Attitudes of Undergraduate Dental Students to Proposed NHS ‘Tie-in’ for Graduate Dentists in the United Kingdom

Attitudes of Undergraduate Dental Students to Proposed NHS ‘Tie-in’ for Graduate Dentists in the United Kingdom | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Attitudes of Undergraduate Dental Students to Proposed NHS ‘Tie-in’ for Graduate Dentists in the United Kingdom Nyah Patel, Leena Soltan, Afra Rahim, Swati Nehete, Jason Stokes, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8800177/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Aims: To explore the attitudes of UK undergraduate dental students towards a proposed mandatory National Health Service (NHS) ‘tie-in’ period following graduation, in which newly qualified dentists would be required to work in the NHS for a minimum period in return for publicly funded training. Methods: An online survey was distributed to elected representatives of the British Dental Association (BDA) Students Committee across all 16 UK dental schools. Quantitative data assessed agreement with government consultation proposals, preferred incentives to encourage NHS participation, and overall support for compulsory service. Free-text responses were analysed thematically. Results: The survey received responses from 32 representatives. Most students opposed the proposed mandatory NHS ‘tie-in’, with 41% strongly opposing and 10% opposing. Financial incentives were the most acceptable approach, with 56% favouring loan repayment schemes and 22% favouring guaranteed training posts. Free-text responses highlighted three key themes: financial support, career progression, and NHS contract reform. Attitudes towards mandatory service varied by year group and familiarity with policy discussions. Students expressed concern that compulsory NHS service could undermine recruitment, reduce professional autonomy, and fail to address underlying workforce challenges. Conclusions: UK dental students demonstrate strong preference for voluntary engagement with the NHS supported by financial and career incentives, rather than compulsion. These findings have implications for workforce planning, suggesting that recruitment and retention strategies should focus on aligning NHS opportunities with graduate motivations and wellbeing. Future research should examine the long-term impact of different workforce incentive models on dental career pathways, NHS engagement, and service sustainability. Health sciences/Health care/Dentistry/Dental education/Dental foundation training NHS dentistry undergraduates dental students dental graduates workforce planning return-of-service incentives career intentions Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Key Points • Most students expressed disagreement with a compulsory service requirement, preferring voluntary engagement with the NHS. Only a small proportion supported the mandatory ‘tie-in’, indicating that compulsory policies may face resistance from the emerging workforce. • Students highlighted financial incentives, structured career progression pathways and NHS dental contract reform as more acceptable strategies to encourage NHS participation. These incentives were seen as more motivating than mandatory service. • The findings suggest that recruitment and retention strategies for NHS dentistry should balance workforce needs with graduate motivations, wellbeing and autonomy. Effective policy may require a combination of targeted incentives, improved career pathways, and contract reform rather than compulsory service, to attract and retain skilled dental professionals. Introduction Health systems worldwide depend fundamentally on the availability, stability and effective distribution of their workforce, commonly referred to as human resources for health (HRH). 1 The health workforce is recognised as one of the six core building blocks of health systems, alongside service delivery, information systems, medical products and technologies, financing and leadership and governance. 2 A sufficient, competent and equitably distributed workforce is therefore essential for ensuring timely access to care and achieving optimal population health outcomes. Yet the recruitment and retention of HRH remain a major global challenge. The World Health Organisation (WHO) estimates that by 2030 there will be a global shortfall of 10 million healthcare workers, driven by factors including insufficient investment in education and training, worker migration and increasing population need. 1 , 3 , 4 Dentistry is no exception. Dentists and members of the wider dental team play a role in promoting and maintaining oral health, which is integral to general health, psychosocial wellbeing and quality of life. 5 , 6 In most countries, including the United Kingdom (UK), oral healthcare is primarily delivered in primary care settings through both privately funded and state-funded services. 7 The global importance of oral health was underscored in 2022 when all United Nations member states adopted the WHO Global Strategy on Oral Health, committing to progress toward universal health coverage (UHC) for oral health by 2030. 8 A central aim of this strategy is to ensure an adequate number and appropriate distribution of skilled oral health workers capable of delivering an essential package of services. Achieving this requires investment in workforce capacity, improved data monitoring and policies that support equitable access to oral healthcare. 9 , 10 In the UK, concerns regarding the dental workforce have intensified in recent years. The number of General Dental Practitioners (GDPs) providing National Health Service (NHS) care in England decreased from 24,684 in 2020 to 23,733 in 2021, the lowest figure since 2014, with multiple factors contributing to recruitment and retention difficulties. 11 A frequently cited issue is the NHS dental contract, which employs a target-based, “bundled care” model that many GDPs describe as stressful, inflexible and poorly aligned with prevention, contributing to low morale and burnout. 12 , 13 These challenges sit within a wider system strain. Public satisfaction with NHS dentistry has fallen from 85% in 2019 to 69% in 2024, 14 and the British Dental Association (BDA) estimates that more than 13 million adults in the UK are unable to access NHS dental care. 14 Evidence suggests that those with the greatest clinical need are often those most likely to miss out on timely treatment, exacerbating inequalities and driving greater reliance on private provision or, in some cases, self-care and “DIY dentistry”. 14 These pressures have renewed attention to NHS workforce and service reform. The NHS 10 Year 14 and the NHS Long Term Workforce 15 plans focus on delivering improved retention, better distribution of staff, enhanced training pathways and a greater focus on prevention and community-based care. Policy priorities in dentistry include expanding NHS capacity, improving children’s oral health, modernising the dental contract, enhancing the roles of dental care professionals and investing in preventive interventions such as fluoride varnish, fissure sealants and supervised toothbrushing. 14 More broadly, the government aims to shift towards the transition from analogue to digital, value-based care, strengthen career development opportunities and reduce reliance on international recruitment by 2035. 14 In this evolving policy context, the early career pathways of dental graduates from each of the 16 UK dental schools (Fig. 1 ) are pivotal, with registration through the General Dental Council (GDC) required after graduation. 16 Most undertake Dental Foundation Training (DFT), an NHS-funded year designed to support the transition to independent practice through supervised clinical work, study days, audits and formal assessment. 17 Successful completion of DFT is required for entry onto the National Performers List for NHS primary care, 17 and all trainees are assessed against a nationally standardised curriculum defined by the UK Committee of Postgraduate Dental Deans and Directors (COPDEND). 17 Additional training routes - including academic and military foundation programmes as well as integrated DFT - Dental Core Training (DCT) schemes - further diversify early career options. 17 – 19 Many graduates progress to DCT, which offers opportunities to consolidate clinical skills, explore specialty interests and broaden career perspectives. 20 – 22 The Dental Gold Guide, outlines the governance, standards and progression frameworks for postgraduate dental training across the UK. 17 Fig. 2 outlines the typical career pathways available to newly qualified UK dental graduates at present. Understanding dental graduates’ career intentions is important for effective workforce planning. 23 Prior studies have shown that career expectations are shaped by the interplay of professional motivations, personal aspirations, working conditions and wider structural factors such as population need. 23 – 26 In the context of growing dissatisfaction with NHS dentistry and increasing numbers of dentists shifting away from NHS practice, insight into the perspectives of prospective dental graduates is more important than ever. 27 Against this backdrop, the UK Government is in consultation regarding the introduction of a mandatory NHS ‘tie-in’ period for newly qualified dentists. 28 This policy would require graduates to undertake a minimum of three years of NHS service as a condition of receiving publicly funded training, justified on the basis that training a dentist costs the taxpayer up to £200,000 and that public investment should be matched by public service. 14 , 15 , 28 The aim is to address workforce distribution issues, increase NHS dental capacity and ensure a more stable and sustainable dental workforce. 28 However, similar return-of-service (ROS) policies internationally demonstrate that such approaches can have promise but also pose many challenges. 