The potential sample size was 295 practices (197 Devon; 98 Cornwall), and 134 responses were included in the final analysis after deduplication and postcode eligibility checking. Dental practice duplication accounted for exclusion of 26 responses, with a further 2 responses removed as they were not within geographical boundaries. This provided a 36% response rate (106 practices out of a possible 295) across Devon & Cornwall. A similar response rate was obtained across the two Counties, but a greater response obtained from those working in NHS / mixed practice compared to solely private practice (see Fig. 1).
94.4% of respondents considered R&R a Major factor in enabling patient access to NHS dentistry. The NHS Dental Contract was widely considered to be the main barrier to R&R of dental associates in the NHS, with income generation identified as a Major (n = 69) or Significant factor (n = 33) by 95.3% of respondents.
Recruitment
A large proportion of practices indicated they had vacancies at the time of data collection (76.6%; n = 82). Fifty-seven percent of practices currently had a vacancy for a dentist (n = 60), and over three-quarters of these vacancies were within NHS practices (n = 46). Several of these practices had multiple vacancies with one declaring as many as 6 unfilled associate positions. Of the private practices responding to the survey, 54% had a vacancy for a dentist (n = 13).
Almost half the practices (48%; n = 51) had vacancy for a dental nurse, with several having multiple unfilled positions. The majority of practices affected were NHS, accounting for 80% of dental nurse vacancies. Other groups from within the dental team appeared to be less affected: hygienists / therapists with 12% vacancy rate (n = 13); receptionists with 10% (n = 11); practice managers with 1% (n = 1). (See Fig. 2)
Previous difficulty in recruiting dentists was reported in 60.7% (n = 65) of practices, with 24.3% (n = 26) of practices reporting this had frequently been a problem, and 36.4% (n = 39) reporting this had always been a problem. Only 1.9% (n = 2) of respondents reported that recruitment of dentists had never been a problem.
Only 5.6% (n = 6) of practices stated they had never experienced difficulties recruiting dental staff. The number of practices experiencing difficulty with recruitment outweighed this considerably, with 27.1% (n = 29) stating they had always experienced difficulties, and 31.8% (n = 34) reporting that they had frequently experienced this difficulty. 65.4% of practices reported that recruitment of dental staff had become much harder in recent years (n = 70), and 24.3% (n = 26) reporting dental staff recruitment had become harder.
There were no significant differences in perception of recruitment of dentists between practices based in Devon and those based in Cornwall (t(104) = .394, p = .117). Correspondingly, there were no significant differences between Cornwall and Devon based practices for reported recruitment or retention issues (t(104)=-.430, p = .459; t(102)=-.281, p = .898 respectively).
Retention
43% said retention of dental staff was an issue; with 28% [n = 30] stating frequently and 15% [n = 16] always. Similarly, a large proportion of practices (78.5%, n = 84) reported retention of dental staff had become increasingly difficult in recent years, with 30.8% (n = 33) reporting it was much harder to retain dental staff, and 47.7% (51) reporting it was harder to retain dental staff.
Recruitment and retention within dentistry in rural and coastal areas has previously been highlighted as a serious issue which directly impacts on the availability oral health care services4. The survey data from Devon and Cornwall provides further evidence that, despite the establishment of a dental school within the region, recruitment and retention of dentists and dental staff remains a major barrier to care. The responses suggest that the situation is deteriorating, with almost 90% of respondents declaring that recruitment of dental staff had become more difficult in recent years. The data also revealed that retention was also a major problem with more than three-quarters of practices reporting that it had now become harder to retain staff.
Influencing factors
The factors considered to influence R&R in Devon and Cornwall are explored within the next section, drawing on analysis of the free-text responses. It is worth noting that when asked to report the main factors affecting recruitment, there were no significant differences between private practice and NHS practice selected response options, with the exception of the response Career opportunities (t(99)=-.794, p = < .001*) which were reported as better within the private sector than the NHS.
Qualitative data
Free text questions invited participants to share their views on the influencing factors impacting on R&R. The answers were analysed thematically and the findings are summarised in Table 1. It is important to recognise that there is overlap within these themes / sub-themes and factors are often inextricably linked and interdependent.
Table 1
Theme | Subtheme |
NHS System | Dental Contract Reform |
Financial Aspect |
Workload |
Economic Challenges | |
Logistics | Location and Travel |
Accommodation and Cost of Living |
Support networks | Support |
Training |
Mental Wellbeing |
Career Development |
NHS System
The current NHS dental contract was seen as the key factor impacting on recruitment and retention within the NHS, which was primarily related to remuneration and workload when compared to the private sector.
‘The NHS dental service is a national disgrace and dentists and staff don’t want to work in it.’ (#13)
The need for urgent change was highlighted by several respondents, with many fearful for the future of NHS dentistry.
