Time to come clean

The Government must create a reasonable debate about what treatments they will allow on the NHS

16 August, 2021 / insider

COVID-19 has meant that I’ve been restricted in my thoughts and planning. Let’s explore the future with hope and expectation. The SNP have, once again, politicised the dental landscape by promising free dental care. The profession is concerned by budget and what can be achieved in the current framework. However, I believe we must cast our eyes to the horizon, not be controlled by thinking which holds us back from wider change and restricts our view to what is possible within the current, government lead system. If we have a wish list, what would it include? What can we do better? How do we achieve a system which allows interaction between private and government funded options? How do we excite our workforce, enhance the scope of DCPs to improve our skills mix and provide the best quality care for our patients? How do we shift the focus towards effective prevention? How do I discuss this in 1000 words!

Perhaps we can look at things from a different angle?

Rather than rebuild a model, how about we look at the effect of what is on offer? Dentistry in Scotland is a system built on balance between NHS and private care which ebbs and flows (very little) based on the budget available through the NHS and that provided by patients privately. By altering variables like the items on the SDR, what gets approved, what patients want and what they can afford (financial wherewithal, global crashes, paying for global pandemics, tax hikes etc.) the profession will flex and alter to suit. There are specialist practices only performing privately and PDS and secondary referral services that only do NHS care (sometimes for free). As most practices in Scotland offer a mix of care, the balance is simple, flexible and is unlikely to require large changes in workforce. This balance works at the moment and, I would suggest, the pot of private cash is fairly static, except for the above-mentioned tensions.

The detail and proportion of the NHS/private split will usually be based on the socio-economic reality of their location, as well as local competition (city vs rural economies). If we skew the variables by offering free NHS care, how will that skew the NHS/Private split? It depends on what’s available on the ‘free menu’. If said menu is greatly reduced, then practices will end up doing more private work based on patient demand. As suggested above, if that pot of private cash is broadly static, then many more practitioners will be competing for the private pound. This will drive prices down, reduce earning and values of practices, reduce inwards and external investment in the sector and create a downwards spiral. Is this the intention of the SG/SNP? I think they haven’t any idea how that may work. Do they care?

Furthermore, specialist referral services (NHS and private) are based on the current menu. If this alters dramatically, these services will have to adapt and quickly. If it’s reduced, do we reduce specialist care accordingly, or does this service then have to mop up all that can’t be done in practice or people are unable or unwilling to pay for privately? Does this create a larger need for secondary referral services in both the NHS and private sector or does one shrink and the other grow?  How do these services interact? Does it happen organically – that will take time to balance out – or do we make a guess at what’s needed and shift resources accordingly?  Surely a large gamble for private services. If the menu expands to include, say implants, then do specialist services have to compete with free GDS performers?

So, if the menu is critical to the balance of the workforce and its viability, who gets to decide it? Currently, dentists are talking about core services, budget and what’s achievable. However, I feel there should be an open debate in public about what patients want. Then it’s up to the Scottish Government to decide what it can pay for. At that point, the SDPC can start bartering about treatment values and that will define the menu. Can I make a plea that the menu ends up broadly as it is? Large shifts will destabilise the profession and its ability to deliver care at a time when there is massive demand following COVID-19 restrictions and the coming introduction of free dentistry.

One of the biggest concerns for the Government, it says, is health inequality. If they wish to remove barriers to care by removing fees, then they cannot restrict the types of treatments available too much. If the SG can only afford a ‘core service’ this will enhance inequality. The counter is, if you want to offer all possible treatments to everyone, for free, is there a budget to support this?  As suggested above, skewing the balance in either direction has significant risk of destabilising the economics and service provision system in Scottish dentistry.

Once we have a decision on what the NHS will provide for free and the budget we have to work with, the profession can make reasonable suggestions on delivery of service. We are in the business of providing care under whatever framework happens to be in place.  If there is no definition of menu or budget in advance, how can we hope to construct a framework to suit?  You don’t open a restaurant, buy thousands of ingredients, employ hundreds of cooks and then just cook dishes regardless.  We must decide ‘what’s on the menu’. 

The Government must come clean about its agenda. They must create a reasonable debate about what treatments they will allow on the NHS. They must give a credible budget and services can be designed to suit. The profession should stop worrying about how things can be delivered and demand to know what we will be asked to deliver.

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