Health, Social Care and Sport Committee

Meeting date: Tuesday, October 24, 2023

Official Report 632KB pdf

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Subordinate Legislation

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National Health Service (General Dental Services) (Miscellaneous Amendment) (Scotland) Regulations 2023 (SSI 2023/247)

The second item on our agenda is an evidence session with the Minister for Public Health and Women’s Health on the National Health Service (General Dental Services) (Miscellaneous Amendment) (Scotland) Regulations 2023. I welcome from the Scottish Government Jenny Minto, who is the minister; Tom Ferris, who is the chief dental officer; Ailsa Garland, who is the principal legal officer; and Tim McDonnell, who is the director of primary care.

I invite the minister to make a brief opening statement.

Good morning, and thank you for the opportunity to speak about the dental regulations, which are to be dealt with under the negative procedure. As the convener has noted, I am supported today by my senior policy officials Tom Ferris and Tim McDonnell, and legal official Ailsa Garland.

If I may, I will talk briefly about the purpose of the regulations, as well as the changes that we will be making under them. As the committee will be aware, the Scottish Government has been working on NHS dental payment reform for some time now. In my letter of 18 October to the committee, I outlined the key components and benefits of the new payment system, which will be implemented in just over a week. I will be happy to take any questions on that during the meeting.

In relation to the regulations, a number of key changes are required to various existing regulations to support payment reform. As part of those changes, we are introducing a single capitation arrangement for all patients, regardless of age, and all treatment items will, where it is clinically appropriate, be available for both adult and child patients.

We are also making changes to support unregistered patients. The system that is known as “occasional treatment”, under which unregistered patients can receive only a reduced set of care and treatments, will be removed through the amendments that will be made by the regulations. That means that both registered and unregistered patients will be able to access the same comprehensive range of treatments, by removal of what might be construed as a two-tiered system of care.

The changes are also focused on bringing clinical practice up to date. The new single capitation arrangement will rest on “managing” the oral health of the patient, by replacing the requirement to

“secure and maintain the oral health of the patient”.

The more achievable aim of managing oral health recognises that self-care is an important determinant of successful oral health outcomes.

I confirm that the equality impact assessment for the regulations reports no significant issues, and that the business regulatory impact assessment reports no adverse consequences.

In summary, the regulations are part of the significant work that we have undertaken to prepare for implementation of payment reform on 1 November 2023. The changes will support the introduction of the most significant reform to NHS dentistry in a number of years, and it is our intention that the reform will help to sustain and improve patient access to NHS dental services for the long term.

I am happy to take questions from the committee.

Thank you for your statement, minister.

How do you intend to evaluate and monitor the impact of the payment reform?

We have been very clear about that since we started discussions a number of months ago with the British Dental Association and, more widely, with dentists in Scotland. That work will start once the system is bedded in. We have already started with some very well-attended webinars to ensure that dentists understand what the changes are and how they will implement them in their practice.

We will constantly keep review of the system in mind. Tom Ferris meets dentists and directors of dentistry regularly through national health service boards and the BDA. We have been very clear with the BDA that we want to work with it to ensure that this is the right start for the reforms that we are looking at.

You mentioned the BDA a couple of times in your answer. Its criticism was that you

“did not consider new models of care or alternative delivery models as part of payment reform”.

Can you comment on why the Scottish Government did not do that?

Yes, I can. I am aware of that issue from my conversations with the BDA.

In Scotland, we have a blended method. It combines a capitation payment for the number of people who are seen by a practice—one of the changes that will be made by the regulations is that adults and children will now be treated for the same fee, which, I think, is positive—and a payment for the services that a dentist provides. I think that that method will work very well, given the variety of dental organisations and businesses that we have.

In fact, yesterday Tom Ferris met some of the academics whom I referenced in my letter of 18 October, who are very supportive of a combined method of paying for our NHS dentistry and think that that is the right way. We have been very clear that we are building on a foundation that we already have in Scotland that works very well and on which practices are already built. I think that the reformed blended system is the right way for us to move forward. In that meeting, Tom Ferris discussed the possibility of making changes in Scotland. The advice that we got from academics from North America, Europe and Australia was that, if we look at how dentists’ services work across the world, we see that a simple lift and shift would not necessarily provide a better service. Their strong view was that we should modernise a system that is already working, which is what the Scottish Government has endeavoured to do, through the changes that we are making with the regulations and payment reform.

Thank you.

