 Good morning, and welcome to the 13th meeting of the Covid-19 recovery committee in 2023. We have apologies from Alec Rowley, who will be replaced by Jackie Baillie. We have apologies from Stuart McMillan, who will be replaced with Ash Regan. This morning, we're going to begin our inquiry into the recovery of NHS dental services. In our first panel, we will be considering public perceptions and experiences of the recovery of NHS dental services. I'd like to welcome to the meeting Margaret McKeith, who is the Assistant Director at the Alliance, Professor David Conway, who is the Professor of Dental Public Health at University of Glasgow, and honorary consultant in dental public health at Public Health Scotland, and Dr Manall Isshelly, who is project coordinator at the West of Scotland Regional Equality Council. Thank you very much for giving us your time this morning and your written submissions. We estimate that this session will run until 10.15, so that gives each member approximately eight minutes to speak to the panel and ask their questions. I'm keen to ensure that everyone gets an opportunity to speak, and I apologise in advance therefore if time runs on too much. I may have to interrupt members or witnesses in the interests of brevity. I invite witnesses to briefly introduce themselves, and I'll start with yourself, David Conway. David Conway, Professor of Dental Public Health at University of Glasgow Dental School, and honorary consultant in Dental Public Health at Public Health Scotland. Good morning. I'm Margaret McKeith. I'm the Assistant Director with the Health and Social Care Alliance. Good morning. My name is Manall Isshelly. I'm a project coordinator for several projects with the West of Scotland Regional Equality Council. Okay, thank you. Can I just say you don't need to touch your buttons? Broadcast will do that for you. Thank you very much. I'll now turn to questions, and I would pass to Murdo Fraser to ask the first question. Thank you, convener, and good morning, panel. Thanks for coming along. I'd like to look at the question of the impact that pandemic has had on access to dental services. I'll start with yourself, Margaret McKeith, because I know the Alliance has done quite a lot of work in this area. Just to contextualise it a little, we all recognise that there's always been a section of the population who are reluctant to go to the dentist anyway. I wonder to what extent we've seen more access problems since the pandemic. Certainly, all MSPs will have been contacted by constituents, raising concerns about the time that's taken to get appointments. This seems to apply particularly to NHS patients, whereas private patients perhaps have found it easier to get access, but NHS patients are really struggling. Indeed, in some parts of Scotland, NHS dentistry has either disappeared entirely or seemed to be disappearing, so there does seem to be an issue with access. What do you think the experience of the pandemic restrictions has been on attitudes towards accessing the dentist and what needs to be done about this? Before I answer the question, I'll put it in context. I think that it might be quite relevant to know how we came about doing this piece of work. This was part of a 12-month primary care and lived experience programme that the Alliance was funded by the Scottish Government to undertake. Part of that was looking at the experiences that people were having accessing primary care services. Our first piece of work was accessing general practice services, and round about that time, when we were speaking to the people leading a dentist to within the Scottish Government, they were hearing anecdotally about people having concerns about accessing dentistry. That's why we were asked to do this short, sharp piece of work. It was time limited, so there were limitations around it, but we were specifically looking at what people's experience has been accessing dentistry and dental services, and we asked them to make reference to the most recent appointment. That would span the Covid period. Out of the people who responded, 50 per cent had been making reference to the experience within the previous six months, so that would be in October 2021 to March 2022, and in total 75 per cent the period between April 2021 and March 2022. That was asked when restrictions were in place and restrictions were being lifted. That was a short, sharp piece of work, so it was key themes that we were able to identify rather than specific detail. However, we found that people did have challenges accessing dental services. We can't compare how they were to pre-Covid. We just know what people's experiences were at the time, and people had significant challenges accessing dental services, particularly NHS services, because we heard from across our survey and our interviews that a lot of AEM practices were not what the understanding was, not accepting new NHS patients. We had reports from two people who said they had been registered as an NHS patient but had been deregistered during this time. I'm basing this on what people told us. We heard that there were a bit of people who were able to pay privately or join as a private patient who were not disadvantaged. There was a significant problem, but our research didn't extend to pre-Covid, so I can't compare that. There also seemed to be a huge lack of understanding around what services were available on the NHS, and we picked up some inconsistencies, whether they were actual or perceived. I'm not sure, but there seemed to be a lot of confusion around, is my dentist open? Can I go? Why can I get this treatment? Why can I not get that treatment? A level of confusion, as well as difficulty getting registered. One of the questions that I was going to follow up and ask you was the level of public information provided to people about what dental services were available during the pandemic, and your response would suggest that people just didn't know what was available? Yes, some did, but some clearly didn't. Again, the rate at an issue that I'm sure my analysis will go on to is the accessibility of information for people, particularly those who have maybe got sensory loss or sensory impairment or those whose English was not the first language. What we heard was a lack of information and, on top of that, a lack of accessible information. For the minority ethnic people, they were struggling to access the dental services by, especially those who just came to the UK prior or during the pandemic, especially the refugee and asylum. They were not able to get registered at all. They have been put in a waiting list and, unfortunately, even young children have been put in a waiting list. Even those who have been registered and moved from their location. I have one story of a Syrian family who has been located in Isle of Butte. They were struggling at Isle of Butte. They decided to move from Isle of Butte to Motherwell because they have people from their community there to receive support. When the mother was with her child, the mother doesn't speak English at all and the child is only 12 years old. There is no sort of support in bilingual support in Motherwell so they get in touch with us to help them to register with the dentist. We tried with all the dentistry at Motherwell and we were not successful. However, because it was an emergency case, we had to call the emergency line that has been published on NHS website, which is 111. We contacted them and asked if it was possible to register the case with them as an emergency case. They said, well, this case is, this person is registered with the dentist. We cannot take them. Yes, they are registered, but they are at Isle of Butte, not at Motherwell. So technically, it is very difficult for the mother to go back. There is no sort of support. You don't have the permission to speak on behalf of them. You don't have the consent. Well, I have the consent. How can I send it to you? So it was a very difficult situation to make this arrangement. Unfortunately, we put the child, 12 years old, as an interpreter to do the interpretation for the mother. However, they have been in the country less than one year and it was a real, real struggle. These stories, we deal with every single day in our organisation. We have, with all services, dental services or NHS services, although there is a huge of information on the website. If we navigate it, for us who speak English, it is not a problem. We can navigate, although sometimes it takes time to navigate this information, but those who do not have the language or their English language level is very low. It is a bit of a struggle for them. They cannot reach the information. Another case I would like to present is about those we managed to book them. They had to wait on a waiting list, and those who were lucky, we needed to respond to a COVID response questionnaire, because if you would like to visit any dentist, you need to respond to that questionnaire. However, the questionnaire was not possible for the patient to respond to. It had a lot of medical information, which they were not able to answer those questions. We had to interfere as well as an organisation to fill that gap and then play as a third party and fill that information on behalf. Again, because we were all of us working remotely from home, it was a bit difficult. We had to do arrangement for them to reach. I have a lot of similar cases because of the challenges and the barriers they face, such as IT skills. Some of them do not have IT skills as well. To deal with this, some elderly people did not know how to use phone to respond to those information. I am quite happy to answer more questions, if you want me to. I am sure that some colleagues will want to come on to that as the session goes on. Perhaps I could go to Professor Convane to get any observations. Do you have in this question of public attitudes in terms of access to dentistry as a consequence of the pandemic? Probably not any information on the actual attitudes or behaviours per se of the public. The data that is largely shared in the report are the routine administrative data that we hold in Scotland to manage the dental service. Those are based mainly on the claims that dentists put into national services Scotland and are used to pay dentists. We have a secondary purpose to look at contacts and treatment activities within dentists. I could share with you a flavour of that over the pre- and post-pandemic, if you like, from the report. I mean, if you can briefly, that would be helpful. Very briefly, the headline figure was pre-pandemic. We were in a relatively reasonably good place, with about 95 per cent of the population registered. That did mask an ILM whereby about three quarters of people were attending regularly. However, in the scheme of things, that was a high level of activity, up to about five and a half million treatment claims per annum pre-pandemic. That dropped to one and a half million in 2020-21 and has reached only 3.8 million treatment claims by dentists, so that is courses of treatment, if you like. That is a drop of about a million and a half. In percentage terms? In percentage terms, that is about two thirds to 70 per cent of 70 per cent activity. So a drop-off of about 30 per cent? A drop of about 30 per cent, but when you look at actual treatments, there are more treatments within each of those claims, so some of the treatments go higher to about 80 per cent, such as fillings, for example, so about 80 per cent of pre-pandemic levels. Thank you very much, Jackie. Could you maybe tell us how the child smile programme was impacted both at a community level and a clinical level? Professor Conway, I think that this is a question for you. Well, yes, and just to declare that we in the University of Glasgow are heavily involved in monitoring and evaluating that programme, which has been a highly successful inception from 2005, 2006 and 15 years of developing and evolving and improving, and improving child oral health in Scotland dramatically over that period. We've seen real reductions. Child smile is several things just for clarity. There's a lot of activity in nursery schools and early primary school. There's a lot of activity with health visitors and support workers who act like link workers in the community, and there's a lot of work delivering it in general dental practices as well. Across all of those areas, we're heavily impacted by child smile, particularly in nursery and schools, which, when we, in our evaluation, supervised tooth brushing programme, which had reached about 90 per cent of nursery schools participating in that programme, and that had been a significant contributor to the improvement in oral health in children, that