the wider components, we have focused on the four initiatives that are expected to have an impact in 2024-25. Where we refer to ‘the plan’ in our report, we specifically mean these initiatives. As these initiatives in the plan were expected to have impact in 2024-25, reporting in November 2024 provides an update on the plan more than halfway through that period, although we acknowledge in the report that the general election will have impacted progress in some areas over that time.

5 There is also ongoing work from the Department of Health & Social Care (DHSC) and NHS England (NHSE) on wider dental contract reform and a commitment in the plan to consult on this. There is no full plan developed yet on contract reform to audit, and therefore this was not in scope for this report either.

6 This report builds on our previous work in this area, including our 2020 memorandum on dentistry in England and our submitted evidence to the Health and Social Care Committee’s 2023 inquiry into dentistry.2,3

Our scope

7 This report sets out information on the current delivery of NHS dentistry services and the development and progress of the plan for 2024-25. It does not seek to examine and report on the overall value for money of the programme, but we offer some reflections on what the government might want to consider as it develops its future plans for NHS dentistry. It looks at:

access to NHS dentistry before the plan (Part One);

development of the 2024 dental recovery plan (Part Two); and

the government’s progress against the dental recovery plan’s objectives and plans for evaluation (Part Three).

8 The plan is applicable to England only, with dentistry – like wider health areas – a devolved policy area. As such, our report focuses on NHS dentistry in England.

1 Units of dental activity (UDAs) are measures of overall dental activity based on the kind of treatment provided. There is no fixed national value for a UDA.

2 National Audit Office, Dentistry in England, March 2020.

3 Written evidence submitted by the National Audit Office, March 2023.

Summary

Key findings

Access to NHS dentistry prior to the plan

9 Access to NHS dentistry across England remains below pre-pandemic levels. In the 24 months prior to the start of the COVID-19 pandemic, 49% of the adult population had seen an NHS dentist. This dropped to as low as 34% in March 2022, and, although it had risen to 40% by March 2024, it remains below pre-pandemic levels. The number of courses of treatment delivered, which are the examination of a patient, an assessment of their oral health and the planning and provision of treatment as a result, fell from 38.8 million in 2019-20 to 12.3 million in 2020-21, recovering to 34.1 million in 2023-24, still 4.7 million fewer than pre-pandemic (paragraphs 1.3, 1.7, 1.9 and 1.11, and Figure 2).

10 There are regional variations in access to NHS dentistry, with some areas of England receiving twice as much care as others, and some areas recovering to pre-pandemic levels quicker than others. At an integrated care board (ICB) level, access ranged from 382 courses of treatment delivered per 1,000 people in Somerset ICB to 800 delivered per 1,000 people in South Yorkshire ICB in 2023-24. Regions across England are recovering from the COVID-19 pandemic at different rates, with London delivering approximately the same number of courses of treatment in 2023-24 as it did in 2019-20, whereas 70% of courses were delivered in the South West in 2023-24 compared with 2019-20 (paragraph 1.15 and Figure 4).

11 There are several issues, beyond just the impact of the pandemic, that are contributing to a lack of access to NHS dentistry:

The dental contract is in need of reform. Dental contracts between ICBs and individual dental practices are based on arrangements put in place in 2006, where they agree to deliver a certain number of units of dental activity (UDAs). UDAs are a measure of overall activity based on the type of treatment provided. Despite some changes to the contract in July 2022, the current contract is widely perceived as needing reform, including by the Department of Health & Social Care (DHSC) and NHS England (NHSE), with many in the sector viewing the contract as a disincentive to perform NHS care when practices have the choice of offering private care too (paragraphs 1.3, 1.4, 1.23, 1.25 and 1.26).

Insufficient provision of NHS dentistry. While there were 34,520 dentists registered to provide dentistry in England in April 2023, responses to a General Dental Council survey suggest 22% of these may only be providing private dental care rather than any NHS dental care. There were 24,193 dentists who provided some NHS dental care in 2023-24, a fall of 483 (2%) since 2019-20 (paragraph 1.19).

Overall spending on primary care NHS dentistry has fallen in real terms, dropping from £3.66 billion in 2019-20 to £3.11 billion in 2023-24, a drop from £65.15 to £53.88 per person in England. Alongside this, dental budgets are not being fully utilised as practices do not provide the full amount of activity that they are contracted to. Between 2017-18 and 2022-23, an average of £182 million a year was recovered by commissioners due to practices’ under-delivery against their NHS contracts (paragraphs 1.27 and 1.28, and Figure 9).

The dental recovery plan

12 NHSE’s and DHSC’s dental recovery plan does not aim to recover NHS dentistry to a pre-pandemic baseline. The dental recovery plan was launched with an aim that “everyone who needs to see a dentist will be able to”, although this ambition is not quantified. DHSC and NHSE expect initiatives in the plan to deliver more than 1.5 million additional courses of treatment in 2024-25, although there is a significant degree of uncertainty in the modelling that sits behind that number. Even if the maximum potential impact is achieved, overall NHS dentistry delivery in 2024-25 would still fall around 2.6 million courses of treatment short of levels in 2018-19 (paragraphs 2.12 and 2.13, and Figure 10).