I declare my interest as an NHS-registered general practitioner.

Minister, thank you for coming. Has any analysis been done on how much extra the average patient who is eligible to pay, and who is not eligible for any free prescriptions, will have to pay?

The problem is that there is not an “average patient”. Everyone in Scotland comes as an individual to see their NHS dentist.

The letters that I have been getting—I am sure that you are the same as me, in this regard—are about access to service. That is what people are really pushing for: they want to ensure that we improve access to NHS dentistry. As I said earlier, what we aim to achieve through the changes in regulations and fee structures is sustainability of services.

Thank you for coming today, minister.

Was any consideration given to other reforms? The current focus is on a disease-centred model. Did you look at preventative, instead of disease-centred, approaches?

I think that what we are looking at is a prevention-centred dental care service. The childsmile programme that we have rolled out to improve the oral health of young children is not disease-centred; it is very much centred on prevention.

We have also been very clear—again—about sustainability of services and ability to access dental services, which I think are really important.

The change that we are making with regard to unregistered patients is also important, because it moves us into the preventative space. When we bring all the regulations together, they show that we want to ensure that there is sustainable access to NHS dental services for the people of Scotland.

In relation to reform, the number of university places for graduates has flatlined, and graduates who qualify tend not to want to go into the NHS because of the funding model. Will the new model attract graduates to the profession?

As we know, we lost one cohort of dental students during the pandemic, which is about 160 students, or 5 per cent of the workforce. I am pleased to be able to let the committee know—I might also have referenced this in my letter—that 183 dental students are going through training this year, which is incredibly positive.

With regard to the point about dental students not wanting to move into NHS dentistry, I know that the COVID-19 Recovery Committee took such evidence. However, evidence that the Scottish Government and officials have had does not, in fact, show that. Many students want to go into the NHS because it gives them such a fantastic training base. My local practice on Islay supports trainees to come and experience working in a rural practice, which gives them a wide range of training opportunities.

That is attractive for training, but will the reforms help to stop the bloodletting from dentistry?

The intention of the reforms is to ensure that we continue to make NHS dentistry attractive to dentists.

I have a final question. What difference will the single capitation arrangement make to patient access and treatment options, and how will you assess the impact of that change?

As I said in response to the convener’s question earlier, we will work very closely with dentists to ensure that we get a note of and recognition of how the changes improve accessibility and sustainability of the service. That will be on-going work, once the system is bedded in.

I thank the panel, in particular the minister, for coming today.

The changes that are coming in on 1 November have caused some confusion and concern among patients, which has been communicated to us. What support is the Scottish Government providing to dentists to respond to an influx of concerned inquiries, and what public messaging and information are being provided to assure people that the change is nothing to be overly concerned about?

We have been aware of that in planning for the change, which will happen next week. As I said earlier, my officials have held a number of webinars with dentists to explain the new regulations and way of working. I understand that they have been extremely well appreciated and well attended. I think that there were about 1,000 people at the first webinar meeting, which was oversubscribed. As a result, another one is being held tomorrow evening to ensure that dentists are across the subject. We are also doing webinars on specific subjects, including periodontistry, to ensure that the reform is widely known about across the profession. Feedback has been incredibly positive.

I thank my officials for the work that they have put into that engagement, because I appreciate how important it is that the professionals absolutely understand the changes that we are making.

09:30  

On public messaging, you are absolutely right. In fact, I walked past a dental surgery in Glasgow the other day and thought, “Oh my goodness, they’ve got their poster out early”, but it was a different poster. We are doing a variety of public engagement and messaging, including posters in dental practices, libraries and so on, as well as a multimedia campaign, so the information will be on the radio and other media outlets. I hope that we have everything covered, but we will evaluate that as we go.

There is an issue around preventative care, which is mentioned in the policy notes. It is concerning that the drumbeat for a routine check-up will slip from six-monthly to yearly. What modelling have you undertaken to assess the impact on overall oral health in the population?

Thank you for that question. The frequency of check-ups has been commented on in the media. The yearly review is in-depth and follows the National Institute for Health and Care Excellence guidelines.

However, it is really important for everyone to understand that it is for the dentist to make the decision based on the patient. In response to Dr Gulhane, I referenced the fact that there is not an “average patient”. It is important to recognise that if your dentist feels that you need to be seen more regularly, he or she can choose that.

