It’s not just about the money: recruitment and retention of clinical staff in general dental practice

Abstract

Increasing difficulties in recruitment and retention of dentists and dental care professionals in general dental practice in the UK is affecting delivery of NHS dental services. Reports of dissatisfaction among the general dental practice workforce indicate there is a significant risk to the future dental workforce supply which will affect access to dental care and worsen oral health inequalities. Understanding the factors related to job satisfaction and dissatisfaction of dental professionals would be useful in managing recruitment and retention issues and ensure a dental workforce exists which is able to meet the needs of the population. The aim of this literature review was to identify factors which contribute to job satisfaction and dissatisfaction of clinical staff in general dental practice. Database searching was conducted systematically through PubMed/Medline, Scopus, Ovid, and the National Grey Literature Collection. Part 1 of this two-part series discusses the factors relating to dentists. Twenty-two relevant articles were identified, which were qualitatively analysed using Herzberg’s motivation-hygiene theory as an analysis tool. Target-driven and restrictive contractual arrangements are a major factor contributing to dissatisfaction of dentists, as well as time pressures, poor quality equipment, and unfair remuneration. Dental contract reform should aim to minimise factors contributing to dissatisfaction and increase factors which increase satisfaction, if sufficient numbers of dentists are to be persuaded to continue to provide state-funded dentistry.

Keywords

Recruitment retention satisfaction dentists

Learning Objectives

• To understand the concepts and principles of Herzberg’s motivation-hygiene theory and its application in the context of job satisfaction of dentists

• To identify existing factors that contribute to dentists’ job satisfaction according to the motivation-hygiene theory

• To synthesise the existing literature to provide a summary of factors for stakeholders to consider in contract reform

Introduction

There are widespread reports of issues in the recruitment and retention of dentists and dental care professionals (DCPs) in general dental practice in the UK, particularly affecting delivery of NHS dentistry.^1-4 These issues have been exacerbated by the Covid-19 pandemic which has caused a backlog of missed dental appointments, and by Brexit which has increased barriers to overseas dental professionals practicing within the UK.^2,5

Access to dental care is a determinant of oral health which enables delivery of preventative care and early intervention on dental disease, with the aim of improving health and reducing social care and wider economic costs.⁶ The ageing UK population are retaining their teeth for longer, requiring more complex dental care and placing greater demands on the dental workforce and provision of care.^7,8 Access to dental care has become an increasingly significant issue in the UK, due to the number of dental practices closing or becoming fully private, which is a barrier to people who are unable to afford private dental care and has a greater affect on people from lower socioeconomic backgrounds.^9,10 If dental practices are unable to fill vacancies or retain dentists and DCPs in NHS practices, people will not be able to access affordable dental care.¹¹

The increase in unfilled vacancies in general dental practices, especially NHS practices in remote and deprived areas, and reports of dissatisfaction among dental professionals indicates there is a significant risk to the future dental workforce supply.^1,12 If dentists continue to leave NHS dentistry, this will worsen the existing access to dental care and increase oral health inequalities, exacerbating what is already a significant public health problem. Understanding factors which predict job satisfaction within general dental practice in the UK would be useful in managing recruitment and retention issues and in designing acceptable dental contracts, thereby ensuring a dental workforce able to meet the needs of the population.

Theoretical framework

Recruitment and retention of individuals within a workforce are associated with job satisfaction.^13-16 There are many different definitions of job satisfaction; the most accepted being positive or negative feelings an individual has toward their work.¹⁷ Job satisfaction is a significant factor in a person’s intention to leave their job, which is highly predictive of this behaviour.^18-20 In addition, high intention to leave also has negative effects on an individual’s engagement with their work.²¹

The Herzberg motivation-hygiene theory (Table 1) suggests that job satisfaction and dissatisfaction exist on separate continuums affected by different factors.^22,23 Two independent processes occur: one where people feel good or satisfied about their work and another where they feel bad or dissatisfied. The presence of “motivators” increases job satisfaction, but their absence does not increase dissatisfaction.^23,24 Improving “hygiene factors” (the term used by Herzberg to describe factors that prevent job dissatisfaction) can prevent job dissatisfaction but does not contribute to job satisfaction.²³

Table 1

Herzberg motivation-

Herzberg’s motivation-hygiene theory is a useful tool in predicting job satisfaction and has previously been applied in other healthcare sectors to understand recruitment and retention of healthcare workers.^14,16,25

The aim of this literature review is to identify specific factors which currently contribute to job satisfaction and job dissatisfaction of dentists in general dental practice.