13 The plan is funded through £200 million of anticipated under-spends in the dental budget for 2024-25. Ringfenced dental budgets were introduced for ICBs in 2023-24, with £392 million underspent against those that year. DHSC and NHSE agreed that in 2024-25 the dental recovery plan will use £200 million from ICBs’ existing dental budgets that would otherwise have been used to offset wider pressures across their NHS budgets, a change which was enabled by DHSC finding £200 million of re-prioritisation savings in its group departmental budget. The stakeholders and ICBs we spoke to had initially believed that new funding would be available for the plan, but NHSE quickly clarified to ICBs, who commission NHS dentistry services, that they would get no increase to their dental budgets as a result of this plan. NHSE has agreed that the overall target of more than 1.5 million courses of treatment will be divided between ICBs based on under-delivery of UDAs in 2023-24, although the approach to do this was only agreed in August (paragraphs 1.29, 2.6 to 2.8, and 2.15).

14 As NHSE and DHSC are reliant on ICBs and dental practices to deliver the plan, there is significant uncertainty about the impact it will have. While NHSE and DHSC modelled the impact of the plan, ultimately its success is dependent on delivery by commissioners and practices. While the plan had been in development since December 2022, key details were still being finalised days before its publication, and we heard from some stakeholders, including ICBs, that they did not think engagement with them in the lead-up to publication was good. NHSE and DHSC told us they held stakeholder engagements in 2023. The ICBs we spoke to were already operating local initiatives that were similar to elements in the national plan. NHSE sought to incorporate elements of some of these local initiatives in its national plan, while also agreeing some local flexibilities to how the plan operates (paragraphs 2.4, 2.5, 2.11, 2.12, 2.14 and 2.15).

Progress to date

15 As of October 2024, NHSE has completed rollout on two of the plan’s four headline initiatives. The new patient premium and uplift to minimum values for UDAs are in place, but no vans have been procured. Potential market suppliers said that there may be challenges around the availability of vans and funding beyond 2024-25, but any further progress was paused when the general election was called. New ministers stated in November that it will be left for ICBs locally to decide whether they go ahead with procuring vans during the remainder of 2024-25. For ‘golden hellos’ there were some ministerial decision-making delays in agreeing allocations for posts across England before the general election was called. Out of an expectation of at least 240 ‘golden hello’ positions, 274 practices have had their expressions of interest to recruit a ‘golden hello’ post approved, and the first dentist had been appointed in October. However, as of November, neither the dental vans nor the ‘golden hello’ initiative are likely to deliver the expected number of additional courses of treatment by the end of 2024-25 (paragraphs 3.2 and 3.3, and Figure 11).

16 Based on initial analysis to date, the plan is not on track to deliver the additional courses of treatment. NHSE expects the new patient premium to deliver 1.13 million of the more than 1.5 million additional courses of treatment expected through the recovery plan. NHSE has thus far analysed data up to the end of September 2024, showing that fewer new patients had been seen in the first seven months of the premium than the equivalent period in the previous year. In September, NHSE began further analysis to better understand the impact that the new patient premium is having, including whether locally commissioned activities could be impacting claims. So far, data do not suggest that the new patient premium is on course to deliver the expected additional courses of treatment by March 2025, although NHSE also has data showing about a 14 percentage point increase in dental practices reporting that they are accepting new patients between December 2023 and September 2024. NHSE has not yet assessed what impact the uplift to minimum UDA values has had against what was expected. Overall dental activity levels are up slightly in 2024-25 compared with 2023-24, but this is in line with DHSC’s predictions about improvements in delivery for 2024-25 without the additional impact of the plan. NHSE and DHSC have agreed an evaluation of the plan that will aim to report in the next 12 months (paragraphs 3.4 to 3.6, 3.14 and 3.15, and Figure 12).

17 The strategic programme risks, risk scores and mitigations that NHSE identified in relation to the plan in March remained unchanged until NHSE revised them in October. A key risk for the plan was that the £200 million will not be spent; as of August 2024, £57 million had been spent and NHSE forecast that around £140 million will be spent on the plan in 2024-25. NHSE is monitoring spend against the wider dental ringfence budget on a monthly basis but did not report monthly on spend against the £200 million dental recovery plan prior to September. We have also seen limited evidence of how NHSE worked directly with ICBs to understand the impact of the plan in local areas in the first few months of the plan, although there was representation from regions at the dental recovery plan board. In October 2024, NHSE revised the strategic risks for the plan, closing the risk around funding and adding a new key risk that the plan would not meet its ambition of delivering an additional 1.5 million courses of treatment in 2024-25 (paragraphs 2.15, 3.6, 3.8, 3.10 and 3.11).

Concluding remarks

18 The dental recovery plan aspires to deliver more than an additional 1.5 million courses of treatment in 2024-25 but is not currently on course to do so. Even if these additional courses of treatment are delivered by the end of 2024-25, the plan would still mean that 2.6 million fewer courses of treatment would have been delivered than in 2018-19.

19 DHSC and NHSE should look to reflect on what has worked in this plan and build upon that as they look to deliver the meaningful reform of the dental contract that they have alluded to. A proper evaluation of this plan will be needed, as well as a review of whether they have sufficient reporting processes in place to make sure that they are getting back from ICBs the data they need to monitor progress with any future plan. They will need to assess how they engage with ICBs and dental practices who are responsible for delivering NHS dentistry in local areas.

Part One

Access to NHS dentistry

1.1 This part of the report sets out background information on NHS dentistry. It examines the landscape prior to the introduction of the dental recovery plan in terms of levels of activity, differences throughout England and factors affecting access to NHS dentistry.

Who is responsible for NHS dentistry?