I was disappointed to be told by my dentist that I had to come back in six months, because I thought that I was looking after my teeth’s health pretty well and was hoping for a check-up in nine months. However, the approach is really focused on the patient. That is what the regulations give us the opportunity to do.

I am sure, Mr Sweeney, that if you were to reflect on that and were being seen by another area of the health service and were told that you did not need to come back in six months but in nine months, you would see that as good news. We need to remember that the frequency of check-ups is based on the patient and the clinical expertise of the dentist.

I also want to raise a concern that the British Dental Association raised, which was about whether that approach is sufficient to narrow inequalities. My recent experience of trying to get an appointment for a check-up in my practice, which is probably in one of the poorer districts of Glasgow, is that it was very difficult, because the permanent dentist has left the practice, which is now using locums.

With regard to patients’ oral health, the change of wording in the regulations from “securing and maintaining” to “managing” arguably places more responsibility on the patient for their oral health. We know how difficult it is to rebook appointments when they are cancelled, and the appointment could slip. That could be even more complex for people who have poor mental health or chaotic lifestyles. Has the Scottish Government anticipated that risk? If so, what plans and measures are in place to mitigate it?

Thank you for that question. As you will have seen in the BDA’s response to the committee’s letter on the regulations, it said that that approach is actually something that it had been looking for. It feels that managing patients’ oral health is doing things at the right level because we all have a degree of responsibility for looking after our health.

I take on board the point about access; I underline, yet again, that we are seeking to improve access through the payment reforms that we will put in place next week.

In your previous answer to me, you spoke of improved access to dental services. Given that the BDA warned that the SNP was overseeing the end of NHS dentistry in Scotland, are you confident—and will you guarantee—that the reforms will lead to improved access for patients?

I have been in this role, and have been an elected person, long enough to know that it is very difficult to guarantee anything in this life. What we have done is based on discussions with dental practitioners in Scotland and takes cognisance of academic research, to which I referred earlier. We believe that it is the right change at this time to ensure that access to NHS dentistry in Scotland is maintained.

Therefore, access will be maintained, not improved.

No. The intention is to also improve access. We have been very clear that we intend that the regulations will improve the sustainability of, and access to, NHS dentistry in Scotland.

To be clear, will the changes improve access for patients?

That is my hope.

Okay.

One of the big issues that dentists talk to me about, when it comes to access for patients who want to register, is lifetime registrations of patients. They say that they feel that when a patient has not engaged with a practice for between three and five years, they should be able to take that patient off their list to allow space for other people to come on board, because their lists are full; however, they say that it is far too difficult to do that. Will you consider making what seem like perfectly reasonable reforms and changes when it comes to lifetime registration?

As I said, we have made it very clear that we will have continual discussions with the BDA about the payment reform that we have introduced.

I am sorry, but the question was not about payment reform; it was about lifetime registration of patients.

I mentioned payment reform specifically because that is what we are talking about now. We have continual meetings with the BDA and dentists, and everything is always on the table when we are in discussion with them.

You are the one who brought up improved access, minister; you mentioned it in response to one of the first questions that I asked you. That move would improve access, according to dentists who come to see me.

What are the plans when it comes to domiciliary visits to improve access for patients who are unable to go to a practice?

If you do not mind, I will pass that question to Tom Ferris.

We have a programme of extended-duty dentists whose main focus is on going into care homes. We hope to extend that programme, which was in abeyance during the pandemic.

We are having more ongoing discussions with that group of dentists to ensure that the 1 November reforms help them to fulfil that purpose. We are absolutely focused on ensuring that residents of care homes, as well as other citizens, have access to NHS dentistry.

Are you saying that that programme is on-going, but is not among the reforms that have been brought in to improve access to domiciliary visits?

No. Most care-home residents are seen either by the public dental service, which is the board-managed dental service, or by enhanced-skill general dental practitioners. I would prefer enhanced-skill GDPs to take responsibility for that work, because that would free up the PDS to work with other vulnerable groups in the community.

Our focus is on making sure that GDPs feel that working in an enhanced-skill environment in a care home is worth their while; our work on that is on-going. It is part of the reforms, and we are trying to ensure that it works. We are having a conversation with them specifically to say, “This is what is on offer. Does it seem as if it is working for you?” We have had one meeting already, and there is another one in the diary.

Thank you.

We have already talked about the shift in language and people taking responsibility for their own oral healthcare. How will the Government support those on low incomes or no income to do so?

