Dentists say they ‘cannot afford’ to provide NHS treatment

MILLIONS of pounds earmarked for NHS dental care in Scotland went unspent last year despite huge treatment backlogs because dentists “cannot afford to work” within the current system.

Figures obtained under freedom of information by the Scottish Dental Association (SDA) show that £343 million was spent by the Scottish Government on General Dental Services (GDS) – that is, high street dentistry – in 2022/23, out of a total dental budget of £431m.

Once spending on Public Dental Services – dentistry provided in hospitals – is deducted, the SDA says the figures point to around £30-50m going unused, with the total outlay also falling short of the £421m spent on high street dentistry in 2018/19 despite growing demand.

The Scottish Government said the data does “not show the underspend which is being claimed”, adding that the budget also included spending on superannuation and measures to prevent oral ill health.

However, it did not deny that there has been some underspend.

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Dr Brendan Murphy, an SDA member who analysed the statistics, said they reflect a growing reluctance among practitioners to take on NHS work because the fees paid no longer cover their costs.

He said: “The truth is, unfortunately, because dentists cannot afford to work within this system that we’ve been discussing for two and half years, the patients are not getting what they need.

“The reason they’re not getting what they need is because the Scottish Government have refused to change the system or put in an interim system, which is what we requested. The Scottish Government agreed to and then reneged on that.”

NHS dentistry is subsidised through a combination of allowances – grants paid monthly or quarterly to practices – plus a fee-per-item model which reimburses dentists for providing treatments such as fillings, extractions and examinations.

Currently, dentists are being reimbursed at a rate of £1.30 for every £1 of NHS work claimed, but this is expected to be cut after September and dental leaders say it is already too low to cover the soaring costs of materials, staffing, energy, and equipment.

During the pandemic, dentists were also offered ventilation grants to upgrade surgeries, but practices applying for the cash had to commit all their dentists to the NHS for a minimum of three years.

In the Greater Glasgow and Clyde region, a predominantly NHS area, uptake was just 18 per cent.

“You have to ask why, when there’s free money being offered to dentists, how bad does it have to be when only 18% of it’s taken up?,” said Dr Murphy, who owns eight practices including four in Glasgow and one in Inverclyde.

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He added that practice owners had refused to be “bullied” by Government into tying themselves to a funding model which was not financially sustainable.

He said: “That [18% figure] more or less confirms the situation for practice owners. If you want to read between the lines, you can be fairly certain that there are around 80% of practice owners who are saying ‘someone within these four walls needs to be wholly private to make this all work’.”

Most dental practices in Scotland are mixed – providing both NHS and private care – but Dr Murphy said the share of time spent on NHS activity had fallen from an average of around 75% pre-pandemic to around 50% now as practices try to “strike that better balance” to cover their overheads.

It has put the profession at loggerheads with the Scottish Government, who want to see NHS activity ramped up.

A recent survey by the BBC found that 85% of dental practices across Scotland will not take on new NHS patients, and in Edinburgh 10,000 patients at Links Dental Practice in Bruntsfield have been told they will have to pay £21.50 per month to remain on its list from October 1 as it de-registers from the NHS and goes fully private.

Dr Murphy said this was the “tip of the iceberg”, with the NHS dentistry likely to become a “core service” providing only basic care unless the funding model is overhauled.

He said: “We’ll maybe take the occasional X-ray or stick a bit of cement on there just to patch that up for you, but we can’t afford to to give you an injection, buy the filling materials, pay the staff, get our hands dirty and do the wipe down.

“That’s the kind of Mexican stand-off that we have.

“If we cannot afford as practice owners to fund it, what we have to do is shrink our NHS diaries, and we’ve told the Government that that is what we’re doing because it’s the only control we have – our time.”

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Dr Murphy said patients who cannot afford private prices are going on waiting lists until practices can cover the cost of providing the treatment on the NHS.

Dr Murphy said: “We cannot say no, if somebody needs treatment, but we’re having to very carefully prescribe it, which we don’t like to do.

“We could say to the patient ‘we’ll get you in in the next couple of weeks and we’ll do it privately’, and we’ve shrunk our NHS diaries to expand that availability on the private sector, but it looks as if we’re being money-grabbing and that’s the headline the Government wants – they want dentists to be perceived to be money-grabbers.”

Public Health Scotland will publish the next set of official dental statistics today, covering the period from April onwards when the 1.7 multiplier was introduced.

NHS dental activity fell sharply during the pandemic as a result of Covid restrictions. However, in exchange for providing at least 20% of their pre-pandemic workload they were reimbursed as if they had completed 85%. This was replaced in April by the 1.7 multiplier, and in June by a 1.3 multiplier

They are expected to show a large spike in NHS activity, but dental leaders from the SDA and the British Dental Association in Scotland, speaking to the Herald on Sunday at the weekend, cautioned that this is misleading.

They said that most of the uptick was driven by a sharp rise in one-off examinations and simple procedures, such making dentures, which dentists could complete quickly and claim for on the 1.7 rate.

Complex courses of treatment – such as patients requiring multiple fillings and root canals – were potentially unaffordable for practices as they could take months to complete, and would end up being reimbursed at the 1.3 rate.

Both the BDA and SDA want to see the fee-per-item model scrapped in favour of alternatives that they say would make NHS dentistry sustainable.

The BDA backs a GP-style funding model where practices would be paid a global sum guaranteeing that they provide specific services, while the SDA has proposed a system that would see dentists spend 60% of their week on a salaried basis providing NHS care.

A Scottish Government spokeswoman said the £343m spend relates “only those direct payments made to independent contractors for NHS dental services which account for part but not all of our spending on NHS dentistry”.

She added: “Throughout the pandemic we provided NHS dentistry with an unprecedented level of financial support, including £50m of additional emergency payments and £35m of free PPE.

“We are continuing to invest in NHS dentistry, including £20m in increased fees for NHS dental teams to see more patients with a particular focus on children and tackling oral health inequalities, and revised interim payment arrangements that presently mean dentists receive an increase of 30% on NHS fees.”


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