Methods

This research was conducted in a narrative literature review format.²⁶ Multiple sources of literature were searched to better understand the issue through a broad range of experiences, values, and perceptions. Electronic searches of databases (PubMed, Scopus, Ovid and National Grey Literature Collection) and website searches (see Table 2) were conducted to identify relevant literature. Inclusion criteria comprised any published or grey literature discussing job satisfaction, dissatisfaction, retention or recruitment of dentists in general dental practice/primary dental care after 1st April 2006. Systematic searches were carried out in June 2022 and updated in May 2023. The full search strategy can be found in Appendix 1, at the end of this paper.

Table 2

Websites searched

Website	Home page
General Dental Council (GDC)	www.gdc-uk.org
NHS England	www.england.nhs.uk
Health Education England (HEE)	www.hee.nhs.uk
Health and Social Care Committee	https://committees.parliament.uk/committee/81/health-and-social-care-committee/
British Dental Association (BDA)	www.bda.org
BDJ in Practice	www.nature.com/bdjinpractice
HealthWatch	www.healthwatch.co.uk
College of General Dentistry (CGDent)	cgdent.uk

Eligibility

To determine eligibility of records, inclusion and exclusion criteria were developed using the Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER) tool (see Appendix 2).²⁷

Study selection and data extraction

Studies identified through the search strategy were screened by the lead author (JAH) and assessed against the eligibility criteria. Selected reports were retrieved and reviewed independently by both authors. A data extraction template was designed using the Herzberg motivation-hygiene theory as a framework to ensure a consistent approach to data extraction, ensure transparency, and enable ease of synthesis of findings. The following data were extracted from each article: author, year, type of article/study, short description of study, dental professional group, motivation factors mentioned, hygiene factors mentioned, and any other factors discussed.

Risk of bias assessment

This review included a diverse range of study methodologies, opinion and grey literature, therefore distinct appraisal instruments were used to critically appraise each record.²⁶

For cross-sectional studies, the Joanna Briggs Institute (JBI) checklist was used.²⁸ Cohort studies were appraised using the Critical Appraisal Skills Programme (CASP) checklist for cohort studies.²⁹ For qualitative reports, the NICE quality appraisal checklist for qualitative studies was used.³⁰ Grey literature and opinion articles were appraised using the AACODS (Accuracy, Authority, Coverage, Objectivity, Date, Significance) checklist.³¹

These tools were used to produce summary evidence quality judgements of low, moderate or high risk of bias for each included article.

Results

Included records

Database searches, carried out in June 2022 and repeated in May 2023, identified 548 records. Following removal of duplicates and screening of titles and abstracts to identify relevant records, a total of 46 reports were retrieved for full text screening. The full text of one record was unavailable, and therefore excluded from the review. Following review of full texts, 26 reports did not meet eligibility criteria and were excluded.

Searching via other methods (reference lists of included records and website searching) identified 16 reports, 14 of which were eligible for inclusion. Therefore, a total of 33 reports were included (Figure 1). Twenty-two reports were relevant to dentists (Table 2) and are discussed in this article. The 11 reports relevant to DCPs are discussed in Part 2 of this series, “It’s not just about the money: recruitment and retention of clinical staff in general dental practice – part 2: dental care professionals” (see pages 55–63).

Included reports had high methodological heterogeneity therefore it was not appropriate to attempt any quantitative synthesis or meta-analysis. The papers are presented through a narrative synthesis.

A summary of the included studies is provided in Table 3. The agreed “motivator” and “hygiene” factors influencing job satisfaction identified in reviewed literature are presented in Table 4.