1.2 The Department of Health & Social Care (DHSC) is responsible for overall healthcare policy in England. NHS England (NHSE), an arm’s length body of DHSC, is responsible for the implementation of health services in England, including NHS dentistry.

1.3 Dental activity is measured in:

courses of treatment: the examination of a patient, an assessment of their oral health and the planning and provision of treatment as a result; and

units of dental activity (UDAs): a measure of overall activity based on the type of treatment provided (Figure 1).

1.4 NHS dentistry is delivered by independent dental practices that enter into a contract with NHS commissioners to deliver an agreed amount of dentistry work, represented by a certain number of UDAs. Although there is a minimum value for UDAs, UDA values are not the same across all contracts and are negotiated between the commissioner and the dental practice. Most practices offer private dental services alongside NHS care.

1.5 From 2013 to 2023, NHSE directly commissioned NHS dentistry services across England. Responsibility for commissioning dental services was delegated to integrated care boards (ICBs) from 1 April 2023. There are 42 ICBs in England, and they are responsible for the planning and commissioning of health services in their area. Nine ICBs assumed commissioning responsibility for at least one of the pharmaceutical, ophthalmic and dental functions in their area in 2022 as early adopters, with seven of these commissioning dental services.

1.6 Patient charges for NHS dentistry are split between the three main bands and have been raised over time since their introduction in the 1950s. NHS patients in 2024-25 are charged between £26.80 and £319.10, although some patients are eligible for full or partial exemption from charges.4 These patient charges are used to partially offset total NHSE funding for dentistry.

Access to NHS dentistry in England

1.7 In the 24 months prior to the start of the COVID-19 pandemic, 49% of adults in England were seen by an NHS dentist. The National Institute for Health and Care Excellence (NICE) advises that an adult with good oral health should see a dentist at least once every two years. Even if all practices fulfilled their total contracted NHS dental activity, this would not provide for the entire population in England.

1.8 Routine dental services were paused at the start of the pandemic due to safety concerns and, when services restarted later in 2020, practices had to introduce additional infection prevention and control measures. NHSE introduced temporary contract arrangements at the start of the pandemic to pay all practices while they could not provide care. When practices re-opened, the activity practices were expected to deliver was gradually increased throughout 2020 and 2021.

1.9 The percentage of the adult population who had seen a dentist in the previous 24 months fell to 34% in March 2022 and recovered to 40% by March 2024.5 Polling in May 2024 suggests that the public viewed dentistry as the least accessible NHS service, with 71% saying it was difficult to access, compared with 64% saying the same thing for GPs, and 42% for A&E.6 In 2022, polling found that more than one in five people who had not had an NHS dental appointment in the past two years had suffered as a result, with the lack of access “causing anxiety, or making it difficult to eat or speak”.7

1.10 Access for children was also affected by the pandemic, with 23% of children seen in the 12 months up to 31 March 2021, compared with 59% in the 12 months up to 31 March 2020.8 This recovered to 55% of children being seen in the 12 months up to 31 March 2024, but there is evidence of negative impacts on children’s oral health in recent years. Government data show that, while the prevalence of tooth decay in 5-year-olds fell from 31% in 2008 to 23% in 2017, that trend has stopped, with the figure at 24% in 2022. Tooth decay was the leading  cause of hospital admissions in 5- to 9-year-olds in 2022-23.

1.11 A measure showing the pandemic’s impact is the number of courses of treatment delivered, which dropped from 38.8 million in 2019-20 to 12.3 million in 2020-21. The number of courses of treatment delivered across England recovered to 34.1 million for 2023-24, but remains 4.7 million fewer than pre-pandemic levels (Figure 2). The highest reduction from 2019-20 to 2023-24 was in band 3 treatments for paying adults (Figure 3).

1.12 Not only have patients faced difficulty in getting appointments, but their overall experience of NHS dental care has been affected. From January to March 2024, 69% of respondents to the GP Patient Survey had an overall positive experience of NHS dental care compared with 84% of respondents that had rated their experience as positive in January to March 2020.9,10

Dental inequalities across England

1.13 There are regional and demographic variations across England in terms of NHS dentistry access, outcomes and patient satisfaction. In 2021 Public Health England found that there were marked inequalities in oral health in England across all stages of the life course, with inequalities in access to dental services across ages, sex, geographies and different social groups.11

1.14 The 2021 Adult Oral Health Survey found that those in lower-income households were less likely to report going to the dentist for regular check-ups: 50% of those in the lowest income quintile said they went to the dentist for a regular check-up, in comparison with 68% and 71% in the highest and second highest income quintiles, respectively.

1.15 Less NHS dental activity is carried out in some areas across England. By region, courses of treatment per 1,000 people in 2023-24 ranged from 475 in the South West to 713 in the North West (Figure 4). At ICB level the variation is greater, with 382 courses of treatment per 1,000 people in Somerset ICB and over twice as much in South Yorkshire ICB, with 800 delivered per 1,000 people. Regions are also recovering at different paces from the pandemic. In 2023-24, London delivered 101% of its 2019-20 delivery of courses of treatment, while the South West delivered 70% compared with 2019-20.

1.16 Patients who do not already have a relationship with a dental practice struggle to get accepted, as practices are not obliged to accept new patients. It is a contractual condition for NHS dental practices to update or verify their practice information online every 90 days, including whether they are accepting new patients.  Data from NHS England’s ‘find a dentist’ website showed in July 2024 that around 10% of adults in England were more than 10 kilometres away from the nearest practice that said it was accepting new adult NHS patients when availability allowed. In one ICB, four in five adults were over 10 kilometres away from their nearest dental practice that said it was accepting new adult NHS patients when availability allowed (Figure 5).12

1.17 Patient experience also varies across the country. At ICB level the proportion of patients reporting a positive experience with NHS dental services ranged from 51% in Somerset ICB to 81% in Coventry and Warwickshire ICB (Figure 6).

