Thirty dentists, 3 dental care professionals, and 13 managers participated in our four focus groups (46 participants in total). Four themes were generated by the analysis to capture key findings:
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1.
Careers: Career development, nurtured in a safe, supported, and learning-focussed space, enables professional advancement.
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2.
Collaboration: Working collaboratively improves oral health outcomes, which in turn supports a sustainable dental workforce.
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3.
Costs: Fair pay and contracts, guided by policies, play a role in retaining dental professionals.
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4.
Contentment: Dental professionals’ satisfaction with their jobs leads to a more sustainable workforce.
Participant quotes are labelled with focus group number (e.g., FG1), and participant number within the focus group (e.g., P5).
Careers
Across professional groups, staff were motivated to develop and learn. This learning was even more critical against a backdrop of increasingly complex patient care post-Covid-19. Cultures supportive of learning were positive driving factors towards workforce sustainability.
For example, practitioners described wanting to diversify their skills and achieve more variety in their working week.
FG1 P3: “…retention comes with variety and if you haven’t got variety, you’re struggling. [It] goes back to changes in NHS practice… you go in and you’re just doing amalgams or extractions, people don’t want that anymore.”
Many felt strongly about the need to host undergraduate students in general dental practices, noting how this would benefit the career insights of the student and could stimulate interest in teaching amongst the staff.
FG4 P2: “Nurses would enjoy the variety of working with a student.”
Similarly, being an Educational Supervisor for the Foundation Dentist [FD] programme was viewed positively. However, the national recruitment process was a source of concern. Being ‘allocated’ a Foundation Dentist removed the autonomy of practices around recruitment. The autonomy to establish a team based on ‘fit’ and trust provided a solid foundation for a positive working environment. The challenges of national recruitment and poor staff allocation were highlighted, particularly in relation to their disproportionate impact on dental practices as small businesses, where a single unsuitable hire could jeopardise the practice’s stability and success.
FG4 P6: “[National recruitment] could break your practice… If I’m a hospital consultant and my trainee is not very good when they’ve left, I’m still a hospital consultant.”
Participants discussed additional barriers to the career development of all professional groups. Many of these related to practical issues, such as costs (of training, and from loss of income in attending an event), and a lack of physical space and time to facilitate best use of skill-mix.
FG1 P5: [They (DCPs) have] additional skills that can be used utilised. But I haven’t got a room for you to see patients to do oral health education. If I did, I would pay you to do it. I physically don’t have space.”
Participants expressed desires to create learning-focused cultures, where open dialogue about mistakes, challenges, and improvement was encouraged.
FG4 P6: “We sat and we problem solved. And we talked about your difficult cases. Which is great to do, and that’s fewer complaints and better dentistry and everybody wins on that.. So it’s a really positive thing to do.”
Collaboration
Collaborations were central to enhancing the experience of dental professionals, shaping clinical practice, and optimising care. This theme explores the nature of collaboration, and its relationship with dental workforce sustainability.
Participants identified the importance of creating strong professional relationships with other team members. This was particularly critical for those new to NHS dentistry or considering leaving it. Establishing these connections was seen as essential in providing the necessary support, guidance, and career development opportunities to help retain staff. Measures that facilitated mentoring, open discussions about challenges, and targeted professional development were viewed as key to sustaining engagement and confidence within the workforce.
FG4 P6: “So what do I do if I’ve got a group of associates who are really struggling to hang on to NHS dentistry, I take them out to do that and I say, where are your problems? How can I assist? How can I support? How can I give you that career development support that you need?”
Some participants described the loneliness of working in remote or small practices, and expressed a desire for regional networking events that would encourage professional dialogue and social connection.
FG4 P5: “Attracting people away from the cities where their comfort zone is, where their social network might be and where their peer network is. And if we had a more formal structure of professional networking around [we] might be more attractive to be able to help us recruit in those areas”
There was a suggestion that a more collaborative relationship with commissioners and regulators built on shared understanding and mutual respect would enhance workforce sustainability. For example, improved lines of communication between agencies (for example, NHS-England and the Care Quality Commission) could dramatically reduce the administrative burden created through duplication of documentation in NHS dentistry.