Table 3

Descriptive summary of included studies relating to dentists

Author(s) (Year)	Study design and participants	Motivation factors discussed (achievement, recognition, responsibility, work itself, advancement, personal growth)	Hygiene factors discussed (working conditions, co-worker relationships, policies and rules, supervisor quality, salary)	Other comments/factors
Stewart et al. (2007)³²	Cross-sectional study, self-reported questionnaire of 141 senior year dental students at Manchester and Dundee University		• Working conditions – time pressures and managing time effectively• Policies and rules – fear of litigation	More female dentists than males expressed a wish to work part-time following qualification, however 23% of the sample felt that males had an advantage over females since they did not take maternity breaks or have the same family responsibilities
Davies et al. (2008)³³	Cross-sectional study, self-reported questionnaire of 53 vocational dental practitioners in Wales	• Work itself – wide ranging, varied clinical work most desirable in future job• Personal growth – access to CPD	• Working conditions – access to high quality premises, working for a corporate body was least desirable• Co-worker relationships – negative opinions towards working in a single dentist practice• Policies and rules – concerns about non-availability of NHS contracts in the area which the respondents preferred to work in, concern about the future of NHS dentistry, private dentistry seen as an attractive alternative to NHS dentistry• Salary – employment benefits such as paid annual leave, sick pay or maternity pay influence career choice	Long-term professional expectations were closely linked with personal lives and support a vision of a favourable work-life balance
Denton, Newton and Bower (2008)³⁴	Cross-sectional study, self-reported survey of 326 dentists in the UK	• Personal growth – higher burnout scores and lower engagement among dentists without postgraduate qualifications	• Working conditions – dentists who work longer hours are more engaged with work• Co-worker relationships – lower number of dentists in a team correlated with higher levels of work engagement• Policies and rules – higher amount of time spent on NHS work associated with negative work experiences	Age – dentists under 30 feel less accomplished
Harris et al. (2008)³⁵	Cross-sectional study, self-reported questionnaire of 440 dental practitioners working in primary care in three trusts in England	• Recognition – respect from being a dentist• Responsibility – having control of own work• Work itself – being able to provide quality comprehensive care, helping people• Personal growth – development of skills	• Working conditions – having adequate time to spend with patients• Policies and rules – working within NHS system more restrictive on being able to provide quality care• Salary – level of income is not the reason many dentists cite when deciding to leave the NHS	Higher job satisfaction in dentists working wholly privately, compared to those working wholly NHS or mixed NHS/privateThose working completely on NHS basis felt more restricted in being able to provide quality care in their workDentists working in high needs areas felt more restricted in being able to deliver quality careYounger dentists identify more strongly with restriction on being able to provide quality care
Holt and Ladwa (2008)³⁶	Opinion article on the need for mentoring in dental practice in the UK	• Advancement – career perspective and taking on additional roles• Personal growth – available programme of professional development	• Working conditions – time pressures• Co-worker relationships – support from experienced colleagues, peer review/study groups• Supervisor quality – high pressure poor practice management
Chestnutt, Davies and Thomas (2009)³⁷	Cross-sectional study, self-reported questionnaire of 496 dentists in Wales		• Working conditions – dissatisfaction with information technology (IT) facilities• Co-worker relationships – non-clinical staff support• Policies and rules – less administration and contracting directly with the local health board	Reduction in the number of dentists agreeing that they “are their own boss”Females were significantly more likely to work 3 days per week or less
Harris et al. (2009)³⁸	Cohort/Longitudinal study which investigated job satisfaction of dentists pre- and post- introduction of the new dental contract in England in 2006	• Recognition – respect from being a dentist• Responsibility – control of work, running a dental practice• Work itself – being able to provide quality care and help people• Advancement – opportunity to develop a specialist interest• Personal growth – having time to improve clinical skills	• Working conditions – time to devote to patients’ needs• Policies and rules – feel as though on a treadmill in NHS, erosion of autonomy due to change in the system	Significant decrease in job satisfaction post-introduction of the 2006 contractFemale dentists and those who had been qualified for more than 20 years were less satisfied following introduction of the new contract
