Scottish Dental Magazine asked Dr Brendan Murphy to give his views on the future of NHS dentistry in Scotland. This is what he had to say:
How do you see access for patients to NHS dentistry panning out?
Access is as poor as we have ever seen – 10 per cent of Associate jobs are unfilled and the remaining GDPs, due to the constraints of SOPs, are carrying out less than half of their pre-Covid treatment levels.
In the pandemic outbreak the Scottish Government struggled with the NHS dental contract, making some effort to understand the costs and mechanics of GDS provision until the Summer COVID juncture when GDPs were least likely to add to their commitment levels and working at an overall significantly reduced level of remuneration.
Children and those in high deprivation areas will probably suffer most of all when it comes to accessing a failing service. Going forward for geriatric and child patients represents an unfathomable task for our profession, which seems to have been put to the back of a long queue.
What issues face GDPs?
We just can’t operate at anywhere near the pre-COVID treatment volumes. It’s absolutely not an option in a dental practice. The economics, however, seem to have been lost somewhere within the corridors of Holyrood. In every other walk of life when we witness the reduction of supply on a cheapened product, the demand increases and therefore no one would surely play with the demand if service/product provision were at breaking point?
The early 15 per cent reduction of treatment values and significant rise in costs has cheapened NHS dentistry. I mean to say this as an economic fact. So, NHS dentistry was always going to be economically poleaxed under the temporary systems the Government has put in place, particularly with the predictions that they will have run from 2020 to 2022 with no real progress as yet on the interim model. There can be no logical economic argument against the reality of what’s going on.
The flip side is that the contralateral ‘private’ supply inevitably and markedly increased with a correlative rise in demand for that service- so many mixed and solely private GDPs had no choice but to increase their private fees at the earliest stages of the pandemic, to balance the 15 per cent NHS ‘tax’ on pre-COVID treatment values. This was paralleled by a 7.5 month NHS dental lockdown period prolonged by a government who were slow to react. Almost all general dentists consequently now do more private treatments. That’s unlikely to flip back.
What impact will free dentistry have?
It’s a nice idea but in terms of making a difference it will be minimal for the next couple of years. It’s likely that fewer people, not more, will access NHS dentistry – partly due to delays in the New Model of Care. Appointments are longer and waiting times up. For many, the dalliance with free NHS dentistry should be tempered with the realisation that the NHS dental service haemorrhages both patients and practitioners at an alarming rate.
For those few patients who currently stand to benefit, they should be considered in the context of the average pre-COVID NHS treatment costs – approximately £19 per adult per annum. So they’ve taken something that was almost free to the average Scottish adult and inadvertently made it more difficult to access through various measures.
What are the alternatives?
There are several practices already converting to monthly plans and the majority are carrying out significantly higher levels of private dental care than the pre-COVID 25 per cent national average. The main point to make is that it’s now often the patient’s choice.
From our perspective, dentistry has become considerably more expensive since COVID. That’s an issue that Government has not properly investigated since the Scotland Act in 1998. Yet they have chosen this period with fixed reduced NHS treatment fees to make Scotland the world’s only developed country to provide all adults with free dentistry. That seems strange, given the lack of evidence or consultation on its requirement.
To be fair, they have admitted that there was no consultation. The timing, given what our staff were going through, was convenient for the Government but poor for patients and dental staff in my opinion. When you consider the minimal access levels for those patients it might help, the summary message from the Government might have been: “It’s not about you (the profession) or the average Scottish patient, it’s about the election.”
How do you think it will tackle the problems you and your colleagues are facing?
They could start by opening up the conversations with GDPs, dealing with correspondence as promised and in earnest – i.e. immediately asking the profession about the expenses and freeing the shackles placed on the job market by COVID support. This means forcing PSD [Practitioner Services Division] to highlight exactly what basis upon which each line 7 COVID support figure is calculated and how it may be affected by an associate moving for example. We were told by the CDO and David Notman that they’d consult with the whole profession. This isn’t happening.
We have been stating unequivocally that NHS dentistry under the current contract is doomed. In all but name, the old SDR is in the bin. We won’t accept a return to those conditions. Some GDPs are fearful for what lies ahead – e.g. the occasionally mooted suggestion that they may be obliged to provide posterior composites within the confines of the NHS or hit high targets. These suggestions require us to remove ourselves from the realities of providing dental treatment under enhanced PPE, with fallow and increased administration which are here to stay according to ‘best practice’, whilst acknowledging the limits of a modern NHS and an ever increasing demand.
In summary, the Government needs to embrace the concept that NHS and private systems can run symbiotically, within each practice, to the betterment of the vast majority of patients.
Have there been discussions on a way forward?
Not with the “whole profession.” They haven’t answered emails sent months ago. I’m unsure as to whether they’re hoping we’ll fade away. That’s unlikely for the next generation. My son’s a third year dental student in Bristol. They’re more likely to go away permanently. I’d say my kids generation are more entitled, they wouldn’t put up with a lack of negotiation for 22 years.
Does that upset you and your colleagues?