all stopped when lockdown came in, so the end of that school year and then for the entirety of the next school year. There were lots of reasons for that in terms of access to nursery and schools and restrictions around that. There was a lot of redeployment of that. Child smile staff, 75 per cent plus, were redeployed into a number of front-line Covid activities, vaccination, so there was a lot of explanations for why that stopped at that period. In the last school year and currently, it's probably, we're back to about 70 per cent of that activity in nursery settings. General dental services in the primary care setting is impacted the same way that I was describing in terms of children's access to dentistry, and I suppose that is worthy of a common post-pandemic, while registrations, because people stay registered once they're registered, that, as I said, they were high. The new registers for the zero to twos where are not coming through post-pandemic, so that was always, always difficult to get children registered, so it was about half of zero to twos were registered pre-pandemic. That was a big goal of child smile to improve that. That's dropped to about 25 per cent post-pandemic. I mean, whilst I would always make the observation that registrations aren't activity, I absolutely agree with your concerns that if people aren't registered in the first place, it's very difficult to then make an impact. Can I teach you to maybe pre-pandemic? I don't know whether it was you or one of the others in your evidence to the committee suggested that, and I quote, prior to the pandemic, persistent inequalities in child oral health were recognised as an on-going challenge for the programme. Can I ask why that was, given the community infrastructure that you've described, which is really effective, and was child smile in need of reform but the pandemic exposed its weaknesses? We recognised pre-pandemic and even still that the inequalities in, by area-based deprivation, that measure, SIMD, that there was a difference in oral health of dental decay levels in children, and that was an on-going aim of child smile to improve and address that. We had made some inroads in that we had improved the population or would pollute the decay levels across all SIMD areas, but we just hadn't levelled that gradient, so we were tuning into what elements of the programme would better target that gradient and improve, particularly in those in the more deprived areas. Child smile is a range of universal things, such as in nursery education but also some targeted initiatives, such as the support workers linked to health visitors and deprived communities. We call it a universal and targeted programme, a proportionate universal-type programme, so it was trying to do that. Has it got back to the level that it was prior to the pandemic? No, I think that we're about 70 per cent in terms of that activity in nurseries, and when we look at the oral health outcome, the worrying statistic on oral health is that the improvement that we've seen for 15 years has stalled. The way we collected that was different, but the improvement's not continued in the same trajectory that we had been observing pre-pandemic. I wonder whether you could just, because you talked about the community workers, health visitors and high-street dental practices, how do you monitor what they deliver in the child smile programme? There's a detailed monitoring programme, so the high-street dentists are monitored in the same way through the claims system through NSS. There is a bespoke database developed by the University of Dundee Health and Informatics Centre that monitors a lot of the activity in nurseries, schools and support workers in the University of Glasgow. We analyse that data and we look at the impacts of delivering and receipt of the interventions and the outcomes in oral health. That's where we've been able to see the linkage between elements of the child smile programme and improvements in oral health. It was a real flagship programme and it has been following the work in Scotland being adopted across the world. We've been part of sharing that message. I'm very proud of the child smile programme. It was something that the last Labour Government put in place and has been subsequently continued by the SNP Government. It's something that has transcended political parties as an excellent programme. If we're not operating at the same level as we were before, what does a recovery programme specifically for child smile look like? We have a management group and we have brought a lot of that health improvement into Public Health Scotland. I remember that Public Health Scotland wasn't there prior to the pandemic, so Public Health Scotland's role in all of that has been ironed out and developed. However, we are conscious of trying to monitor that and trying to improve the uptake of the different elements of the programme. Particularly, the one that we want to get back to is the nursery supervised tooth brushing programme. I think that there are still challenges in that sector in terms of fully getting brushing back into some hesitancy, some nervousness about some elements of tooth brushing. I mean, there was a lot of issues around concerns about Covid spread, for example. So we had to redevelop the guidance to ensure that those concerns were taken care of. One final thing before—I don't know if any of the other members of the panel want to comment, but one final thing to Professor Conway, because you mentioned slow recovery of training and support for the programmes. Why is that and how urgent is it that programmes for adult oral health are reinvigorated? As the same goes for that, they are probably more in their infancy, the programmes for adults and children. They are newer programmes, five years or so. They are more focused on training different staff, such as care workers and care homes, to improve oral health. They are not as multifaceted. As I said, we are reviewing them collectively. What can they learn from child smile? It is different processes. The fact that child smile also includes the general dental services and the high street dentists is a real important element to that. I don't know if anybody has got anything to add. I think that that is okay. Some of our survey respondents made a comment to the fact that they were going to the dentist when there was a dental emergency. One of the questions that we asked was what would good dental services look like and what came across quite clearly was that more of a focus on prevention. That would be perhaps an adult version of the child smile programme, but it is a focus on prevention and a public awareness raising of the need to go to the dentist. It is around why people should go to dentists and why people should maintain good dental and oral health. It is also around what not to do, around smoking, tobacco, etc. There was an identified gap in public health information, as well as information on what services were available at how to access dental services and a lack of information around the charging structure, for instance. I think that an awareness raising campaign would be very helpful. Thank you. Anything to her? Well, we had a very good experience during the pandemic. We worked closely with Charles Myll team because part of the project was raising awareness about the health services to minority ethnic. We worked well with them because we invited them along, although it was online through Zoom, but they have provided a lot of educational services and, plus, they have advised us when we struggle where we can register those families. They provided a list of all the dentists around Glasgow, which was very helpful. The other question was from us to them, can we find any minority ethnic dentists in those places? They said that it is quite difficult to find something from the data, but the only way we can advise you is to try to phone them all. You will probably end up finding those who have minority ethnic background. Following their advice, we managed to reach a few people. I think that they are doing well, although there is some gap between the minority ethnic and the Charles Myll team, but we are trying to help them to reach these unreachable communities. That sounds very positive. Thank you, convener. Professor Conrie, can I ask you a quick question? You said that you are currently running about 70 per cent of what you were previously in terms of the Charles Myll uptake, and that it was a bit hesitant to say in the nursery education programme that we are getting supervised brushing. Is that from staff or is it from families? We are probably, to be honest, at the stage of trying to identify where those barriers and facilitators lie, whether they are at staff level, whether they are a head teacher of the unit or whether it is even an educational directorate level. However, we are trying to explore some of the ways that we can try and improve and build that into the daily activity. Using some of the examples where it is working, can we spread that word in those those that are not back up? There always were some nurseries in early years establishments that were engaged in the programme, and that was a gap that we pre-pandemic wanted to address as well, so it is an ongoing challenge to try and optimise that. Are you confident that you can get the levels back up to where they were pre-pandemic? I would like to be optimistic that we could. That is the key improvement. We are wanting to do a bit of communications with this group to say that this has made such a big difference. It has made a big difference to the health of the children in nurseries. We are doing a bit of work to see the impact on school attendance of the relationship between dental decay, the high need for general anesthetics, for extractions and time off school. There are wider social benefits to improving the health of the children, and they have been part of that effort as well. I would like to follow on from the question that Jackie Baillie said about inequalities. There always was an inequality, and I think that you said in your submission, Professor Cymru that that was increasing pre-pandemic anyway, but the pandemic has exacerbated that considerably, and the figures would back that up. The gap has grown from 7 per cent to 12 per cent from 2010 to 2020, but from 2020 to 2022 and up to 20 per cent. That is an obvious direct correlation with the impact of Covid. I think that looking at the pressures that have been put on the dentistry and reading through some of the evidence, the idea that the longer period of time between seeing a dentist means that, when you see a dentist, the treatment required is going up significantly, and therefore the time per patient has gone up significantly. It is almost a perfect storm here, and even when you speak to private dentistry, they are incredibly busy as well. It is actually quite difficult to get at a point with a private dentist. We are obviously in a situation where the system is under extreme pressure. Given that this is a Covid recovery committee, what is the pathway back from that? Where do we start? I think that it is a big challenge. I think that we have been here a little bit before in early 2000. There was a workforce crisis in dentistry back then. There was a challenge to get access to dentistry when a dentist opened a practice. There is an image that you can find out from Stonehaven, which is around the block. There was a lot of concerted effort across oral health improvement and services, workforce planning, modelling, recruitment and increasing numbers of dentists in the system. The workforce is part of the challenge. The drop does not look like a lot in the scheme of things, but it is a big drop that we have had directly due to Covid. The dental schools had a year where they did not output a whole cohort of students, so every year dental school was deferred, so we did not have the output. We have dropped a new joiners to the workforce. The numbers of dentists that are active in the workforce are down. That is a big part of that, so that is probably an important part to start on the solution. In terms of inequality, we had them before, and we were always keen to address them to meet that unmet need. It is exacerbated because there is a smaller number of appointments, and the gap between those more affluent and more deprived is stretched a little bit because the least deprived are less likely to access and are less able to get in. I am always interested in the prevention angle of healthcare in general, but in dentistry it would seem that that is something that we need to, as a long-term solution, but we have a short-term crisis. Again, looking at how we work our way out of