Willett and Palmer (2009)³⁹	Cross-sectional study, self-reported questionnaire of 428 vocational training dentists in England and Wales		• Working conditions – anxiety around getting a job in a preferred location and the need to relocate• Policies and rules – NHS units of dental activity (UDA) targets• Salary – NHS capped income
Brown et al. (2010)⁴⁰	Cross-sectional study, self-reported questionnaire of 189 early retired due to ill health dentists from the UK	• Recognition – patient perceptions	• Working conditions – most common cause of early retirement due to ill health was musculoskeletal conditions due to working practices• Policies and rules – NHS work, pressure of system cause of stress	48% report their early retirement due to ill health was entirely work related and 42% reported it was partly work relatedRe-employment of early retired dentists due to ill health was significantly associated with age, dependents, cause of early retirement, and whether their health had improved28% retired due to mental and behavioural disorders such as anxiety and depression, which could have been managed with more support from services such as occupational health
Hill et al. (2010)⁴¹	Qualitative study, semi-structured interviews of 23 dentists from the UK who had retired early due to ill-health	• Recognition – professional standing/status	• Working conditions – staffing issues, lack of time, anxious or uncooperative patients• Co-worker relationships – Professional support networks	Most common factor in ill-health retirement was anxiety, depression or stress, followed by musculoskeletal diseaseBusiness of dentistry stressful – business management training would have been useful
Holt and Ladwa (2010)⁴²	Opinion article discussing mentoring in general dental practice in the UK	• Work itself – a sense of purpose and contributing to the greater good• Personal growth – programmes to support professional development	• Co-worker relationships – having a supportive mentor
Harris, Dancer and Montasem (2011)⁴³	Qualitative study, semi-structured interviews of a purposive sample of 20 dentists in England on their motivation following a change in contractual arrangements	• Achievement – achieving a good clinical result, having an “end-point” in a treatment plan• Responsibility – control over decision making and clinical freedom• Work itself – being able to do the job well is easier in the private sector	• Working conditions – having enough time with patients• Policies and rules – pressures imposed by healthcare system (NHS), difficult to provide good quality of care within the “framework” of the NHS• Salary – having to work harder to maintain income	Running a business within a healthcare system is a negative aspect of the jobConflicts between asking patients for money and providing healthcare
Newton et al. (2011)⁴⁴	Qualitative study, structured interviews of 14 final year dental students in the UK on their career expectations and influences on their career plans	• Responsibility – obligation and responsibility to provide oral healthcare for all (via NHS) and having freedom over clinical work• Work itself – giving back to the community• Advancement – opportunities for career progression	• Policies and rules – NHS system restrictive range of treatments available and limited development of skills• Salary – remuneration under NHS system, financial security	Family life, work-life balance also influences career plans
O’Selmo, Collin and Whitehead (2018)⁴⁵	Cross-sectional study, self-reported questionnaire of BDA members working in general practice in England	• Work itself – patient-related factors such as helping people was the most cited factor for motivation	• Working conditions – corporate practices less likely to have sufficient staff, corporate environment negatives• Co-worker relationships – corporate dentists less likely to receive support from colleagues than non-corporate• Salary – majority of corporate and non-corporate dentists disagreed they were fairly remunerated	Majority of respondents dissatisfied with their jobCorporate dentists less satisfied with their job than non-corporate
Collin et al. (2019)⁴⁶	Cross-sectional study, self-reported questionnaire of 2,053 dentists in the UK	• Recognition – negative public perception of dentists• Responsibility – clinical freedom	• Co-worker relationships – associate dentists feeling unsupported by practice management, politics within dental team, corporate environment• Policies and rules – GDC regulation a significant source of stress, NHS bureaucracy and UDA targets, fear of litigation and complaints• Salary – financial factors a significant cause of stress	General practice dentists reported highest levels of stress compared to other types of dentistsConcerns about moving towards a corporate mentality that places profits above care of patients