29 Amid NHS workforce pressures, declining morale within NHS dentistry and ongoing contract reforms, it is essential to understand how current undergraduate dental students perceive the proposed NHS ‘tie-in’ period. Exploring these perspectives provides critical insights to inform policy development, ensure alignment with workforce motivations and support the creation of a sustainable, engaged and well-distributed dental workforce for the future. Aims and Objectives: This study aimed to explore the attitudes of undergraduate dental students towards the proposed NHS ‘tie-in’ for newly qualified dentists in the UK. The objectives were to identify key influences shaping students’ views, including preferences, perceived barriers, and motivating factors that inform their perceptions of the proposal. Methods: Study design This study employed a mixed-methods, cross-sectional questionnaire design. A mixed-methods approach was chosen to capture both the distribution of student attitudes through quantitative measures and the underlying reasoning through qualitative data. Quantitative data were collected using structured questionnaire items, while qualitative insights were obtained from free-text responses, enabling exploration of participants’ concerns, perspectives, and recommendations regarding the proposed NHS ‘tie-in’ for newly qualified dentists. Methods Study design This study employed a mixed-methods, cross-sectional questionnaire design. A mixed-methods approach was chosen to capture both the distribution of student attitudes through quantitative measures and the underlying reasoning through qualitative data. Quantitative data were collected using structured questionnaire items, while qualitative insights were obtained from free-text responses, enabling exploration of participants’ concerns, perspectives, and recommendations regarding the proposed NHS ‘tie-in’ for newly qualified dentists. Participants and Setting Participants comprised undergraduate dental students representing each of the 16 UK dental schools on the BDA Students Committee. Two students from each dental school serve on this committee and are elected to represent their respective institutions. In addition to the student representatives, there are cross-representatives from other committees within the BDA such as the Dental Academic Staff Committee (DASC). The committee’s remit includes advocating for dental students’ interests through engagement with dental schools, the Dental Schools Council (DSC), COPDEND and other interested parties. The committee convenes biannually to provide a formal forum for student concerns to be raised and addressed. Data Collection The questionnaire was developed using Microsoft Forms and consisted of 10 items (Figure 3). Data was collected via an anonymous online survey link, which was distributed to eligible participants and available between 16 October 2025 and 1 November 2025. Inclusion and Exclusion Criteria Inclusion criteria were undergraduate dental students enrolled in years BDS1–BDS5 at UK dental schools who were elected members of the BDA Students Committee and serving their current mandate at the time of data collection. Incomplete survey responses were excluded from analysis, as were responses from non-UK undergraduate dental students. Data Analysis A 100% response rate was achieved from eligible committee members. Quantitative data included demographic variables (year of study) and awareness of the NHS tie-in proposal, as well as attitudes measured using five-point Likert scale items relating directly to the proposed policy. Descriptive analysis was undertaken to summarise quantitative findings. Qualitative free-text responses were analysed using thematic analysis to identify key themes relating to reasoning, concerns, and recommendations expressed by participants. Ethical Statement Participation in the study was voluntary, and completion of the questionnaire constituted implied consent for participation and use of anonymised data for research purposes. All data were collected anonymously, and no patient data were involved. The NHS Research Ethics Committee decision tool indicated that formal ethical approval was not required for this study. Results A total of 32 responses were obtained from the 16 UK dental schools, with two respondents representing each institution. All members of the BDA Students Committee expressed a shared understanding that the proposed NHS ‘tie-in’ would include the Dental Foundation Training (DFT) year, despite this not being explicitly clarified within the current policy proposal. With regard to year of study, 38% of respondents (n = 12) were in their penultimate year (BDS4), and a further 38% (n = 12) were in their third year (BDS3). Final-year students (BDS5) accounted for 22% of the sample (n = 7), while 3% of respondents (n = 1) were in their second year (BDS2). The majority of participants were UK-resident students (90%, n = 28), with international students comprising 10% of the sample (n = 3); this variable was included to determine respondents’ fee status. Overall attitudes towards the proposed NHS tie-in for graduate dentists were predominantly negative. Forty-one per cent of respondents (n = 13) reported being strongly opposed to the proposal, while a further 31% (n = 10) indicated opposition. One quarter of respondents (25%, n = 8) expressed neutral views, and only 3% (n = 1) reported support for the proposal. These findings are illustrated in Figure 4. Table 1. Distribution of responses by undergraduate year group (BDS2–BDS5). Year of Study Description Percentage (%) Number (n) BDS2 Second Year 3% 1 BDS3 Third Year 38% 12 BDS4 Penultimate Year 38% 12 BDS5 Final Year 22% 7 Total 101% * 32 Table 2. Residency status of dental undergraduate respondents. Residency Status Percentage (%) Number (n) UK-resident 90% 28 International 10% 3 Total 100% 31 Table 3. Distribution of undergraduate dental students’ attitudes towards the proposed NHS ‘tie-in’ for graduate dentists. Sentiment Percentage (%) Number (n) Strongly Opposed 41% 13 Opposed 31% 10 Neutral 25% 8 Support 3% 1 Total 100% 32 To further explore respondents’ views on the proposed NHS ‘tie-in’, three targeted questions and statements were derived directly from the UK Government’s recent consultation on the policy. Responses to these items, captured using Likert-scale measures, are presented in Figure 5. Quantitative responses Regarding the statement that dentists should make a minimum commitment to NHS dentistry in return for the taxpayer’s investment in their education and training, 31.3% (n = 10) of respondents were neutral. An equal proportion, 31.3% (n = 10), agreed that dentists should spend a proportion of their time working in NHS dentistry in the years following graduation, while 40.6% (n = 13) disagreed that graduate dentists who choose not to make a minimum commitment should be required to repay some or all of the public funding invested in their training. When asked about the duration of any minimum commitment, 53% (n = 17) felt that graduate dentists should not be required to make any commitment, 44% (n = 14) selected “2 years or fewer,” and 3% (n = 1) chose “3 or 4 years.” Regarding incentives that would increase acceptability, 56% (n = 18) indicated that loan repayment would be most effective, 22% (n = 7) selected “guaranteed training posts,” 3% (n = 1) chose “relocation support,” and 19% (n = 6) provided alternative suggestions, which were explored further through an open-ended qualitative question. Qualitative responses Free-text responses from two survey questions were analysed together using thematic analysis. Key genres were generated from the data and refined into themes through constant comparison across responses. Three main themes were identified: financial remuneration, NHS contract reform, and career support and early career development. Of the 39 total qualitative responses, 33.3% (n = 13) referenced financial remuneration, 33.3% (n = 13) referenced NHS contract reform, and 30.8% (n = 12) referenced career support and early career development (Figure 6). 1. Financial Remuneration Financial remuneration was frequently mentioned by participants in relation to NHS retention. Participants described a perceived gap between professional responsibility in NHS dentistry and current financial compensation, particularly in relation to tuition debt and workload. Several respondents indicated that higher pay could influence the decision to remain in NHS practice. Financial incentives such as salary supplements, targeted grants, or “golden hello” schemes were mentioned. One participant stated, “remuneration would have to be improved… alongside an overhaul of the UDA system.” Some participants referred to the fairness of mandatory service expectations relative to the funding of dental education. Responses noted that dental students incur tuition debt and receive limited NHS bursary support. Some participants suggested that any obligation to serve in the NHS should reflect the level of public investment received. 2. NHS Contract Reform The need for changes to the NHS dental contract was raised by participants. Participants described workload expectations and the structure of the current contract, particularly the UDA system, as influencing their views on NHS dentistry. One respondent commented, “The UDA system must be revised in order to make it appealing for graduates to stay.” Some participants referred to contract structure as affecting graduates’ decisions regarding NHS careers. One participant stated, “The aim should be on improving the NHS dental sector so that it’s more appealing… rather than tying-in graduates to a system that isn’t currently appealing.” Concerns were also raised about mandatory service requirements in the absence of changes to the contract. Participants described potential negative outcomes, including discouragement from NHS careers or leaving the profession. 3. Career Support and Early Career Development Participants reported that support and information regarding NHS commitments were important considerations. One respondent stated, “as much support as possible should be provided.” Participants highlighted mentorship, guidance, and manageable working conditions during early postgraduate years. Transparency in career prospects was also mentioned. One participant indicated, “match the same employment opportunities that the graduate would have after leaving a DFT year.” Other participants described the need for clearer tie-in proposals, noting current proposals appeared incomplete. Some participants referred to early career support in relation to confidence and workload management. One participant commented, “improved early support would help graduates manage both confidence and workload.” Discussion This study provides contemporary insight into current UK undergraduate dental students’ views on proposed NHS ‘tie-in’ arrangements at a period of considerable uncertainty for the dental workforce. The findings demonstrate strong opposition to compulsory service commitments among the student cohort, with 41% strongly opposing and 10% opposing the proposed NHS ‘tie-in’, compared with only 3% supporting such measures. Responses to questions aligned with the ongoing UK Government’s consultation 28 further highlighted resistance: 18.8% strongly disagreed and 21.9% disagreed that dentists should make a minimum NHS commitment in return for public investment in their training, while 40.6% disagreed and 37.5% strongly disagreed that graduates who choose not to work in the NHS should repay public funding. Although 31.3% agreed that dentists should spend a proportion of their early career providing NHS care, attitudes overall indicate a clear preference for autonomy rather than mandated service. Consistent with this, respondents overwhelmingly favoured incentive-based models over a compulsory ‘tie-in’, with loan repayment support identified as the most acceptable incentive (56%), followed by guaranteed training posts (22%). Free-text responses reinforced a desire for meaningful financial support, clearer and better-structured career progression pathways, and substantial reform of the NHS dental contract. These attitudes must be interpreted in the wider context of recruitment and retention pressures within UK dentistry. 