Factors affecting access

1.18 The pandemic is not the only factor that has affected access to NHS dentistry. We outline below other factors identified through our fieldwork. This is not necessarily an exhaustive list.

Workforce

1.19 Dentists are free to choose whether they provide NHS or private dental care, or a mix, with most dentists in England providing a mix of both. In 2023-24, 24,193 dentists were providing some NHS dental care. This number had fallen by 483 since 2019-20, a decrease of 2%. There were 34,520 dentists registered with the General Dental Council (GDC) in England in April 2023 but the GDC found that 22% of the dentists in England whom it surveyed in December 2023 did not provide any NHS dental care, only private dental care.13 There are regional variations in the number of NHS dentists per 100,000 people, ranging from 31 to 126 at a sub-integrated care board level in 2023-24 (Figure 7).14

1.20 NHSE routinely reports on the number of dentists who provide some NHS dental care. It has been working to improve data on workforce, and has implemented a mandatory survey for practices providing NHS care, with the first publication of these data in November 2024. These data suggest that, in March 2024, for practices providing some NHS care, there were 10,539 full-time-equivalent (FTE) general dentists providing NHS care, which is 70% of the total FTE general dentists working in those practices.

1.21 In 2021 NHSE assessed that morale in the dental profession was at an all-time low and that there had been a further shift of practitioners to the private sector. The Review Body on Doctors’ and Dentists’ Remuneration (DDRB) 2024 report found that “attracting dentists to NHS work is increasingly difficult, resulting  in significant under-provision of NHS dentistry”. Morale among the dental workforce is poor and has declined since the pandemic, with the 2022-23 dental working patterns survey reporting that only 18% of respondents rated their morale as high, or very high.

1.22 Stakeholders told us that the issue is not necessarily a lack of dentists in the country, but that not enough dentists are incentivised to do sufficient NHS work, and that some areas find it harder to recruit than others. Some stakeholders also said that workforce issues could be improved by expanding the roles of dental care professionals such as dental nurses, dental therapists and dental hygienists and improving the dentistry education system. Regulations were amended in 2024  to enable hygienists and therapists to supply or administer specific medicines under exemptions.

Contract reform

1.23 The current dental contract arrangements have been in place since 2006 and are widely viewed as needing reform. We heard criticism that current arrangements lack adequate incentivisation for practices and do not reward prevention. The Nuffield Trust found in 2023 that the contract is “increasingly unattractive to many dentists and the private sector can offer higher pay”. We also heard concerns from some commissioners that they have faced an increase in contract handbacks during COVID-19, and that they have faced challenges with the inflexibility with commissioning despite improvements.

1.24 DHSC began contract reform in 2010, testing changes through a prototype programme. Further prototype contracts ran between 2016 and 2019, testing arrangements that combined payment by activity with a fixed amount paid per registered patient, rather than the existing system of just payments by units of activity. The prototype arrangements ended in March 2022. DHSC’s evaluation of the prototype found that access and activity had reduced under the different contract arrangements, and no significant improvement in preventative treatment was seen.

1.25 In July 2022, NHSE announced changes to the dental contract, the first major changes since 2006, including:

dividing band 2 treatments into three categories to reflect different levels of complexity of treatment;

introducing a minimum indicative UDA value of £23;

encouraging practices to recall adults with good oral health for check-ups every 12 to 24 months, rather than six;

introducing legislation to enable commissioners to address worsening access due to persistently under-delivering dental contractors; and

requiring practices to update their details on the NHS directory of services on a quarterly basis, making it easier for patients to find an NHS dentist.

1.26 Changes also enabled practices to deliver up to 110% of their contracted activity where this was agreed by commissioners and led to the publication of new skill mix guidance that supported dental care professionals to work within the NHS. NHSE at the time of the reforms stated they would work with the sector on a further phase of reforms. NHSE collects data on courses of treatment delivered under the new band 2 treatments and the proportion of treatments delivered by other dental care professionals, but we have seen no evidence of a full evaluation of the 2022 reforms by either DHSC or NHSE.

Spend on NHS dentistry

1.27 The total amount spent by commissioners on primary care NHS dentistry has fallen in real terms over the past five years, dropping by £555 million from £3.66 billion in 2019-20 to £3.11 billion in 2023-24 (Figure 8), a drop from £65.15 to £53.88 per person in England. In nominal terms, total spend has increased by 0.6% over that same period. Total income from patient charges has also fallen in real terms over this period, from just over £1 billion in 2019-20, to less than £800 million in 2023-24, with a drop to just over £300 million during the first year of the pandemic, which was offset by an increase in NHS spending to protect the income of practices during the pandemic. Over the same period, the fees charged to patients have decreased on average by 4% in real terms.

1.28 Decreases in real-terms spending on primary care dentistry are driven in part by dental practices not delivering their specified UDAs in their contracts, leading to commissioners recovering money from these practices. In 2017-18 to 2019-20, failure to deliver contracted UDAs led to an average recovery of £149 million per year. In 2020-21 and 2021-22, different thresholds for recovery were applied to acknowledge the impact of the exceptional circumstances COVID-19 presented, and so recovery amounts fell before rising to £479 million in 2022-23 (Figure 9).

