'This will be the end of NHS dentistry': Warning practitioners will quit or go private in bitter funding battle with Government

"We're so far off routine recalls and routine examinations, but the Government just don't seem to understand that."

McColl, a dentist in Govanhill - one of Scotland's most deprived areas - and chair of the British Dental Association's (BDA) Scottish Dental Practice Committee is speaking to the Herald on Sunday just 24 hours after bombshell statistics revealed the sheer scale of the pandemic's impact on NHS dental care.

Source: Public Health Scotland

During 2020/21, there were nearly 390,000 fewer dental treatments carried out on children, and 3.3 million fewer for adults, compared to 2018/19 - the last full financial year unaffected by Covid.

In both cases, the figures represent a drop of 77.5 per cent against pre-pandemic levels.

The enormous backlog is at least one of the reasons why Health Secretary Humza Yousaf wrote to the profession on October 21 signalling the end of Covid support grants from April 1 2022.

READ MORE: Warning over rocketing NHS dental waiting lists and faster treatment for private patients

The cash was designed to keep NHS dentistry afloat over a period when infection control restrictions severely limited the number of patients being seen.

Since November 1 2020, all forms of treatment - including crowns, fillings, and other aerosol-generating procedures (AGPs) - have been permitted on the NHS, with practices performing at least 20% of their pre-pandemic NHS workload reimbursed with the equivalent of 85% funding.

Source: Public Health Scotland

Initially, Covid rules stipulated a maximum of ten NHS patients per day and no more than five AGPs, though these caps (which did not apply to private patients) have since been dropped, and physical distancing rules in healthcare settings cut from two metres to one.

In June, the Government provided £1,500 per surgery to help dentists upgrade ventilation systems to 10 air changes per hour, enabling them to cut their fallow time between patients from one hour to 10 minutes.

And yet, one year on, reports are rife of patients being refused previously routine procedures on the NHS only to be told they are available privately instead.

So what's happened?

One dentist at a mixed practice in East Renfrewshire, who did not want to be named, said one issue is the "huge backlog" of acute and emergency dental problems needing priority on the NHS.

Source: Public Health Scotland

This poses a dilemma, he said, if patients are presenting with work that needs done but does not necessarily rank as urgent.

"You have to weigh up: 'do I put back patients under the NHS who are having emergencies in order to accommodate that other patient, or do I see them privately?'"

However, he added that there is also an element of some dentists being selective in order to protect their Covid grant, which is gradually whittled down as soon as their NHS workload exceeds the 20% threshold.

He said: "There are practices who are still not seeing enough patients - they are in a sense benefitting hugely from the Covid grant.

"Other practices which are in more demanding areas are seeing their Covid grant reduced because they're having to do more work.

"If you are exceeding 20% then whatever you're being reimbursed for in terms of those claims will be deducted off the Covid grant.

"There will be undoubtedly an element of 'I'm not going to see my Covid grant reduced by doing cosmetic or aesthetic work on patients', which pre-pandemic they would have been entitled to.

"You'll always have few who milk the system, but the vast majority of dentists as of two months ago were operating at 50-60% of pre-pandemic levels of NHS activity so there is absolutely no indication that dentists are milking the system.

"But they have to work within the safety guidelines. The 50-60% of pre-pandemic activity would tie in with the fact that you've got all this increased infection control and triaging."

READ MORE: Dentists' anger amid 'ludicrous' funding row

In a letter to the Cabinet Secretary on October 15, David McColl acknowledged that "a minority of practices are reporting low levels of activity while receiving Covid support payments", but stressed that a return to the pre-pandemic payment model "unfairly punishes the whole sector".

As for the ventilation grants, take up has been patchy.

According to McColl, only six practices out of 270 in Greater Glasgow and Clyde have applied.

He invested nearly £4,500 himself buying two Hepa filters for each of his three surgeries and can now see 10 to 15 patients per day, compared to around 30 pre-Covid.

David McColl, chair of the Scottish Dental Practice Committee and a dental partner in Govanhill, Glasgow

However, he requires permission from the health board, who own the health centre, to install new ventilation systems.

"For fixed ventilation in my three surgeries, the quote was £30,000," said McColl, adding that there had been a proliferation of companies "cashing in" and "claiming all sorts of wild figures" for ventilation.

"We need clear guidance. We need Government to procure a ventilation company to go round all practices and find out exactly what we need.

"It's very easy for the Government to give out a grant of £1,500 per surgery and say 'get on with it', when actually that won't even touch the sides."

Some believe the reluctance is also rooted in mistrust: by taking the money, practices tie themselves into providing NHS care for at least three years.

Pre-pandemic - and as recently as May this year - the Government and its advisors were promising to review the low-cost, high-turnover business model which relied on dentists seeing 30 to 40 patients a day to cover their costs.