this short-term and long-term, any of the pan-lob is not happy for anyone to speak this long-term and short-term, how do we map our way out of this sort of crisis in dentistry? I can maybe pick up on the comment about health inequalities, and I think that Covid has exacerbated, which is already a significant issue for many, and certainly across not just our worker in the dental services but the wider alliance work, where we are seeing the impact that health inequalities are having on many, many people. One thing that we did realise is that half of the respondents were not aware of the NHS low-income scheme, for instance, so perhaps having more people to have access and support to pay for dental services would perhaps be part of the solution. Again, it is that awareness raising of what is available and what is there to support people accessing services, but what came across not surprisingly, but it was not particularly happy reading, is that people saying that dental care is now a luxury for us. Somebody made comment about a scale in polish on the NHS, which is £38. That would put some people off, because that could be a weekly food bill for a family. We were heeding things like that coming through, and 38 per cent of respondents, so that is almost 50 per cent, said that no dental treatment should be free of charge, the same as other healthcare is free of charge, so that came across. Again, the thing is that no dental treatment, those are right, not a luxury, and for many they are seeing it as a luxury right now. It is not happy reading. I am just interested in digging a bit deeper, because the reality is that for many people dentistry is free of charge. What you are saying to me is that those who do not recognise that dentistry is free of charge, so that there is a marketing issue here? Absolutely, absolutely. During the work that we did on accessing GP services, there was quite a large public messaging campaign around new GP practices still open, it may look different, et cetera, et cetera, and I think that that was reasonably successful, so something around maybe a longer term campaign around accessing dental services, support with treatment, know about options available, and support for paying that, and what would make you eligible for free dental care, because I think that lack of understanding or lack of knowledge is potentially putting some people off. Imagine Dr Shelly in the communities that you are working with, that messaging would be even more difficult. Yes, although they shun right when we done that project, it was three years of challenging changing behaviour, so we tried to raise awareness about the services that are available as well as changing their behaviour, because we are dealing with people who have a different culture, so we try to understand their cultures and how these cultures impact on their oral health, so then we had to design our delivery to make them to understand how their daily practices impact their oral health, so it was quite what we have found that there is lack of understanding, understanding the system, so they don't understand the system, they don't know exactly if, for example, if they give birth, the baby has the right to register from zero, so because we engage them, we give them a questionnaire to see the level of their knowledge, so the vast majority of the group of people that we worked with, and they are the first people from different backgrounds, their knowledge was between 20 to 50, so if they reach 50, most of the people they thought dentistry will cost them if they go, and even when they register they say, we don't know that if we go every six months it's free of charge, they don't know about that, so there is a lack of information, lack of awareness, as well as difficulty to navigate what is available in the system, most of the vast majority we deal with they struggle financially, so they are living in the private areas, plus they are struggling financially, so they were not aware, even myself, I became aware about using the child smile team when they do the flotchering for the fluoride, we don't have the information that they can reach for times that year by doing twice at the school and then at the dentist because so many of them they go there, they do the routine check, the dentist doesn't offer that, so all this information was provided while we were delivering that project, so it's a bit difficult for them yes because of the language barrier, difficult for them because misunderstanding of the system and because of the digital excluded because they are most of them they are they don't use computer or they don't have even the capacity to buy computer or access or have the skills to use, so we have a complex case to be honest. Do I have time for a small one? Possibly we'll come back to it, right? John Lennon Thanks convener, well maybe I should start with a confession in that I go to the dentist when they send me a reminder, my dentist has stopped sending reminders, therefore I have not been to the dentist since before Covid, so I'd be interested to know if that is a common experience if we think, but I think my main point to start with is you've talked especially yourself Professor Conway about claims being at 70%, fillings being at 80% compared to pre-Covid, I mean is there an actual measure of how people's actual dental health is, I mean does somebody get 100 people in a room and look at their mouths and see if it's deteriorated over the last three years or because with children I think there is a measure of decay as I understand it. Programme in primary schools, yeah the national dental inspection programme, primary one, primary seven, we've got good data, adults not so good, limited to some questions in the Scottish Health Survey which is self-report and so the measure that we pulled out of that is really whether people have no teeth or not so the dental is really the end game of poor oral health, so there's very little adult oral health information. I think there's an opportunity to collect that in primary care routinely and we've thus far not taken that opportunity to capture diagnostic information like you would in any other health context so you could get simple oral health information from that contact in the moment we're just left with like you were saying just the treatment so the activity rather than the health, something that's a gap. Yes and so that takes me on to kind of well what can we do about that and also well first actually before that then it's so we can assume that for quite a lot of the population including myself our dental health is deteriorating and perhaps we'll continue to deteriorate for the next few years until that 70% goes up again. I don't know if we would definitely know that but yeah certainly over time it would generally deteriorate without any intervention and prevention as was asked before actually it's a really cornerstone of what dentistry is and should be about as well. So I suppose my next question then for all of you is where should we go from here? I mean the government has said in its response that they plan to continue the blended system of payment with listing all the different things fee per item, capitation, allowance and direct reimbursement payment. Should we be moving to more like a GP system where they're paid a much larger amount for? I think the actual costs and the payment of dentistry is probably a bit beyond my expertise input to be honest but certainly on the prevention side which is where I'm more interested I've totally agree with the previous question that prevention is a route to where we should be prioritising. Child smile is an excellent example of trying to do that really right. We did some modelling so it doesn't come for free but even the brushing programme costs approximately £2 million per annum but we realised within five years £5 million of savings in reduced treatment costs so it's a case study in preventive spend so you invest but you can realise these savings and I think dentistry per se is an untapped potential for prevention. There's a lot of common risks between what we do in dentistry what the risk facts for dental disease like gum disease is the main risk factor smoking so actually a really important role for dentists to deliver smoking cessation do that properly get that reimbursement so in terms of reimbursement I would be investing in some of that prevention rather than just always on the treatment side. Okay I mean I take your point the financial side's not your primary area of expertise but it obviously has an impact and I mean some of the information we've been given it's sounds like the NHS dentistry is dying and the private dentistry is growing I mean if we ended up with private dentistry full stop would there be any prevention then? I mean that that's the big gap in the data this private data the level of private activity we don't know whether that is filling that gap or whether it's not completely filling it I mean I think maybe you've got some survey information on that. Yeah again but again our survey was very very very small so I wouldn't deem we only had like 91 respondents took to the survey itself and out of the 79 were registered for NHS dental services four were had a private dental plan one who responded was unable to register due to availability of NHS services and two had left their practice as they're the two who were unregistered as they're practice was no longer seeing NHS patients so out of the people we who responded to us 79% were registered but that's no way I've got no way of knowing how that what reflection that is on the national stats. Can I just check if this survey has been published as yet? No it hasn't it hasn't been published yet we're hoping we're still sort of in discussions with the primary care team within Scottish Government who this was a piece of work sort of commissioned by them as part of grant funding and we know we there were sort of two in flowing with with the survey itself and we were just sort of still waiting for that formal sign-off but we're very keen to publish it yes I think that'd be helpful very keen to publish it and that's why I wasn't able to share it ahead of this this committee. Okay I understand that so I mean looking forward have you got views on that as well do you think I mean we just tidy up the present system or is it do we need something more major than that? I think my own personal view based on my own experiences and based on what we've heard during this short piece of work is I think the public radical overhauls perhaps required. I think there's there's a there was something people who did respond generally people who respond to our surveys have got a strong feeling either way they're either very happy or very unhappy and one of the what came through in some of the free text was a concern by by two or three I think what three people have said that they're seeing I think desecration was the word one of the the respondents use of NHS services and the creation of a two-tier system and having fears of a move to a completely private system and the yeah so that we didn't specifically ask that but that people volunteered that that information them themselves but do you have views at all about on the financial arrangements or is that not your scope? I think there's not no no that's not that's not our area of expertise and we didn't we were more interested in asking people what their understanding of the charging structure was not what the what the charging structure is because I'm not I'm not fully understanding of the charging structure. If I could come to you dr. Shelly do you think I mean you've talked a bit about more information we need to get more information about the present system so is that what we need to do or should we actually be changing the system? I think it's changing the system to be honest because I will present a case okay this happened during the pandemic again the case was a she she had a she just registered with a dentist she know her dentist she contacted the dentist for emergency because her filling was falling and then the the dentist said you are an NHS patient we we are sorry we cannot take you but I am I'm suffering I I need emergency treatment and I said well we cannot book you under the NHS because an NHS exact the word what they said because I was in the middle of the conversation it's on hold at the moment what we can take do is to book you with a private and they offered offered her a private an appointment private appointment the following day that was a bit disappointed for me a second second case was a bit similar but a there was a the cost was a bit high they said we the treatment is not covered with the NHS we can we can give you an appointment