Coronavirus: Dentists' anger amid 'ludicrous' funding row - and warning NHS model 'is finished'

"Everyone is tearing their hair out over what appears to be rules and regulations just made up on the spur of the moment," one dentist told the HoS.

A quarter of dental practices across Scotland have yet to re-open and there are fears - particularly for mixed NHS-private practices - that some will never recover financially.

And despite bulging waiting lists, strict infection control and social distancing measures mean that the number of patients who can be treated each day is - and will continue to be - severely reduced.

"We are just a profession in crisis, and collectively our concern is that dental health in Scotland will relapse several decades," said another dentist, based in Glasgow.

There are several strands to the profession's disquiet, but one of the most complex is around funding.

After dental practices were ordered to close in March, the Scottish Government said those providing NHS care would be compensated through a system of monthly support packages.

Private-only practices, of which there are around 30 in Scotland, would receive nothing, while NHS and mixed practices (the latter make up the majority, totalling around 980 practices) would receive payments equivalent to 80% of their average monthly NHS income.

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To explain: under normal circumstances patients receiving NHS care, who are eligible to pay, cover 80% of the cost of their treatment up to a maximum of £384 while taxpayers foot the remainder.

In the case of under-18s, students, pregnant women, new mothers or those on a low income, the Government reimburses practices for 100% of the cost.

The vast majority of dental practices in Scotland offer a mix of NHS and private work.

These mixed practices might generate 50% of their income from private treatment fees and 50% from NHS patients.

As a result they would only be reimbursed through the support payments for 80% of half their income.

Now these support payments face being whittled down further after the Scottish Government told dentists to submit claims for treatments carried out in January, February and March, but not completed before Covid struck.

This might include, for example, a patient requiring 10 fillings but who only got seven prior to lockdown.

The sting in the tail was that dentists were told these "work-in-progress" sums would then be deducted from their monthly support payments.

David McColl, a dentist in Glasgow's Govanhill and chair of the Scottish Dental Practice Committee, said the "ludicrous" policy could cost his practice alone around £30,000.

"They can't seem to see why that's unfair," he said. 

"They're saying is they're a 'top up' payment.

"They can't seem to get their head round the fact that all this work was done pre-Covid - it's nothing to do with the Covid support payment.

"We can only generate income within practice by doing work. By lifting drills and doing work.

"So if you want NHS dental practices to be there are the end of it, you have to support the practices and their staff."

The situation means that it is practices with the least amount of NHS income normally which are most at risk: the solely private practices, or mixed practices in more affluent middle-class areas which generate a sunstantial portion of their income from private clients. 

There are growing fears in the profession for the sustainability of some as furlough (which was limited in mixed practices) ends and staff costs - the single biggest expense for any practice - increase at a time when income is a fraction of the norm.

Dental practices which have re-opened are allowed to see a maximum of 10 patients a day and - in the NHS - only for basic procedures such as tooth extractions, dressings, and X-rays, which are currently free.

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Patients requiring aerosol-generating procedures (AGPs) such as fillings, root canal, and scaling can be referred to one of Scotland's 71 urgent dental care centres.

The Scottish Government say more than 41,000 patients with acute dental problems have been treated at these hubs between March 23 to June 30.

But dentists say access, capacity and which treatments are actually available varies markedly by area.

Mr McColl said: "One of my dentists is currently based at one of these hubs on one day per week, but they're still not doing AGPs.

"It's a complete waste of time her being down there.

"She's got one patient booked in this morning [Thursday].

"These urgent dental care centres are not being managed properly."

If and when AGPs can resume in NHS dental practices, patient turnover will be curtailed by Covid-related control measures.

Dentists performing AGPs will be required to wait an hour from the time they put the drill down before deep-cleaning of the room can even take place.

Requirements for cumbersome PPE and caps on how many people can share a waiting room at once add an extra barrier.

"You're looking at possibly seeing two patients in the morning and two in the afternoon, per dentist," said Mr McColl, who owns three dental practices.

"Across my three surgeries, we'd normally be seeing 90-100 patients a day in total."

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A major bone of contention in recent weeks has been the split in what is available to NHS versus private patients - and angst over where that leaves mixed practitioners.

The Scottish Government has no power to ban private-only dental practices from performing AGPs, resulting in what some have condemned as "two-tier" dental care.

Dr Mohammad Samad, chair of the Scottish Dental Practice Owners group which represents more than 700 NHS surgeries, said this had confused the public and left the profession in "state of disarray".