The Government supports people on low incomes in a number of ways. I think that between 20 and 25 per cent of adults in Scotland do not have to pay for their NHS treatment. The fact that we have free examinations is important as well.

Earlier, I highlighted other initiatives, such as childsmile for getting younger children into the habit of cleaning their teeth, which have been incredibly helpful. Statistics that came out today show that 82 per cent of primary 7 schoolchildren have no obvious tooth decay. That high level backs up the investment that we have put into the preventative side of oral healthcare for children.

We know that there is an issue with stalling registrations for very young children—aged between zero and two—which are 25 per cent lower since the pandemic. There seems to be a lag in areas of higher deprivation. How can the reforms be carried out in a way that minimises health inequalities? How are we going to get on top of that?

That is a really important question to ask. Broadly speaking, we intend to maintain access to NHS dentistry across Scotland through the reforms. I will hand over to Tom Ferris.

On registration for zero to two-year-olds, that is the lowest cohort, and it always has been. It takes particular initiatives to ensure that we improve that, and we did that primarily through the childsmile programme. That was in abeyance over the pandemic, and it has only just got back up to strength, so I see those figures beginning to improve over the next few months and years. However, we should not be complacent.

If you are a parent with a young child, it is very difficult to think that there is another thing that you have to do in going to get your child registered, so the childsmile teams in nurseries and practices work in co-ordination to make that as seamless and easy as possible.

Although that figure has always traditionally been lower, Evelyn Tweed is right that it is lower than it has been before, but childsmile should make the difference again.

The BDA is

“concerned that certain aspects of the new Determination 1 may result in unintended consequences, which may result in an increase to oral health inequalities. For example, a single examination fee which does not take account of disease experience, may favour patients with minimal past dental disease and/or current dental disease”.

Do you share those concerns? How will any unintended consequences be monitored?

As I have said on a number of occasions, we believe that this is the right reform, building on the foundations of the way that dentistry is funded and provided in Scotland.

It is also incredibly important that we continue the dialogue with our dentists to ensure that we are getting the right changes made, whether they relate to governance, workforce or access, which are all important.

I know that Tim McDonnell wants to make some comments about access.

This also responds to a previous question. Because we have an independent contractor model in Scotland, the confidence of the contractors working in the sector is a critical factor in relation to both the sustainment and improvement of access. Because we have engaged with the profession throughout the development of the regulations and, critically, the payment system, and because we will keep engaging with it—whether through town-hall meetings through my team, or through the webinars that the minister has referenced—that will help to build confidence in the profession that the payment measures can sustain access. They will allow independent contractors to make good business decisions that can promote and sustain the oral health of the population and its access to critical NHS dentistry.

Dentistry is one of those areas in which patients find it more difficult than others to raise concerns and give feedback on treatment and on-going reforms. Is there a plan in place to ensure that people can have their voices heard and that ways of giving feedback—good or otherwise—are advertised so that people can input into the system?

That is a really good question. The first thing that came into my head on NHS dentistry, and NHS boards more widely, was that people can feed in their views on the Care Opinion website. To be honest, high street dentistry—if I may describe it as that—is very much constructed of individual businesses, as Tim McDonnell has just said. However, I encourage people to use Care Opinion if they want to give feedback on NHS dentistry.

09:45  

Good morning, minister and other panel members. How will the reforms assist in retaining people in NHS dentistry and recruiting new people into it?

That is a very wide question. As I have said previously, the changes in the fee structure and the regulations will maintain and ensure the sustainability of the service across Scotland.

On encouraging people into dentistry, one of the areas that we want to look at is the workforce. There have been two pretty big impacts on the dentistry workforce. One is from Brexit and the difficulty that it created in getting dentists from outwith the United Kingdom to come to the UK. I have written to all my counterparts and their chief dental officers in the four nations, and we are organising a meeting to talk about how we can improve the throughput if dentists wish to come to practise in the UK—and specifically Scotland, from our perspective.

We also want to look at improving the workforce within dentistry. For example, there are some very highly skilled dental technicians, and we would like to explore giving them a bigger locus in seeing patients. We are talking about the possibility of doing that. That is not a magic bullet that will solve our issues, so we are working together on a lot of things. That is why the connections and discussions that we have with dentists, as Tim McDonnell and Tom Ferris have highlighted, are so important, whether they are through the BDA more widely or through the NHS directors of dentistry.

Minister, we know that dental services have been struggling to recover to pre-pandemic levels and that there has been a significant backlog of patients awaiting treatment. How will the reforms enhance the recovery and sustainability of NHS dentistry in the short term and the long term?

