This blog will provide an overview of NHS dentistry in Scotland. It will also highlight some of the long-standing challenges for NHS dentistry, many of which were exacerbated or made more obvious by the COVID-19 pandemic. It will also look at some aspects of the proposed reforms, which are currently being discussed and negotiated.
The last time detailed scrutiny was carried out on dentistry in the Scottish Parliament was in 2005, when the Health Committee commissioned research and held a short inquiry in February 2005. Dental practices are private businesses. Some dentists do not carry out NHS work.
SPICe has been receiving a high number of enquiries about people finding it hard to access an NHS dentist, so this blog looks as some of the factors that might be behind this. There has also been a high volume of parliamentary questions asked about access to NHS dentists and the challenges facing NHS dental services.
The COVID-19 Recovery Committee carried out out a short inquiry into NHS dental services in Scotland. Full dental services were among the last to return to normal because of the infection risks of the ‘aerosol generating procedures’ (AGPs) and the requirement to leave time gaps between patients. Many procedures involve AGPs (high speed drilling and water spray) and time is required to fully ventilate consulting and treatment rooms between patients (fallow periods).
This is a longer blog than normal. We’ve therefore added a contents popout below to make navigation easier.
This blog was updated on 22 June 2023, to add more information on the inequality gap for children when broken down by health board, as well as the extent of recovery in participation levels.
This blog was updated again on 23 August 2023 to include information about dentists’ earnings and expenses and an update on the revised fees and treatments that dentists providing NHS services can claim for. Reference to the short inquiry carried out by the COVID-19 Recovery Committee and a link to a letter to the Minister for Public Health and Women’s Health on issues raised have also been added.
How are dentists not like GPs?
All dentists, like doctors, have to be registered with the UK regulatory body – the General Dental Council – in order to practice in the UK, regardless of whether they are doing only private work, solely NHS work or a mix of the two. Most high street dentists do a mixture of NHS and private work.
Dentists have never been quite so embedded within the National Health Service, as say, GPs. One of the key differences is that dentists can carry out both NHS and private dentistry from the same practice. GPs can set up a private practice, but would have no contract with the health board. If a GP contracts their services to the local NHS board, they have to provide primary care services to the population in their local catchment area. This work would practically exclude any option of taking on private patients too.
There is no contractual requirement for a dentist to provide a basic level of service, whereas there is for a GP. A dentist is directly reimbursed for the treatments s/he provides to their NHS patients. These treatments are limited, and detailed in the Statement of Dental Remuneration, the SDR. For example, if a person is receiving NHS treatment only from their dentist, they couldn’t have implants fitted or any cosmetic dentistry carried out.
However…health boards do directly employ dentists to work as salaried dentists. Most of these will work within the Public Dental Service.
The legislative bits
Section 2C of the NHS (Scotland) Act 1978 places a duty on NHS boards to provide and secure provision of primary medical, or GP services for their populations. NHS Boards aren’t, on the other hand, required to provide a full dental service to their populations, but are required to keep a list of dentists providing NHS services available in their area. The go-to Regulations that apply to General Dental Services – high street dental practices – are the NHS (GDS) (Scotland) Regulations 2010. More information on general dental services can be found on NHS Scotland’s public-facing website, NHS Inform.
Section 25 of the 1978 Act merely requires boards to ‘make arrangements’ with dental practitioners and to publish a list of dentists who undertake ‘general dental services’ under those arrangements. However, health boards do provide emergency dental care through the Public Dental Service if someone is not registered with a high street dentist .
‘High Street’ dentists
The vast majority of the population are registered with a high street dentist who will offer NHS and private services and often a combination of the two. Since 2010, once a patient registers with a dental practice, they are registered for life, unless of course they move and register with a new dentist. It used to be that if someone didn’t make contact with the practice within 15 months, they would be removed from the list. Dentists get paid a ‘continuing care and capitation fee’ on a monthly basis for the patients on their list. This fee reduces to 20% if a patient isn’t seen within 3 years, so creating an incentive for dentists to remind patients to have a check up.
The Public Dental Service
Since 2014, there has also been a Public Dental Service (PDS), run by NHS boards. Dentists working for the PDS are salaried, employed by the NHS board and can provide general dental services, working in a similar way to high street dentists, but from NHS premises and only offering NHS services, no private ones. The PDS replaced the Community Dental Service in 2014.
