'Exploitable' payments model encouraged dentists to 'cash in'

Both organisations are pushing for an overhaul in the way NHS dentistry is funded to prioritise patient need.

It comes as the latest set of dental treatment statistics, due to be published on Tuesday, are expected to show a significant uptick in NHS activity from April onwards.

Health Secretary Humza Yousaf previously said that the Government had been “greatly encouraged” after the number of dental examinations carried out in April soared to 232,000, compared to 125,000 in total during January to March.

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Covid measures, which had limited the number of patients dentists could see, were de-escalated in April with the Scottish Government introducing the temporary 1.7 payment model at the same time to encourage more NHS consultations.

However, dental leaders say the model incentivised a rapid increase in one-off appointments or simple procedures - such as making dentures - rather than driving up the turnover of patients requiring complex courses of treatment, such as multiple fillings and root canals, which might take months to complete.

The multiplier rate was cut to 1.3 in July, which dentists say fails to cover soaring costs of equipment, materials, staffing and energy.

Douglas Thain

Douglas Thain, chair of the Scottish Dental Committee, said: “When the multiplier was at 1.7, people who hadn’t done very much for quite a long time awoke very abruptly and labs that we’d used right through the pandemic were doubling their lead times for work because so many people were cashing in while the going was good.

“The trouble is if you opened a course of treatment during the 1.7 period and that course of treatment extends into the 1.3 period, then everything that was done during the 1.7 period is paid at 1.3 when the course of treatment ends.

"And if the treatment extends past this quarter, where the multiplier might be reduced further, it will ultimately be paid at whatever the level is then.

“The incentive to do comprehensive treatment courses and new patients just isn’t there. What works are short-sharp, in-and-out one appointment type visits, which don’t help new patients one bit because they, by their nature, tend to need a lot of treatment.”

The number of dental treatments carried out on the NHS fell dramatically during the pandemic and still remained much lower than 2019 levels as of February this year (Source: Public HealthScotland)

Mr Thain, a dentist in Coatbridge, added that he expects the statistics on Tuesday show an “absolutely massive” increase in NHS activity, but cautioned that this would be misleading.

He said: “I think you’d find that a small number of people have done an exceptional amount of activity.

"But how much of that activity is directly in patients’ best interests and how much is just the quickest way to get the NHS money?

“That’s not necessarily meant as a criticism; I think getting as many claims submitted by the end of the [1.7] quarter as possible was probably the ‘last hurrah’ in terms of practices fattening up accounts before things get a lot worse.

“Anecdotally, the labs we use for making dentures said they’d never been as busy as they were during that multiplier period.

"People who hadn’t used them at all for months or even years were suddenly making dentures to fill every available space.

"That’s NHS activity, it’s money paid out by the taxpayer to dentists, but it’s not addressing the toothaches and the problems that registered patients, and even unregistered patients, actually have.

“It’s undeniable, and I’m sure dentists aren’t unique: if there’s a system put in front you, you work out how to make it work best for you.

"The fault is the Government’s for creating a system that is so easily exploitable.”

READ MORE: Warning dentists will quit or go private in bitter funding battle with Government 

David McColl, the chair of the BDA’s Scottish Dental Practice Committee who runs a practice in one of Glasgow most deprived areas, said the multiplier model was “geared toward statistics, not healthcare”.

He said: “What the [Scottish Government has] done is prioritise examinations because it suits their statistics.

"That’s alright in affluent middle class areas where people aren’t needing much work done, but in the Central Belt it’s just creating longer waiting lists.

“Most of the people I’m seeing need work done - they need two, three, four follow-up appointments, so that’s probably creating an even bigger backlog.

“What they’re measuring are people who’ve completed a course of treatment; what those stats aren’t measuring is the people who still need extensive work done.”

David McColl (Image: kk)

Mr McColl said he had repeatedly warned the Scottish Government that the model would worsen health inequalities by encouraging dentists to prioritise straightforward patients.

He said: “I said to people like [chief dental officer] Tom Ferris: ‘can you explain to me how your strategy is going to reduce health inequalities, because what you’re doing is increasing health inequalities?’.

“The kind of person I want to get in and see is someone who needs one appointment, two at the most, because then I can get them in and out and get a 1.7 multiplier - or a 1.3 multiplier now - but if I’m getting in someone who needs four to six appointments, that’s going to take me six to nine months to get through, and I can’t claim until it’s completed.

“His answer was ‘we’re taking a holistical approach to health inequalities’. That doesn’t mean anything.”

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

Dentists now fear that the Scottish Government is set to cut the multiplier altogether after September, despite warnings that it will make providing NHS care unaffordable.

It comes after research by the BBC found that 80 per cent of dental practices in Scotland were not accepting new NHS patients.

In nine local authorities - Dumfries and Galloway, Dundee, Midlothian, Moray, Orkney, South Ayrshire, Western Isles, Angus and Inverclyde - the BBC could not find a single practice taking on new adult NHS patients.

The Scottish Government has stressed that 95% of adults in Scotland are currently registered with an NHS dentist, but problems arise when people move house and try to register with a new dentist. Registration levels also do not reflect how often people are being seeing and what dental treatments, if any, they are receiving on an NHS - rather than private - basis (Source: Public Health Scotland)

Mr Thain said dentists are already “leaving the NHS in their droves”, and only a complete overhaul of the payment model could stop the rot.

The SDA has proposed having practitioners spend around 60% of their working week on a salaried basis providing core dentistry, with the rest of the time spent doing more expensive fee-per-item NHS work such as crowns, bridges and dentures, with private sessions outwith that for cosmetic work such as teeth whitening.

“For us it’s what’s right, rather than what makes money - that’s our big concern,” said Mr Thain.

“This would guarantee that you’ve got experienced dentists with some incentive to treat deprived children, because they don’t have to look at the clock.

“There would be no incentive really not to do the stuff that’s most beneficial to patients, because your income’s the same at the end of the day - it doesn’t matter if you spent two hours taking a kid’s tooth out and doing their fillings, or made five dentures in that space of time.

“Whereas, at the moment, the difference is that one is a complete loss and the other is quite a profitable way to spend your time.”

The BDA opposed the reduction in the multiplier from 1.7 to 1.3, because the latter would not cover expenses, but Mr McColl said he would prefer a GP-style model where practices receive a “global sum” payment for providing core NHS services, with the autonomy to spend it in a way that best meets the needs of their own patient mix.

Public Health Minister Maree Todd

However, he said there had been “no engagement” from Government on a revised payment system.

He warned that a return to the pre-pandemic fee-per-item model - potentially scaled down from 400 to as few a 50 treatments - would be catastrophic for NHS care.

Mr McColl said: “The knock on effect will be that it’s very difficult to recruit staff to NHS practice.

“Private practice will increase. Current NHS practice owners will not be able to sustain the business model and they will end up selling their practice, probably onto one of the corporates, and once the corporates have enough practices and enough control, from then it’ll be the corporates who are dictating what’s happening with NHS dentistry.”

Public Health Minister Maree Todd said: “Dental teams across the country have worked very hard to see patients as infection prevention and control measures reduce. Many are now seeing as many patients as possible and they deserve our gratitude.

“We are continuing to provide NHS dental services with an unprecedented level of financial support - at present dentists receive an additional 30% payment on each treatment they provide under the new system of interim support, and this applies equally to all fees and treatments.

“We will continue to work closely with sector to deliver meaningful and sustainable changes to the provision of NHS dental services to tackle the backlog and ensure everyone can access the treatment that they need.

"It is our ambition to regather that momentum and ensure we have a NHS dental service that is unequalled in the world today.”