we can give you a price for the private and we can take you immediately and that was again it's a bit disappointed how come as a as a dentist you refuse to take me under an NHS and then you what is the policy so so do you think how should we change the system should it become more like a GP that there's virtually no private GP work and it's all in the NHS to be honest is I have a comment about even gps because I have okay we'll not go there we'll not go there so I don't want to go for that but I think is as a as a patient I need to know my right and I need a policy that protect my right and I need the dentist know that's my I know that I have the right to go for the treatment under the NHS and you need to offer me that I don't know how we put that in practice it's a bit difficult right okay thanks so much if I can just have a final question one of the new things that seems to have come up is vaping and I just wondered professor conway is is there any evidence that vaping is causing harm to especially young people's mouths no no evidence that I'm aware of in fact we've got a trial or we're involved with a trial has been led by Newcastle to do smoking cessation in dental practices dental settings where there's three arms of this trial prescribed vape starter kits e-cigarette nrt and brief intervention so we'll be looking at which most effective at reducing smoking cessation but also as part of that we'll be looking at the gum health associated with these different interventions obviously smoking is very bad bad for your gums and your own health and we'll be looking at vaping as part of that study okay thanks so much thanks okay Brian you had a shorts up yeah I think you know we're trying to look look forward from the decisions that were made during the pandemic the impact on dental services I think you know hindsight is 2020 of course but trying to understand what we would do in a similar situation do you think there restrictions the interventions were were correct or appropriate of given where we are just now the impacts in the slow recovery with the decisions made the right decisions looking back at the time when the decisions were being made dentistry was at the top risk occupation for covid we're right in people's oral cavities and auto phanics and aerosol generating procedures so there was a real uncertainty of how that went and how much we could do to to mitigate it so the the infection prevention control measures were very high bar the PPE was very high the restrictions were were really I think I think they were right and then when you go back in it actually we didn't we we didn't see the the huge numbers of infections certainly we couldn't necessarily identify any from from patient to dentist and that's not to say dentist didn't get covid and but we couldn't necessarily identify that that link across so they were they were right and strict and then it was how we went back but I think there are lots of lessons for future pandemics about like sector specific like how you would prepare for that how you'd prevent it I mean some of the things like the ventilation of dental clinics was something that we probably took our eye off the ball if we're being honest and actually should should have been like a perspective of pandemics that actually ventilation is an issue in dental settings so I think there's there's a lot of lessons to do that I mean there's a lot of good road the dentist did step up in a number of different areas like surveillance and vaccinations and there's other actions that they took part in so it is that balance of the direct covid support activities redeployment versus actually keeping some of that service on the road and I mean again it was a really amazing effort to get while dental practices stopped to have 70 urgent dental care centres established across the country for emergency care I mean this is at a time when no one was leaving our houses so some of that work was was impressive in the heat of that that decision making I think the difficulty has been coming out of that I think it's just taken us an awful long time and then all the other things that come come with it just on that coming out of it and I fully accept that I got that question that was it proportionate at the time for me it was absolutely hot that's the only way it could have been done because you're spraying people's mouths and stuff's going to go everywhere so I understand that that was absolutely essential but it's the recovery part that I am more interested in at the moment did you lose dentists through covid as a result of the stress that that put on them because I remember going to my dentist and they were completely PPI'd in masks going about with huge gloves it looked absolutely I was in there for a half an hour and felt awful and they were dressed and full matt has and they were like that all day so how many people actually dropped out of the profession I don't know that okay but there have been there have been people left yeah in terms of that 190 and the other workforce so there's lack of new joiners to the system but obviously some some leavers as well or early leavers you know so yeah that that that work has continued to be monitored by by nest to look at look at that okay in getting people back in you also said earlier on in your evidence that the dental school output you weren't getting enough new dentists coming through the system how do we sort that is there is there a way to increase the numbers of people that are actually in the courses that can be finalised and brought through or are they just not wanting to go into dental practice no there's no there's no issue with the numbers and filling the numbers of dentists dental school places the main thing I was saying was we had one year where we didn't have an output so they didn't graduate and they didn't go into the system and go into the NHS after that that was a that was because they didn't they couldn't get the experience in the training so that was happened to every every dental student across scotland but there's not an issue like recruiting but all I mean is that first time we did increase the the numbers of places when it increased the the numbers of dental places to meet that demand and also there was other activities around trying to recruit dentists from from overseas from european union very proactive around that and whether that's similar types of measures might might be required to increase the workforce okay and where is the workforce just now in terms of what it was pre-pandemic to what it is at the moment as far as we can tell it's 190 it's not exact headcount but it's 190 less dentist claiming activity right okay and are those posts that you're actively trying to to fill or is that people going into the private sector and just not claiming anymore or there could some of them could be some of that number could be completely opting out the NHS we don't know that right okay yeah absolutely yeah thanks very much the pressure coming just on this question of training you said you know there's no difficulty filling the places do we have enough university places for dentists at the moment I wouldn't give you an answer to that but I think that that could be there could be a bit of modelling done to work that through be in mind that that lever is quite slow yeah please turn it on in your five six years maybe seven by the time you make the decisions and get that through so it has to be other things in the interim as well okay thank you okay anyway else get any other questions no right okay thank you very much folks that would exist to the end of that session um giving us a lot to think about um so I'd like to thank you if you would like to raise any other issues then the clerks will keep in touch with you if there's anything else that you want to bring up with us give us any more information and I'd like to thank you very much for your time and I will now suspend this part of the meeting we will now continue to take evidence on the inquiry I would like to welcome our second panel to the meeting Adele McElrath the interim director of dentistry and the dental practice advisor at NHS Borders Anthony Visokie the director of dentistry at NHS Shetland and Dr Declan Gilmore the director of dentistry at NHS Tayside thank you very much for giving us your time this morning on zoom now we estimate this session will run up until about 11 20 and each member will have approximately eight minutes to speak to the panel and ask their questions if you'd like to respond to an issue being discussed please type r in the chat box and we will bring you in and I'm keen to ensure that everyone gets an opportunity to speak so I apologise in advance therefore if time runs on too much I may have to interrupt members or witnesses in the interests of brevity and I'll now turn to the questions and pass you over to Ash Denham Ash Denham my apologies Ash thank you convener and good morning to the panel I'd like to start by asking about funding so this was funding that was allocated 2021 2022 to support the recovery of services so five million was made available for ventilation improvements and then in 2021 7.5 million was made available for the purchase of electric red band handpieces and motors so can I ask did the funding improve the availability of practices to see more patients and did it build in that long-term resilience into the system do you have somebody in particular I think um Anthony I think you're indicating that you'd like to come in that's a good morning good morning community thank you Mr Reagan um the the funding was primarily targeted at improving the ventilation to a required level in order to improve access or to improve the amount of follow time which was the time that had to be left in between patients after generating aerosols so that was that was something that certainly improved the the access and will have a legacy long-term from the point of view of him having the the surgeries and the practices that that air changes that was that was required for these procedures was is something that's now there and is there as a legacy the electric motors was something that certainly was a help to begin with and a lot of practitioners used them in order to try and improve patient access and by improving patient access what I mean is actually by seeing more patients per day when they were able to before these before these fundings were available having said that electric motors because the restrictions are now reduced or removed altogether then the electric motors are not particularly giving giving any more access than they would have done prior to Covid okay thank you anyone else on the panel that would like to come in on those points emory ash okay so should there have been funding provided for for other measures because you're saying there that the electric motors perhaps wasn't maybe as helpful as it might have been so other measures that might have improved that rate of recovery of services and looking into the future now as well in terms of funding for support or reform is there other other types of funding or other issues that need to be funded in order to to move forward into the future just put your hand up we'll go to Declan yeah Declan can you go ahead please hello nice nice just responding to your to your comment on your red banded handpieces weren't maybe as useful as we may have hoped I would say it was it was a reaction to what our knowledge was at the time and it was probably something that was very very welcome and very useful at that stage so I wouldn't want it to seem as though this was money that was not well used or well-purposed and you know so going forward as well you know these these handpieces will still be utilised within practices for treating patients not in the initial way that they had been intended in terms of reducing the amount of time in-between patients and increasing access but the actual day-to-day dentistry these handpieces will continue to serve the provision of NEHS dentistry so I wouldn't like to think that money has now been wasted in any shape or form and in terms of future funding I think you'll be aware that there's a new statement of determination remuneration for the USDR for dentists so a new pathway in terms of remunerating the dental professional and general dental services and this is something that we've not got full insight into at the minute. We currently have Scottish Government and the BDA in negotiations and talks and we're waiting to see what the outcome of those talks and negotiations are and you know we'll hopefully find that that is those are talks that will help to retain and recruit more NEHS TDS services work within Scottish dentistry. Okay thank you that's very helpful