Politics and the dentist
In the first of a series of interviews with individuals in key political and strategic positions, looking at the place of dentistry in politics, policy-making and the wider healthcare landscape, Sarah Allen speaks to Anas Sarwar, Labour MSP and former spokesperson for health
Healthcare is arguably one of the biggest political footballs there is: plans for the NHS can influence election results hugely; an NHS funding claim on the side of a bus was the defining image of the Brexit campaign. However, among all the political claims, counter-claims and rhetoric, and the laser-focus on the high-profile healthcare issues of the day, it can often feel that dentistry is the lost specialty. Individual oral health issues are increasingly gaining traction in the political arena, but oral health as a key area of healthcare practice is still conspicuous by its absence in governments’ long-term healthcare policy in most UK nations, and funding for dental services continues to fall.
In Scotland, the Oral Health Improvement Plan (OHIP) was launched to great fanfare in January 2018. However, it was not without its detractors who were concerned about some of its core elements.
It was felt that although the OHIP was full of action points, most of those actions pledged to investigate or discuss rather than to do, and there has been little visible action since the launch. Indeed, the biggest development has been the reversal of the OHIP proposal to change the recall period for the majority of patients from six months to up to 24 months. A potential further complication in moving forward has now been added in the lack of a new permanent Chief Dental Officer following the retirement of Margie Taylor.
In light of all of this it seems fair to ask just how seriously dentistry is taken by governments, parliaments and those who influence and drive national healthcare policy.
In the first of a series of interviews in which Scottish Dental examines the status of dentistry in our political and policy frameworks, I spoke to Anas Sarwar, MSP for Glasgow, former Scottish Labour spokesperson for health and ex-GDP. Anas sits as a member on a number of health-related cross-party groups and is the co-convener of the cross-party group on cancer. As such, he was a key figure in lobbying to change the Oral Health Improvement Plan proposal for 24-month recall. Between 2010 and 2015 Anas was the MP for Glasgow Central.
“there has been a creeping neglect of NHS dental services in recent years”
Lack of importance
I started by asking Anas whether he thought that dentistry and oral health were taken seriously enough in politics and whether they had the profile that they needed to have.
“I think the sad, honest answer is that, more often than not, the industry is perhaps seen as being an easy cut to make. I don’t think it gets the profile or level of importance that it deserves or perhaps has received in previous years. I remember when I was a dental student there was a real priority in government around recruitment and retention, particularly for GDPs and for remote areas of Scotland. I think there was a drive to improve the delivery of NHS dentistry services, but I think there’s been a creeping neglect of NHS dental services in recent years. I think that’s a combination of a lack of importance and engagement at a decision-making level, but I don’t think you can give isolated criticisms to the government around that to be frank; I think the profession itself has to have some self-criticism as to how it has projected the importance of dentistry, how it has lobbied the government as to issues around dental practice, and how it has fought its corner.
“I’ll give you a practical example. I am an NHS dentist by background, a lot of friends are dentists, my wife is a dentist, so I’m close to NHS dentistry and dentists. But when I was the health spokesperson for the Scottish Labour Party, having done that role for almost two and a half years, I struggle to think of any occasion over that time where we got meaningful dialogue and engagement with the dental profession or lobbying around their priorities and getting a fair deal. I think that’s a negative both for the profession and for the people that rely on dental services.
“This is not a criticism that is a secret. I’ve made it openly to the BDA, for example, about what more I think they could or should be doing to fight dentistry’s corner, and I think it has got better in recent months. I think you can see that from the lobbying we did together around the long-term plan for NHS dentistry, particularly the challenges around 24-month check-ups and the challenges around oral cancer.”
We’ll come back to what more the profession could and should be doing to engage with and lobby parliament, but I wanted to explore whether Anas thought that recent high-profile campaigns, such as 24-month recall, risked becoming causes célèbres, which threatened to obscure dentistry’s role within healthcare policy and strategy as a whole.
“I understand and agree with why there was a focus on oral cancer. It was a very good focus, and I hope we got a good result from it and that there will be a long-term focus on it, but we shouldn’t mistake NHS dentistry as purely being a profession where you prod ‘em, drill ‘em and fill ’em. That is a large part of the job around treating decay and highlighting prevention, but the role of the dentist, particularly at a time when we have such a huge vacancy rate around GPs for example, in our primary care model should be as a genuine partnership within a reformed community care and health services portfolio.