12,30,31 Evidence suggests that the morale of early-career dentists has fluctuated markedly over the past decade, associated with reductions in allowances, inflexible career structures, increased working hours and the pressures of NHS commitment, alongside uncertainties surrounding practice ownership. Financial pressures further compound these issues. 32 As of April 2024, the DFT salary remains £40,776 and average NHS associate earnings have stagnated at approximately £60,000 despite rising living costs. 33 At the same time, dental graduates face record debt levels, averaging £52,922, with commercial borrowing having doubled since 2013 and over 60% of students reporting financial difficulty during their studies. 34 These pressures contribute to stress, anxiety and uncertainty about postgraduate pathways. 35 Sustainability of NHS dentistry is therefore a major concern for dental students, many of whom express a desire to continue providing NHS care but feel financially unable to do so. 36 As a result, many early-career dentists reduce their NHS commitment in favour of private practice, driven largely by a need for financial security and a perception that the current NHS contract limits both progression and remuneration. 11,33,37–39 The present findings align with this evidence, suggesting a misalignment between government proposals to introduce a ’tie-in’ and the priorities of the emerging workforce. Students instead call for clearer career pathways, structured support and improved contractual conditions - findings consistent with calls in the literature for better guidance, mentoring and confidence-building to support transition into practice. 25,40–43 The preference for incentives over compulsion echoes wider trends in graduate expectations. Rising tuition fees and increasing debt levels influence stress and career decision-making, 34 and students balance a range of personal, financial and professional goals when considering their early careers. 23,24,44 Long-term aspirations are often shaped by opportunities for professional development, 44 and students trained in different healthcare systems have been shown to respond to systemic incentives and constraints in diverse ways. 45 Studies examining attitudes towards general practice, DFT and the transition into independent practice consistently show that students value supportive environments, manageable workloads and opportunities to develop clinical competence. 26,46–51 Regional initiatives have been used successfully to support the transition into DFT, suggesting that positive, scaffolded approaches may be more effective than mandatory service. 52,53 International comparisons offer additional context. Countries such as the Philippines, South Africa, and Thailand have introduced compulsory service primarily to address the uneven distribution of health professionals, particularly in rural regions. 54 In Europe, 78% of dental schools permit graduates to practise immediately after qualification, while others - including Belgium, Croatia and Slovenia - mandate one year of vocational training, irrespective of the broader healthcare system. 55 Recent reforms in Ireland and elsewhere illustrate attempts to encourage greater public–private collaboration, 7 yet international evidence also demonstrates that dental providers often respond negatively to abrupt contractual changes or compulsory service obligations, as seen with the 2006 shift from fee-per-item to UDAs in England and Wales. 56 These examples suggest that international mandatory-service models may be of limited applicability in the UK without broader systemic reform. Any proposal for an NHS ‘tie-in’ must also consider risks to morale, wellbeing, recruitment and professional autonomy. Dentist wellbeing is influenced by system-level regulation, workplace demands and personal factors, 32,57 and many NHS-committed dentists report that they have considered leaving general practice. 36 The NHS Constitution pledges to support staff wellbeing, yet dentistry is recognised as a highly stressful profession; 32,57 mandatory NHS service could therefore hinder recruitment and discourage prospective applicants. In planning for the future workforce, policymakers, universities and deaneries should consider how compulsory service or perceived restrictions on professional autonomy may affect applications to dental school, retention within the NHS and long-term career intentions. The dental workforce is shaped by demographic, economic, social and technological pressures 23 and ensuring a sufficient and sustainable workforce requires alignment between government strategy, educational structures and professional expectations. Significant NHS commitment has been associated with poorer wellbeing, 32 underscoring the need for system-level improvements. Governance principles further emphasise the need for policy to be implemented ethically, effectively and transparently. 23 International workforce frameworks similarly highlight the necessity of strengthening the health workforce to ensure universal health coverage. 58 Lessons from the medical workforce may also be instructive. Student loan forgiveness schemes have been suggested to aid recruitment and retention, with nursing, midwifery and allied health students currently receiving £5,000 annual grants via the NHS Learning Support Fund. 59 Evidence from Malaysia suggests that financial incentives such as scholarships for postgraduate training may be more effective in retaining public-sector dentists than compulsory service. 60 Recent UK-based workforce reports further advocate investment in staff retention initiatives and reduction of financial barriers. 61 Overall, the findings from this study suggest that mandatory ‘tie-in’ systems may be poorly aligned with the expectations and motivations of the emerging dental workforce. Incentive-based approaches that include financial support, opportunities for career development and meaningful NHS contract reform may be more effective, sustainable and acceptable methods of strengthening NHS dentistry while respecting the professional autonomy of new graduates. 62 Strengths and Limitations A strength of this study is that it represents the first national exploration of BDA Students Committee representatives’ views on proposed return-of-service policies, capturing perspectives from across all sixteen UK dental schools. With two elected representatives per school, most of whom were familiar with national workforce discussions and the NHS ‘tie-in’ proposals, the sample offers informed insights from students nearing qualification. The focus on those in their penultimate year of study is also defensible, as evidence suggests that final-year students and new graduates hold broadly comparable views on career expectations, motivations and professional intentions. 44,63 However, the study has several limitations. The overall sample remains small relative to the UK’s population of over 5,000 dental students, which may limit representativeness. As participation was confined to elected BDA Student Committee representatives response bias is possible. The exploratory nature of the work, while appropriate for an emerging policy topic, means that findings should be interpreted as indicative rather than definitive. Furthermore, reliance on self-reported attitudes introduces the potential for social desirability effects, and perspectives captured at a single time point may not fully reflect how opinions evolve during transition into professional practice. A larger, more diverse sample would improve generalisability and allow for more robust quantitative analysis. Future Research Directions Future research should examine how different ROS policy designs influence motivation, retention and early career choices within the UK context. Longitudinal studies following students into practice would help clarify the longer-term effects of mandatory service, while qualitative work could explore the experiences of those completing such obligations. Given the limited evidence relating specifically to dentistry, profession-focused research is needed to understand how ROS schemes might affect dental workforce mobility, postgraduate training pathways and engagement with NHS care. Economic evaluations comparing ROS programmes with alternative retention strategies would further support evidence-informed policy development and help anticipate unintended consequences. Conclusion International evidence demonstrates that ROS policies can shape workforce distribution but may also influence career decision-making, satisfaction and long-term retention in complex and sometimes unpredictable ways. Persistent gaps in the literature underscore the need for robust, profession-specific research before implementing similar approaches domestically. A clearer understanding of how service obligation, such as the proposed NHS ‘tie-in’ for newly qualified dentists, interact with individual motivations, training trajectories and workplace environments will be essential for designing policies that support both workforce sustainability and trainee wellbeing. Declarations Acknowledgements: We extend our appreciation to all of the members of the BDA Students Committee for their input in this survey. In addition, we appreciate the support of the BDA Library in carrying out the literature search. Author Contributions: NP, JK, LS, AR, SN, JS contributed to the conception and overall design of the study, data collection, and manuscript writing. All authors reviewed the manuscript prior to final submission. Funding: The authors received no financial support for the research, authorship, and/or publication of this article. Data availability: Data can be provided by the corresponding author upon reasonable request. Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. References Haakenstad A, Irvine CMS, Knight M, Bintz C, Aravkin AY, Zheng P, et al. Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the global burden of disease study 2019. Lancet. 