The nub of the reforms is about ensuring that we sustain NHS dentistry in the long term. Like you, I have received lots of emails about the access that people have to dentistry. We have the reforms, but we also need to remember that the Scottish Government has put other grants in place. For example, the Scottish dental access initiative offers £100,000 for a new practice in an area. We have been in discussions with health boards to ensure that we target those grants in the right areas. We also have some remote—although I do not like using that term—grant payments, which are really important.

The conversations that Tom Ferris and I have with the health boards are also important, because the boards have a responsibility to look at how dental services are being provided in their jurisdictions. I was pleased to hear that Scottish Borders, Dumfries and Galloway and Highland are now working together to encourage more dentists to come to areas that have had recruitment issues. As I said to David Torrance, we also need to keep an eye on the breadth of skills in dental surgeries to ensure that they are supported.

Are there any concerns that the increased costs will discourage those who pay for part of their NHS dental treatment from seeing their dentist? Could that have an impact on sustainability and early treatment?

We should remember that everybody under 26 gets free dentistry and, as I have said, between 20 and 25 per cent of adults do not pay for their NHS dentistry. What we had to do was look at the best way of ensuring that we sustained the number of dentists and dental practices in Scotland, and it was felt that a slight increase in the fees was the right move. The fees are still capped at £384.

As I think I mentioned earlier, the concern that I have been hearing with regard to dentistry is about access. That is the issue that we believe the changes and amendments in the regulations will help us to address.

I have another very short question, but I should first say that I entirely appreciate and understand the logic behind this. With the current cost of living crisis et cetera, will you be closely monitoring the situation, just in case it throws up any issues?

Most definitely. The cost of living issue floods through every decision that we make just now, so it is absolutely something that we will be keeping an eye on.

Thank you very much.

I thank the minister and her officials for attending today.

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National Health Service (General Dental Services) (Miscellaneous Amendment) (Scotland) Regulations 2023 (SSI 247)

Agenda item 3 is consideration of two negative instruments, the first of which is the instrument on which we have just taken ministerial evidence. The purpose of the instrument is to make specific changes to existing regulations to support payment reform and to make the miscellaneous changes that the Government had intended to make at the next opportunity of amending the existing regulations.

I again declare an interest as a practising NHS GP.

A lot of dentists are still concerned that these changes do not address the root cause of their problems and do not feel that they will be enough to sustain services, especially in rural and deprived areas. Indeed, they do not feel that the changes will allow the Scottish Government manifesto pledge of free dentistry for the under-26s to happen. Over the next year, I would like to see evidence to assess these changes and the improvements that have been made to access as a result.

Thank you for those comments. Obviously, they will now be part of the Official Report.

I propose that the committee make no recommendations in relation to the instrument. Are we agreed?

Members indicated agreement.

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Health and Care Professions Council (Miscellaneous Amendment) Rules Order of Council 2023 (SI 2023/995)

The purpose of this instrument is to provide the Health and Care Professions Council with the power to increase fees charged for processing and scrutinising applications for admission to its register, for renewal of registration and for readmission or restoration to the register. It also enables the practice committees and appeal panel to hold remote hearings outside of emergency periods. The policy note states that the Health and Care Professions Council’s fees were previously updated from July 2021 and that offering remote hearings alongside in-person hearings will make it easier for some attendees, such as those with mobility or mental health conditions, to engage with the process.

The Delegated Powers and Law Reform Committee considered the instrument at its meeting on 26 September 2023 and made no recommendations in relation to it. Moreover, no motion to annul has been lodged.

I believe that Sandesh Gulhane has a comment.

I again declare an interest as a practising NHS GP.

I want to take this opportunity to tell the committee and the public that I have received a lot of emails and correspondence from members of the Health and Care Professions Council who are opposed to the increase in fees, given the global cost of living crisis and their feeling that the increase is not justified. A lot of people are unhappy about this but, in the council’s defence, I understand that this is the first increase in fees in years and that the council feels that, if it does not increase them, it might well go bust. It is, I think, a very difficult decision that is being taken.

Again, those comments will be part of the Official Report of the meeting.

I propose that the committee make no recommendations in relation to the negative instrument. Are we agreed?

Members indicated agreement.

I suspend the meeting to allow for a changeover of panels.

09:55 Meeting suspended.  

10:05 On resuming—