“The biggest thing for healthcare professionals across the board is looking at those individuals who are hardest to reach, particularly in areas of extreme deprivation where there is poverty, high incident rates of heart disease and tooth decay, poor life expectancy, issues with how people live their lives, alcohol and substance misuse. Quite often, for those hardest-to-reach individuals, a click moment can come in their lives, more often than not from an interaction they have with another human being. A dentist could be that click moment.
“How you interact with a patient coming through your door, how you behave with them, how you engage with them, how you treat them, how you give them confidence in themselves and in the treatment you’re giving them, could be that click moment, signposting them to other services or making them look at how they live their lives and how that impacts their health and their families.
“If you recognise that dentists have that role as equals with all other professionals around health and social care, that I think will lead to a greater focus on dentistry and dental services. I think that has to be the focal point for all those bodies that represent dentists.”
Anas has experience in both Westminster and Holyrood, and sits on a wide range of health committees, so I asked him whether he thought it was hard for dental representatives to get a seat at the table and whether he felt dentistry need to be taken more seriously by politicians.
“I remember when I was making a decision about what I wanted to do with my life, my studies and university. I chose dentistry but I’m not sure I would have made that decision now. I think dentistry then was seen as being a more attractive option compared with even general medical practice.
“I’m not sure that’s the case now and I think it is partly due to the fact that there has been a loosening focus on the importance of dentistry, and a frustration from dentists around the respect that they’re given as a profession, and the place they are given alongside other healthcare professions. That needs to change.
“There is a role for dentists around the clinical aspect but if you are to defend the profession in the interests of the communities you serve, then how you strengthen your representative bodies, how you sharpen your elbows and have the confidence to fight your corner is part of how you can get greater parity with other NHS services.”
What are the potential consequences of this lack of meaningful representation within political policy and strategy making?
“My fear is that there is creeping privatisation in NHS dentistry. There is more and more of ‘let’s make things that little bit more challenging’ so that people will opt to either provide more private dental services or patients will turn more toward private dental services. I think that would be really regrettable and I don’t think that will work for patients, government or dentists.”
It seems we have to accept that there is a significant lack of understanding about the dental profession among politicians, but I was curious to understand whether Anas felt that there was a similar lack of understanding about the role of dental professionals, both as a distinct discipline and within the wider framework of healthcare, with the public and whether there was a role for politicians, influencers and dental professionals to play together to educate people about dentistry.
“Yes, and I think the challenges around general medical practice have brought that into much sharper focus. If you look at the stats, around one in three GP practices in Scotland are reporting a vacancy, and that trajectory looks like things will get more difficult rather than there being any quick solution – you can’t magic up hundreds of GPs overnight.
“To cope with the challenges, the only way is to have a broad-range, multi-disciplinary approach to primary care, changing the culture where people automatically assume that any issue that arises is a matter for their GP. As we look at service redesign and reform of the NHS to make it fit for purpose for the 21st century, to make it resource and workforce fit, we are going to have to look at developing genuine community care rather than a focus on seeing primary care as being just the GP practice.
“I think another reason we need to do this is that, with an aging population, we are going to see much more demand for services in the community, and as you see greater advancements in healthcare you are getting more and more people who are living longer and with multiple conditions.
“This means you need more generalists rather than specialists, and a push toward people being in their home and community, rather than in social care. If you accept that as happening, then how service is redesigned and how funding and workforce matches that needs to be rethought.”
On this topic, I asked Anas about a key thread, and one of the more controversial aspects of the OHIP, the emphasis on treatment within domiciliary care. I wanted to know if he felt this was really one of the fundamental issues facing NHS dentistry and whether it was just too big to address as things stood, without significant and sustained financial investment into NHS dental services.
“I think the biggest fundamental issue is, if you match remuneration to purely how many bums you can get on the seat, how many teeth you can drill and fill, and how many individual pieces of treatment you can do, then the focus of that treatment plan and the holistic care we want for every person in Scotland doesn’t hang on the individual.
“It becomes about a profession which is purely probe, drill and fill. Dentistry is more than that, which goes back to changing the culture. But you will only change the culture if you set that priority from the top down, in partnership with people in the community, and have the resource model and the workforce model to meet that. I’m not sure we’re at that stage yet.”
I asked what Anas thought it would take to get to that stage.