2022 Jun 4;399(10341):2129–54. Stockton DA, Fowler C, Debono D, Travaglia J. 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Prevalence and Incidence of Stress Among UK Dental Students: A Systematic Review and Meta-analysis. Int Dent J [Internet]. 2025 Jun 1 [cited 2025 Sep 27];75(3):2314–22. Available from: https://www.sciencedirect.com/science/article/pii/S0020653924016149?via%3Dihub Buckland E, King T, Barnett R. Motivations for NHS dentistry in England. Br Dent J [Internet]. 2025 Sep 12 [cited 2025 Sep 27];239(5):327–31. Available from: https://www.nature.com/articles/s41415-025-8714-3 Witton R, Plessas A, Wheat H, Baines R, Delgado MB, Mills I, et al. The future of dentistry post-COVID-19: perspectives from Urgent Dental Care centre staff in England. Br Dent J. 2021; Davda LS, Gallagher JE, Radford DR. Migration motives and integration of international human resources of health in the United Kingdom: systematic review and meta-synthesis of qualitative studies using framework analysis. Hum Resour Health. 2018 Jun 27;16(1):27. Sharma AR, Manangazira T, Shah Z, Lowers V, van der Zande M, Heddi I, et al. What, when and who determines foundation dentists’ views about a future career in NHS general dental practice: a post-pandemic qualitative study by peers. British Dental Journal 2026 [Internet]. 2026 Jan 5 [cited 2026 Jan 9];1–8. Available from: https://www.nature.com/articles/s41415-025-9112-6 Field J, Sabev B, Davies J, Dixon J, Murphy D, Vital S, et al. Recommendations for Enhancing Oral Health Professional Education Through the Student Voice: The ADEE-EDSA Partnership in Action. European Journal of Dental Education [Internet]. 2025 [cited 2025 Sep 27];0:1–7. Available from: /doi/pdf/10.1111/eje.13123 Field J, Dixon J, Davies J, Quinn B, Murphy D, Vital S, et al. O-Health-Edu: A vision for oral health professional education in Europe. European Journal of Dental Education. 2023 May 1;27(2):382–7. Dixon J, Field J, Vital S, van Harten M, Roger-Leroi V, Davies J, et al. O-HEALTH-EDU: A viewpoint into the current state of Oral Health Professional education in Europe: Part 1: Programme-level data. European Journal of Dental Education [Internet]. 2024 May 1 [cited 2025 May 25];28(2):591–606. Available from: /doi/pdf/10.1111/eje.12989 Dixon J, Tubert-Jeannin S, Davies J, van Harten M, Roger-Leroi V, Vital S, et al. O-Health-Edu: A viewpoint into the current state of oral health professional education in Europe: Part 2: Curriculum structure, facilities, staffing and quality assurance. European Journal of Dental Education. 2024 May 1;28(2):607–20. Gallagher J, Clarke W, Wilson N. Understanding the motivation: A qualitative study of dental students’ choice of professional career. European Journal of Dental Education. 2008 May;12(2):89–98. Wolf TG, Otterbach EJ, Zeyer O, Wagner RF, Crnic T, Ilhan D, et al. Influence of Oral Health Care Systems on Future Career Environment of Dental Students in Europe. Int J Environ Res Public Health [Internet]. 2021;18(16). Available from: https://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med20&DO=10.3390%2fijerph18168292 Mariño R, Manton D, Reid K, Delany C. Preparedness for dental practice in Australia: a qualitative study on the experiences of final-year students and new graduates. BMC Med Educ [Internet]. 2023 Dec 1 [cited 2025 Sep 28];23(1):1–9. Available from: https://link.springer.com/articles/10.1186/s12909-023-04306-0 Ali K, Tredwin C, Kay E, Slade A. Transition of new dental graduates into practice: a qualitative study. European Journal of Dental Education [Internet]. 2016 May 1 [cited 2025 Sep 27];20(2):65–72. Available from: /doi/pdf/10.1111/eje.12143 Bazoua C, Rahim A, Robinson R, Webster J, Brierley DJ. Exploring the Ways in which Generation-Z Dental Students Learn and How this Could Impact Dental Foundation Training. https://doi.org/1012968/denu2023509724 [Internet]. 2023 Oct 11 [cited 2025 Sep 27];50(9):724–7. Available from: /doi/pdf/10.12968/denu.2023.50.9.724?download=true Honey J, Lynch CD, Burke FM, Gilmour ASM. Ready for practice? A study of confidence levels of final year dental students at Cardiff University and University College Cork. Eur J Dent Educ [Internet]. 2011;15(2):98–103. Available from: https://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med8&DO=10.1111%2fj.1600-0579.2010.00646.x Leadbeatter D, Madden J, Ross B, Russell E. Transition to dental practice: Newly graduated dentists’ views of being successful in dental practice. European Journal of Dental Education [Internet]. 2020 Nov 1 [cited 2025 Sep 27];24(4):753–62. Available from: /doi/pdf/10.1111/eje.12565 Royal College of Surgeons of England. National Survey of Dental Foundation/Vocational Training 2018 Summary Report. 2018. Blaylock P, Ellis JS, McCracken GI. The transition from dental school to postgraduate dental foundation training: strengthening the interaction between stakeholders. Br Dent J [Internet]. 2018;224(4):269–73. Available from: https://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med15&DO=10.1038%2fsj.bdj.2018.79 Dental postgraduate training opportunities in Wales. Br Dent J [Internet]. 2026 Jan 9 [cited 2026 Jan 19];240(1):20–20. Available from: https://www.nature.com/articles/s41415-025-9502-9 Antonio CT, Guevarra JP, Medina PN, Avelino MD, Agbon AG, Sepe DC, et al. Components of compulsory service program for health professionals in low- and middle-income countries: a scoping review. Perspect Public Health [Internet]. 2020 Jan 1 [cited 2025 Dec 12];140(1):54–61. Available from: https://scholar.google.com/scholar_url?url=https://journals.sagepub.com/doi/pdf/10.1177/1757913919839432&hl=en&sa=T&oi=ucasa&ct=usl&ei=pSY8aevFJrLrieoPwNLAkQw&scisig=ALhkC2Qpa0ayc-_jTVvsgv6bBCdE O‐HEALTH‐EDU: A viewpoint into the current state of Oral Health Professional education in Europe: Part 1: Programme‐level data - Dixon - 2024 - European Journal of Dental Education - Wiley Online Library [Internet]. [cited 2025 May 25]. Available from: https://onlinelibrary.wiley.com/doi/10.1111/eje.12989 Tickle M, McDonald R, Franklin J, Aggarwal VR, Milsom K, Reeves D. Paying for the wrong kind of performance? Financial incentives and behaviour changes in National health service dentistry 1992–2009. Community Dent Oral Epidemiol. 2011 Oct;39(5):465–73. Gallagher JE, Colonio-Salazar FB, White S. Supporting dentists’ health and wellbeing - a qualitative study of coping strategies in “normal times.” Br Dent J. 2021; Campbell J, Buchan J, Cometto G, David B, Dussault G, Fogstad H, et al. Human resources for health and universal health coverage: fostering equity and effective coverage. Bull World Health Organ. 2013;91(11):853–63. NHS Learning Support Fund (LSF) | NHSBSA [Internet]. [cited 2025 Dec 12]. Available from: https://www.nhsbsa.nhs.uk/nhs-learning-support-fund-lsf Che Musa MF, Bernabé E, Gallagher JE. Career expectations and influences among dental students in Malaysia. Int Dent J [Internet]. 2016 Aug 1 [cited 2025 Dec 7];66(4):229–36. Available from: https://www.sciencedirect.com/science/article/pii/S0020653920315252 Davda LS, Radford DR, Scambler S, Gallagher JE. Accreditation and professional integration experiences of internationally qualified dentists working in the United Kingdom. Human Resources for Health 2022 20:1 [Internet]. 2022 Jan 10 [cited 2025 Dec 7];20(1):7-. Available from: https://link.springer.com/article/10.1186/s12960-021-00703-y Palmer NOA, Kirton JA, Speechley D. An investigation of the clinical experiences of dentists within the national dental foundation training programme in the North West of England. Br Dent J [Internet]. 2016 Sep 23 [cited 2025 Sep 27];221(6):323–8. Available from: https://www.nature.com/articles/sj.bdj.2016.683 Newton P, Cabot L, Wilson NHF, Gallagher JE. The graduate entry generation: a qualitative study exploring the factors influencing the career expectations and aspirations of a graduating cohort of graduate entry dental students in one London institution. BMC Oral Health 2011 11:1 [Internet]. 2011 Sep 24 [cited 2025 Dec 3];11(1):25-. Available from: https://link.springer.com/article/10.1186/1472-6831-11-25 Additional Declarations There is no duality of interest Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8800177","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":588828553,"identity":"10d4d92e-ba5e-4911-96b2-dadd91a55452","order_by":0,"name":"Nyah Patel","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYHACNjDJx97AwAwTYmwgrMWAgY3nAMlaJBKI1GIukfzscUHNHzk2yTeGnwsqbBj42xvYJGfg0WI5I83ceMYxA2M26Rxj6Rln0hgkzhxgk9yAR4vBjQQzaR42g8Q26RwDad62wwwGEglskg/wakn/Js3zz6C+TfKM8W8iteSYAQ03SGCT4DFD2ILXYWfelEnP7DM2bONJK7PmOZPGI3HmYLMlPu8bHE/fJl3wTU6en/3w5ts8FTZy/O3NB2/24NHCIACPDg4DEMlDOCL54ZHO/gC/ylEwCkbBKBixAAAn0UPmeiU1oAAAAABJRU5ErkJggg==","orcid":"","institution":"British Dental Association","correspondingAuthor":true,"prefix":"","firstName":"Nyah","middleName":"","lastName":"Patel","suffix":""},{"id":588828554,"identity":"b91bea03-4901-407e-9219-23f9632b2671","order_by":1,"name":"Leena Soltan","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Leena","middleName":"","lastName":"Soltan","suffix":""},{"id":588828555,"identity":"d7b61ea2-b001-4695-9ac6-bcf47c45edd6","order_by":2,"name":"Afra Rahim","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Afra","middleName":"","lastName":"Rahim","suffix":""},{"id":588828556,"identity":"c350efc1-f8f9-4a18-b39c-d4953f37ab05","order_by":3,"name":"Swati Nehete","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Swati","middleName":"","lastName":"Nehete","suffix":""},{"id":588828557,"identity":"da5822f7-e9e0-45c6-a576-be3e2a63103e","order_by":4,"name":"Jason Stokes","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Jason","middleName":"","lastName":"Stokes","suffix":""},{"id":588828558,"identity":"e46d13a8-8497-4a32-965f-0b4fd8bd7ff1","order_by":5,"name":"Joshua Kennedy","email":"","orcid":"https://orcid.org/0009-0007-3555-0853","institution":"British Dental Association","correspondingAuthor":false,"prefix":"","firstName":"Joshua","middleName":"","lastName":"Kennedy","suffix":""}],"badges":[],"createdAt":"2026-02-05 18:45:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8800177/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8800177/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102602098,"identity":"a14f0082-f8fa-4a79-aeb0-c61db68c1010","added_by":"auto","created_at":"2026-02-13 13:13:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":113436,"visible":true,"origin":"","legend":"\u003cp\u003eGeographic distribution of the 16 dental schools across the United Kingdom.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8800177/v1/601dd3ced48083b30c9024b6.png"},{"id":102747220,"identity":"ee5142db-dcf9-4800-958f-4ce4bba91b46","added_by":"auto","created_at":"2026-02-16 09:04:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":122588,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of typical early career pathways for UK dental graduates post-graduation at present.