The future of NHS dentistry
With oral health inequalities likely to be exacerbated by the pandemic, Scotland’s CDO has posed the question: ‘What does it mean to be an NHS committed practice?’
“In this pandemic, we’ve all been faced with the stark consequences of health inequalities,” said Professor Cynthia Pine, Professor of Dental Public Health at the Institute of Dentistry, Queen Mary University of London. “The imperative going forward is how do we reduce health inequalities?” Professor Pine was speaking last month at ‘The Summit’, an online event organised by the Scottish Dental Association to discuss the future of NHS dentistry which attracted more than 350 participants.
Speakers included Tom Ferris, Scotland’s Chief Dental Officer (CDO) and Professor Phil Taylor (PDF), Dean of Dental Surgery at the Royal College of Surgeons in Edinburgh. Presentations were also delivered by Dr Brendan Murphy (PowerPoint), principal dentist at Appletree Dental Care in Glasgow, and Cameron McLarty (PowerPoint), principal dentist at Bute Dental Care in Rothesay.
Professor Pine reviewed the evidence on tooth decay among children in Primary 1 (aged four to five). In 2008, only 42 per cent of children from the poorest communities in the first year of school had no obvious tooth decay, compared with 73 per cent of the same age children from the most affluent homes. Ten years later, after the introduction of the Childsmile programme, each percentage had improved, to 56 per cent and 86 per cent, respectively. “The programme has resulted in a considerable benefit to both groups,” said Professor Pine. “But the most worrying thing about this is that the difference in caries prevalence between the most and least deprived communities in 2018 is virtually the same.”
The professor also highlighted the lack of engagement of children from deprived areas with the NHS dental healthcare system, despite lifetime registration. One in five children from the most deprived areas has not been seen by a dentist for at least two years (compared with one in 10 of children from the least deprived areas). “The concept of lifetime registration has many advantages,” she said. “However, I don’t think we can take it as equivalent to lifetime registration with a doctor. As we know, medical attendance is largely symptom-led; that is the opposite of what we would want from dentistry. A publicly funded healthcare system should have a focus on addressing these inequalities in health and in healthcare uptake.”
At the other end of the age spectrum, said Professor Pine, as adults are retaining an increasing proportion of their own teeth, they will need “considerable maintenance and complex care”. Overall, she said, the care of young and old will require a workforce comprising a mix of skills; more dental nurses and therapists dealing with simple procedures and a clear requirement for dentists to focus on complex care for older adults.
Professor Pine also raised the issue of recall intervals. Are those attending every six months, who do not necessarily need to, reducing capacity for those in greater need who are not attending? In the most deprived areas, 38 per cent of adults have not attended a dentist for at least two years (compared with 27 per cent in more affluent areas). “What should a publicly funded system provide for patients? How do we put patients at the heart of what we’re doing?” asked Professor Pine, adding: “There’s a gap between registration and participation. If we’re going to improve health, we need engagement.” Figures from 2018 show that 5.1m people in Scotland are registered at a dentist, but 1.5m have not been seen in the last two years. “This is pre-COVID,” she said. “So, by definition, that can only have got worse.”
Professor Pine said that in addressing the issue of the Statement of Dental Remuneration (SDR) it should be asked whether participation should be incentivised specifically to reduce oral health inequalities. Even before COVID, she said, the Oral Health Improvement Plan proposed a system that supports preventative care and that an oral health risk assessment should form the basis of more structured recalls and a simplification of payments.
Acknowledging Professor Pine’s reference to the Oral Health Improvement Plan, Tom Ferris, the CDO, commented: “That document could almost be of the 1970s, it just seems such another era – that pre-COVID era feels so long, long ago. It’s another world, another planet. So, I think we need to be mindful that while there are lots of good things in it – things have moved on.”
The CDO said the consultation process had shown that the public was not clear what exactly is meant by NHS dentistry. The description provided by dental teams might vary from practice to practice. “I think if they understood the system that they were in, perhaps they would engage with it more, and they would seek care more regularly,” he said.