It upsets our majority very much but these views are my own. We need young dental professionals to feel that the NHS is a good place to be. It’s the repeated but as yet undelivered promise of consultation with the “whole profession.” I wouldn’t want my colleagues to think we have given up, far from it, but it leaves you feeling you’re banging heads off walls. We ‘get’ the behemoth that’s the NHS, and the more critical areas within it such as cancer therapies and surgical wards, but engagement now is essential whilst there’s a chance of salvaging something reasonable.
What are the effects ‘on the ground’?
The vast majority of GDPs are seriously concerned by the semi-permanent nature of reduced treatment fees. Given how lowly they (GDPs) regarded the pre-COVID SDR payments it’s a significant blow and they will therefore be more inclined to repair than replace, contradicting any suggestions of ‘normal service.’ We are securing the short term prognosis but not always making a full restorative plan. These are based upon concerns regarding a system that’s long been broken.
To be clear, we are not turning our backs on patients but will inevitably reduce the vast majority of restorative works based upon a treatment value of circa £9 for a small filling, of which associates receive 45-50 per cent. Does the public think that the majority of dental professionals should be pressed into working for £4.50 in the age of fallow periods, lengthened appointments and enhanced PPE? If you put 10 such similar AGPs together – a full day’s work – you’ll get less than the average call-out fee for a plumber or joiner.
Our profession – most at risk from COVID and the next pandemic – has already said ‘no’ to the possibility of normal practitioner profiles, whilst the Government is no further forward on a New Model of Care.
And the biggest challenge, as a practice owner?
It’s not the practicality of clinical dentistry I’d say any more, it has to be the pressure of no diary white space for emergencies, but also the ball and chain created by COVID Support for associates. We are powerless to affect it going forward and often it’s completely unexplained to associates and practice owners. Whilst they now appear to fix the future financial penalties forced upon those dentists who may yet be ill or absent through injury, the Government has not fixed historical anomalies with the ‘test period.’
The assessment period is brutally punitive for those who were absent from work in the year before COVID. GDPs taking time off for pregnancy, injury, illness or mental health before COVID, are therefore still beholden to financially crippling Covid Support – on a semi-permanent basis because their assessment is founded upon that period of absence.
As if all of the above were not enough, this continues to force evermore GDPs away from NHS dentistry and by proxy, countless dental nurses, hygienists, therapists and dental technicians then follow. Naturally, there’s more pressure on those who remain. This is the most damning NHS dental legacy of the pandemic.
After 18 months there are people who’s COVID Support is still based on a time when they moved practice or were off through sickness, injury and/or mental health. It’s heartbreaking for those dentists affected.
You were involved in a proposal submitted to the Scottish Government for the New Model of Care.
What’s the thinking behind it?
The initial thinking was about the NHS commitment, as it’s been historically perceived and how dentistry has changed radically in our working lifetime. The existing system cannot work- it’s so difficult to mix NHS/private diaries and keep track of administration whilst operating efficiently to a busy diary.
A young dentist nowadays might be more likely to commit to doing three NHS days per week (in much the same way as most of my GP friends do) and freeing up a couple of private days. They would expect, however, to be remunerated similarly to GPs, particularly given the available rewards within the private sector, which so many more are enjoying right now- sufficient appointment lengths and nice labwork etc.
Furthermore, it’s wrong for the private sector to be stacking up the NHS deficiencies and staff deserve similar rewards to those working in hospitals and community.
The idea of forcing all dentists within a mixed practice to operate within the NHS – as seen within the threatened 2024 ventilation grant claw-backs – is a non-starter. The Government is taking the wrong line here by creating that division. Each dentist has earned the right to their own clinical freedom and each NHS patient and Scottish citizen/employee deserves the same fresh air, whether they’re NHS or private.
My response to that was to not apply for some practices and redouble my efforts to make our practices less reliant on those income streams, whilst ensuring all NHS patients are not disadvantaged in any way. So the proposal is about proper clinical freedom within NHS dentistry, mixing that with the ability to provide patients with the preferred aspects of modern dentistry.
Do you think that there’s still hope for a strong NHS dental service going forward?
Yes, but it’s been dealt two hammer blows following decades of neglect which predates the first Holyrood Government. Brexit and Covid have yielded poor returns on recruitment and consequently hindered maintenance and development of NHS treatment providers. It might not be the NHS dental services that the Scottish Government wants or hopes for. They’ll need to arrest the abnormal haemorrhage quickly and they’ve put themselves under tremendous pressure through a commitment to increase provision of a service when everything else pointed to a shrinkage of that service through the economic pressures discussed.
Any left of centre government will want to avoid the accusation of privatisation through the back door but there is a risk of that, through a shrinking core service – at least partially. It would be nice to think that we could go back to offering patients almost “all of the options, all of the risks” within the NHS but that might now be an unrealistic prospect as we are running out of time. It’s the one commodity we don’t have unfortunately, and GDPs will make decisions based on saving jobs and paying bills, whilst providing qualitative patient care.
The last 18 months have been a reminder of those priorities and the NHS versus private conversation must be number four on that list. If the government might act swiftly regarding proper consultation, a strong NHS dental service becomes more probable than remote.