O’Selmo et al. (2019)⁴⁷	Qualitative study, semi-structured interviews with a purposive sample of 11 dentists in the UK	• Recognition – positive perception from the public• Responsibility – autonomy over own work, loss of autonomy more greatly felt in corporate sector• Work itself – helping people• Advancement – structured career progression	• Working environment – maintenance of equipment, investment into practice, corporate practice• Co-worker relationships – experienced nurses• Policies and rules – persecution from regulator (GDC), NHS contract impediment to good practice, associates want changes made to UDA system• Supervisor quality – relationship with principal dentist• Salary – decline in remuneration	Job securityIn corporate jobs, profit is seen as the priorityBrexit may lead to a drop in supply of associates which may improve working environments
BDA (2020)⁴⁸	Written evidence to the Health and Social Care Committee from the BDA on burnout and resilience in the NHS workforce in England	• Work itself – being able to manage patients’ health appropriately	• Policies and rules – fear of litigation, contractual targets, red tape, bureaucracy, over-regulation by the GDC• Salary – financial viability of practices (NHS and private) causing stress among dentists	Burnout significant issue for dentists – occupational stress significant factorCovid-19 pandemic caused uncertainty
NHS Digital (2020)⁴⁹	Cross-sectional study of primary care dentists (principals and associates) in the UK, responses from 5,383 dentists in 2018–19 and 5281 in 2019–20	• Recognition – receiving recognition from others• Work itself – feeling good about the job, having the chance to do challenging and interesting work• Advancement – career progression	• Working conditions – recruitment and retention of dental team members, having the equipment and resources to do the job properly• Policies and rules – NHS regulations, GDC regulations, practice inspections (e.g. Care Quality Commission [CQC]), decontamination policies, risk of litigation and cost of indemnity• Salary – increasing expenses and declining income, disparity between treatment complexity and financial return (unfair pay), inadequate levels of remuneration for preventative care	Principal dentists have higher levels of motivation and morale compared to associate dentistsPrincipal dentists in Scotland have highest motivation on average, and in Wales lowest motivationAssociate dentists in Scotland have the highest average motivation, and those in Northern Ireland the lowest overall average motivationStrong correlation between the amount of NHS work and negative motivation of dentistsLonger hours and less annual leave taken by dentists who spend more time on NHS work
Gallagher and Scambler (2021)⁵⁰	Opinion article on the transition to a female majority of the workforce in dentistry in the UK	• Advancement – women are under-represented at high levels in practice (practice ownership), need career path and development into leadership roles and as mentors• Personal growth – training in additional skills	• Working conditions – flexible working patterns• Policies and rules – inflexibility in facilitating parental leave for men and women, system redesign for English contractual arrangements to avoid financial penalties	More women dentists work part-time and women dentists have better morale than men
Gallagher et al. (2021)⁵¹	Qualitative study, purposive sample of 20 dentists working in England completed a semi-structured interview	• Achievement – finding things that create a sense of self-worth• Recognition – recognising and enjoying successes• Responsibility – leadership from early career dentists in reforming the profession as part of professional responsibility• Work itself – variety of work• Advancement – dentists who have been able to mix clinical work with upskilling or teaching are more fulfilled, “portfolio careers” attractive but limited within general practice setting• Personal growth – developed coping mechanisms	• Working conditions – being able to work at an optimal pace, practice ethos and culture• Co-worker relationships – a happy team, good relationship with dental nurse and the practice team, availability of professional support networks• Policies and rules – many plan to leave NHS dentistry without reform of the system, many would consider working for the NHS under a different contractual arrangement (Scotland fee per item seen as better), disconnect with regulatory body (GDC) around complaints and more transparency and fairness needed• Supervisor quality – a clinical lead was preferable to a practice manager• Salary – parental leave
Davda et al. (2022)⁵²	Qualitative study, semi-structured interviews of internationally qualified dentists (IQDs) working in the UK	• Work itself – respondents liked that there is no need to “sell” treatments to patients when working within the NHS	• Co-worker relationships – some IQDs felt valued by their colleagues but others reported variation in team dynamics, access to social media professional support groups• Policies and rules – those who have worked less than 5 years less likely to feel empowered to raise concerns, integration into the workforce affected by the structural processes of registering in the UK	Lack of support from professional organisations
Pal et al. (2022)⁵³	Opinion article on career pathways for general dental practice	• Advancement – structured career advancement/paths