The way the PDS operates across Scotland varies widely. It is far more prominent, and does register patients for routine care, where there is a shortage of high street dentists. NHS Western Isles and NHS Borders are two boards where the PDS provides a wider service, whereas in most other health boards the PDS provides emergency care for people who are not registered with a dentist, as well as providing services to people with higher access needs. NHS Fife provides information about their Public Dental Service on its website, which clearly explains the role of their PDS.
Health boards have told the COVID-19 Recovery Committee that their PDS has been under pressure over recent months as people find it hard to register or access care from a high street dentist. Some are looking to recruit additional staff to the service.
Independent dental practitioners – high street dentists – will sometimes make themselves available to cover out of hours shifts with the public dental service for emergencies. High street dentists will have arrangements for covering out of hours care, and those offering NHS services must have them in place.
Dentistry in secondary care
The NHS Hospital Dental Service (HDS) accepts patients on referral from medical and dental practitioners. Consultants in other areas and specialties, including emergency dental services, also make referrals.
Through the HDS, patients can be either treated in outpatient clinics or, if needed, admitted as inpatients or a day cases.
Inpatient and day case treatment is available at:
- Glasgow Dental Hospital
- Dundee Dental Hospital
- Edinburgh Dental Institute
- general hospitals.
There are no inpatient beds in the dental hospitals or the dental institute so all inpatient activity occurs in the general hospitals.
Dentists working in the Hospital dental service are salaried dentists, employed directly by health boards.
What about the finances?
Most people register with a high street dentist – a private contractor who may or may not offer NHS services. NHS patients pay 80% of the cost of their treatment, but the cost is capped at £384 for a course of treatment. Some people, including children, and those under 26, receive their treatment free.
The Scottish Government has pledged to make NHS treatment free for everyone before the end of this Parliament, which, based on receipts, would cost the government around £75 million a year. The budget for dentistry for 2023-4 is just over £476 million, which presumably covers the continuation of Childsmile, the preventative programme aimed at very young children. The overall budget for NHS health services for 2023-4 is £12.1 billion.
How are dentists paid?
Dentists providing General Dental Services submit itemised claims monthly to Practitioner Services, part of NHS National Services Scotland, for the work they have carried out. Dentists can also receive a range of other payments, allowances and grants, including capitation payments for the continuity of care they give to their registered patients.
Every year, NHS Digital, the part of NHS England that publishes NHS related data, publishes a report on the earnings and expenses of dentists who undertake a proportion of NHS dentistry within their practice (so the data excludes dentists who only register and treat private patients). NHS Digital provide data on all four UK nations. The most recent statistics were published on 27 July 2023.
Issues facing dentistry – what has emerged post-pandemic
General dental services were hard hit by the pandemic. Many dentistry procedures produce an aerosol spray (AGPs) which would spread any respiratory infections. Dentists were required to cease carrying out any of these procedures for a time. In addition, because a dental patient can’t wear a mask when undergoing treatment, dental surgeries had to have a ‘fallow’ period between each patient to allow for air changes. The length of time for these gaps depended on the quality of ventilation. Some surgeries would have no mechanical ventilation, and only windows whereas others might have sophisticated equipment allowing for faster throughput of patients.
On top of this, a whole cohort of trainee dentists were unable to qualify because they could not fulfil the practical aspects of their training during the pandemic. Fewer dentists are coming from abroad to work in the UK too. According to the NHS Scotland dental workforce report 2021, there were also reduced intake targets to BDS courses in 2021 and 2022, meaning that six years on, there will be fewer dentists entering the profession.
As in all settings, government advice was frequently updated over the two years, and final restrictions, including mask wearing when not in the dentist’s chair, were some of the last to be lifted from healthcare settings. Scottish Dental is the web portal for information about dentistry, and a COVID-19 hub provided all the official guidance and other information for dentists throughout the pandemic.
Funding was provided through health boards for high street dentists to improve ventilation or to buy variable speed drills. However, there was a condition imposed that contractors applying for funding for ventilation had to continue to provide NHS dental services till 1 April 2024.