1.29 In 2023-24, NHSE introduced a dental budget ringfence for the first time, covering primary, secondary and community services and providing clearer ICB reporting and accountability. Prior to this, commissioners had been provided with funding to cover pharmacy, optometry and dentistry, meaning that there was not a specific NHS dental budget. In 2023-24, the dentistry budget was £3.7 billion.15 NHSE reports that there was a £392 million under-spend against this budget. The element of this under-spend where primary care contractors (dental practices) have been paid for commissioned activity which was not delivered is being recovered via adjustments to payments made to dentists in 2024-25. As in previous years the finalised recovery figure will be confirmed in the next financial year following a reconciliation process. Data show that, in 2023-24, 41% of contracts with a target of more than 100 UDAs delivered less than 90% of that target. Across England 83% of all contracted UDAs were delivered.16

4 Patients do not have to pay for NHS dental services if they are under 18, or under 19 and in full-time education; pregnant or have had a baby in the last 12 months; being treated in an NHS hospital and their treatment is carried out by the hospital dentists; or receiving low-income benefit or under 20 and a dependant of someone receiving low-income benefits. Patients can get support with paying some of the costs through the low-income scheme.

5 Visits to dentists include orthodontists visits.

6 YouGov/British Dental Association Survey Results, May 2024, with a sample size of 1,707 adults in England (accessed 15 October 2024).

7 Key findings from Healthwatch England’s national dental polling, February 2022, with a sample size of 2,026 adults in England (accessed 16 October 2024).

8 Visits to dentists include orthodontists visits.

9 Overall positive experience refers to people reporting their experience as either ‘very good’ or ‘fairly good’.

10 The survey was conducted differently in 2024 so comparisons with previous years may reflect differences due to methodology.

11 Public Health England transferred its health protection functions into the UK Health Security Agency, and its health improvement and public health functions into the Office for Health Improvement and Disparities and NHS England.

12 The ‘find a dentist’ service provides information on which practices are accepting new patients “when availability allows”, but this is not defined by NHS England.

13 The General Dental Council asked dentists to complete a voluntary survey as part of their annual registration renewal in December 2023: 19,286 dentists working in England responded to the survey and may have been working in different care settings such as general dental practice, community dental services or hospitals. 

14 Dentists can work on multiple contracts at the same time which may be in different locations, meaning they can be recorded against multiple different areas.

15 The ringfenced dental budget of £3.7 billion covers primary, secondary and community dental services, net of patient charge revenue. The total spend, as reflected in Figure 8, of £3.1 billion in 2023-24 only refers to primary care dental activity. This is why the total budget for 2023-24, minus the under-spend, does not equal total spend on dentistry as that spend figure does not account for secondary and community dentistry, or patient charge revenue.

16 There are some limitations with this dataset; for example, it does not include UDAs awarded for flexible commissioning.

Part Two

The dental recovery plan

2.1 This part of the report outlines the development of the 2024 dental recovery plan (the plan), funding of the plan and the evidence base for what it is expected to deliver.

2.2 In February 2024 the Department of Health & Social Care (DHSC) and NHS England (NHSE) published a policy paper, Faster, simpler and fairer: our plan to recover and reform NHS dentistry (the plan). The plan aims to deliver more than 1.5 million additional NHS dentistry treatments (or 2.5 million appointments) by the end of 2024-25 through four headline initiatives (Figure 10).

2.3 The plan includes other initiatives, under the umbrella headings of Smile for Life (a focus on preventative care and oral health in young children) and workforce support and development. These initiatives are not expected to deliver additional dental activity in 2024-25. While some progress was made on these wider initiatives before the 2024 general election, DHSC and NHSE are now awaiting a decision from the new government about priorities for dentistry and the future of these initiatives. In our report, we focus on the four headline initiatives expected to expand access in 2024-25.

Timeline for development of the dental recovery plan

2.4 In December 2022, officials presented options to ministers for a dental recovery plan that included a new patient payment, incentive payments for dentists, and mobile dental vans, noting that improvements should be delivered as soon as possible, with a hope that it could be launched in 2023. The plan was published on 7 February 2024, in part delayed due to ministerial changes and consequently changing ministerial priorities, a need to secure agreement on the plan from multiple government departments and a lack of clarity on how the plan would be funded. Two days before publication of the plan NHSE and DHSC were yet to agree how the plan would be funded, when the new patient premium should launch, and how responsibilities would be divided.

2.5 Guidance for regional directors of finance on the financial implications of the plan was issued on 13 February 2024, and integrated care boards (ICBs) received guidance on the launch of the new patient premium from 1 March on 15 February. Details of how ‘golden hello’ payments would work were agreed by NHSE in April 2024 with guidance for ICBs published in May; the contribution that each ICB was expected to make (based on their unit of dental activity (UDA) under-delivery in 2023-24) to the additional 1.5 million treatments was not confirmed until August.

Funding for the 2024-25 dental recovery plan

2.6 The plan is being funded through £200 million of anticipated under-spends against the 2024-25 ringfenced NHS dental allocation, and so the introduction of the plan did not result in any increase to ICB dentistry budgets. Previously NHSE had expected to use these under-spends to offset wider pressures in the NHS in England in 2024-25 with the agreement of DHSC ministers.