Table 4

Summary of factors relating to job satisfaction and dissatisfaction of dentists

	Motivators(increase job satisfaction)	Hygiene factors(prevent job dissatisfaction)
Dentist	• autonomy/control over own work• able to provide high quality care• helping people• development of skills• variety of work• opportunity to take on additional roles• structured career path	• non-target driven and unrestrictive contractual arrangements• adequate time to spend with patients• access to quality equipment• fair remuneration• non-corporate environment• reduced risk of litigation• flexibility of work including part-time options• preferred location which is not a high-needs or rural area• employment status• supportive peers/mentoring• availability of professional networks

Risk of bias

All the reports included in this review were individually assessed for risk of bias using the appropriate quality assessment tool described in the Methods, and a summary judgement made of low, moderate or high risk of bias (Appendix 3). Factors which only appeared in articles determined to be at a high risk of bias were excluded from the summary table (Table 3).

Discussion

The purpose of this literature review was to identify specific factors that contribute to job satisfaction and prevent job dissatisfaction of dentists in general dental practice. This review found that there may be factors specific to certain groups, e.g. females and those at different ages and career stages.

The most prominent overall factor associated with job dissatisfaction found in this literature review was working under target-driven, inflexible, and restrictive contractual arrangements, which was mentioned in over half of included reports. The majority of these were in relation to NHS arrangements in England and Wales. The risk of dentists leaving the NHS to go private due to the focus on targets over quality was an issue raised in an independent review of NHS dentistry in England and Wales in 2009, and there have been minimal changes in contractual arrangements since then.⁵⁴ A previous report on the motivation level of dentists by NHS Digital found that motivation level is inversely correlated with the amount of NHS work carried out.⁴⁹ However, dentists in Scotland have higher morale and provide more NHS dentistry compared to dentists in other countries of the UK.⁴⁹ There is evidence suggesting that fee-per-item payment models, such as those in Scotland, are associated with more clinical activity and less preventative advice.^55,56

The present study identified that providing quality care and helping people increases job satisfaction of dentists,^45,47 however it is reportedly difficult to provide good quality of care within the “framework” of the NHS.^43,44 Some dissatisfaction (hygiene) factors which featured in the present review, such as unfair remuneration for work done under the NHS,^44,49 inadequate time to spend with patients,^35,42,43 and lack of access to/no investment in quality equipment,^37,47,49 may be consequential of NHS contractual arrangements.

In July 2022, NHS England announced marginal changes to the English dental contract for 2022/2023, including introduction of a minimum Unit of Dental Activity (UDA) value and increasing the number of UDAs claimable where the course of treatment involves three or more teeth, or for complex procedures such as root canal treatment.⁵⁷ These changes may reduce dissatisfaction of dentists regarding remuneration under the NHS contract but do not increase access to dentistry.^44,49

Time pressures are cited as a source of stress for dentists and can impact a dentist’s ability to provide quality care to their patients, which can lead to poorer care outcomes.^58,59 In the present study, time was a factor mentioned frequently in relation to working in NHS dentistry.^35,36,43 Earning potential is linked directly to the amount of time taken to complete a course of treatment.⁶⁰ Autonomy/control over work was a commonly mentioned satisfaction (motivator) factor in the literature examined in this review.^{35,38,44,46,47}

Associate dentists have little influence over the equipment they are provided with by the owner of the practice.⁴⁷ There are many stresses faced by practice owners associated with running a dental business and the business aspect of dentistry has previously been described as a source of moral tension due to the conflict between asking patients for money and providing healthcare.^41-43,61 Increasing bureaucracy and regulation has been previously cited as a barrier to investment by practice owners.⁶² Dental practices with poor quality equipment are not attractive workplaces.^37,47,49

Younger dentists are less satisfied and feel more restricted by contractual arrangements to be able to provide quality care.^35,38 Career plans, particularly of newly qualified dentists, may be influenced by employment benefits such as annual leave, parental leave, and sick pay.^33,50,51 Self-employment is the traditional status for dentists working in general practice, but the Covid-19 pandemic highlighted that associates have little protection or rights, as there were many instances of practice owners who did not pass on payments given to NHS practice owners which were intended for associates.⁶³ There are benefits and drawbacks of employed and self-employed status and potential impacts on productivity and income, which should be considered if an employed model is adopted or offered as an option within general dental practice. The BDA conducted focus groups of associate dentists in 2021 which revealed that dentists do not believe NHS working conditions and constraints would change if associates were employed.⁶³ This highlights that the situation around NHS contractual arrangements is more complex than simply changing the model of remuneration, it definitely is about more than just the money.