He highlighted two of the plan’s recommendations; that there should be a new contract, a ‘new model of care’, and that the issue of governance should be addressed. The new model of care proposed comprised four main elements: an oral health risk assessment (OHRA), a prevention and periodontal care pathway, an NHS treatment ‘toolbox’, and a new system of remuneration. “In terms of governance, we felt that the Scottish Dental Practice Board was a bit anachronistic, that there were also various agencies involved in governance and that it all needed to be streamlined,” he said.
Pre-pandemic, that streamlining process had begun, as had the development of the OHRA and discussions on the care pathway. But that work stopped with the pandemic. “Roll forward a year, and where are we? I don’t want to make this a post-mortem on the past year; it should be a recognition of where we are now and where we want to go. There are clearly now issues beyond what we were addressing; some very immediate, that we need to resolve,” he said. Ventilation was a key issue and addressing the reduction in patient throughput.
Other issues included the currently reduced NHS income, as well as unregistered patients and the lack of incentive for practices to take them on. “We also need to find a more sustainable interim financial support process for practices and dentists,” he said. “While we stood up support measures almost overnight a year ago, I did not think that in a year’s time I would be here talking about financial support measures.” The CDO cited the issue of maternity pay (subsequently addressed in an update last month) and of people joining a practice or moving to a new one, where financial support is an issue.
“In terms of the systemic concerns that the pandemic has thrown at us, I think we need to be quite clear now going forward,” said the CDO. “What are our expectations of an NHS committed dentist? What is an NHS committed practice? I don’t think it’s about having 500 registered patients of whom so many actually pay an NHS charge; I don’t think that’s a measure of commitment at all.
“We need to have a dialogue about what that means. Are you a small business, and it’s about profitability, or are you an ‘anchor institution’ within your local community? You’re there with the GP, with the pharmacist as a core part of the healthcare delivery system for the local population? I think, ideally, it is a bit of both. We need to have that conversation.
“We need to have clarity over the role of the private sector. Our experience over the pandemic is that there hasn’t been a particularly smooth relationship between NHS and private dentistry. I am not anti-private sector at all, but I think need to be clear about where they’re positioned within our community. The patient charge is something that we have to have a conversation about, especially if we move to a more preventive based system. If we can’t get rid of the patient charge altogether, will the public value prevention enough to pay for it? That’s a question we need to speak to the public about. And, unless you are exempt, the burden of the patient charge falls most on those with the least disposable income.”
The public, he said, had made clear to him and Ministers their feelings about what they perceived as a two-tier system, exacerbated by confusion over the governance of entirely private, of entirely NHS, and of mixed practices. That issue should have been addressed when Health Improvement Scotland took over governance of entirely private practices, he said, but “we are where we are; it is something we are going to have to address”.
The CDO indicated that he would prefer to move to an arrangement where instead of more than 3,000 bespoke contracts with individual dentists, there were instead around 1,100 practice-level contracts. “However, the behaviour of a very small number of practices towards their associates, their assistants, and their team, gives me pause for thought. But it is a conversation we need to have.”
Other issues to be addressed, he said, were the influence of corporates and the need for the Government to retain a direct link to dentists, the increasing role of technology, the need to have more intermediate, specialised, services available on the high street and, as mentioned by Professor Pine, a better skills mix.
“So, what I would say is that there needs to be a longer-term discussion about the future dental contract in Scotland and that there are five key principles we need to be clear about; that contract must be preventative, there must be a new model of care delivery, it must be accountable to both the patient and the NHS – with clarity over private dentistry’s place – and it needs to be deliverable.
“It needs to be simple, easy to understand both for the profession and the public, so that we can make clear the NHS offer to the patient. It needs to be coordinated between primary, intermediate and secondary level care. And it needs to be sustainable, both for practices to ensure their long-term survival and for the Government to ensure that it is affordable.”