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8800177/v1/68ee7b1eb9695456558bdec4.png"},{"id":102747229,"identity":"44479dda-2c50-4936-a44c-450c9010c068","added_by":"auto","created_at":"2026-02-16 09:04:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":236807,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eQuestionnaire structure and content used to assess undergraduate dental students’ attitudes towards the proposed NHS ‘tie-in’.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8800177/v1/f40e4dbc810872f7e6fdfaf2.png"},{"id":102602100,"identity":"06cf2f9f-9cea-4bed-bcb5-c9ea8271c28a","added_by":"auto","created_at":"2026-02-13 13:13:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":54334,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eDistribution of undergraduate dental students’ attitudes towards the proposed NHS ‘tie-in’ for graduate dentists.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8800177/v1/8541c2ec582d89e8f5dd6b52.png"},{"id":102602102,"identity":"8148ae8f-b75d-41c3-8d71-1e11cd0ec15a","added_by":"auto","created_at":"2026-02-13 13:13:52","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":69561,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eLikert-scale responses to three statements derived from the UK Government’s consultation on the proposed NHS ‘tie-in’ for graduate dentists.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8800177/v1/e4a149ee5b8d23c1d4826a0e.png"},{"id":102747154,"identity":"d0097d95-226a-4915-8a15-eaa07f0b0791","added_by":"auto","created_at":"2026-02-16 09:04:01","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":80092,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eProportion of qualitative responses referencing each theme: financial remuneration, NHS contract reform, and career support and early career development.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8800177/v1/1aa9ce79a00ab42f5d79d2a4.png"},{"id":104403177,"identity":"d30749bc-8763-45c6-ade7-891e8149445c","added_by":"auto","created_at":"2026-03-11 12:17:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1338983,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8800177/v1/357d95ff-5f1f-4a4d-894d-f21002921466.pdf"}],"financialInterests":"There is no duality of interest","formattedTitle":"Attitudes of Undergraduate Dental Students to Proposed NHS ‘Tie-in’ for Graduate Dentists in the United Kingdom","fulltext":[{"header":"Key Points","content":"\u003cp\u003e\u0026bull; Most students expressed disagreement with a compulsory service requirement, preferring voluntary engagement with the NHS. Only a small proportion supported the mandatory \u0026lsquo;tie-in\u0026rsquo;, indicating that compulsory policies may face resistance from the emerging workforce.\u003c/p\u003e\u003cp\u003e\u0026bull; Students highlighted financial incentives, structured career progression pathways and NHS dental contract reform as more acceptable strategies to encourage NHS participation. These incentives were seen as more motivating than mandatory service.\u003c/p\u003e\u003cp\u003e\u0026bull; The findings suggest that recruitment and retention strategies for NHS dentistry should balance workforce needs with graduate motivations, wellbeing and autonomy. Effective policy may require a combination of targeted incentives, improved career pathways, and contract reform rather than compulsory service, to attract and retain skilled dental professionals.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eHealth systems worldwide depend fundamentally on the availability, stability and effective distribution of their workforce, commonly referred to as human resources for health (HRH).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The health workforce is recognised as one of the six core building blocks of health systems, alongside service delivery, information systems, medical products and technologies, financing and leadership and governance.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e A sufficient, competent and equitably distributed workforce is therefore essential for ensuring timely access to care and achieving optimal population health outcomes. Yet the recruitment and retention of HRH remain a major global challenge. The World Health Organisation (WHO) estimates that by 2030 there will be a global shortfall of 10\u0026nbsp;million healthcare workers, driven by factors including insufficient investment in education and training, worker migration and increasing population need.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDentistry is no exception. Dentists and members of the wider dental team play a role in promoting and maintaining oral health, which is integral to general health, psychosocial wellbeing and quality of life.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e In most countries, including the United Kingdom (UK), oral healthcare is primarily delivered in primary care settings through both privately funded and state-funded services.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The global importance of oral health was underscored in 2022 when all United Nations member states adopted the WHO Global Strategy on Oral Health, committing to progress toward universal health coverage (UHC) for oral health by 2030.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e A central aim of this strategy is to ensure an adequate number and appropriate distribution of skilled oral health workers capable of delivering an essential package of services. Achieving this requires investment in workforce capacity, improved data monitoring and policies that support equitable access to oral healthcare.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the UK, concerns regarding the dental workforce have intensified in recent years. The number of General Dental Practitioners (GDPs) providing National Health Service (NHS) care in England decreased from 24,684 in 2020 to 23,733 in 2021, the lowest figure since 2014, with multiple factors contributing to recruitment and retention difficulties.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e A frequently cited issue is the NHS dental contract, which employs a target-based, \u0026ldquo;bundled care\u0026rdquo; model that many GDPs describe as stressful, inflexible and poorly aligned with prevention, contributing to low morale and burnout.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e These challenges sit within a wider system strain. Public satisfaction with NHS dentistry has fallen from 85% in 2019 to 69% in 2024,\u003csup\u003e14\u003c/sup\u003e and the British Dental Association (BDA) estimates that more than 13\u0026nbsp;million adults in the UK are unable to access NHS dental care.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Evidence suggests that those with the greatest clinical need are often those most likely to miss out on timely treatment, exacerbating inequalities and driving greater reliance on private provision or, in some cases, self-care and \u0026ldquo;DIY dentistry\u0026rdquo;.\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThese pressures have renewed attention to NHS workforce and service reform. The NHS 10 Year\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e and the NHS Long Term Workforce\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e plans focus on delivering improved retention, better distribution of staff, enhanced training pathways and a greater focus on prevention and community-based care. Policy priorities in dentistry include expanding NHS capacity, improving children\u0026rsquo;s oral health, modernising the dental contract, enhancing the roles of dental care professionals and investing in preventive interventions such as fluoride varnish, fissure sealants and supervised toothbrushing.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e More broadly, the government aims to shift towards the transition from analogue to digital, value-based care, strengthen career development opportunities and reduce reliance on international recruitment by 2035.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn this evolving policy context, the early career pathways of dental graduates from each of the 16 UK dental schools (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e1\u003c/span\u003e) are pivotal, with registration through the General Dental Council (GDC) required after graduation.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Most undertake Dental Foundation Training (DFT), an NHS-funded year designed to support the transition to independent practice through supervised clinical work, study days, audits and formal assessment.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Successful completion of DFT is required for entry onto the National Performers List for NHS primary care,\u003csup\u003e17\u003c/sup\u003e and all trainees are assessed against a nationally standardised curriculum defined by the UK Committee of Postgraduate Dental Deans and Directors (COPDEND).\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Additional training routes - including academic and military foundation programmes as well as integrated DFT - Dental Core Training (DCT) schemes - further diversify early career options.\u003csup\u003e\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Many graduates progress to DCT, which offers opportunities to consolidate clinical skills, explore specialty interests and broaden career perspectives.\u003csup\u003e\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e The Dental Gold Guide, outlines the governance, standards and progression frameworks for postgraduate dental training across the UK.\u003csup\u003e17\u003c/sup\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e2\u003c/span\u003e outlines the typical career pathways available to newly qualified UK dental graduates at present.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eUnderstanding dental graduates\u0026rsquo; career intentions is important for effective workforce planning.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Prior studies have shown that career expectations are shaped by the interplay of professional motivations, personal aspirations, working conditions and wider structural factors such as population need.\u003csup\u003e\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e In the context of growing dissatisfaction with NHS dentistry and increasing numbers of dentists shifting away from NHS practice, insight into the perspectives of prospective dental graduates is more important than ever.