The British Dental Association has said there can be no complacency from the Scottish Government on the crisis in NHS dentistry, following yesterday’s debate in the Scottish Parliament, in which MSPs raised the heart-breaking case of a single mother going without food to pay for care, with others travelling hundreds of miles for access or embarking on ‘DIY’ dentistry.
The BDA’s own recent surveys found 83% of dentist respondents in Scotland had treated patients that had performed some form of DIY dentistry since lockdown.
Some reforms to the discredited small margin/high volume system NHS dentists work to were rolled out in November 2023. This system has been in crisis for a generation but proved undeliverable during the pandemic. Facing soaring costs, some practices were left delivering some NHS treatments at a financial loss.
The BDA had been seeking a decisive break from this system, and a move to a patient-centred, prevention-focused model of care. The Scottish Government refused to break with the overall framework.
The BDA stress that this must be the beginning, not the end of the road for reform, and that access, outcomes and inequalities need to be closely monitored.
David McColl, Chair of the British Dental Association’s Scottish Dental Practice Committee said:“MSPs and patients across Scotland have sent a clear message: the Scottish Government cannot pretend it’s ‘Mission Accomplished’ on NHS dentistry.
“Recent reforms may ease problems, but Ministers can’t afford to take their eyes off the crisis in this service.”
SCOTTISH GOVERNMENT ACCUSED OF ‘EXCRUITIATING NEGLECT’
The British Dental Association Scotland has welcomed the coming debate in the Scottish Parliament on the challenges facing NHS dentistry.
Scottish Liberal Democrat Willie Rennie MSP, who is leading Wednesday’s debate, accuses the SNP Government of “excruciating neglect”, revealing cases who have travelled to India for dental care and who have performed “DIY dentistry” with tools purchased from Amazon.
The BDA’s own recent surveys found 83% of dentist respondents in Scotland had treated patients that had performed some form of DIY dentistry since lockdown.
Some reforms to the discredited small margin/high volume system NHS dentists work to were rolled out in November 2023. This system has been in crisis for a generation but proved undeliverable during the pandemic. Facing soaring costs, some practices were left delivering some NHS treatments at a financial loss.
The BDA had been seeking a decisive break from this system, and a move to a patient-centred, prevention-focused model of care. The Scottish Government refused to break with the overall framework. The BDA stress that this must be the beginning, not the end of the road for reform, and that access, outcomes and inequalities need to be closely monitored.
Charlotte Waite, Director of British Dental Association Scotland said:“The crisis in this service has seen desperate patients take matters into their own hands, or head overseas for care that should be available in their own communities.
“The Scottish Government unveiled some reforms back in November. Time will tell if it’s enough to turn the tide, so those who want and need NHS care can secure it.”
Services in all UK nations face hit, Northern Ireland an existential threat
The British Dental Association has warned the European Parliament’s vote to ban dental amalgam from 1 January 2025, will send shockwaves across the UK’s already struggling dental services.
Silver amalgam is the most common material for NHS permanent fillings across the UK. Fillings represent around a quarter of all courses of NHS treatment delivered in England, with amalgam used in around in around a third of procedures.
BDA estimate treatment times and costs of alternative materials are over 50% higher than those of amalgam. [1]
On 14 July, the European Commission adopted a proposal to revise the Mercury Regulation, to introduce a total phase-out of the use of dental amalgam and prohibit the manufacture and export of dental amalgam from the EU from 1 January 2025 – 5 years earlier than expected.
The vote will hit all four UK nations but will have a disproportionate impact on services in Northern Ireland, which has the highest proportion of filled teeth of any UK nation. [2] Under post Brexit arrangements, Northern Ireland will be expected to phase out dental amalgam on the same basis as EU member states. Divergence means the rest of the UK faces disruption and higher costs given the impact on supply chains, but not a formal ban.
In an open letter to all four UK Chief Dental Officers, the BDA stress there are currently no alternative restorative materials that compete with amalgam on speed of placement or longevity, meaning the ban will eat into clinical time and resource that are in short supply, likely creating further access barriers.
There are no indications where the millions in additional funding required will come from nor the workforce to carry out the tens of thousands of extra clinical hours.
MEPs also backed amendments stating that Member States need to “ensure appropriate reimbursement is made available for mercury-free alternatives” to limit the socio-economic impact. The BDA say the same approach is need from all UK Governments.