2.7 As part of agreeing the dental recovery plan, NHSE received assurances that the risk caused by using £200 million of dental under-spends to fund the plan, rather than wider NHS pressures, would be dealt with before budgets were finalised for the year. In July 2024, five months after the plan launched, DHSC confirmed to NHSE that it would find £200 million of re-prioritisation savings across DHSC group budgets for wider NHS pressures to ensure that the dental under-spend in 2024-25 could be used to fund the plan. The total under-spend for 2024-25 will not be known until after the year end, but in 2023-24 the under-spend against the dental ringfence was £392 million.

2.8 Stakeholders and ICBs told us they were initially unclear about how the plan would be funded, in part due to reference to new funding being made available in the foreword of the published plan. Four of the five ICBs that we spoke to told us there was initial confusion over whether they would receive additional funding to deliver the plan. NHSE clarified to ICBs shortly after the plan was published that ICBs will receive no additional funding for NHS dentistry to deliver the plan and are expected to use under-spends within their budgets to fund the national initiatives. Levels of delivery against contracts, and therefore under-spend, vary across the country, with some ICBs using more of their dental budgets for dental commissioning than others, and so the amount that ICBs can spend on initiatives in the plan will vary. The financial risk within individual contracts is limited to the agreed contract value, but should delivery of UDAs in an ICB area increase, it could potentially reduce the funding available for other local initiatives.

The evidence base and modelling of the plan

2.9 In developing the plan, DHSC and NHSE considered a longer list of other initiatives that might have helped increase access to NHS dentistry. While DHSC and NHSE estimated the cost and impact of each of these initiatives, there was no formal options impact assessment published, and for the four chosen initiatives, we have not seen an analysis of why the costs between those were allocated as they were. DHSC and NHSE told us that the four costed initiatives were chosen following internal discussions with the goal of ensuring affordability within the £200 million based on estimated take-up and to maximise access for under-served populations.

2.10 It is unclear whether there was always agreement over the value for money of certain initiatives within the scheme. NHSE suggested that it did not feel that vans offered good value for money as there was insufficient evidence that enough vans could be procured and were in the right place. The decision to include the minimum UDA uplift to £28 was a ministerial one, and DHSC’s own analysis suggested that there is a weak correlation between increasing the UDA value and increased contract delivery for UDA values below £30. DHSC’s engagement with the sector, however, showed that the perceived unfairness of wide variation in UDA values contributed to dentist dissatisfaction with NHS dentistry, and that the uplift in minimum UDA value aims to address that.

2.11 All the initiatives in the plan rely on take-up by ICBs at a local level and delivery by dental practices. NHSE therefore consulted with some ICBs while developing the plan to try and draw lessons from what was already working. Most of the plan’s initiatives allow for some level of flexibility at a local level. One ICB we spoke to has increased the minimum UDA value in its area to £30 rather than £28, and ICBs can opt dental practices out of the national new patient premium where local schemes are in place. For example, in Greater Manchester ICB there is a dental access quality scheme, which aims to increase access for new patients by supporting practices to be open to new patients, keep their public availability updated and treat an agreed number of new patients. Greater Manchester ICB’s intention is to retain the local scheme, but practices may only participate in either the local scheme or the national new patient premium. Two of the ICBs we spoke to also previously had recruitment incentive schemes in place, similar to the national ‘golden hello’ payments. One region, covering multiple ICBs, is operating the ‘golden hello’ scheme but with the payment in full up-front, rather than phased over three years as in the national plan.

2.12 Examples like these demonstrate that there is significant uncertainty within DHSC and NHSE’s estimate that the plan could deliver more than 1.5 million additional courses of treatment in 2024-25. In March 2024, shortly after the plan’s launch, the then responsible minister acknowledged that the modelling had a “high likelihood of not being reliable”. NHSE modelled high- and low-range forecasts for the impact of each of the initiatives. However, it is unclear how the model arrived at the final numbers included in the plan, which does not include these ranges or reflect uncertainty about the overall number of 1.5 million additional treatments. Likewise, while the plan does set out what assumptions have been used  in calculating additional courses of treatment, it is less clear how some of these assumptions were developed.

2.13 If the plan delivers the anticipated additional courses of treatment, and if dentistry continues to recover in line with its current post-pandemic trajectory, DHSC estimates that courses of treatment in 2024-25 will reach 37.1 million, 2.6 million short of the 2018-19 pre-pandemic baseline of 39.7 million.17 DHSC has acknowledged that the plan does not aim to recover NHS dentistry fully to the pre-pandemic baseline, despite the plan promising to expand access so that everyone who needs a dentist will be able to access one.

Stakeholder consultation

2.14 We heard different views from NHSE and DHSC and from stakeholders on the extent of consultation that informed the plan. NHSE and DHSC held stakeholder engagements over the course of 2023. However, stakeholders told us that, while some organisations had regular meetings with DHSC and NHSE, much of it was informal and some stakeholders felt engagement lacked influence. There were long periods where no progress was made on the plan where stakeholders said they felt they were not kept informed about progress. At the beginning of the plan, NHSE told us that given the uncertainty around the final content and funding of the plan it believed it was not possible to provide regular updates on progress, as DHSC and NHSE only confirmed the final set of initiatives in the days before publication.

2.15 ICBs that we spoke to also had mixed experiences of engaging with NHSE and DHSC. While some met with the national team to discuss local initiatives and any overlap with the proposed national schemes, they did not always feel that these conversations were then fully taken into account. NHSE felt that it had engaged with ICBs in advance of the plan’s publication, but needed to balance local solutions with initiatives that would work at a national level. NHSE built flexibility into the new patient premium guidance to allow ICBs to opt practices out of the national scheme where a local scheme was in place. In May 2024, NHSE proposed distributing the additional courses of treatment among ICBs based on under-delivery of UDAs in 2023-24, which was agreed only in August.