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAgainst this backdrop, the UK Government is in consultation regarding the introduction of a mandatory NHS \u0026lsquo;tie-in\u0026rsquo; period for newly qualified dentists.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e This policy would require graduates to undertake a minimum of three years of NHS service as a condition of receiving publicly funded training, justified on the basis that training a dentist costs the taxpayer up to \u0026pound;200,000 and that public investment should be matched by public service.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e The aim is to address workforce distribution issues, increase NHS dental capacity and ensure a more stable and sustainable dental workforce.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e However, similar return-of-service (ROS) policies internationally demonstrate that such approaches can have promise but also pose many challenges. \u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAmid NHS workforce pressures, declining morale within NHS dentistry and ongoing contract reforms, it is essential to understand how current undergraduate dental students perceive the proposed NHS \u0026lsquo;tie-in\u0026rsquo; period. Exploring these perspectives provides critical insights to inform policy development, ensure alignment with workforce motivations and support the creation of a sustainable, engaged and well-distributed dental workforce for the future.\u003c/p\u003e\n\u003ch3\u003eAims and Objectives:\u003c/h3\u003e\n\u003cp\u003eThis study aimed to explore the attitudes of undergraduate dental students towards the proposed NHS \u0026lsquo;tie-in\u0026rsquo; for newly qualified dentists in the UK. The objectives were to identify key influences shaping students\u0026rsquo; views, including preferences, perceived barriers, and motivating factors that inform their perceptions of the proposal.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMethods:\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study employed a mixed-methods, cross-sectional questionnaire design. A mixed-methods approach was chosen to capture both the distribution of student attitudes through quantitative measures and the underlying reasoning through qualitative data. Quantitative data were collected using structured questionnaire items, while qualitative insights were obtained from free-text responses, enabling exploration of participants\u0026rsquo; concerns, perspectives, and recommendations regarding the proposed NHS \u0026lsquo;tie-in\u0026rsquo; for newly qualified dentists.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eStudy design\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a mixed-methods, cross-sectional questionnaire design. A mixed-methods approach was chosen to capture both the distribution of student attitudes through quantitative measures and the underlying reasoning through qualitative data. Quantitative data were collected using structured questionnaire items, while qualitative insights were obtained from free-text responses, enabling exploration of participants’ concerns, perspectives, and recommendations regarding the proposed NHS ‘tie-in’ for newly qualified dentists.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eParticipants and Setting\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants comprised undergraduate dental students representing each of the 16 UK dental schools on the BDA Students Committee. Two students from each dental school serve on this committee and are elected to represent their respective institutions. In addition to the student representatives, there are cross-representatives from other committees within the BDA such as the Dental Academic Staff Committee (DASC). The committee’s remit includes advocating for dental students’ interests through engagement with dental schools, the Dental Schools Council (DSC), COPDEND and other interested parties. The committee convenes biannually to provide a formal forum for student concerns to be raised and addressed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eData Collection\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe questionnaire was developed using Microsoft Forms and consisted of 10 items (Figure 3). Data was collected via an anonymous online survey link, which was distributed to eligible participants and available between 16 October 2025 and 1 November 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eInclusion and Exclusion Criteria\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion criteria were undergraduate dental students enrolled in years BDS1–BDS5 at UK dental schools who were elected members of the BDA Students Committee and serving their current mandate at the time of data collection. Incomplete survey responses were excluded from analysis, as were responses from non-UK undergraduate dental students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eData Analysis\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 100% response rate was achieved from eligible committee members. Quantitative data included demographic variables (year of study) and awareness of the NHS tie-in proposal, as well as attitudes measured using five-point Likert scale items relating directly to the proposed policy. Descriptive analysis was undertaken to summarise quantitative findings. Qualitative free-text responses were analysed using thematic analysis to identify key themes relating to reasoning, concerns, and recommendations expressed by participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthical Statement\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipation in the study was voluntary, and completion of the questionnaire constituted implied consent for participation and use of anonymised data for research purposes. All data were collected anonymously, and no patient data were involved. The NHS Research Ethics Committee decision tool indicated that formal ethical approval was not required for this study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 32 responses were obtained from the 16 UK dental schools, with two respondents representing each institution. All members of the BDA Students Committee expressed a shared understanding that the proposed NHS \u0026lsquo;tie-in\u0026rsquo; would include the Dental Foundation Training (DFT) year, despite this not being explicitly clarified within the current policy proposal.\u003c/p\u003e\n\u003cp\u003eWith regard to year of study, 38% of respondents (n = 12) were in their penultimate year (BDS4), and a further 38% (n = 12) were in their third year (BDS3). Final-year students (BDS5) accounted for 22% of the sample (n = 7), while 3% of respondents (n = 1) were in their second year (BDS2). The majority of participants were UK-resident students (90%, n = 28), with international students comprising 10% of the sample (n = 3); this variable was included to determine respondents\u0026rsquo; fee status.\u003c/p\u003e\n\u003cp\u003eOverall attitudes towards the proposed NHS tie-in for graduate dentists were predominantly negative. Forty-one per cent of respondents (n = 13) reported being strongly opposed to the proposal, while a further 31% (n = 10) indicated opposition. One quarter of respondents (25%, n = 8) expressed neutral views, and only 3% (n = 1) reported support for the proposal. These findings are illustrated in Figure 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e \u003cem\u003eDistribution of responses by undergraduate year group (BDS2\u0026ndash;BDS5).\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"363\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear of Study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBDS2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eSecond Year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBDS3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eThird Year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e38%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBDS4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003ePenultimate Year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e38%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBDS5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eFinal Year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e22%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e101%\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e32\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e \u003cem\u003eResidency status of dental undergraduate respondents.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidency Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003eUK-resident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003eInternational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e100%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e31\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e \u003cem\u003eDistribution of undergraduate dental students\u0026rsquo; attitudes towards the proposed NHS \u0026lsquo;tie-in\u0026rsquo; for graduate dentists.\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSentiment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Opposed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e41%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpposed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e31%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeutral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e25%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupport\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e100%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e32\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTo further explore respondents\u0026rsquo; views on the proposed NHS \u0026lsquo;tie-in\u0026rsquo;, three targeted questions and statements were derived directly from the UK Government\u0026rsquo;s recent consultation on the policy. Responses to these items, captured using Likert-scale measures, are presented in Figure 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative responses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding the statement that dentists should make a minimum commitment to NHS dentistry in return for the taxpayer\u0026rsquo;s investment in their education and training, 31.3% (n = 10) of respondents were neutral. An equal proportion, 31.3% (n = 10), agreed that dentists should spend a proportion of their time working in NHS dentistry in the years following graduation, while 40.6% (n = 13) disagreed that graduate dentists who choose not to make a minimum commitment should be required to repay some or all of the public funding invested in their training.