A Scottish enlightenment

11 April, 2019 / indepth
 Sarah Allen    Mark Jackson

In the second of our series of interviews examining the status of dentistry in the political and policy frameworks of Scotland, our editor, Sarah Allen, speaks to Alex Cole-Hamilton, MSP for Edinburgh Western, Scottish Liberal Democrat spokesperson for health, and member of the parliamentary Health and Sport Committee.

In the interests of full disclosure, I should start by saying that Alex Cole-Hamilton is my local MSP; his children even go to the same local primary as my children. But this was not why I wanted to speak to him in this series. As dentistry is not an area of healthcare that politicians speak about very often, when we do hear anything about dentistry in Scotland from political circles, it all tends to be through the prism of Scottish Government and we very rarely hear anything from the other parties, even from their health spokespeople. I’d never met Alex before this interview, in any context, so I was therefore very keen to hear from him as a politician with no background in health or dentistry, and in light of his health portfolio, to gauge his understanding of the issues facing dentistry, to see how often these crossed his desk, and whether he had faith that dentistry held its rightful place within healthcare among his political colleagues, of all parties. I started with my now customary opening gambit, what place does dentistry hold in the political consciousness of Scotland?

“I think it is a Cinderella specialty in many ways. I think that is evident in the fact that we still don’t have a Chief Dental Officer,” said Alex. “The fact that Margie still has not been replaced speaks volumes about the amount of priority the government affords to this agenda. Also, we’ve got notional workstreams within the Scottish government like the Oral Health Improvement Plan (OHIP) but there’s not really a timeline as to how that’s to be reviewed or whether the Health Committee can even take evidence to review the efficacy of the OHIP. That is something I and other colleagues in opposition parties have asked clerks, so I hope we will have an opportunity to road test how that’s going.”

the dental sector is facing pressures from all sides and it doesn’t yet have the attention of government to resolve that

Well, not the most positive of starts, but the lack of both a permanent CDO and of any information about the progress and next steps of the OHIP have been causing increasing concern with practitioners and dental organisations alike. Perhaps dentistry just isn’t considered that important by people who are not exposed to it very often. Do Alex and his colleagues understand the critical importance of dentistry within the healthcare landscape, and the very real issues that it faces?

“Dentistry is really important, and it is about far more than just dental health. Dentists are often the first people to catch early signs of oral cancer. They can flag up concerns about vulnerable patients, and they may well
be the first person that patient has seen for a while, meaning the dentist will be able to spot other health issues through that contact. I think also the landscape is very different than other professions within the health service because of the fine balance between the private and NHS patient base. 

“We’ve got a workforce shortage, one in seven posts are currently unfilled and there is an increasing struggle to recruit dental nurses. So I think the dental sector is facing pressures from all sides and it doesn’t yet have the attention of government to resolve that.”

Which once again begs the question I have put previously to others, how does it get that attention?

“I think opposition MPs who have the portfolio are alive to it. I know you’ve spoken to Anas [Anas Sarwar MSP interview in last edition] and I think it’s really helpful that he is a dentist and understands the landscape so that has really pushed this to the fore, although he no longer has the health brief he is still agitating. I think it’s partly that, and partly dentists understanding they have a voice and seeking out meetings with government and opposition politicians. Also talking to their patients about what is going on in the sector as well. The thing that elicits most change in politics is when constituents come to you with a concern, and if your dentist is saying ‘I’m on the verge of shutting up shop here because it’s no longer viable for me, please speak to your MSP about it’, we will take that very seriously.”

I wondered whether he felt there was also a need for direct lobbying by groups and organisations such as the BDA.

“Definitely. They’re actually very good at that I think, and one of the reasons I asked the clerks in the Health Committee for staging posts in the implementation of the OHIP was because it was a specific ask of the BDA. That was very effective because I realised, in meetings with the BDA, the depth of the profession. It’s not just about check-ups, it’s a whole comprehensive suite of care that’s offered to patients in dental surgeries.”

