A numbers game
John Swinney recently announced the decision to change the health board structure in Scotland: reducing 14 regional health boards to just two. The Government’s reason for this is to save money and, so they say, improve healthcare options and outcomes.
Unfortunately, based on multiple experiences of its ruthless efficiency, I believe this will be ill-conceived, unconvincing and very expensive. The wish list of joined-up ‘Once for Scotland’ decision-making is unlikely to be more than a procession of meetings, disagreements with unions and a rebrand. The Government has confirmed there will be no compulsory redundancies. Therefore, there will be a massive cost for voluntary redundancy or early retirement packages and index-linked pension payments. All the while, the actual processes and improvements in service would need to be created, tested and introduced with fewer staff.
I have, for many years, suggested that a reduction of health boards makes a lot of sense. Each board must duplicate many features, from payroll and human resources (HR) to statutory committees which produce solutions but do so in small pockets, rather than with national consistency. Each process contributes to a mire of workflow, policy and roll-out in small geographic areas with small populations.
I believe there should be three boards: East, West and Highlands and Islands. The East and West boards would be largely similar; incorporating the needs of a tightly-packed population in the central belt with more rural services extending to their northern or southern extents. The requirements of the Highlands and Islands, with their sparse population, large geographic distribution and associated challenges, is already well understood by the existing boards. That existing knowledge and inter-board communication should create an easy redistribution, relocation and rationalisation of resource.
There is an argument to remove elements from each board which can be dealt with nationally. For example, payroll and HR, with small geographic centres as required for face-to-face interactions. Dentistry is currently largely run and supported by national structures for most of its functions, such as management teams in health board areas. They have Directors of Dentistry and Dental Practice Advisers. Nationally coordinated, small, localised teams for these functions would seem reasonable. A decision about their scale would likely be a geographical consideration based around the number of practices or Public Dental Service locations each group would support.
The 2026-2031 plan has only one mention of dentistry, relating to a proposed re-evaluation of the ‘Golden Hello’ system in place for medics and dentists working in rural areas. No mention of our shameful caries rates, paediatric general anaesthesia waiting times, or methods to improve the oral health of our nation. There is scant mention of preventative advice or behaviour change to reduce the healthcare burden in Scotland and no mention of a mechanism to improve oral health, increase staffing or provision of dental care. I am certain there are other documents available which point to these things, but when there are repeated mentions of projects or proposals which affect very small portions of our society, it would seem remiss not to mention dentistry or oral health.
Perhaps there is a view that dentistry is in hand. Unfortunately, I would disagree. After three decades in practice, I find the work today harder and more voluminous than before. Some of that relates to the increase in the aesthetic desires of patients. However, the vast amount of work relates to greater numbers of teeth present requiring more maintenance. My single biggest complaint is that people simply do not understand the influence diet has on their bodies and lives. I firmly believe a good diet can make up
for poorer brushing.
Where am I going with all this? Reduced numbers of boards should allow, in dentistry, for more consistent and evidence-based approaches to be more easily coordinated and developed to affect change across Scotland. We do not have that big a country or population to require 14 times the organisational structures. A nationally-organised guidance and delivery system already exists in Practitioner Services via the CDO’s office. It should lead to a bit less admin and greater consistency. That might help care be delivered a little better using fewer admin staff. Perhaps that small change can result in increased funding and staff, thereby improving clinical outcomes? It will not make a big difference. It will not save millions, let alone the billions required to fill the deficit. Certainly not quickly. That is not the reason I suggest fewer boards. I would be happy to see some of the fat trimmed but it is mainly about a consistent approach and message being delivered more easily.
If there are savings, I would love to see a national programme to educate and motivate our population to understand what good diet and exercise looks like and the lifelong benefits it can deliver. Reduced interaction and need of healthcare, medications, joints replacements, sick days, benefits claims and simply a healthier, happier life. I am tripping over social media sludge telling me of apps and supplements, treatments and tests which will improve my life expectancy. It is non-evidenced nonsense designed to monetise and prey on our insecurities. Simple, early education of our children has proven to work, through Childsmile, and seen some improvements in brushing and associated oral disease. This mechanism needs funded and rolled out to improve our diets and exercise. That would be a simpler, more effective use of the funding and staffing, creating whole body benefit – not just our oral health.
Arthur Dent is a practising NHS dentist in Scotland. Have a comment or question for Arthur? Leave a note below in the comments section, or email arthurdent@sdmag.co.uk