17 Initial modelling by DHSC used 2018-19 as the base year to compare against, as it was the last full year unaffected by the COVID-19 pandemic. Elsewhere in our report we have used 2019-20 as our base year, as this allows us to use the most up-to-date single data series from the NHS Business Services Authority, which began in 2019-20.

Part Three

Achievements to date

3.1 In this part we look at how NHS England (NHSE) and the Department of Health & Social  Care (DHSC) have implemented the dental recovery plan (the plan), monitored its progress, what has been achieved and future evaluation plans.

Progress on implementing the plan

3.2 DHSC and NHSE have completed roll out of two of the four initiatives aimed at expanding access and providing more than 1.5 million additional treatments: the new patient premium and the unit of dental activity (UDA) uplift (Figure 11). For ‘golden hellos’, there were some ministerial decision-making delays in agreeing allocations for posts across England before the general election was called. Out of an expectation of at least 240 ‘golden hellos’, 274 practices have had expressions of interest approved across England, and the first dentist had been appointed in October. No dental vans have been procured. Potential market suppliers said that there may be challenges around the availability of vans and funding beyond 2024-25 but any further progress on this initiative paused when the general election was called. New ministers stated in November that it will be left for integrated care boards (ICBs) locally to decide whether they go ahead with procuring vans during the remainder of 2024-25. By the end of August, £57 million had been spent on the plan.

3.3 DHSC and NHSE assumed that dental vans and ‘golden hello’ payments would deliver around 60% of their full year possible delivery of treatments (280,000 courses of treatment and 30,000 courses of treatment, respectively), due to the lead-in time for their implementation. This would have required the initiatives to be fully operational by September 2024, which has not been achieved, and these initiatives have delivered no additional courses of treatment.

Monitoring changes in access to services

3.4 NHSE’s main analysis to date focuses on the impact of the new patient premium, which is expected to deliver the majority (1.13 million) of the additional 1.5 million courses of treatment. The actual data thus far show that fewer new patients are being seen in the first seven months of the premium being operational than the equivalent period last year, and data do not suggest that the premium is on track to deliver the expected number of additional courses of treatment (Figure 12). Analysed data beyond September are not yet available because there is a time lag of up to two months between courses of treatment ending and dentists submitting their claims. As of October 2024, no data were available on the impact of the UDA uplift, with further analysis needed.

3.5 Data that dental practices report to NHSE suggest that there was an increase between December 2023 and September 2024 in the proportion of practices accepting new patients “when availability allows”, rising from 16% to 30% for all adult patients and 26% to 41% for children.18 Monthly reporting on UDAs delivered shows a small increase in the early months of 2024-25, but this is in line with DHSC expectations that, even without the plan, there would be an increase of 3.7% in delivery. Despite this, a Health Insight Survey from the Office for National Statistics, published in October 2024, found that 96.9% of the 752 adults who responded that they did not have an existing relationship with a dentist had been unsuccessful in making an NHS dentist appointment in the 28 days before responding to the survey.19

3.6 NHSE began work in September (seven months into the new patient premium’s operation) to gather qualitative data from ICBs and local dental networks to better understand the impact that the new patient premium is having and clarify whether the data are providing an accurate picture. This includes identifying whether interaction with local schemes for new patients has affected the national premium’s impact. Further evaluative work is planned, ahead of a decision on the premium’s future towards the end of the year.

Governance and oversight of the plan

3.7 NHSE and DHSC are leading on different aspects of the dental recovery plan, with NHSE responsible for the implementation of the four main initiatives, and DHSC responsible for the wider preventative work such as Smile for Life and workforce support and development.

3.8 NHSE has a dental recovery plan board, with oversight of the workstreams that NHSE leads on and whose functions include ensuring join-up between teams in NHSE and DHSC. The board membership includes representation from regional colleagues. There was also an implementation group, which reported to the board and which had five workstreams covering:

mobile dental vans;

workforce;

finance, contracting and commissioning;

communications; and

data monitoring and evaluation.

3.9 A separate dental and optometry board within NHSE has oversight of the wider work of the dental team. Before the announcement of the general election, NHSE and DHSC were also holding weekly meetings with the Secretary of State for Health & Social Care and the responsible minister to update on the plan.

Risk management

3.10 NHSE’s dental recovery plan board meets monthly and receives an update on strategic programme risks. Between March and September 2024, there were five strategic programme risks to delivery of the plan that covered funding, capacity, stakeholder engagement, provider participation, and local delivery. These risks and mitigating actions were reported as unchanged from March to September 2024, and NHSE did not provide more detailed risk assessments underlying these strategic risks, saying that these related to the implementation of the scheme and had been largely resolved. The key risk identified around funding was that the £200 million would not be fully spent. Between April and August 2024 £57 million was spent on the plan (Figure 11), and NHSE has forecast a spend of £140 million over the whole year. NHSE is monitoring spend against the wider dental ringfence budget on a monthly basis but did not report monthly on spend against the £200 million dental recovery plan prior to September.

3.11 In October 2024 the dental and optometry board met and discussed wider risks around NHS dentistry, including some relating to the plan. The board closed the risk score related to fully using the £200 million intended for the plan, explaining that this is now part of monthly ICB assurance reporting. Other risks were added, including a key risk that the plan will not deliver the more than 1.5 million additional courses of treatment expected by NHSE and DHSC. These updated risks were noted by the dental recovery plan board at its October meeting.