“It is really easy for people to think that the biggest problem facing the NHS is money, and I’m not saying money isn’t a problem, of course it is, but a more fundamental problem is a people problem. Not that they aren’t adequately trained or engaged; I think the greatest thing about the NHS is the people who work in it, but it’s about having enough resource to adequately support, and enough people so everyone can do their jobs properly. If there are not enough of you, and you have more work as a result of that, then you lose the time to care. You have to give clinicians the time to care and not just the time to treat.”
The conversation then moved to the OHIP. One of the criticisms levelled against the OHIP has been that it, in Anas’s own words, “promises a lot of thinking”.
“There comes a point where you need to stop reviewing and thinking, and start actually doing. I think there is a direct correlation between someone’s oral health, their self-confidence and their life outcomes and life chances. It is no coincidence that the areas where you see the highest levels of poverty and deprivation and unemployment are also the areas where you see the poorest levels of oral health. It is a sad reality of life that people are judged on more than just their ability, they are also judged on their appearance.
“Would you ever have a First Minister, for example, who had missing front teeth or had severely decayed teeth or didn’t have an aesthetic smile? You wouldn’t and, if we accept this correlation, that in itself is a reason to recognise why dentistry has an important role to play.
“It goes back to my point about the click moment and that for many of the most hard to reach people, their interaction with their dentist may be the only interaction they have with any healthcare professional.”
It is easy to agree that dental professionals have a crucial role in reaching the hard to reach, but I wanted to understand more about whether Anas believed the OHIP supported this critical role, or whether key groups were lost within the Plan. One example is the issue that individuals can often fall off a cliff as they age, getting lost in the system, ceasing their regular or semi-regular contact with their dentist and only appearing again in the system once in domiciliary care. It seems to be a big gap in the OHIP and means that patients with complex requirements are going to be seen by dentists with whom they don’t have a relationship. I asked Anas whether he thought this was important?
“The key word is ‘relationship’. That relationship between clinician or professional and the individual is really crucial. I know from my own experience that I built a relationship and a trust with my patients which meant they would talk to me about more issues than what was going on in their mouth, and I felt more confident in asking them about problems they were having and how that related to their healthcare. That human interaction is an important part of delivering effective, respected and quality healthcare. That has to be a fundamental principle.”
“There comes a point where you need to stop reviewing and thinking and start actually doing”
One issue that dentists have regularly raised with Anas is relationship between the profession and the GDC, and he was anxious to raise this. In this magazine, I have been critical of the GDC and the culture of fear that seems to have been generated around them, so I was interested to hear whether Anas felt that criticism was justified, based on his conversations.
“The relationship between the GDC and the profession seems to be one of policing rather than partnership. There is of course a role for policing and investigation to ensure there is quality, but if even Police Scotland believe that the future of policing is through being a partnership with their communities rather than purely policing their communities, and I’m hopeful that the GMC recognises this too, then I think that the GDC has to have that same thought and culture change as well. I think that is a more effective future model and I will take it up with the GDC shortly.
“The bottom line is that there are probably individuals within the GDC who want to create a culture of fear, but I think that is a very naïve approach to take and actually undermines the profession and undermines the point of the GDC. If we want clinicians to respect the profession and their patients and, crucially, recognise when they get it wrong and have the confidence to recognise when they get it wrong, then having the body that oversees them being in partnership is really important.
“Dental professionals are public servant who have dedicated their lives to caring for other people. I’m not suggesting that some of them don’t get things wrong or there are instances when it is right that the GDC steps in and takes tough action, but you don’t tar every professional with the same brush, so I would say to the GDC, create a partnership rather than a culture of fear.”
Privilege and honour
To finish, I asked Anas whether there was anything else that had particularly struck him about the dental profession’s interaction with the political world and whether he had any final piece of advice as to how it could raise its profile and importance in parliament.
“Don’t think it is someone else’s job. If dentists think it is someone else’s job to go and make the argument and make the case for dentistry, then I fear they’ll get left behind. Yes, be true to your profession, work hard in your profession and in your role as a clinician, but don’t lose sight of the importance and strength of your representative bodies and the ability to advocate for the long-term benefit of you and your profession.
“To get a place in dental school, to be a qualified professional, to have meaningful employment is a privilege and an honour and I think that privilege and honour extends beyond just the remuneration value and the impact on your family.
“The largest privilege and honour is that you are in a position to care for your fellow citizens. If you see it as that privilege and honour, then you have a duty not just to practice the profession but to protect that profession as well.”