Adele I think you wanted to contribute. Yes absolutely good morning panel it's really in relation to your question about funding I mean currently our blended payment model which really does it is comprised of item of service as already discussed and obviously the fees and allowances I mean there was a 30% uplift in one of those specific allowances the general dental practice allowance which really did support many practices within NHS borders for which I can speak of. The current situation the current climate within dentistry has really significantly changed and that would really be in relation to dental inflation the cost of providing primary care dentistry is very expensive at the point of delivery so lab fees for example have completely and utterly astronomically in many cases risen to an untangible level that practitioners and practice owners are really struggling to look at dental materials and staffing increases in wage which is arguably your biggest expenditure on a monthly basis if you're a practice owner so the new payment reform is indeed incredibly welcome is required and will be very positively taken the issue of dental inflation however is still something that perhaps would cause a concern for the future so I'm not quite sure what additional funding could be available. Okay thank you and I think Anthony wants to come back in as well. Thank you it was simply to maybe further qualify my comments regarding the electric motors and to echo what Declan said I think at the time that they were made available they certainly did increase the ability for access and to increase the amount of patient treatments being able to be done and certainly they're not going to sit galling dust long term they will be used on-going within NHS dentistry I just think my point was more to do with the specific relation of these on-going access in the future but it was very welcome at the time and it certainly was done from my understanding with the best of intentions in order to help dentists and help patients access patients. Okay and your views on whether other measures that should have been funded to improve that rate of recovery and you know other funding for the future? Well I think at the time at other measures I think that that would be very difficult because there was so there was so much restrictions on what we could do amount of patients that could be seen within a dental practice or within any setting at the time so the sector was really working at its optimum level given all the restrictions at that point or certainly as a general term it was going forward it's touching on what Adele said you know there has been a recognition that the system we're working on needs to be looked at and that's a historical issue that perhaps was highlighted during Covid and gave an opportunity to review and take stock and I understand that's on going at the moment with a view to a new payment system going forward in the relative of the near future I understand it's under negotiation at the moment. Okay thank you convener. Thanks very much. Thank you convener. Good morning to the panel. I'd just like to explore the support that NHS boards give to dentistry services more generally because we're in a quite strange situation are we not where dentists are independent contractors and yet as NHS boards you've got responsibility to ensure the general health of the population which is delivered through this kind of network of in effect you know independent businesses. So just to give you an example I'll maybe I'll direct this first of all to Declan Gilmour so just to put it into context either constituent came to me last week for our practice in NHS Tayside that this constituent is registered with a NHS practice in in Perthshire and it's just been told that she won't get a six month check-up that she's been used to but the practice is moving to a 12 month check-up and as we've already heard this morning actually she's perhaps one of the more fortunate ones because some people don't get any check-ups at all if with her NHS dentist but I'm interested in exploring what exactly what is the role of the health board here you know what do you do actually to make sure that there's good access to NHS dentistry in the areas which you have responsibility for and I'll start with with dr Gilmour hi there so well as you might be aware that there's no legislation to it's different to our doctor colleagues or general medical practitioners that the health board is not required to ensure that there's dental provision in the same way to that end though in terms of provision of dental services you know there's a wide blanket here in terms of provision of public dental services which has the remit in terms of delivering child smile and caring for within the tyside area anyway delivering dental care within our nursing homes and our care homes and delivering special needs care within the children community through to overseeing our independent contractors as well in terms of ensuring safe care for our populations within tyside and across Scotland as well of course health boards are responsible for ensuring that practices deliver a safe and working environment and working to certain standards within a framework called the combined practice inspection which is a large part of our governance within practice and that's within practices that are providing NHS dental care any practices that are purely private they have to go through his to ensure that they're sort of ticking all the correct boxes in terms of delivering safe care and within tyside itself we're aware that there's an access issue you mentioned the patient that is going to 12 month check-ups and that's potentially you know sort of quite acceptable and sort of the dentist has done an assessment on that patient's oral health and has deemed that 12 months we recalls are satisfactory to ensure that that patient maintains oral health and I wouldn't have any argument with the dentist in that situation. Beyond that tyside we know like all health boards across Scotland presently we're aware there's an access issue in terms of NHS dentistry and to that end we have set up a task force that involves or combines people from the dental or the health board executive, myself, primary care, Scottish Government and our finance department to sort of see if there's ways that we can facilitate access but for ourselves we're really one of the big problems we have is and it's already been alluded to in your discussions with Professor Conway is the recruitment problem so at present we have empty surgeries within tyside and that's seen across you know again other health boards we're not unique in that respect and we do not have enough staff dental staff to fill off the available surgeries and that is one of the problems that we have. Again it's also been discussed earlier on that people have maybe taken early retirement post pandemic or maybe had lifestyle changes just made lifestyle choices that they're going to work work less hours and these are the sort of challenges we're facing within the health board at the minute trying to address it discussing across the board as to sort of any other fatal ways that we might be able to help but without more more dentists to fill all the surgeries we will find this challenging. Okay thank you to either of the other witnesses want to add anything to that. Yep Adele. I'm muted. Yes absolutely I mean health boards we have absolutely no role or oversight into having to or been able to have even have a say as to what dental practices who registers what patients how many NHS patients the only role that health boards actually have nationally is to offer emergency and unschedule care to those who can't access GDS and also obviously the core remit of the PDS is slightly different with slightly different targeted patients. However within NHS boarders and at you know feedback from regular area dental committee meetings which are very well attended by all of GDS NHS boarders it really has been highlighted to myself very clearly that the barriers that are faced by many are very my rad and in function there's workforce issues there's the ability to to recruit on all aspects of the team there is also the changing demographics within that many people have reduced their sessions or reduced their commitments to actually work the business running costs and the actual costs of being able to deliver NHS dentistry currently within the rigid free NHS structure has been identified as a barrier there's certainly been no practices within NHS boarders that have identified that they wish to reduce their NHS commitment that they don't want to offer NHS care but they quite simply and it has been reported within every DC have had to look at augmenting income streams to be able to continue to deliver that NHS care to that end when I was appointed in July 22 as the director of dentistry on an interim basis I completed a survey with then we had 16 NHS GDS practices to further understand what was happening with the workforce because again the these are independent third party contractors the health board has no oversight who's employed where how many people are employed that's you know that we have absolutely no oversight of that and of that survey that I sent out I received 12 responses which was quite a good response rate and all of those 12 responses every single practice at that time reported significant and retracted recruitment and retention issues on all levels of staff they also reported that more than 67% had reduced their NHS availability to deliver NHS care now that may well be because they've had to augment their income streams or indeed the work-life balance which really has become apparent post-pandemic or potentially both of those and that also more alarm in the morning more than half intended to further reduce their NHS time commitment sessions not NHS commitment but the time available to deliver NHS dental care okay thank you thank you very much Adele I don't know if Anthony Vosochew wants to come in from NHS Shetland but I wanted to ask a follow-up which I'm interested to get your perspective on Adele and others and that is you talked about the role of health boards in providing emergency care has there been a substantial knock-on impact therefore on the hospital dental service because we're seeing this problem of access so can you can you talk about the experience there please yes so in NHS borders our public dental service has actually had to remobilise their own services and also devote some significant time and manpower to being able to support access to unscheduled and emergency care so yes the remobilisation of NHS borders public dental service for their core remit of patients that's patients with special and additional needs of complex medical conditions has been much more stagnated we also in NHS borders have a much higher percentage of patients that could actually be registered within an NHS GDS setting as a legacy from the last access crisis but we cannot look to rebalance that because we have nowhere at the moment access is very challenging and quite frankly precarious within NHS borders so we would have nowhere to be able to place these patients the increasing demands that have been placed upon the pds to you know undertake domiciliary care is really increasing as well so in terms of what the health board can do though and in terms of what we have done pre-pandemic we had completed an oral health needs assessment now that needs assessment really does set out our challenges it gives us a focus and it sets us where we're going to where we want to go where we need to go device 10 priorities which we've reviewed and decided that they are still completely and utterly relevant those priorities obviously ranging from ranging the profile of oral health to meeting the needs of our raging population to maintaining and improving access to maintaining and improving recruitment and retention to to look at the structure of our pds the workforce in our pds and very importantly actually an engagement between the wider dental community the dentists and their dental teams and the most important of all the the patient and all of the public that we serve so we really look at that and we're really working on that and as part of that work which has helped us to be able to target our child smile return it's really helped us to look at community mapping within our services it's really helped us support a very receptive cd office when i've approached them on two occasions to increase our sdmi application area which was to further support access and widen access within our board area so whilst i appreciate the the actual oversight as a board that we would have over an independent gds contractor