Dentists were also compensated for the reduction in work they were able to carry out in the form of emergency support payments, sustainability payments and, later, from April 2022, a top-up payment regime whereby they were paid a multiplier of their regular fees for the work they carried out. Calculations were based on their activity and income levels prior to the pandemic.
The pandemic, and the resultant complex payment and support arrangements for high street dentists, has exposed long-standing calls from the profession for reform. Dentists argue that they cannot afford to continue to participate in NHS dentistry because the sums paid for the work they do not cover the costs and fees associated with carrying out that work. The British Dental Association, the body that represents dentists working across the UK, presented the case for reform and improved remuneration to the Review Body on Doctors’ and Dentists’ Remuneration for 2023-24.
From the point of view of people needing to be seen by a dentist or wishing to register for NHS dental services, problems of access, waiting lists to register and to be seen, have been increasing over recent months.
NHS Scotland workforce projections up to 2030 highlight the following:
Dental Workforce in Scotland Report 2021, NHS Scotland
- “Based on the current number of registered patients per dentist, the forecast increase in the demand for dental services is forecast to increase the demand for dentists.
- Based on a series of estimates and assumptions, the supply of dentists is forecast to fall short of the number of dentists required to maintain current registration rates.
- There is considerable uncertainty over the inflows from other, typically non-UK, sources that have an immediate impact on the number of dentists in Scotland.”
Participation and access
The availability of NHS dentists inevitably has an impact on access to dentistry. There has been anecdotal evidence of dentists ceasing to carry out NHS work, deregistering patients and switching to private only practice. The COVID-19 Recovery Committee surveyed all the geographical health boards and asked how many high street dentists had ceased to offer general dental services to patients. Results are shown in the table below. Percentages show the proportion of total provision withdrawn or reduced.
NHS Board | No. and % of practices withdrawing from GDS | No. of practices reducing GDS (eg children only registration) |
4 (13%) | 3 withdrawing from adult provision to children only | |
0 (only 1 independent practice, which is struggling to recruit) | ||
Lanarkshire | 0 | 3 withdrawing from adult provision to children only. |
3 (5%) | 28 (47%) reduced registrations | |
0(only 1 independent practice, struggling) | ||
5 (8%) | 5 (8%) | |
Information not available – board aware of 1 practice withdrawing completely | 39 dentists in 14 practices applied to deregister patients in bulk. | |
0 (4 independent practices in total) | 1 – children only 3 reduced workforce | |
4 known to have withdrawn (% not provided) | 1 confirmed now seeing children only. Some practices deregistering patients | |
0 | 18 (100%) have reduced NHS dental care | |
0 | 21 (23%) practices have reduced NHS dental care | |
0 | 2 practices closed 2(soon to be 3) practices – children only (4% of total of 72 practices) | |
0 | 1 practice deregistered 4000 adult patients. Others have withdrawn some provision | |
1 (2%) | 3 practices reduced provision (5%) 6 only registering children under 18. 9 only registering children but treating adults and children (23%) |
Nearly all of the health boards cite that recruitment and retention of staff – both dentists and other dental professionals – has had an impact on the ability to deliver NHS dental services, both in the Public Dental Service (NHS salaried dentists) and in independent high street practices. Many are not working at their pre-COVID activity levels.
The chart below shows the proportion of registered patients who attended their NHS dentist over a number of years. The area in grey covers the two years when COVID-19 restrictions were in place. The decline in activity is unsurprising because of the restrictions. Up to September 2022 (the most recent data) participation was recovering. However, given the information received from health boards about reductions in provision and recruitment and retention issues, it will be interesting to see whether participation levels continue to rise steeply or suffer as a consequence.
Source: PHS Dental statistics – registration and participation 24 January 2023
Participation by adults went from a high of 68% in March 2018 to a low of 41% in March 2022, recovering to 47% by September. Participation by children was better, going from 53% in March 2022 to 66% in September 2022. Participation by children was 85% in September 2018.
Inequalities
Access to health services is linked to inequality. Researchers based at the University of Glasgow sought to quantify the impact of COVID-19 pandemic on access and inequalities in primary care dental services in Scotland using data from 2019 to 2022. They found that while inequality was exacerbated during the pandemic, it existed before, with a higher proportion of adults and children from the less deprived areas having contact with a dentist than those in the most deprived.