The Nuffield Trust warned in December that NHS dentistry was at the most precarious moment in its 75-year history. The BDA warn that without decisive action, this ban will only hasten the service’s demise.
While the BDA has long supported a phase-down in dental amalgam, it believes this rapid phase-out is neither feasible nor justifiable. Dental amalgam has been in use and extensively studied for 150 years as a restorative material. Its safety and durability are well established, and it remains the most appropriate material for a range of clinical situations.
BDA Chair Eddie Crouch said:“When we are set to lose a key weapon in the treatment of tooth decay all four UK Governments appear asleep at the wheel.
“When alternative materials can’t compete, this will add new costs and new uncertainties to practices already on the brink.
“Without decisive action this could be the straw that breaks the back of NHS dentistry.”
[1] BDA research on treatment times and costs, 2023. Figures are derived from a comprehensive research study into NHS dental treatment times. A unit price per treatment has been generated using official figures for dental expenses, courses of treatment and dentist earnings (available through NHS digital), supplemented by further BDA research.
[2] Total number of Teeth Filled per 100,000 population by UK nations and Financial Year, From Family Practitioner Services General Dental Statistics for Northern Ireland 2022/23
In Northern Ireland’s Item of Service Claims 2022/23, amalgam was used as a material in 153,000 of the 353,000 claims for permanent fillings on adults and children, or 46% of the total.
While amalgam use is not centrally recorded in England, the BDA understands these represent around a third of fillings placed in England on the NHS.
The British Dental Association has warned MSPs the pandemic has had an unparalleled impact on NHS dentistry, that leaves the service facing an existential threat.
As the professional body prepares to give evidence to the COVID-19 Recovery Committee inquiry into NHS dentistry today (22 June 2023), it has published new analysis showing the scale of the backlogs.
Initially closed to routine care, and then facing exacting Infection and prevention control guidelines that reduced patient throughput, lost capacity on the high street exceeds general medical practice and secondary care, resulting in backlogs that will take many years to clear:
Dentistry has lost over half (52%) of its capacity since lockdown, when comparing examinations delivered since March 2020 with typical levels pre-COVID.
For GPs, that figure is just over 30% (when looking at lost face-to-face appointments). It is just over 6% for hospital outpatients and in terms of volume, inpatient care appears to have already recovered lost ground.
By any measure captured in official data, whether it is examinations or Statement of Dental Remuneration (SDR) activity claims, Scotland has lost more than a year’s worth of NHS dentistry.
Ongoing access problems are fuelling backlogs, with patients presenting with higher levels of clinical need. In recent BDA surveys over two thirds (67%) of dentists cite higher needs patients requiring more clinical time as a key issue on return to ‘full’ capacity. The only comparable problems are those concerning recruitment and retention of dentists (61%).
Dentist leaders say it will be impossible to restore pre-pandemic activity without radical change. The low margin/high volume model the service works to was incompatible with working through the pandemic and cannot form the basis for a meaningful or sustainable recovery.
This leaves the service at a crossroads: with a contract that is unfit for purpose, underfunded, overstretched and facing the challenge of deep and widening oral health inequalities. BDA Scotland fear that an exodus of dentists from the NHS is already in motion. This shift is going unseen in official data, that counts heads not the amount of NHS work dentists do. These workforce statistics give an NHS full-timer the same weight as a dentist doing one NHS check-up a year.
Recent BDA surveys indicate only 1 in 5 (21%) of practices have returned to pre-COVID-19 capacity. The professional body say hard limits on restoring capacity, and the existential threats to NHS dental services require a proportionate response from the Scottish Government.
David McColl, Chair of the British Dental Association’s Scottish Dental Practice Committee said:“COVID hit dentistry like no other part of the NHS in Scotland.
“We’re not asking for special treatment, just a proportionate response. One that recognises the scale of the backlogs and the existential threat to this service.
“NHS dentists are already walking away from a broken system. There can be no recovery without reform.”
The British Dental Association has responded to new figures from the Scottish Liberal Democrats warning the oral health gap between rich and poor children will widen, given ongoing access problems, and the growing exodus from a broken NHS system.
Official data from Public Health Scotland has already shown the fall in participation is hitting those in most deprived communities the most. In September 2008, the gap in child participation between the most and least deprived areas was three percentage points; this had increased to seven percentage points by 2010, eighteen percentage points (55.3% compared to 73.1%) in September 2021. The figure now stands at twenty percentage points (55.9% compared with 75.8%).