there's a lot of work that that goes on there's a lot of communication there's a lot of open discussions and in a board like nhs boarders which may have a large geographic area we do actually only have 19 practices now one of those is an orthodontic practice so a very approachable knowledgeable um basis is formed with all practices yeah maybe just see the others want to come in i just i don't have any of those want to say anything about the the impact on the hospital dental services or emergency care yeah answering this okay yeah yeah thank you so um i think um i'd like to draw a distinction between the hospital dental services which are a secondary care and the public dental services which are directly directly um provided by health boards and i think that's probably what we're talking about here um but yes in order to echo what um Adele has said that the public dental services have had to initially were the initial real mobilisation of the dental services in entirety and then they moved on to um providing this which is commonly termed a safety net for these unregistered patients um which can't access unscheduled or emergency care and and frankly the public dental services is neither um funded for or set up structured for this type of care it's it's set up for what they do which is the special care the the priority groups and therefore that's had two effects in my opinion it's had the effect of taking the focus of the public dental service away from these priority groups and also not being able to provide the the volume of treatment that is expected in general dental practice because it's a different a different demographic of patients um and i think it's been um it's been that the public dental service has stepped up really well but i think they've been asked to do um work that they're not necessarily structured for if i may can i comment on a couple of points you made earlier um so yes so just just to um say that you know that going back to in more general terms we are working in a very unique funded model um and it's it's i think the frailties of that can sometimes come to the fore and that's where what was talked about earlier about the oversight of of BORVs over independent practitioners which is can be can be quite limited um i think the um not not to sort of make this too shirtless specific but the reason i put in the evidence i submitted was to look at changing the balance within NHS Shetland in order to try and address that specific problem which is not necessarily the answer for many health boards but certainly um we believe it's the answer for our health board um and finally just to touch on your constituent that mentioned about the annual exam i think that's something that um we're very wedded to this six monthly exam and i think there's been a lot of evidence and certainly clinical guidance from the nice guidance a number of years ago to say that um the the frequency of recall examination should be patient specific but i think it's it's in our national psyche that we need to go in every six months so actually being advised you need to go in annually is not necessarily to the detriment of that patient and i think there's a there's a bit of work to be done both from the profession um in order to um give that message to individual patients but also in general to say that you know some patients need to be seen regularly less frequently some patient needs to be seen more frequently and i think possibly in a smaller context but it would that would come into the ability to recover so rather than starting to recover to see every single patient every six months which is a big ask it may be that you know this um this sort of divergence from this rigid six month check-up that people are used to would actually help access okay thank you understand Declan you'd like to come in yeah to be honest i think Anthony's really covered everything i was going going to say there and maybe just to again re-emphasise the difference between the hospital dental services being different to emergency dental care which is largely provided sort of a again a blender type system between public dental services and our gdps come on come the weekend okay Jackie would you like to come in yeah i want to pursue what the board is responsible for in terms of oversight and it was something that that um Anthony touched on um it so i'm keen to know so for example take scale and polish um first line prevention one would think um 59 percent operating at pre pandemic levels so there's still a way to go to recover that service in terms of the board do you have any oversight of that is that happening in your area can you take action or does the problem belong to somebody else and i'm happy to go to shetland first um thank you um so so specific items of treatment are are um uh decided on clinical judgment and that clinical judgment is um when a patient is seen by the need for that patient or the needs of that patient are assessed a treatment plan is discussed and completed the oversight of a health board on on that individual micromanagement i suppose you would want to say is is almost nil what a health board does is um provide make ensure that anybody who is um applying to provide nhs services within that health board is appropriate has the passes the appropriate applications they are then um randomly monitored from the perspective of the treatment they do there is a deckland touched on the three yearly combined practice inspections which ensures that the treatment is carried out and in a safe and appropriate environment so the health boards um oversight on this sort of thing is far more global than than specific to an individual treatment the needs of an individual patient okay let me clarify then i'm not talking about needs of individual patients i'm talking about preventative measures that we know have an impact on the population so let me illustrate it in a different way we know there's the there's a growing inequality between children and young people registered with dentists actually participating in their local dental surgery um prior to the pandemic well in fact in 2010 it was seven percent um that gap is now 20 between the the least well off areas in the most well off areas now that's a huge inequality in attendance levels do you get involved in monitoring that trying to adjust that you're shaking your head no no not really i mean it's it's something that you know we look after the registrations we ensure that the people that the dentists who are registered to are listed to provide nhs care to register patients for the guidance but again it's not something that we would have an oversight of obviously there is within the guidance and within the fee structure there is the ability to provide preventative care and child smile and there's been additional fees added to the fee structure over the last couple of years in order to try and encourage that but that's that's the limit to the the amount of oversight that we can we can see where we can give okay can i just sense check that with the other boards i take it you're in agreement with what's been said by shetland yep i'm getting nods thank you um one final question from me it so the Scottish Government have committed to abolishing all dental charges now given the challenges that that you've outlined dentists leaving the nhs not enough staff people making lifestyle changes and given that the service is not operating at the level it was before how possible do you think this is and how much extra resource do you think would be required can i go to taste side first there's a there's a deep and difficult question to answer um resources i think i'd like to think that the alanthly would agree that it's it's numbers of dentists that we're looking for first and foremost we need to need more of those um that one and again adel touched on it very eloquently earlier on and i didn't touch on it but spoke in detail uh that the new sdr needs to look in such a way that it attracts dentists and retains dentists within within the system personally speaking i think one of my greater concerns is that if the new statement of dental remuneration isn't attractive to our independent gds colleagues um that we will see a further um transition away from nhs dental provision towards private dentistry um and the resulting consequences there so my greatest concern at the minute is that the new sdr um is such that it keeps dentists nhs dentistry within um the provision of gds and uh if we don't do that if you don't focus on that um you know it doesn't matter how we think around the edges in terms of um providing access via general dental services or hospital dental services which exist more in Dundee, Edinburgh, Aberdeen and Glasgow um there's only so much of the fallout of that that um they they can they can cope with and thus thereafter there's the the problem that their core limits the things that they have to deal with in their secondary and tertiary care um that they are actually not able to them meets their uh obligations on that that respect so it's a push very hard um to ask bars that be uh to ensure that the new sdr is as attractive as possible uh to um retain uh dent dentists within nhs services uh again Adele touched on um the dental inflation uh whenever she's speaking earlier and uh i know within the report there there's an example there of uh it wasn't actually terribly accurate the report that was uh common from one of the the dentists talking about denture fees and that was actually uh i'm pretty sure that we're referring to denture repair fees and already the right of date because inflation's taken that further away from those um those numbers that were mentioned within our practice we get 21 pence and 10 pence for a dental repair and our lab um charges us 32 pence um including their collection and delivery fees so we're we're losing money in every dental repair we do uh denture repair we do for for patients so these are the sorts of things that are you know sort of a barrier towards uh dentists continuing to work and provide services within nhs gds so that strikes me as a rather long answer to say that until we resolve the problems that exist then any question of abolition of charges is probably for the birds um i see you nodding Adele would you like to add anything to that yes um yes um hugely supportive of exactly what deckland has said um to abolish nhs patient charges i would see actually is a very positive move i mean to remove a significant barrier for so many people to be able to access care can absolutely only be positive um the real issue with dentistry primary care dentistry and gds at the moment um is deeper than that and there are more it's more my radar in function as i've tried to explain so dentists being whether they're paid in 100% from the government or 80% from the patient um would not make a dentist leave or stay within the nhs and i can speak for the nhs borders practitioners that i speak with often there is a reluctance to have to augment income streams to maintain the level of nhs provision there is no nobody wants to deliberately go private to my knowledge for that you know for that basis it's patience it's patient care it's that's what dentists generally want to deliver at a very high level absolutely thank you all very much thank you okay thank you jackie i'm going to move on to john now and i'll come back to you just because this john steen kind of follows on thanks so much convener um so i mean there's been a lot of doom and gloom obviously rightly around the pandemic and all that's happened i just wonder if anything good has come out of the pandemic as by way of like lessons we can learn for the future dr gilmore i suppose if something similar was to happen again we are probably better placed in terms of how we respond to that that would all depend on uh sort of i suppose the potential type of virus or that that was to maybe arise in the future in its form of transmission as to whether um the measures we had in place this time were still suitable for um for for any future pandemic but again that's doom and gloom let's hope that doesn't happen um one very positive thing that we've found within certainly within tyside was the relationships between our fellow general dental practitioners and also our public dental services as well and our hospital dental services we've got a much better um understanding of um sort of how each different sector works and um that has arisen from probably working within the dental hubs whenever uh they were created for one of the better word at the start of the pandemic to deliver emergency care at the start of the pandemic and so certainly something very positive from from that perspective i would say personally