The chart below shows only inequality in relation to children, where the inequality gap grew during the pandemic, and persists. Children’s participation dropped more in the most deprived areas than in the least deprived. In March 2022, participation was 44% in the most deprived and 63% in the least deprived. The gap was 9% in March 2018, and rose to 19% in 2022. By September 2022 it had widened further to 20%.
The charts below show some variation in the inequality gap for children when broken down by health board, as well as the extent of recovery in participation levels. Recovery in participation appears to have been slower in the island boards. However, because of the smaller populations a smaller number of dentists, and possibly additional challenges created by the remote geography, any change will have a more immediately noticeable impact.
The chart below shows participation (attendance and treatment) levels for children, and the deprivation gap in percentages, before and after the pandemic, broken down by health board area of residence.
Children’s oral health inequality before and after the pandemic
Participation describes the proportion of registered children attending NHS Dental Services within last two years.
Deprivation gap describes the percentage point differences in participation (within each health board) between children in 20% most and least deprived areas of Scotland.
Note that the island health boards don’t have any areas that are within the 20% most deprived in Scotland.
Health board | Participation, March 2020 | Deprivation gap, March 2020 | Participation, September 2022 | Deprivation gap, September 2022 |
Ayrshire and Arran | 85% | 10% | 62% | 19% |
Borders | 91% | 6% | 77% | 12% |
Dumfries and Galloway | 84% | 15% | 58% | 19% |
Fife | 86% | 7% | 66% | 18% |
Forth Valley | 87% | 10% | 67% | 18% |
Grampian | 85% | 9% | 70% | 20% |
Greater Glasgow and Clyde | 82% | 11% | 64% | 21% |
Highland | 84% | 7% | 67% | 13% |
Lanarkshire | 85% | 11% | 63% | 18% |
Lothian | 86% | 8% | 70% | 21% |
Tayside | 87% | 11% | 71% | 18% |
Orkney | 87% | – | 57% | – |
Shetland | 85% | – | 55% | – |
Western Isles | 81% | – | 42% | – |
Scotland | 84% | 10% | 66% | 20% |
Source: Public Health Scotland Dental statistics – registration and participation – January 2023
Workforce – the number of dentists offering General Dental Services/NHS dentistry
Recruitment and retention issues in dentistry are not unique to Scotland, and in January 2023 a scoping review was carried out because these had been highlighted as a concern, particularly in rural and coastal areas of England, and a contributory factor in recovery of dental services. A scoping review addresses wider questions than a systematic review, and entails looking at a wide range of evidence including websites, rather than conducting any empirical research.
The review came up with five factors affecting recruitment and retention:
Recruitment and retention in dentistry in the UK, scoping review,2023
- The contract – the way that dentists are remunerated for providing dental services.
- Limited opportunity for career progression with NHS dentistry.
- Increasing costs and indemnity undermining and reducing income.
- Brexit and the pandemic making it difficult for overseas applicants to register to work in the UK.
- Specific geographical challenges in rural areas including transport links, lack of training opportunities and lack of family/personal connections.
The review also commented on anticipated challenges to the future workforce and some potential strategies. The reviewers concluded:
“Within the literature, the perilous state of NHS dentistry is widely acknowledged; although there appears to have been little progress in addressing the underlying issues. Further delays will undoubtedly impact on patient care, leading to a deterioration in oral health and unnecessary suffering for many. This will predominantly affect the most vulnerable in society, resulting in greater oral health inequality.
Our review also found that the situation appears to be particularly acute within R(ural)&C(oastal) areas, but data needs to be collected and analysed to provide a better understanding. Well-informed, evidence-based decisions are essential in mapping out the future of dentistry in the UK, but this must not delay immediate action at a local, regional and national level.”
The table below shows how an overall increase of registered dentists since 2010 has dropped off since the pandemic. There were 3,396 registered NHS dentists in March 2010. The number grew to a high of 3,735 in September 2019. In the three years September 2019 – September 2022, the number has dropped back to 3,438, the lowest number since 2011.