\u003c/p\u003e\n\u003cp\u003eWhen asked about the duration of any minimum commitment, 53% (n = 17) felt that graduate dentists should not be required to make any commitment, 44% (n = 14) selected \u003cem\u003e\u0026ldquo;2 years or fewer,\u0026rdquo;\u003c/em\u003e and 3% (n = 1) chose \u003cem\u003e\u0026ldquo;3 or 4 years.\u0026rdquo;\u003c/em\u003e Regarding incentives that would increase acceptability, 56% (n = 18) indicated that loan repayment would be most effective, 22% (n = 7) selected \u0026ldquo;guaranteed training posts,\u0026rdquo; 3% (n = 1) chose \u003cem\u003e\u0026ldquo;relocation support,\u0026rdquo;\u003c/em\u003e and 19% (n = 6) provided alternative suggestions, which were explored further through an open-ended qualitative question.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative responses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFree-text responses from two survey questions were analysed together using thematic analysis. Key genres were generated from the data and refined into themes through constant comparison across responses. Three main themes were identified: financial remuneration, NHS contract reform, and career support and early career development. Of the 39 total qualitative responses, 33.3% (n = 13) referenced financial remuneration, 33.3% (n = 13) referenced NHS contract reform, and 30.8% (n = 12) referenced career support and early career development (Figure 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Financial Remuneration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinancial remuneration was frequently mentioned by participants in relation to NHS retention. Participants described a perceived gap between professional responsibility in NHS dentistry and current financial compensation, particularly in relation to tuition debt and workload.\u003c/p\u003e\n\u003cp\u003eSeveral respondents indicated that higher pay could influence the decision to remain in NHS practice. Financial incentives such as salary supplements, targeted grants, or \u0026ldquo;golden hello\u0026rdquo; schemes were mentioned. One participant stated, \u003cem\u003e\u0026ldquo;remuneration would have to be improved\u0026hellip; alongside an overhaul of the UDA system.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome participants referred to the fairness of mandatory service expectations relative to the funding of dental education. Responses noted that dental students incur tuition debt and receive limited NHS bursary support. Some participants suggested that any obligation to serve in the NHS should reflect the level of public investment received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. NHS Contract Reform\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe need for changes to the NHS dental contract was raised by participants. Participants described workload expectations and the structure of the current contract, particularly the UDA system, as influencing their views on NHS dentistry. One respondent commented, \u003cem\u003e\u0026ldquo;The UDA system must be revised in order to make it appealing for graduates to stay.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome participants referred to contract structure as affecting graduates\u0026rsquo; decisions regarding NHS careers. One participant stated, \u003cem\u003e\u0026ldquo;The aim should be on improving the NHS dental sector so that it\u0026rsquo;s more appealing\u0026hellip; rather than tying-in graduates to a system that isn\u0026rsquo;t currently appealing.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConcerns were also raised about mandatory service requirements in the absence of changes to the contract. Participants described potential negative outcomes, including discouragement from NHS careers or leaving the profession.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Career Support and Early Career Development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported that support and information regarding NHS commitments were important considerations. One respondent stated, \u003cem\u003e\u0026ldquo;as much support as possible should be provided.\u0026rdquo;\u003c/em\u003e Participants highlighted mentorship, guidance, and manageable working conditions during early postgraduate years.\u003c/p\u003e\n\u003cp\u003eTransparency in career prospects was also mentioned. One participant indicated, \u003cem\u003e\u0026ldquo;match the same employment opportunities that the graduate would have after leaving a DFT year.\u0026rdquo;\u003c/em\u003e Other participants described the need for clearer tie-in proposals, noting current proposals appeared incomplete.\u003c/p\u003e\n\u003cp\u003eSome participants referred to early career support in relation to confidence and workload management. One participant commented, \u003cem\u003e\u0026ldquo;improved early support would help graduates manage both confidence and workload.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides contemporary insight into current UK undergraduate dental students\u0026rsquo; views on proposed NHS \u0026lsquo;tie-in\u0026rsquo; arrangements at a period of considerable uncertainty for the dental workforce. The findings demonstrate strong opposition to compulsory service commitments among the student cohort, with 41% strongly opposing and 10% opposing the proposed NHS \u0026lsquo;tie-in\u0026rsquo;, compared with only 3% supporting such measures. Responses to questions aligned with the ongoing UK Government\u0026rsquo;s consultation\u003csup\u003e28\u003c/sup\u003e further highlighted resistance: 18.8% strongly disagreed and 21.9% disagreed that dentists should make a minimum NHS commitment in return for public investment in their training, while 40.6% disagreed and 37.5% strongly disagreed that graduates who choose not to work in the NHS should repay public funding. Although 31.3% agreed that dentists should spend a proportion of their early career providing NHS care, attitudes overall indicate a clear preference for autonomy rather than mandated service.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsistent with this, respondents overwhelmingly favoured incentive-based models over a compulsory \u0026lsquo;tie-in\u0026rsquo;, with loan repayment support identified as the most acceptable incentive (56%), followed by guaranteed training posts (22%). Free-text responses reinforced a desire for meaningful financial support, clearer and better-structured career progression pathways, and substantial reform of the NHS dental contract.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese attitudes must be interpreted in the wider context of recruitment and retention pressures within UK dentistry.\u003csup\u003e12,30,31\u003c/sup\u003e Evidence suggests that the morale of early-career dentists has fluctuated markedly over the past decade, associated with reductions in allowances, inflexible career structures, increased working hours and the pressures of NHS commitment, alongside uncertainties surrounding practice ownership. Financial pressures further compound these issues.\u003csup\u003e32\u003c/sup\u003e As of April 2024, the DFT salary remains \u0026pound;40,776 and average NHS associate earnings have stagnated at approximately \u0026pound;60,000 despite rising living costs.\u003csup\u003e33\u003c/sup\u003e At the same time, dental graduates face record debt levels, averaging \u0026pound;52,922, with commercial borrowing having doubled since 2013 and over 60% of students reporting financial difficulty during their studies.\u003csup\u003e34\u003c/sup\u003e These pressures contribute to stress, anxiety and uncertainty about postgraduate pathways.\u003csup\u003e35\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSustainability of NHS dentistry is therefore a major concern for dental students, many of whom express a desire to continue providing NHS care but feel financially unable to do so.\u003csup\u003e36\u003c/sup\u003e As a result, many early-career dentists reduce their NHS commitment in favour of private practice, driven largely by a need for financial security and a perception that the current NHS contract limits both progression and remuneration.\u003csup\u003e11,33,37\u0026ndash;39\u003c/sup\u003e The present findings align with this evidence, suggesting a misalignment between government proposals to introduce a \u0026rsquo;tie-in\u0026rsquo; and the priorities of the emerging workforce. Students instead call for clearer career pathways, structured support and improved contractual conditions - findings consistent with calls in the literature for better guidance, mentoring and confidence-building to support transition into practice.\u003csup\u003e25,40\u0026ndash;43\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe preference for incentives over compulsion echoes wider trends in graduate expectations. Rising tuition fees and increasing debt levels influence stress and career decision-making,\u003csup\u003e34\u003c/sup\u003e and students balance a range of personal, financial and professional goals when considering their early careers.\u003csup\u003e23,24,44\u003c/sup\u003e Long-term aspirations are often shaped by opportunities for professional development,\u003csup\u003e44\u003c/sup\u003e and students trained in different healthcare systems have been shown to respond to systemic incentives and constraints in diverse ways.\u003csup\u003e45\u003c/sup\u003e Studies examining attitudes towards general practice, DFT and the transition into independent practice consistently show that students value supportive environments, manageable workloads and opportunities to develop clinical competence. \u003csup\u003e26,46\u0026ndash;51\u003c/sup\u003e Regional initiatives have been used successfully to support the transition into DFT, suggesting that positive, scaffolded approaches may be more effective than mandatory service.\u003csup\u003e52,53\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInternational comparisons offer additional context. Countries such as the Philippines, South Africa, and Thailand have introduced compulsory service primarily to address the uneven distribution of health professionals, particularly in rural regions.\u003csup\u003e54\u003c/sup\u003e In Europe, 78% of dental schools permit graduates to practise immediately after qualification, while others - including Belgium, Croatia and Slovenia - mandate one year of vocational training, irrespective of the broader healthcare system.\u003csup\u003e55\u003c/sup\u003e Recent reforms in Ireland and elsewhere illustrate attempts to encourage greater public\u0026ndash;private collaboration,\u003csup\u003e7\u003c/sup\u003e yet international evidence also demonstrates that dental providers often respond negatively to abrupt contractual changes or compulsory service obligations, as seen with the 2006 shift from fee-per-item to UDAs in England and Wales.