speaking again i've just you know very new to the role of dod and also dental practice advisor um but i would say that our relationships with Scottish Government and policy makers and that within um that sector have improved there's greater communication during that time time as well i don't know if my colleagues would uh would feel the same way but i personally think that that has been a positive over the last number of months that's positive miss macklerath yes i'm unmuted absolutely one of the things that i was going to put rts in to speak was actually the team environment the communication that has greatly improved between gds and pds that shared partnership which is part of our oral health needs assessment and i hope to develop that in the future shared care pathway um has really been paved during the pandemic the communication with the cdo's office and the deputy cdo's as well i completely agree with declyn has been absolutely fantastic in the relationships that boards have been able to make with cdo's office as well one very good news story however that's came out for nhs borders is with the cdo being so receptive to hear the issues and the precarious concerns that i had about access within nhs borders and could evidence um we have very successful sda grant allocation scheme we've actually had two new practices um that have actually opened within the past year as part of that scheme we've had a third application which has been approved for our practice you know the acquisition of an existing practice which will safeguard the nhs dental care provision that's actually offered at that practice with a further extension of our sda area to now encompass the entire board area um i am aware that i have another two applications imminent both one is to move an existing surgery and expand and another one is to expand a current surgery now there are still issues with recruitment concerns with recruitment and it is worth noting that of these two new sda practices that have opened the slots one of them kind of had more than 7 000 patients applied to be on the waiting list before they were even open with no advertisement so they can no longer register any more patients until they can actually recruit and the other one is really struggling to recruit they have two dentists there they're really struggling to recruit and with the fee structure and the rising dental inflation is having to consider augmenting their their income stream and still maintain the nhs commitment as per the terms and conditions of that grant but having to look at other income streams appropriately there so that there are good news stories there are good news stories um but there are still the challenges that exist can i just clarify a couple of points based on that answer um do the the two new practices are they taking nhs are they mixed practices that will do some hn nhs and some private and on the recruitment point who sets the the wages and salaries for dental staff is that um each practice or is there any uniformity no so that's each practice gds independent gds they are third party businesses so the owners will pay their staff what they decide to pay their staff they will organise a specific percentage with their associate dentists as well which is you completely unique to them to be able to do so and the health board has absolutely no oversight over anything to do with that at all it's not part of the agenda for change that perhaps we would have in the public dental service there in terms of um taking on new patients i mean of these two new practices one is taking on new patients the other one can't until he actually gets some more people to come and work for him because he is literally um has seven thousand people wanting to register for him and possibly growing as well um in terms of private nhs almost every nhs gds high street dental practices a mixed economy practice you know if you do one white filling and in essence you would be a mixed economy practice the public dental service can only offer what's available within the remit of the sdr general dental practices can offer that and other treatments should the patient wish and should it be suitable for the patient okay thanks i might come back to you on that point afterwards but okay mr wasachi um shetland you're a bit smaller so i'm guessing you're all friends with each other so did did you gain anything out of the pandemic positive um yes we're all very friendly up here um so i think in general terms there was always because of the the nature of the of the the size um of the of the area there was always a more of a informal relationship than there would have been in bigger boards for that reason you know just that that that um that possibility but i think going back to what's been said earlier and and certainly i've i did some work or do some work with 4th valley health board as well and know that one of the biggest positives out of the pandemic has been this increased collegiate working environment that we all have both within health boards between health boards um and also between health boards and the the chief dental officer office so there's been an awful lot more communication an awful lot more contact with each other in order to try and um work our way through these um these challenges that we're all faced okay thanks and my other main question is going forward should we be trying to change the whole system and i think from your paper from shetland there is quite a desire to change it um partly because i think you've only got one private practice if i'm correct so to start with shetland then would you just bring the whole thing into the public sector and get rid of the private sector in a word yeah well not get rid of the private sector because there is a there is a role for it um but um i think so in general terms going back to what's been spoken about already is that we have a very unique funding model in that where the the 80 percent of the provision of dental services nationally are provided by independent contractors now these independent contractors have um have have their fees set by a third party so that just touching on what you said just now about you know what does a health board have on that how do they how do practices pay their staff out all this and they all have different overheads they all have different you know the overheads in in borders are different than central Glasgow they're different than Inverness they're different than than shetland but we all those that are providing NHS services work to the the same fee structure so as an independent business that that can be quite restrictive so that's where the the mixed economy practice really is is a must in order to make sure that these practices are viable with them with going back to the the evidence i submitted regarding shetland the the structure of the majority of dental services being provided by general dental services i.e. the high street dentist for want of a better phrase in the majority of other health boards relies on their being a significant robust framework of high street dentists in order to to provide that so if for instance in Glasgow there's an excessive or greater Glasgow and Clyde than an excessive 200 dental practices so if there's a if there's a follow-off in one or two the the the body of the gds still can still take on the majority of the work the problem that we've had in shetland specifically is that over the years there's been an attempt to replicate that but you've been sort of working from a standing start so there's not the the structure there to take on the the the lion's share of the of the work and therefore rather than going down that road my proposal and certainly i'm still in discussions and very positive discussions with scots government and with the cdo is that we are a little bit more in control of our own destiny in an island situation and we take it more we take the services more under the under the umbrella of directly directly delivered services from the health board rather than relying on independent practices and the the challenges they face and the other the other reason for doing that is that you know it's it's simply not feasible for somebody in shetland that can't get to a gds practice to drive to another health board to be seen whereas they may be able to do that in a mainland health board so that there is a specific or a unique situation there that this new model is right that's great i appreciate that that it is quite unique in in shetland dr Gilmar can i move on to you i mean should we be thinking radically of changing the dental system to more like the gps so the gps almost 100 percent do work for the public sector and drop the private side it requires such a radical change of how we provide things just now and presently there's a restriction on what can be profiled via the statement dental remuneration in terms of dental care and that would then have to be funded in such a way that it makes it attractive again for people to stay within dentists to continue providing general dental services within the nhs which would require a significant monetary input from Scottish Scottish Government and at present we've got a new statement of dental remuneration that has been we've got the side of it just now and the main issues that we'll have going forward is will it be properly funded and remunerated to continue making it attractive to gdps and i think personally at present it's maybe best way forwards maybe evolution rather than revolution might be the the phrase to take forwards there and complete the smantling of the system just now i know that some would definitely argue for that but it would have to be funded in such a way that it keeps dentists within the nhs services and then you'd have to make decisions as to do you include dental implants within such a service and i think that'd be very hard to bring within a new structure as well but my feeling on it at the moment would be revolution rather than revolution okay um get the last miss mackerel rath that question as well very quickly your sorry if i can just ask you for a brief response miss mackerel rath would you agree with dr gilmar i completely agree with dr gilmar that's great that's fine right i am going to come to you but there's one thing i'm just looking for clarification from your dealt if that's possible the grants that you were talking about i presume is that the the 100 000 pound scottish government grants that allow you to set up a new practice yes the scottish dental access initiative that enables you to either open a new practice by an existing practice or extend your current practice to widen the access to nhs dental care thank you it also brings with it the recruitment and retention eligibility within that area for new dentists if i get time at the end i might come back to you about that brian what do you just do thank you good morning to the panthca i'd like to just dig a little bit into inequalities i think we heard in the last session there around you know the inequalities are increasing but the the pandemic has you know really exacerbated that quite quite dramatically and i would suggest that one of the things we really need to be doing just now is looking at how we one reduce inequalities to the whole preventative agenda for which it was very eloquently put that dentistry is an untapped is untapped a great degree in terms of of the prevention agenda so with those two in mind you know the sub prevention and the inequalities what what do you think the role of health boards are in reducing that kind of inequality within dental care and oral hygiene can i come first to you miss michael bath so yes yes health boards have a great role to be able to to look over that and it's been in the very fortunate position that we are currently reviewing our oral health needs assessment i feel that we've been able to do the absolute maximum that we can when the end up programme was re-established we did the primary ones but we also did the primary to us because they would have been lost they would have been misbeset those children as a priority as well we did the very innovative test of change we delivered fluoride varnish at that point of contact we've extended our child smile we've recruited another oral health support worker we've extended the education extended the sites that we can deliver that extend where we can infiltrate and where we can deliver our packs and that they are also delivered at and signposted at food banks now as well as our early learning establishment establishments we've actually had a 97 percent response from early learning establishments with child smile within the borders the government as well did also extend the child exam for gds so that