There will be a number of reasons for this drop, which will hopefully be discussed during the COVID-19 Recovery Committee’s inquiry. It could be that dentists have retired or gone abroad, or switched to private work only. We looked to see whether the decrease in NHS dentists translated into an increase in private dentists, by looking at dentists registered overall. Any dentist (and other dental care professionals) working in the UK has to register with the UK regulator, the General Dental Council. However, it is not safe to assume that the gap between NHS dentists and the total number registered equates to dentists moving to private practice. Some dentists who have retired remain registered and they/others might be working occasional shifts for practices or the public dental service in out of hours work for example. The General Dental Council publishes its own registration statistical report, and data is broken down by UK nation in monthly reports.
From the survey of health boards, the exit from NHS work has not yet been dramatic, except in areas where there are very few practices. Recruitment and retention issues appear to be the most pressing suggesting it is the supply of dentists, whether from training or abroad that is creating the current pressure in the system. However, as the review notes, and as is reported in other health settings, such pressure has an impact on morale and the willingness to continue working within the NHS.
What the Scottish Government is saying about the number of dentists
The Scottish Government said in Dental services for all, published in March 2022:
“We’re delivering record investment in dentistry – with a 9% increase in the budget for NHS dental services in 2022-23 – and there has been a 39% increase in the number of high-street dentists in Scotland between 2007 and 2021. Last year there were 55.6 dentists per 100,000 of the population providing NHS care in Scotland compared to 39.9 in England.”
However, as noted above, the Dental Workforce in Scotland report, 2021, published by NHS Scotland concludes:
The projected changes in the size and composition of the population are forecast to increase the demand for dental services during the forecast period. (up to 2030)
Based on a series of estimates and assumptions, the supply of dentists is forecast to fall short of the number of dentists required to maintain current registration rates.
Over recent weeks and months there have been a high number of questions asked in the chamber about dentistry and dental services.
What the Scottish Government is saying more generally
The COVID-19 Recovery Committee also wrote to the Scottish Government with a series of questions about recovery of dental services. The Government’s response was received on 25 May 2023, before further questions were asked in the Chamber.
The letter describes the support that was offered to support independent contractors throughout the pandemic and the particular challenges faced. It acknowledges and outlines the reform that is underway, and also that because of the way dentists are paid – for items of activity, any change, such as a demand for more comprehensive examinations or preventative advice, takes more time, impacting the amount of work that dentists can do and invoice for.
It states in the letter that:
“We have set out a programme of payment reform and consulted widely with the sector, building on the Oral Health Improvement Plan from 2018, to co-design a modernised system of payment that empowers dentists and support teams to provide sustainable clinical care. This new system is more transparent for patients and provides a financial package that ensures future sectoral buy-in and the long-term viability of NHS dentistry. The Scottish policy response has been configured to take account of dialogue and observed impact on public sector dental provision in other jurisdictions, notably England, Wales and Northern Ireland.”
It also adds that the problems for dentistry are similar to those faced by ‘many sectors of the broader economy’.
In an answer to a PQ, the government has said that payment reform will be implemented by 1 November 2023. Discussions with the British Dental Association began on 10 May 2023.
On 27 July 2023 the Scottish Government Minister for Public Health and Women’s Health, Jenni Minto, wrote to the sector about changes to the fees that dentists are paid, part of the promised reforms. Scottish Dental has links to the letter and to the detail of the changes.
Short inquiry by the COVID-19 Recovery Committee – Recovery of NHS Dental Services
In June 2023 the Committee carried out the inquiry across three committee meetings. It also sent out a survey to dentists who provide NHS services to understand their views.
The inquiry tracked progress on the aims set out in the NHS Recovery Plan 2021-2026. This included a commitment to return NHS dental services to pre-pandemic levels.
The inquiry tracked progress on this commitment, with a focus on the following issues—
- Whether funding has improved ventilation and other equipment;
- Whether NHS dentistry services have recovered to pre-pandemic levels; and
- How access to services is being targeted in communities that experience health inequalities.
The Committee then wrote to the Minister for Public Health and Women’s Health on 5 July 2023.
Because the Committee was then wound up, the response will be sent to the Health, Social Care and Sport Committee, and this Committee will decide whether they wish to carry out further scrutiny of NHS dental services.
Anne Jepson
SPICe Research