The BDA has warned that lower levels of participation will inevitably translate into a higher dental disease burden, with deep oral health inequalities expected to widen even further given the cumulative impact of limited access to services, the temporary suspension of public health programmes, and the impact of lockdown diets. Lower participation will reduce the chance of picking up early signs of decay at routine check-ups, and delays in treatment will mean higher costs to the NHS and worse outcomes for young patients.
The professional body has stressed that reform to the broken low margin/high volume model the service works to are now essential, and that a new model has been pledged for rollout in the autumn. At present certain key treatments can be delivered at a financial loss, accelerating the exodus from the service. A recent BDA survey showed over half (59%) of high street NHS dentist reported having reduced the amount of NHS work they did since lockdown. Over four in five (83%) said they plan to reduce or further reduce their NHS commitment in the year ahead.
The BDA says that the future of the service hinges on reform providing it with firm foundations, with a decent, sustainable model that can deliver for patients and dentists across Scotland.
David McColl, Chair of the British Dental Association’s Scottish Dental Practice Committee said:“The oral health gap between rich and poor kids is set to widen.
“It’s a national scandal. Prevention is better than cure, but dentists are losing the chance to nip problems in the bud. The growing exodus from the NHS may make that permanent.
“Tooth decay is already the number one reason for hospital admissions among young children. It will take real reform to bring this service back from the brink.”
The British Dental Association has responded to new figures from the Scottish Liberal Democrats, acknowledging that the Scottish Government’s consistent use of registration figures to illustrate the supposed ‘recovery’ in the service is effectively meaningless.
Patients in Scotland are registered for life, so the key focus must be on participation, which remains stubbornly below pre-COVID levels.
The professional body has stressed that reform to the broken low margin/high volume model the service works to are now essential, and that a new model has bee pledged for rollout in the autumn.
At present certain key treatments can be delivered at a financial loss, accelerating the exodus from the service. A recent BDA survey showed over half (59%) of high street NHS dentist reported having reduced the amount of NHS work they did since lockdown.
Over four in five (83%) said they plan to reduce or further reduce their NHS commitment in the year ahead.
The BDA says that the future of the service hinges on reform providing it with firm foundations, with a decent, sustainable model that can deliver for patients and dentists across Scotland.
Charlotte Waite, National Director of the British Dental Association Scotland said:“When patients are put on the books for life registration is a meaningless metric.
“What really matters is the patients getting through our doors, and on that note NHS dentistry has not returned to anything resembling ‘business as usual’.
“This service is at a tipping point. Without reform there can be no recovery.”
The British Dental Association has warned the future of NHS dentistry in Scotland is in doubt, and action here must be high on the agenda for the next First Minister.
A devastating new survey of dentists across Scotland reveals:
An exodus is in motion.59% of dentists say they have reduced the amount of NHS work they undertake since lockdown – by an average of over a fifth.This movement is going unseen in official data, which counts heads, not commitment, and gives the same weight to a dentist doing a single NHS check-up a year as an NHS full timer.
Over 4 in 5 (83%) now say they will reduce – or further reduce – their NHS commitment in the year ahead. Over a third (34%) say they will change career or seek early retirement.
Just 1 in 5 (21%) say their practices have returned to pre-COVID capacity. 61% cite recruitment problems as an issue, over two thirds (67%) cite treating patients with higher needs requiring more clinical time.
A sustainable model must be in place come October. 90% cite financial uncertainty as having a high impact on their morale.
Health Secretary Humza Yousaf recently stressed NHS staffing was “at a historically high level”, with ‘record’ numbers of dental staff in hospitals alongside medics and allied health professionals. However, NHS Education for Scotland data indicates an 8% drop in high street NHS dentists delivering care since lockdown, a fall from 3,038 in March 2020 to 2,791 in September 2022.
The BDA stress even this fall understates the full scale of losses in light of this new survey evidence. The Scottish Government has never attempted to make a ‘Whole Time Equivalent’ estimate of the NHS dental workforce. Most dentists combine NHS and private work, and the BDA warn that without these estimates movement to the private sector is going undetected, and workforce planning is effectively impossible.
NHS dental care free at the point of use remains a central Scottish Government policy. BDA Scotland has long warned that any return to the service’s ‘business as usual’ model – low margin and high volume – will put practices under huge financial pressure and will likely lead to closures or movement to the private sector, with many practices left delivering some NHS care at a loss.