Disconnected

It was heartening to hear that through direct action and his roles in parliament, Alex had developed a good understanding of the importance and breadth of dentistry, but his initial lack of knowledge was once again proof that the general public really does not understand it at all. Mindful of his previous comments about the power of the public, I asked Alex whether he thought there was any way that the profession and politicians could work together to address that lack of understanding.

“I think so. I’ve learnt a lot in recent months, holding this portfolio, in terms of the links I didn’t understand between, say oral health and dementia in older people in care homes. The fact that, with good reason, the Scottish Government used oral health in children to understand poverty and deprivation, because there is a direct correlation. 

“There is an inexorable link between oral health and a whole range of wider social issues and health issues. The health of somebody’s mouth can be a barometer for a great many other things and that is why dentists are hugely important to the prevention agenda. I think it is incumbent not just on dentists but on politicians who are public-facing, to evangelise on the importance of dentistry and good oral hygiene.

“I’ll give you an example of where I’ve been concerned. Dentists are often let down by the wider NHS as well, as there is sometimes a disconnect. I had a constituent whose dentist referred her into secondary care because of a worrying sign of early onset mouth cancer. But when the referral went into the wider NHS a letter sat in a dictaphone for two months before it was even typed up. 

“This is down to antiquated systems and it is a problem across the wider NHS. These are systems that were deployed in the 1970s but not suited to the modern world. That dentist operated in good faith to say this needs to be looked into, and that didn’t happen in good time. It ended well, but I think the systems and processes that wrap around the NHS don’t always work.”

I thought it was really pertinent that Alex was raising a perceived disconnect from his perspective of looking at healthcare in its broadest sense. It can often seem from within that dentistry is disconnected from the rest of healthcare and the poor relation to medicine, so I asked Alex whether he felt that it was incumbent on politicians to ensure that they involve dental professionals in their wider examination of general healthcare issues such as sugar intake for example?

“Absolutely, and I think sugar is a fantastic example because we have in Scotland a very particular relationship with sugar and fat. In fact, our stats are far worse than  England and Wales in terms of obesity, COPD, and other diet-induced conditions and lifestyle-induced conditions from smoking and drinking. As such I think there is an imperative for political parties to come together and have those meetings but I don’t think that’s happening. 

“The Health Committee have had several presentations on the stubborn reluctance of these stats to drop – people are still getting fatter, kids are still getting teeth pulled at a very early age – and this is mostly because of dietary reasons, and lifestyle to a certain degree.

“We have had strategy after strategy after strategy in Scotland. We have measured oral health as one of the 45 national indicators from the concordat in 2007, and it is still one of them, but it’s not actually making a difference. We’re not changing the tide. When that happens, I think it’s time to start legislating, which means rather than things being voluntary in terms of sugar reduction and re-formulation of products, they’re mandatory and you cannot sell certain items with a sugar content that exceeds X or Y. 

“I think there needs to be a duty on producers to make it clear on packaging what is contained within the product and I think we need to invest in alternatives and in education. While the political will is there, talk is cheap, and I say this as a liberal – I don’t believe in banning things or limiting things more than is necessary, but when it is a public health emergency we need to take action.”

Rudderless

Is there a role for dentistry to take the lead in this then, as no one else is? And who in dentistry instigates this and tells everyone, enough is enough, time to stop talking, time to do something?

“Yes, and that’s why we absolutely need a new CDO and I’m really dismayed that we’ve been without one for as long as we have. Because without that then the profession is slightly rudderless in terms of its influence in government. When you have a permanent CDO you have someone who can lead the agenda, whether that’s saying ‘right we’re going to have a particular offensive against the over use of sugar in our food and drinks’ or starting public awareness campaigns. 