\u003csup\u003e56\u003c/sup\u003e These examples suggest that international mandatory-service models may be of limited applicability in the UK without broader systemic reform.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAny proposal for an NHS \u0026lsquo;tie-in\u0026rsquo; must also consider risks to morale, wellbeing, recruitment and professional autonomy. Dentist wellbeing is influenced by system-level regulation, workplace demands and personal factors,\u003csup\u003e32,57\u003c/sup\u003e and many NHS-committed dentists report that they have considered leaving general practice.\u003csup\u003e36\u003c/sup\u003e The NHS Constitution pledges to support staff wellbeing, yet dentistry is recognised as a highly stressful profession;\u003csup\u003e32,57\u003c/sup\u003e mandatory NHS service could therefore hinder recruitment and discourage prospective applicants.\u003c/p\u003e\n\u003cp\u003eIn planning for the future workforce, policymakers, universities and deaneries should consider how compulsory service or perceived restrictions on professional autonomy may affect applications to dental school, retention within the NHS and long-term career intentions. The dental workforce is shaped by demographic, economic, social and technological pressures\u003csup\u003e23\u003c/sup\u003e and ensuring a sufficient and sustainable workforce requires alignment between government strategy, educational structures and professional expectations. Significant NHS commitment has been associated with poorer wellbeing,\u003csup\u003e32\u003c/sup\u003e underscoring the need for system-level improvements. Governance principles further emphasise the need for policy to be implemented ethically, effectively and transparently.\u003csup\u003e23\u003c/sup\u003e International workforce frameworks similarly highlight the necessity of strengthening the health workforce to ensure universal health coverage.\u003csup\u003e58\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLessons from the medical workforce may also be instructive. Student loan forgiveness schemes have been suggested to aid recruitment and retention, with nursing, midwifery and allied health students currently receiving \u0026pound;5,000 annual grants via the NHS Learning Support Fund.\u003csup\u003e59\u003c/sup\u003e Evidence from Malaysia suggests that financial incentives such as scholarships for postgraduate training may be more effective in retaining public-sector dentists than compulsory service.\u003csup\u003e60\u003c/sup\u003e Recent UK-based workforce reports further advocate investment in staff retention initiatives and reduction of financial barriers.\u003csup\u003e61\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOverall, the findings from this study suggest that mandatory \u0026lsquo;tie-in\u0026rsquo; systems may be poorly aligned with the expectations and motivations of the emerging dental workforce. Incentive-based approaches that include financial support, opportunities for career development and meaningful NHS contract reform may be more effective, sustainable and acceptable methods of strengthening NHS dentistry while respecting the professional autonomy of new graduates.\u003csup\u003e62\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eA strength of this study is that it represents the first national exploration of BDA Students Committee representatives\u0026rsquo; views on proposed return-of-service policies, capturing perspectives from across all sixteen UK dental schools. With two elected representatives per school, most of whom were familiar with national workforce discussions and the NHS \u0026lsquo;tie-in\u0026rsquo; proposals, the sample offers informed insights from students nearing qualification. The focus on those in their penultimate year of study is also defensible, as evidence suggests that final-year students and new graduates hold broadly comparable views on career expectations, motivations and professional intentions.\u003csup\u003e44,63\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, the study has several limitations. The overall sample remains small relative to the UK\u0026rsquo;s population of over 5,000 dental students, which may limit representativeness. As participation was confined to elected BDA Student Committee representatives response bias is possible. The exploratory nature of the work, while appropriate for an emerging policy topic, means that findings should be interpreted as indicative rather than definitive. Furthermore, reliance on self-reported attitudes introduces the potential for social desirability effects, and perspectives captured at a single time point may not fully reflect how opinions evolve during transition into professional practice. A larger, more diverse sample would improve generalisability and allow for more robust quantitative analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFuture Research Directions\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFuture research should examine how different ROS policy designs influence motivation, retention and early career choices within the UK context. Longitudinal studies following students into practice would help clarify the longer-term effects of mandatory service, while qualitative work could explore the experiences of those completing such obligations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven the limited evidence relating specifically to dentistry, profession-focused research is needed to understand how ROS schemes might affect dental workforce mobility, postgraduate training pathways and engagement with NHS care. Economic evaluations comparing ROS programmes with alternative retention strategies would further support evidence-informed policy development and help anticipate unintended consequences.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eInternational evidence demonstrates that ROS policies can shape workforce distribution but may also influence career decision-making, satisfaction and long-term retention in complex and sometimes unpredictable ways. \u0026nbsp;Persistent gaps in the literature underscore the need for robust, profession-specific research before implementing similar approaches domestically. A clearer understanding of how service obligation, such as the proposed NHS ‘tie-in’\u003cem\u003e\u0026nbsp;\u003c/em\u003efor newly qualified dentists, interact with individual motivations, training trajectories and workplace environments will be essential for designing policies that support both workforce sustainability and trainee wellbeing.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our appreciation to all of the members of the BDA Students Committee for their input in this survey. In addition, we appreciate the support of the BDA Library in carrying out the literature search.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNP, JK, LS, AR, SN, JS contributed to the conception and overall design of the study, data collection, and manuscript writing. All authors reviewed the manuscript prior to final submission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData can be provided by the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Conflicting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHaakenstad A, Irvine CMS, Knight M, Bintz C, Aravkin AY, Zheng P, et al. 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BMC Oral Health 2011 11:1 [Internet]. 2011 Sep 24 [cited 2025 Dec 3];11(1):25-. Available from: https://link.springer.com/article/10.1186/1472-6831-11-25\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"NHS dentistry, undergraduates, dental students, dental graduates, workforce planning, return-of-service, incentives, career intentions","lastPublishedDoi":"10.21203/rs.3.rs-8800177/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8800177/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAims:\u003c/strong\u003e To explore the attitudes of UK undergraduate dental students towards a proposed mandatory National Health Service (NHS) ‘tie-in’ period following graduation, in which newly qualified dentists would be required to work in the NHS for a minimum period in return for publicly funded training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e An online survey was distributed to elected representatives of the British Dental Association (BDA) Students Committee across all 16 UK dental schools. Quantitative data assessed agreement with government consultation proposals, preferred incentives to encourage NHS participation, and overall support for compulsory service. Free-text responses were analysed thematically.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The survey received responses from 32 representatives. Most students opposed the proposed mandatory NHS ‘tie-in’, with 41% strongly opposing and 10% opposing. Financial incentives were the most acceptable approach, with 56% favouring loan repayment schemes and 22% favouring guaranteed training posts. Free-text responses highlighted three key themes: financial support, career progression, and NHS contract reform. Attitudes towards mandatory service varied by year group and familiarity with policy discussions. Students expressed concern that compulsory NHS service could undermine recruitment, reduce professional autonomy, and fail to address underlying workforce challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e UK dental students demonstrate strong preference for voluntary engagement with the NHS supported by financial and career incentives, rather than compulsion. These findings have implications for workforce planning, suggesting that recruitment and retention strategies should focus on aligning NHS opportunities with graduate motivations and wellbeing. Future research should examine the long-term impact of different workforce incentive models on dental career pathways, NHS engagement, and service sustainability.\u003c/p\u003e","manuscriptTitle":"Attitudes of Undergraduate Dental Students to Proposed NHS ‘Tie-in’ for Graduate Dentists in the United Kingdom","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-13 13:13:42","doi":"10.21203/rs.3.rs-8800177/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bccf1310-60d4-4d55-a2f4-7b963e1391d5","owner":[],"postedDate":"February 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":62643686,"name":"Health sciences/Health care/Dentistry/Dental education/Dental foundation training"}],"tags":[],"updatedAt":"2026-03-06T19:45:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-13 13:13:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8800177","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8800177","identity":"rs-8800177","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}