The SNP leadership election has seen key deadlines to reform this broken system move. The profession had anticipated the Scottish Government would reveal changes to the payment model on 1 April, that would be rolled out from October.
The BDA stress a sustainable model must be in place come October, when the current bridging payments that uplifted NHS fees finally lapse, exposing many NHS practices to unsustainable costs.
David McColl, Chair of the British Dental Association’s Scottish Dental Practice Committee, said:“Behind hollow boasts on record workforce numbers is a service that is hollowing out.
“The majority of dentists have pared down their NHS work, and many more are set to follow. It’s an exodus that’s going untracked by government but is the inevitable result of working to a broken system.
“NHS dentistry’s survival requires rapid action, with meaningful reform and sustainable funding.
“The steps taken in the next First Minister’s First Hundred Days will determine whether this service will have a future.”
Online poll of General Dental Practitioners in Scotland, Fieldwork February 2023, 526 respondents:
What changes in your working life do you anticipate in the next 12 months? % Net Likely n
I will reduce my personal NHS commitment 83% 439
I will change career/seek early retirement 43% 178
Approximately what proportion of your income was NHS based prior to March 2020?
% n
100% (exclusively NHS) 4% 23
90-99% (NHS) 43% 227
80-89% (NHS) 23% 122
70-79% (NHS) 13% 69
60-69% (NHS) 4% 22
50-59% (NHS) 4% 22
40-49% (NHS) 2% 11
30-39% (NHS) 1% 3
20-29% (NHS) 2% 12
10-19% (NHS) 1% 4
1-9% (NHS) 2% 9
0% (exclusively private) 0% 2
Approximately what proportion of your income was NHS based now?
% n
100% (exclusively NHS) 2% 8
90-99% (NHS) 25% 134
80-89% (NHS) 19% 98
70-79% (NHS) 14% 71
60-69% (NHS) 9% 48
50-59% (NHS) 11% 60
40-49% (NHS) 6% 32
30-39% (NHS) 4% 20
20-29% (NHS) 4% 20
10-19% (NHS) 3% 16
1-9% (NHS) 3% 16
0% (exclusively private) 1% 3
309 respondents reported a fall in NHS work between March 2020 and February 2023 – with an average drop of 22%.
Please estimate your practice’s current overall capacity compared to pre-COVID levels.
100% (my practice is at full capacity) 21% 111
90-99% 17% 91
80-89% 22% 116
70-79% 19% 102
60-69% 10% 54
50-59% 4% 21
40-49% 0% 2
30-39% 0% 2
20-29% 1% 4
10-19% 0% 2
1-9% 0% 2
0% (my practice is not operating) 0% 0
Don’t know 4% 19
What factors would you say are constraining your practice from operating at pre-COVID capacity (select any that apply)
% n
Recruitment and retention problems for dentists 61% 304
Patient cancellations/Did Not Attends 44% 220
Ongoing Infection Prevention and Control restrictions 18% 93
Staff sickness 43% 213
Higher needs patients requiring more clinical time 67% 336
For each of the statements below please rate the impact each currently has on your morale working as a dentist
Net High impact % n
Inability to provide pre-COVID levels of care 61% 321
Without reform NHS dentistry will go from crisis to collapse
Following yesterday’s debate in the Scottish Parliament the British Dental Association has urged the Scottish Government to deliver meaningful reform to NHS dentistry by the autumn, stressing failure to do so will take the service from crisis to collapse.
On Tuesday Ministers announced a ‘bridging payment’ – originally due to lapse on 1 April 2023 – which uprated NHS fees by 1.1 would continue to October 2023. With spiralling costs BDA Scotland has continued to stress that the traditional high volume/low margin model NHS dentistry works to was now unsustainable and removing the payment would push practices to bankruptcy or into the private sector.
Despite needed progress on this extension, BDA Scotland warns a new sustainable model must be in place by 31 October, otherwise the extension will only delay the inevitable. Practices are already facing the risk of providing care that involves laboratory work – like dentures – at a loss.
NHS dentistry in Scotland has not returned to anything resembling business as usual. Recent data has indicated claims submitted by NHS dentists for dental work are 43% down on 2019 levels and suggest a growing exodus from the NHS workforce.
David McColl, Chair of the British Dental Association’s Scottish Dental Practice Committee said:“There was little need for a debate on whether NHS dentistry in Scotland is in crisis. On access, on workforce, on inequalities, wherever data exists it points to a service on the brink.
