Covid Scotland: What's happened to NHS dentistry?

Many thousands of patients have now gone over two years without seeing a dentist, and treatment backlogs accumulated as infection controls severely limited the number of patients who could be seen and what procedures could be done.

READ MORE: Warning NHS dental treatment backlog 'impossible to clear'

The result, two years on, is a"two-tier" system where only the most urgent or emergency cases can be prioritised for NHS care while those who can afford to go private do so for everything else.

Some practitioners fear that NHS dentistry as we know it is doomed.

In light of this, the Scottish Government this week outlined a revised payment system which will enable dentists, from April, to claim 170 pence back for every £1 of dental treatment done on the NHS.

By December 2021 around 100,000 patients were seen by an NHS dentist, compared to around 300,000 in December 2019

So how did we get here?

Like GPs and pharmacists, high street dentists are independent contractors, rather than salaried NHS employees.

The model, a legacy from the establishment of the NHS, means that dental practices are run as businesses where a certain range of services are contracted to the health service for an agreed fee.

Dentists who own the practices - the partners - draw their earnings and pay their staff from the profits once all their overheads are covered (though practices providing an NHS service also get taxpayer support towards rent and rates, as an incentive to remain in the NHS).

The vast majority of practices are mixed - providing both NHS and private treatment, to varying ratios.

READ MORE: 'This will be the end of NHS dentistry' - Pay row looms between dentists and Scottish Government 

Before Covid, this 'low-cost, high-turnover' model tended to rely on dentists seeing 30-40 NHS patients per day (the high volume necessary to cover the costs given the comparatively low return in terms of fees), with practice income topped up through more lucrative private work: cosmetic treatments, more aesthetically appealing crowns and fillings, or three-monthly check-ups funded by private dental plans.

When the pandemic came along, the picture became even more confused.

At first, all but emergency dental work was banned. Then, in summer 2020, a split emerged as dentists providing treatment on a private basis were able to resume the full range of treatments - including crowns, fillings, and other procedures involving aerosol-generating tools - as long as requirements around ventilation, cleaning and PPE were met; on the NHS, aerosol-generating procedures were outlawed until November 2020.

A mixed practice was therefore able to provide treatment to paying patients that it could not provide, under the same roof, on the NHS, because NHS care was subject to Government control - but the independent sector was not.

Even after aerosol-generating procedures resumed on the NHS, the number of patients allowed to be seen on the NHS each day was initially capped at 10 - yet no such cap existed for private turnover.

The number of children being seen by an NHS dentist is also still well below pre-pandemic levels (Source: Public Health Scotland)

In recognition of the fact that the 'low-cost/high-volume' NHS model of dentistry no longer worked in a scenario where fallow time and physical distancing limited the number of patients who could be seen each day, the Scottish Government introduced Covid support grants guaranteeing practices 85% of their pre-pandemic NHS income in exchange for doing at least 20% of their pre-pandemic NHS work.

By last autumn, most dentists in Scotland were exceeding that and achieving around 50-60% of pre-pandemic NHS activity, but the Government is understood to have become frustrated by a minority perceived to be taking advantage of the generous support packages and using the bulk of their time for private work.

The number of people registered with an NHS dentist in Scotland has been climbing since 2006, but the percentage actually 'participating' (attending the dentist) has fallen over the same period from nearly100% of those registered to 65% pre-pandemic, and 50% by September 2021

In October, it announced the grants would end from April 2022 even as Covid restrictions on healthcare would remain.

The profession responded with a reluctance to accept Government funding for high-spec ventilation which would enable practices to see more patients - but tie them to the NHS for three more years.

Instead, surveys revealed that a majority of dentists expected to quit the NHS and go fully private, or at least to substantially reduce their NHS commitment, amid fears that ramping up NHS patient numbers would only lead to Covid outbreaks and sanctions by their regulator.

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

A practice can earn around the same from seeing 10 private clients per day as it would from 50 NHS patients, for example, meaning much more time can be spent on and between each appointment.

With spiralling backlogs and the general public increasingly confused and angry by a situation where they find themselves unable to get a check up or filling any time soon on the NHS, only to be told they could get exactly that in the same practice next day if they went private, the Government has unveiled its new "multiplier" payment model.

It will be reviewed every three months according to required Covid mitigations, budgets and dental activity, but from April to June every £1 of NHS work will be reimbursed with £1.70 of taxpayer funding.

The Scottish Government says the "balance of policy priority now needs to focus on increasing patient care" and believes this temporary fix will incentivise an increase in NHS activity closer to pre-pandemic levels.

Table illustrating revised payment income in place from April, compared to pre-pandemic income and emergency top up 'Covid support grants' (Source: Scottish Government)

It remains to be seen whether it delivers value-for-money for taxpayers or goes far enough to tackle waiting lists, however.

For example, a dentist whose monthly pre-pandemic NHS activity earned them £5000 can do 60% of that activity (i.e £3000-worth) and receive £5,100.

That compares to the £4,250 they would be getting now under Covid support grants.

But if a majority already were doing 50-60% by last autumn, won't this just mean most dentists getting more cash for the same amount of NHS activity?

Meanwhile, negotiations around a longer-term solution are set to get underway in Spring: the Government has ruled out a return to the pre-pandemic fee model and promises "a fully sustainable payment system that better reflects modern dentistry".

We certainly need it.