FG2 P4: “It just seems to be a lot of duplicate work and nobody’s sharing the information with each other. So then we have to submit it again…You don’t have to do that if you’re a private practice.”
Collaboration also extended to the public and ways of changing negative perceptions of dentistry and oral health. Many participants emphasised their willingness to create meaningful, and important connections within local communities and cited an example of how positive an outreach education activity had been for a staff member. However, these motivations were hindered by systemic barriers (e.g., financial constraints).
FG2 P7: “I went to a school the other day and it was the best day of my life…[But] there’s no funding for it… It’s all based around private dentistry, earning the money, earning the money. There’s no community. There’s no education.”
Costs
Funding issues – relating to financial pressures, commissioning, and contractual constraints – were a large focus of discussions. These factors were central to the operational viability of dental practices and the retention of practitioners within the NHS.
The NHS General Dental Services (GDS) contract was negatively perceived. One participant described a colleague earning more money outside of dentistry, communicating a sense of unfairness about the current system of renumeration.
FG2 P4: “I’ve got a dentist who worked full time and has reduced her NHS commitment to not go and work in a private practice. She’s actually opened a pizza restaurant and is earning more money through the pizza restaurant than she is in, in dentistry.”
Commissioning was felt to be too restrictive, failing to value health promotion. The current contractual framework, with a pressure to deliver mandatory services as Units of Dental Activity (UDAs), discouraged use of skill-mix or any professional activities outside of direct patient care. Participants described feeling like a “hamster on the wheel” [FG1 P5] constantly chasing ‘UDAs’.
Additionally, contractual arrangements meant that practices sometimes felt restricted in hiring Foundation Dentists: they could not justify the space needed for a Foundation Dentist when their UDAs did not count towards practice targets. Practices accepted this was short-sighted for workforce sustainability, but the immediate pressures for the practice to survive outweighed longer-term concerns.
FG2 P4: ”In my practice, I can’t afford to have a surgery given to an FD because of their UDAs, we have such a high target their UDAs don’t count towards the targets. I couldn’t afford to have an FD in there.”
There was broad agreement that additional funding is required to sustain NHS dentistry. While practitioners may remain committed to NHS clinical care, practice managers saw NHS business as being financially non-viable. There was a clear tension between the provision of NHS care and the functioning of a practice as a viable business.
FG2 P4: “[I’m] pushing to say the practice cannot continue as an NHS practice. Financially, it can’t do it. The accountants are telling us, the bank is telling us, I’m telling them, they’re [practitioners] are the ones who are telling me saying, no, we want to stay NHS… I keep telling them that we’re not charity workers.”
Contentment
The multi-dimensional factors that contribute to, or detract from, contentment, and the implication of these factors for workforce sustainability are explored in this theme. This section also explores the close relationship between contentment and the decision to transition to private practice.
Central to this theme was the recognition that living and working in the North East offers a high ‘quality of life’. Many felt this could be better promoted.
FG4 P1: “The North East is a great place to live and work and we should acknowledge that… well supplied with schooling, housing, interconnected transport links…If we’re looking to enhance the workforce, we should be selling that.”
There was pride in working for the NHS, especially relating to the provision of continuity for patients and communities. This pride was central to contentment and fuelled practitioner resilience.
FG2 P4: “They’ve seen those patients grow up from being a child to an adult who’s bringing their kids to the practice now…if it was money orientated, they would have jumped ship a long time ago.”
However, several barriers to job satisfaction or contentment were identified, including challenges in maintaining work-life balance, lack of career opportunities in the North East for practitioners’ family members, and not feeling valued in the same way as other NHS staff.
FG2 P8: “I think people were quite put down during Covid because dental nurses were not considered part of NHS, because there were all these NHS perks which was not available for dental nurses.”
In relation to private practice, many seemed defensive regarding their engagement, and eager to express that the primary incentive for transitioning to private practice was not always financial. Rather, it was frequently the desire to sidestep the bureaucratic burden of the NHS and provide higher quality care for patients.
FG4 P5: “It’s stick after, stick after stick after stick. And as a practice owner you go, why am I putting myself through all of this regulation when with one simple manoeuvre I go, I’m not playing this game anymore?”
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