3.12 Although this is not reflected in the formal risk assessment, NHSE has separately highlighted risks with the implementation of the new patient premium. NHSE acknowledges there may be some practices that proactively encourage known patients, rather than unknown patients, who had not been seen in 25 months or more to attend, in order to claim the new patient premium. This is within the rules. Practices could also switch patients between practices to claim a payment when the patient is not, in fact, new. NHSE considers the risk of fraud with the new patient premium as low due to the way payment rules have been designed and are assessing whether any additional checks are required on top of existing post-payment fraud checks. NHSE also planned for public-facing communications about the new patient premium to be gradually increased in its initial weeks to prevent appointment demand outstripping supply and reduce the risk of new patient frustration at being unable to book an appointment.

Future evaluation of the plan

3.13 In the published plan DHSC and NHSE committed to track local experience during roll-out and to work with stakeholders in the sector to evaluate the plan.

3.14 In August 2024, NHSE told us that it had not reached out to other stakeholders about evaluation as it was too early, and that it was developing key lines of enquiry. Also in August 2024, DHSC proposed an evaluation approach for five key elements of the plan (the four headline initiatives to expand access along with the Smile for Life preventative programme), including:

using published and management data to track delivery and impact; and

a process evaluation to understand whether interventions are effective and, if not, why not.

3.15 This evaluation approach has been endorsed by DHSC’s Research and Development Committee, and DHSC intends to develop its evaluation approach further and will refine it with NHSE. DHSC intends for the evaluation to be conducted within the next 12 months with exact timings to be confirmed.

18 The ‘find a dentist’ service provides information on practices are accepting new patients “when availability allows”, but this is not defined by NHS England. 

19 The survey was conducted between 20 August and 11 September 2024. Overall, it received 97,412 responses, with 752 respondents saying that they did not have a dentist and had tried to access NHS dental care in the previous 28 days. The Office for National Statistics has labelled the statistics from the survey “official statistics in development”, and so these are not official statistics.

Appendix One

Our investigative approach

Scope

1 We conducted an investigation into the dental recovery plan, a plan published in February 2024 which aims to provide a boost to NHS dentistry after the impact of the COVID-19 pandemic. One of the plan’s headline ambitions was to deliver more than 1.5 million additional courses of treatment in 2024-25.

2 This report provides an overview of the access to NHS dentistry prior to the plan, how the plan was developed and how it is currently progressing, including NHS England’s (NHSE’s) and the Department of Health & Social Care’s (DHSC’s) plans for evaluation.

3 This report has not sought to examine and report on value for money but has reflected on key issues to consider moving forward with NHS dentistry. Our findings are based on evidence we collected between June and November 2024.

Methods

4 In examining these issues, we drew on a variety of evidence sources, including interviews, a stakeholder roundtable, document review and data analysis.

Interviews

5 We carried out nine interviews with key individuals and teams with experience or knowledge of the development of the dental recovery plan from DHSC and NHSE, including the Chief Dental Officer, and HM Treasury. These interviews covered a range of areas including the background, management and evaluation of the plan, the funding for the plan, and the data and modelling used to inform the plan.

6 We held an in-person roundtable with 14 attendees from 11 organisations:

the British Dental Association;

the Association of Dental Groups;

the College of General Dentistry;

the Dental Schools Council;

the British Association of Dental Therapists;

the Society of British Dental Nurses;

Healthwatch;

Toothless in England;

the Oral Health Foundation;

the Nuffield Trust; and

the British Society of Dental Hygiene and Therapy.

7 We also held separate interviews with other stakeholders, including the General Dental Council, the British Fluoridation Society, the British Association of Dental Nurses and a patient and public voice representative. These stakeholders were selected as DHSC had engaged with them in the development of the plan.

8 We also held interviews with five integrated care boards (ICBs) to understand the current challenges they are facing for NHS dentistry, ICBs’ involvement with the development of the plan, and the role they play in delivering and monitoring the plan. These ICBs were:

NHS Greater Manchester ICB;

NHS Norfolk and Waveney ICB;

NHS Coventry and Warwickshire ICB;

NHS Surrey Heartlands ICB; and

NHS Cornwall and the Isles of Scilly ICB.

These interviews included representatives from regional commissioning bodies and local providers. We selected five ICBs based on a mix of high and low performance across a range of indicators, those that were selected for the dental vans initiative and early adopters of dental commissioning, in addition to aiming to speak to ICBs from different regions. We consulted specialist colleagues within the National Audit Office to support with the methodology for selecting these ICBs.

9 All of our interviews were conducted virtually using Microsoft Teams. We did not record the interviews but took a note of each and recorded a transcript of some interviews. The stakeholder roundtable was held as a fully in-person event.

Document review

10 We reviewed more than 200 documents from DHSC and NHSE to inform our findings and help us understand the background to the plan, the evidence base that was used and how it has delivered. These documents included:

board papers and minutes;

documentation on the plan’s management and progress;

submissions to ministers;

NHSE and DHSC engagement with stakeholders;

correspondence between departments; and

proposal and planning documentation.

Data analysis

11 We analysed publicly available data published by NHSE and the NHS Business Services Authority on access to NHS dentistry, the current workforce and the overall cost of NHS dentistry. We also analysed data provided to us by NHSE on how the plan has delivered so far, and data on the ‘find a dentist’ service.

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