“You can hear Catherine Calderwood, the CMO, any day of the week on the radio talking about health promotion in the wider sense, but you rarely hear anything about dentistry or oral health, and I think that’s the disconnect. You need that leadership, but the CDO can also act – and this is really vital for their role – as a critical friend to government and say, ‘the unintended consequences of this legislation or this strategy are that people’s oral health is going to deteriorate, or at best it’s not going to get any better’.”

In lieu of a permanent CDO I wondered whether there was more of an imperative on the new Directors of Dentistry, who, at time of speaking were being appointed in an interim capacity, to take on some of this mantle of leadership.

“In the absence of a permanent CDO then I think they have to step up to that role, but it’s whether they can get the access to the high command of government to make things happen. Often times, strategies come together across the 14 health boards, and it’s a great idea, it allows cross-fertilisation of best practice and allows us to gather together the details and data of the landscape in which dentists are working, but that’s just a veneer and window-dressing unless it’s actually meaningful, and real change happens as a result of it. We have CEOs and chairs of health boards, and they don’t have a direct line to the Cabinet Secretary, for medicine they go through the CMO, so dentistry is decapitated at the moment. That sounds a bit extreme, but without that leadership I don’t have the faith that the Dental Directors will have the access to the very top of government.”

As Alex had referred to the issue of many strategies, no impact, I wanted to explore his thoughts about seemingly successful strategies such as Child Smile, which has been lauded for improving oral health in the general child population but criticised for failing to close the deprivation gap it sought to address.“This is a great example of an effective strategy that has worked well in some parts of the country, but not in others. I have first-hand experience of Child Smile as I have three small children, all of whom have more awareness of their dental health than I ever did. But that reach is to the connected population. There is a disconnected population who very sadly don’t necessarily have particularly engaged parents who are there to support that understanding of oral health. They are also more likely to be exposed to high sugar and fat content meals, snacks and drinks, and, arguably, this is a blunderbuss strategy which is reaching everybody, but not getting the penetration with the people who need it most. But that is not atypical; this is the case with a lot of health-related strategies. The people who are educated, engaged and concerned will benefit, but those who are on the periphery, who face deprivation, who face multiple chaotic lifestyle factors, it will be good for the day it is delivered but it will then fall by the wayside. And that is the holy grail of public policy, how do we get sustained change in the families that need it most?”

Money matters

In that light, as Alex has already said that dentists are often the first line of reaching these groups, there must be a role for them to play in that ongoing education and outreach. Does this not call, therefore, for the strategy developers to work more closely with dental practitioners to create strategies that are achievable? One of the criticisms of the OHIP, for example, was that there was consultation but, when it came out, the profession were left with big questions about how it was actually going to be achieved. Where was the funding coming from? How was it going to be done in practice? Where is the investment to make it happen? In lieu of any commitment of funding for it, and with dental budgets continuing to be cut, how can the political world work with the profession to really push home these messages and look at what is really needed. Is the OHIP itself veneer, with lots of ‘nice to haves’ but ‘impossible to delivers’?

“Money matters and the nomenclature of this is really interesting. If you get government talking about a ‘plan’ or a ‘framework’ I always wince because I know there’s no money attached to it. If it’s a ‘strategy’ then there is usually money behind it. That’s where a lot of dismay from dentists came from because they felt this was virtue signalling; it is acknowledging the problems and hinting at solutions but not actually bankrolling those solutions.”

Perhaps one of the issues in getting funding for dentistry is the more overt mix between private, paid for NHS care and free NHS care in dentistry, which Alex had mentioned earlier. Do politicians, and the public, feel that dentistry doesn’t need money invested into it as they think it already has lots of funds coming in through this mix?

“This is a really interesting question because it speaks to a much broader debate about the public understanding of healthcare which is free at the point of delivery. The public believe, erroneously that when you go to your GP you’re seeing an NHS employee funded by the taxpayer and it’s all part of the big NHS offer. They don’t understand that most GPs are private contractors. There is a huge amount of privatisation within the NHS already, we just don’t see it, because we’re not actually asked to hand over a credit card at the end of the consultation. That’s the difference, because if you go to the dentist, even through the NHS, there will usually be something to pay and I think people see that as an aberration. That’s not fair on dentists because that’s the system as it’s been designed, so that puts them at an immediate disadvantage in terms of public perception because there is this cynicism that dentists are in it for the money. All that is very wrong, but it is difficult to explain it to people as they are handing over their credit cards.”