“There is no evidence to support this as many countries worldwide have been completing AGPs during the outbreak with no spread of Covid-19 in the public or the profession,” said Dr Samad.

The Scottish Dental Clinical Effectiveness Programme (SDCEP), which advises the profession, are in the process of reviewing the evidence.

Mr McColl said he would "rather know exactly where we are with the evidence before we proceed", but not all of his colleagues agree.

"A routine dental exam alone, requires the use of air to dry teeth," said one Glasgow dentist, speaking to HoS anonymously.

"Without the ability to dry teeth and tissues, we cannot reliably diagnose decay or problems.

"We can also not reappoint patients for treatment such as fillings, root canal treatment, crowns, bridges, veneers.

"This will give rise to concern, as patients may learn they have decay, but we are unable to tell them when we can treat it.

"Practices have been inundated with requests for items requiring aerosols, and are as yet, unavailable to provide them on an NHS basis."

Another said mixed practices had been scared off doing AGPs for private patients after a memo from NHS Greater Glasgow and Clyde's chief of dentistry, Lee Savarrio, said this should only cover "urgent dental care" and breaches could result in "referral to the police or the General Dental Council".

"It's absolutely outrageous that dentists are being threatened with referral to the police for doing dental treatment," said the dentist, adding that the UK-wide Faculty of General Dental Practice said the risk could be effectively mitigated with high-grade PPE, deep cleaning, and a fallow period after treatments.

"There's no good reason for dentists, with these mitigations in place, not to be carrying out AGPs. This blanket ban [for NHS patients] is just ludicrous."

The dentist - who works in a mixed practice in East Renfrewshire and asked not be named - said he had "no doubt" some private-only practices, which are more common in areas such as the Highlands, Grampian and the Borders, would also fold as a result of losses incurred during lockdown.

"They've been completely neglected by Government," he said.

"Even with AGPs, they won't be making enough to survive unless there's a sea change in the public's perception of the risk from Covid."

He added that the huge backlog of NHS dental work could even signal the end of routine care for all.

"The NHS model is finished now. It was dependent on low fees and high turnover of patients - that's gone," he said.

"It cannot survive when you're being told you can see a maximum of 10 patients a day. That could be anything from a third to a quarter of normal practice.

"There's going to be huge waiting lists for treatment, so does the NHS move onto a different model?

"For example: 'you're not getting AGPs unless your oral health meets a particular bar' - and cut back on patients that way."

Ross McLelland, dentist in Aberdeen

Small private and mixed practices may have been eligible to apply for a Covid-19 Business Support Grant worth £10,000 through their local council, if the rateable value (RV) of their property was up to £18,000.

But most practices would have an RV above this threshold and the next level up - for grants worth £25,000 - has excluded dentists.

There is no guarantee that insurance companies will offer a safety net either. 

Ross McLelland, sole proprietor in a private-only dental practice in Aberdeen, struggled to claim cover for business interruption and is now also facing major hikes in his   premiums. 

He said: "I tried to make a claim early on and they denied liability.

"My policy actually has a pandemic clause which covers this situation, but because Covid-19 was ‘new’ they said it wasn’t applicable.

"However I found another section in the policy and went at them again and they have accepted liability under the ‘Prevention of Access’ clause.

"So I am covered for loss of gross business income, but it will take a while to sort out. And will I survive in business long enough to receive the claim?

"Interestingly I also just got my renewal quote. My premium has just gone up 25% from July 31.

"So they’re not wasting any time recouping funding before they’ve even made any current policy payments to anybody.

"Not all businesses will have Business Interruption Cover, and many insurers are trying to get out of it even if you have it."

A spokeswoman for the Scottish Government said dentists were receiving "an unprecedented amount of financial help". 

She added: "The Scottish Government is making exceptional payments to the value of £12 million per month to support NHS dental incomes.

"There is now a substantial investment package in place to support NHS dental services – as well as deploying the Scottish Government budget for NHS dental services, we are investing an additional £2.75 million per month. 

“Mixed NHS and private practices are being supported through NHS financial support measures and other business support measures that are more appropriately aligned to private dental practice. 

"We have consistently said that receipt of NHS financial support should not be a bar to ensuring dental practices are able to access other funding.

"Moving into Phase 3 has ensured NHS patients can be seen for a wider range of treatments. Initially this will be about reassuring patients that are not in need of urgent dental care.

"It will still be necessary to prioritise the needs of those patients with urgent dental problems, but practices will now be able to start providing other dental treatments.”