The present review found that flexible and part-time work is desired, especially among newly qualified and female dentists.^32,50 This agrees with a recent report on dentist working patterns which found an increase in part-time working for dentists.⁶⁴ The proportion of female dentists has been rising in the UK, and in 2021 the GDC register for dentists was 51.5% female and 48.5% male.⁶⁵ There has also been an increase in the number of dentists who want a “portfolio” career, where they work part-time in general practice and have one or more additional roles elsewhere, such as teaching or even a role outside of dentistry.⁶⁶ The findings of this review are reflective of this, as dentists desire a variety of work,^33,51 opportunities for additional roles^36,51 and opportunities to gain further qualifications and develop skills.^{34,36,38,42,50} These prospects are unlikely to be found within general dental practice where the work is regarded as repetitive.^40,67 In addition, this review found dentists have concerns around litigation and complaints,^32,46,48,49 which has previously been reported as the biggest concern of dentists up to five years post-qualification.⁶⁸

There has been an increase in the number of corporate dental bodies in the UK (multiple dental practices owned by one dentist or company), due to their ability to employ economics of scale and manage the increasing burden of bureaucracy and regulation.⁶⁸ Findings from this review suggest that there is a perception among dentists that corporate environments focus on profit over quality care.^45-47 Dentists who work in corporate environments are less satisfied than non-corporate dentists.⁴⁹

The present study suggests availability of professional support networks could increase the retention of dentists.^40,41,51,52 Dentists are at high risk of burnout, anxiety, and depression from the stressful demands of the job.^49,51,69 A study in 2022 found that dental professionals may not understand how, or may be unwilling, to access formal help.⁶⁹

This review identified factors relating to job location. Newly qualified dentists have anxiety over securing a job in a preferred location³⁹ and there have been few incentives to work in rural or high-needs locations,³⁸ although a recently launched scheme in Wales is offering preferential terms to attract graduates to work in rural and remote localities. It has been previously reported that recruiting dentists in rural and more deprived locations is challenging⁴⁸ so without initiatives that remove the potential for this to be a factor contributing to dissatisfaction, it is unlikely these locations will become more attractive to dentists. This has the potential to further exacerbate oral health inequalities and lead to poorer outcomes for patients in rural and more deprived areas, as patients in these areas will find it challenging to access timely dental care and resort to seeking care in inappropriate places, such as the Emergency Department, putting more pressure on other areas of the healthcare system.

From the literature available, there is insufficient evidence to make any definitive conclusions about the impact of Covid-19 or Brexit on the dental workforce, but this is a topic which warrants future investigation due to the prediction that it will lead to a reduced supply of dentists and dental care professionals. A reduction in the supply of dentists and dental professionals may improve working conditions as demand increases, however there is likely to be increased competition from private practices and they may be able to offer more attractive positions compared to NHS practices.

Conclusion

Current contractual arrangements are contributing to the dissatisfaction of dental professionals, and any changes should consider minimising or removing factors identified in this review which lead to dissatisfaction, and introduction of factors which increase satisfaction, to firstly retain the existing workforce and to attract dental professionals to NHS dentistry. This is crucial to ensure there is a dental health workforce that is able to meet the needs and demands of the population.

Footnotes

Appendices

Appendix 3

Quality Assessment of included records: summary judgement table of included articles

Acknowledgements

Part of this research was carried out in partial fulfilment of a Master’s in Public Health by the first author (JAH).

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It’s not just about the money: recruitment and retention of clinical staff in general dental practice – part 1: dentists

Abstract

Keywords

Learning Objectives

Introduction

Theoretical framework

Methods

Eligibility

Study selection and data extraction

Risk of bias assessment

Results

Included records

Risk of bias

Discussion

Conclusion

Footnotes

Appendices

Acknowledgements

References