Our conversation moved on in more general terms to Alex’s own experiences as a patient and we started talking about how frequently we visit our GDPs. Of course, this raised the inevitable spectre of the controversial action in the OHIP to increase recall times; an action which has been recently been revoked. 

Or has it?

“The proposed changes to recall were myopic, they felt driven by financial sustainability rather than positive patient outcomes. That would have an impact on the morale of dentists in Scotland because first of all it suggests they’re not as valued. The idea that you only need to see your dentists every 18 months to two years suggests that it’s a lesser consideration, and it might also have the unintended effect of making people not take their oral health so seriously. Dentists want to do right by their patients, and they can’t do an adequate job if there are big tracts of time between seeing patients because relationships are important, you need to trust your dentist more than perhaps you do any other medical professional because, invariably, they are very intimate appointments, you are very vulnerable on their chairs. You need that atmosphere of trust and it is harder to sustain that if you have to keep asking your dentist’s first name again every time you see them. 

“For all those reasons I think it was a bad suggestion, but I don’t think it is one that has necessarily gone away because the pressures in public policy terms mean that money will always drive things, so we have to continue to defend the frequency of appointments.”

Are we looking at implementation by stealth therefore? With the OHIP’s Oral Health Risk Assessments (OHRA) still in the wings is it a case of the headline being ‘it’s ok, we’re not going to do that anymore’ but an individual’s OHRA suggesting it anyway?

“Absolutely. The government is constantly flying kites and testing things. This was an example of something that didn’t play well but obviously they wouldn’t have flown the kite, as the government doesn’t like putting messages out there which are unpopular, unless there is a real reason or argument for it. There will still be hawks who are saying we really need to tighten belts and this is a definite way to do it, so I think this will be an ever-present threat now it’s out there and the SNP have taken some damage for it. They don’t take damage for things they’re not going to pursue further down the line, so there is a definite potential risk of it being implemented by stealth.”

As we all know, the recall issue first gained real public traction because of its link to oral cancer, but what about the rest of the oral cancer agenda? Is that still in people’s minds, or has this headline-grabbing element pushed it off the table?

“It is a live issue and it is clear that we may have won the battle on recall but we may not have won the war. Again, this comes back to the lack of leadership in the profession and the lack of a critical friend at the top. We need a CDO to keep whispering in the ear of the Cabinet Secretary
to say, we are about more than just white teeth. We are part of the comprehensive health of our patients and Scotland’s citizens.”

Primary issues

Since this interview, the issue around leadership and profile of dentistry seems to have worsened, as it has become clear that the Cabinet Secretary has in fact removed dentistry from her portfolio and demoted it to Joe Fitzpatrick, Minister for Public Health, Sport and Wellbeing. This is something neither Alex nor I knew at the time, but I did ask him what he saw as the primary issues for dentistry. What were the big topics that with a permanent CDO in place should be raised with politicians across the board?

“It’s a broad range. Some of which we’ve covered. Workforce pressures, we have a diminishing pool and vacancies. Not just for dentists but for other dental professions such as dental nurses. This is largely because we’ve not been able to uplift the pay of dental nurses to match the changes in the living wage. There are always going to be financial issues. All of these pressures lead into pressures around dentists’ own mental health. I think we often forget that the people who are delivering care are struggling themselves in many ways. 

“Dentists, while they might be working in a busy city, might be isolated from peer support and might go most of your day without a meaningful conversation with another adult. That’s incredibly dispiriting. A huge range of issues and, at the moment, no one is really speaking to those at the highest levels of government.” 

Categories: Interview / Magazine

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