This overhaul has now stalled,with the Scottish Government insisting that the priority must be "seeing patients and helping to clear current backlogs" rather than making "wholesale changes" to the dental sector, which it says would take "considerable time".

"This will be the end of NHS dentistry if they push this through," said McColl.

"The very notion that we can go back to where we were and generate enough turnover in the practice to keep things afloat is frankly ludicrous.

"If you look at this pre-pandemic treatment model, the payment that they will give my practice for taking out a tooth is £17.30.

"That's to pay the rent, pay the rates, pay all my staff, pay for all my materials - £17.30. That's just impossible.

"The nurse and receptionist together are getting paid more than that an hour.

"Some practices will make a business decision and either leave the NHS or reduce their commitment to the NHS, or some practitioners will not see how their businesses are going to be financially viable and I think they will either retire - prematurely - or sell their practices.

"All they are going to do with these proposals is increase inequalities." 

READ MORE: One in four hospital 'Covid' patients not admitted because of the virus

The bottom line for many of those on the frontline is that returning to pre-pandemic caseloads is fundamentally unsafe, with one warning that practitioners will simply "ignore the Government" rather than risk Covid outbreaks and sanctions from their regulator.

With Covid grants withdrawn, they said many will simply make up their income with more private work - where they can spend more time with patients - rather than ramping up NHS volumes.

"There will be privatisation of dentistry through the back door," they added.

The situation is particularly ironic given the SNP's pledge to make NHS dentistry free for all adults - something only feasible if patients can find an NHS dentist willing to give them NHS treatment.

Health Secretary Humza Yousaf is facing a backlash from dentists over plans to withdraw Covid support grants from April 2022

There are some sceptics in the profession, however.

"I've got no backlog," says Ross McLelland, owner of Waverley Dental in Aberdeen, one of Scotland's few 100% private practices.

"I did that by doing extra days, extra sessions, and taking no holidays for 18 months. I just worked like a dog."

As a wholly private practitioner, McLelland received no Covid grants or free PPE supplies, but was able to resume a full range of treatments from June last year.

He invested £5000 in ventilation capable of delivering 20 air changes per hour to cut fallow time from the outset, as well as bringing in family groups at once so that they could get treatment back-to-back.

He said: "I wasn't really doing check ups at that point. I flipped it and anyone who had a problem, I saw them.

"I took over management of the appointment book. I was dentist and receptionist and my patients had total access to me during the day and at home in the evenings by email.

"Anyone who contacted me was put in the same day or the next day, and when somebody came in I did everything.

"I did their treatment and their check up - X-rays, scaling - and got everything up to date."

By December 2020, he was back to routine check-ups and treatment as required.

Ross McLelland, a private-only dentist in Aberdeen

McLelland acknowledges that his patient list is around a third of that compared to an average mixed NHS-private practice, and that the delay in restoring AGPs on the NHS - plus caps on patient numbers - has exacerbated NHS waiting lists.

However, he points out that a survey by the Chief Dental Officer in March this year - to which 65% of practices responded - found that, on average, 89% of treatment rooms were in use and 66% were ventilated to the 10 air changes-per-hour minimum requirement. 

"If 90% of treatment rooms are already in use, with two thirds ventilated to the appropriate standard, where is the problem?," said McLelland.

"That allows for a shed load of work to be done."

READ MORE: What's really behind the worst winter crisis facing the NHS?

He added that his practice regularly has patients "banging on the door" claiming their own dentists won't treat them, and insists the profession is increasingly "fudging" the line between private and NHS work.

"That's always gone on and it's become very apparent in the last 18 months. It's blatant now."

Chairtime utilisation (ie. patients being treated) at Waverley Dental from first lockdown until April 2021 (Source: Ross McLelland)

As for the future, he believes the sector is headed back to the 1990s, before Scottish Government grants for rent and rates were used to entice practitioners back into the NHS.

"We're definitely heading down the route of increased private dentistry and lack of NHS, like it was in the 1990s, with queues round the corner when more and more dentists started going private.

"There were these overnight conversions where practices were basically saying to patients 'as of Monday we're private, so sign here or b****r off'."

The Scottish Government said it has provided dentists with £50 million in support payments, £35m of PPE, £5m for ventilation upgrades and £7.5m on new dental drills. 

A spokesman said their plans will help dentists "to see more patients face-to-face", adding: “Ministers and patients have a legitimate expectation that after nearly two years of reduced access, that as soon as it is safe to do so, NHS dental services can resume normal levels of activity. 

"Now is not the time to create wholesale changes to the dental sector, which would take considerable time, the priority must be on seeing patients and helping to clear current backlogs."