‘I am leaving NHS and going privately as my patience with the current contract is over’ (#14)
Respondents noted that a lack of investment in NHS dentistry was a barrier to R&R within NHS practices. The financial constraints imposed by NHS funding impacted on the ability of practices to remunerate staff at a competitive rate, which was seen as a factor in recruitment and retention of staff.
‘Lack of investment in NHS dentistry is the main reason for practices inability to offer staff competitive salaries.’ (#51)
Workload under the NHS was another issue raised, and many felt the continuing pressure to deliver UDA targets within an increasingly challenging environment, led to significant stress and increased risk of mistakes, complaints and legal action.
‘Risks of litigation, inability for dentists to provide the time and care patients need, pressures from practices to see more patients than appropriate for each dentist. Increases risk of mistakes, serious issues being missed such as oral cancer.’ (#50)
Economic challenges
Many respondents highlighted the lack of investment in NHS dentistry and reported the impact of the COVID-19 pandemic on the ability to retain and recruit dental staff within the NHS.
‘Many dental nurses left during/post covid-19 due to the increase workload for no reward.’ (#60)
Wage stagnation within the NHS and the rising cost of living, led to staff seeking alternative roles within the job market.
‘COVID and people deciding to take alternate careers…….in lots of places supermarkets are paying the same and have far less expectations on the role.’ (#99)
A number of respondents also suggested that ‘Brexit’ was a particular barrier to recruitment and retention of non-UK dentists.
“BREXIT makes recruitment of EU dentists much more difficult” (#21)
Logistics
Location and travel were cited as an issue to R&R due to access to training, poor transport links, road congestion during summer months, and a preference for younger staff to live in urban locations19.
‘We lost one dentist as her commute became intolerable as the traffic in Cornwall in the summer months has become incredibly congested, and she needed to work closer to home with her young children.’ (#109)
Accommodation and cost of living was identified as another factor, with house prices rising significantly in recent years.
‘It is also more difficult in Cornwall now given the price of housing is astronomical.’ (#109)
Support networks
Respondents frequently mentioned “support”, although this had several different elements including clinical, emotional and financial support. Leadership and management, mentoring and the value of personal and professional networks were also identified as important.
‘Working in a rural practice can be quite isolating for younger dentists especially after the support of the dental school environment.’ (#86)
Isolation was also highlighted in relation to cultural identity and lack of diversity within many rural areas.
‘There is definitely a cultural barrier too, being a single British Hindu woman, I am firstly the only female dentist in my practice and there is definitely a cultural barrier ie Diwali which would widely be celebrated in my previous practice in London here in Devon some of my colleagues had never even heard of it which can make one feel more isolated.’ (#20)
Access to training was seen as a potential barrier to R&R, with dental professionals having to travel significant distances to support their continuing professional development.
‘More courses/teaching in Cornwall to enhance further training …. not having to travel to Bristol and beyond for any worthwhile course...’ (#119)
The reduced number of Dental Foundation Training practices in the area, their distribution and ongoing mentorship were also highlighted as a potential issue.
‘I also think the NHS needs to consider alternative options for foundation training and or mentor training - this would help newer dentists.’ (#4)
The inability to retain students from Peninsula Dental School beyond graduation was highlighted as a frustration, and this was linked by some as shortcoming in admissions where too few ‘local’ students were being given the opportunity to train as a dentist or a therapist at the University of Plymouth.
‘Recruit local students to the dental school, otherwise they all return back to their homes in UK away from Devon.’ (#19)
Deterioration in the state of mental health and well-being amongst many in the profession, particularly those within the NHS, was highlighted. Although dentistry has always been considered a stressful occupation, the views of our respondents appeared to suggest this was getting worse.
‘In over 30 years of practice I cannot remember a time when morale and enthusiasm for dentistry was lower.’ (#116)
Career progression was reported as a reason for dental staff leaving the NHS, and in some cases the profession, which aligned with the work of Holmes et al20. The lack of opportunities within dentistry, particularly the NHS, was deemed to impact deleteriously on retention with respondents describing a desire for staff to be keen to pursue “new challenges” (#86), “career development outside of dentistry” (#25) and “opportunities for a bigger or different challenge” (#26). This appeared to affect dental nurses more than any other group within the dental workforce.
Recruitment solutions
The final question in the survey invited respondents to provide any additional comments, which led to a number of suggestions on what could, and should, be done to improve R&R within the region. The solutions tended to reflect the factors already identified within the survey. These included addressing issues at a local, regional and national level and focussed on NHS dental contract reform (DCR), local recruitment into dentistry, increased numbers of training places, incentives to retain Peninsula graduates to stay in Southwest, better access to training / CPD and improvements in peer support and mentorship.