“The Scottish Government made the right call by not prematurely pulling the plug on vital support.
“The question is now whether come October we’ll have the reforms needed to give this service a future. Failure to do so will take us from crisis to collapse.”
More than 90 dentists withdrew from NHS Lothian dental list from 2021 to June 2022, a Freedom of Information request submitted by the Scottish Labour has revealed.
Sarah Boyack warns of a health crisis as waiting times for A&E and NHS dentistry continue to spiral, while delayed discharges have gone up.
Scottish Labour’s FOI request revealed that between 2021 and June 2022, 92 dentists withdrew from NHS Lothian dental list. As at beginning of June this year, out of the 163 general dental practices in Lothian, only 51 confirmed that they are accepting patients, with some accepting children only.
Since 8th May 2022 and up until 11th December, there has been only one week during which the percentage of people seen within Scottish Government’s 4-hour target was above 70 per cent – in the week ending 11th December more than 1,756 people were stuck in A&E for more than four hours – only 63.6 per cent of those attending NHS Lothian’s emergencies were seen within 4 hours. In the same week, 353 people were stuck in A&E for more than 12 hours.
This comes as the recent monthly report on delayed discharge shows rates in NHS Lothian for October 2022 soaring to 1,644 compared to 1,420 in September 2022.
This makes NHS Lothian the second-worst performing health board in Scotland, only topped by NHS Greater Glasgow and Clyde, with 3,848 delayed discharges in October 2022.
October recorded the highest average number of beds occupied per day due to delayed discharges in Scotland since the current guidance came into place in July 2016.
Scottish Labour MSP for Lothian Sarah Boyacksaid: “Another month, another set of damning statistics from NHS Lothian.
“On top of the cost of living crisis, which is taking its toll on people’s mental and physical health, we see piling pressure on our NHS, worsening patients outcomes and huge waste of public money.
“With the freezing cold, people will get sick and they will require care. That’s why we need support to GPs to allow them to respond to the rising demand and handle cases, whenever possible, at primary care level.
“These are not just figures – it is someone’s dad, friend or life partner; it’s the NHS staff who is overworked and underpaid; it’s the people who left our health service because they simply couldn’t cope.
“With a general election approaching, now is the time focus on what really matters and make a difference for millions of people.”
Dentists have warned that the Scottish Government’s last-minute extension of financial support for NHS practices must go hand in hand with meaningful reform to avert a crisis in the service.
A new ‘bridging payment’ will replace the current ‘multiplier’ set to expire on 1 October, uplifting NHS fees a rate of 1.2 for the next three months, falling to 1.1 for the period up to April 2023.
The Cabinet Secretary had previously told the BDA that the multiplier – which at its current level increased NHS fees by 1.3 – had not been included in the Scottish Government’s budget forecasting. The professional body has not ceased reminding officials that without an adequate interim funding package several key treatments including extractions, and anything – like dentures – that requires laboratory work, risk being delivered at a financial loss.
The BDA stress that the new support package cannot presage a return to ‘business as usual’ from April 2023. Dentist leaders stress that in the months ahead efforts must be made to deliver needed change to the broken high volume/low margin model NHS dentistry is based on. Without reform, this package will simply delay an inevitable exodus of dentists from the NHS that is already evident in other UK nations.
While COVID emergency measures have been withdrawn, dentistry in Scotland has not returned to anything resembling pre-pandemic norms, with practices continuing to work under capacity in the face of an historic backlog. Latest figures indicate 261,537 claims were made by dentists delivering NHS treatments in July 2022, less than 60% of the number made in the same month in 2019.
Recent research by the BBC indicated 9 in 10 practices UK-wide were unable to take on new adult patients. In Scotland figures stood at 82%, the multiplier likely playing a decisive role.
David McColl, Chair of the British Dental Association’s Scottish Dental Practice Committee said:“The Scottish Government seem to have recognised the wholesale inadequacy of the funding model for NHS dentistry.
“It’s not rocket science. Without additional support, the basics of NHS care – from extractions to dentures – would have been delivered at a loss. No business can operate on that basis.
“We now need some serious long-term thinking. Unless Ministers are prepared to revisit the system this service is built on, this funding will amount to sticking plaster on a gaping wound.
“If this is just delaying the return to a broken ‘business as usual’ then millions of patients stand to lose out.”