increased the fee for the child exam we we never used to get a fee for that and that was increased and they also extended the age that adentists could get paid to deliver fluoride application up to the age of 12 it used to pre-pandemic be six and you can claim your child smile and you'll claim up until the patient's 18 as well so that's not quite answered your question i feel i think i've maybe digressed a little have a i'm sorry i can do that i promise myself i wouldn't do that today you may have a role in politics then if that's the way you do i think that i think what i'm trying to do is get to the to the to the solution part about we know that we know that there's been real issues we know that there's increasing inequalities we know there's a you know that there's there's a there's a problem with with you know for example the length of time between treatments has increased so much during the pandemic we heard again in that last session that the treatment that's actually required now there's an increase in the treatment actually required so all of it's really a kind of perfect storm around you know the the squeeze on on any chance dentist time and it's how we it's how we look at a long-term strategy of bringing that inequality back down again or or we prevent inequalities rising any further before we bring it back down again so you know if i could widen it out to that you know i'm happy to to take any comment from any of the panel but i'll give you another chance miss mackerel to come back on to the path you're absolutely correct it's not about focusing on the one preventative programme it's about looking at all of the preventative programmes that we've got you know we've got open wide we've got caring for smiles we've got mouth matters it's about maximising those programmes to improve education to really raise the profile about oral health but it's about scratching the surface almost and saying who's underneath who's left behind out of those programmes and being able to have the intelligence behind that i know that within my board nhs borders we have a very strong oral health improvement team we communicate part of that good news story of covid was the team working the improved team working between gds pds and all of the domains within our health board and we really have maximised to our very best ability all of our preventative programmes and continue to do so and have community engagement i have to be honest though that for me personally uh is where a lot more benefit could potentially happen on an Asian wide basis but perhaps professor corn we may be best to to call back in for that question brian okay if i go if i can go to Tayside with with the similar sort of see me get a response to my question but broaden that out slightly because one of the things we did here in the previous in the previous session was that there was a lack of understanding of what nhs services are actually available especially in the lower siamd areas so it's almost a marketing issue here so if i could expand it into that dr gilmore around where what nhs services can do what the boards can do to alleviate that particular issue because that seems to me something that we should be able to tackle dr gilmore i don't know that we're almost put in the cart before the horse here with that question with all due respect because um while i completely agree with you that we need to maximise sort of the um be very transparent in terms of what's available and make sure that the wider public from from all sectors of the community are aware of what's available um we probably come back to the fact that actually even if you are aware of what's available um that gaining access to these services it continues to be problematic so um we need to sort of address both sides of the of the coin there in terms of advertising making folks aware of what what is available to to them much like Adele has just just mentioned there um you know sort of we've got a tremendous a group of people a superb team within pds that's delivering child smile and maximising awareness within that um within their their remit and um we're also working with their other healthcare providers within pyside um to deliver um you know the information that patients require to just to fully understand what what's available to them um and uh beyond that we're sort of using our columns teams to uh advertise via social media platforms communicating what's available and as well as oral health improvement messages as well so i think you know if i brought it out as far as we can here so if we understand where the issues are we understand as we just discussed there Dr Gilmour that um you know we do need to we need to make sure that everybody's aware of what services available to them you touched on there the fact is the service it's not just about getting them to make them aware of what they're entitled to but also that that's available so if i go to Mr Vassacci for the for the key question do we have the resource to tackle the inequalities the increasing inequalities that we are seeing post pandemic um in a word no um we don't touching on a lot of the comments that have already been um been made already there isn't the workforce there isn't the i think you mentioned the perfect storm earlier on we have an increased need because people have not been seen we have a backlog we have a reduced workforce um we have uh you know independent practitioners just as as Declan mentioned about actually costing them money to provide nhs services all that together means that a simple answer to that is at the moment no i don't think we do have the the resource to to recover services as i stand okay fine we've given that we are sitting in the Covid recovery committee we are trying to look at a map a map a way out of of the current problem so we're looking here for for the positive steps that we can take within this building on this environment here that could help to alleviate the issues where how do we plan our way out of this i'm coming back to you mr preserchi well it's it's a challenge um i think it's i think maybe going back to the preventive measures i think that's something that we need to to um really focus on because they were a huge success especially child smile um comment i just have i could make the comment that in addition to professor cornwys evidence that it was specifically commented on in shetland that child smile team is a vital point of contact to the health wars during the pandemic and during the restrictions and we have the the second lowest decay rate in Scotland in shetland and we're trying to maintain that so it's a it's a it's a it's a maintaining what's been done well already but i think perhaps going back to a more general answer and i'm talking about what can be delivered my own my own opinion is that we need to maybe clarify what what is involved in providing nhs dental services and is that to maintain the health of the population or is that to mean to provide all dental services and there is a difference and i think that's something that that would comes into how the how the services appropriately funded for providing what what it needs to provide i don't know whether one of our other two um whether i'd a dealer or doctor gilmore yep and you know it's it's such a complicated answer to your question but you know there's no way that the three of us could you know even maybe possibly begin to answer that in any great detail or depth i think it's a question that needs to be put to the directors to the cdo to the clinical leads and pds to the clinical directors of our hospital services to if you're looking for a pathway all these sort of different factors and facets within the provision of dentistry within scotland need to be brought together and each individual sort of needs and wants and problems to discuss as a whole and then sort of brought together to find a pathway which was obviously everything that's a web of connections between the different services as well so we all rely upon each other to provide dental services and this is going to require i think all of us to come together if you want to have a structured pathway towards recovery and not one that i think that myself or antony or adel can provide for you just now although i will give miss mackerel rathwy opportunity to to impend to that question if you have anything you would like to add you know honestly i think that antony and declan have both really hit that on the head it is too complicated a simple question brine to be able to give you a simple answer to because there are so many facets to where there are so many issues initially i firmly believe that prevention education and signposting for all and a maximisation of our oral health improvement programmes as well as our payment reform which we are really desperate to see if that supports the profession going forward is a very good place to start because our blended payment model our item of service we all saw during the pandemic when we were very well supported but with our Covid emergency top-up payments activity dropped now it dropped for many reasons ipc there was staff working in different bubbles follow so on and so forth but activity dropped and the taxpayer deserves a well balanced economical best service possible and the item of service item in dentistry has always worked for for that basis in terms of activity it's about getting the other factors correct but stretching the profession it is workforce it is those changing demographics it is some governance around the the nuances between different practices and who has what oversight over what it is largely dental inflation and the running courts it absolutely literally is within a an independent gds setting thank you thank you very much by the other couple of points i just want to bring back up yourself you've talked a number of times about the dental inflation what do you mean by that is that just our general inflation that we're all experiencing just now or is there some other factor that we're not picking up on so it's that so it's the cost of your utility bills which we're all experiencing right now but it's the cost of lab fees which are rising exponentially declin has touched upon that that in the past three months they keep hiking and hiking and hiking to the point that in many instances they are actually more expensive than what dentists are actually being paid it's the cost of materials dental materials to actually purchase as well so is it the lab fees that are driving your inflation plus materials so i'm not an economist so i have absolutely no um i think i'd be a great answer on that i just been i refer to dental inflation that's what i mean i mean the increasing increasing running costs to run a practice okay in terms of the staffing um is it just dentists that you're missing or is it nurses hygienists is it across the board across the board and are you competing with private services our health wars competing with private services for the same staff absolutely pds are struggling to recruit in so many vacancies not just dental vacancies for dentists where we struggle on to recruit hygiene therapists hygiene therapists at the moment are largely being used as almost private hygienists and they're you know can get whatever they can in private practice and you're trying to compete against that we're struggling to get nurses dcps to stay there's also some training issues i mean mentor which is a large nurse training provider online i think there's something about the grants are going for people over the age of 25 as well so it's going to be even harder for practices to get more experienced people coming through to train as dental nurses so it's the it's the home sector convener okay is anybody else wants to add anything to that or are you content at review just if i may convener just to answer what Adele said there i think it is right across the board i think we've lost a lot of staff not including dentists over the pandemic and it was described very very well earlier that what was being asked of dental staff and a lot of people left you know what they had to wear PPE the risks we were at a height we were at the highest risk and a lot of people a lot of dental nurses a lot of people working within the sector left the profession as a result of that um frankly the the ability for independent practices to compete with the private sector on wages is very difficult and therefore the the combination of that has meant that we've let we've lost a lot of staff and attracting them back is going to be very difficult okay Declan do you want to add anything or are you content yeah quite content with the element that we have funded very succinctly there so no nothing to add i think we'll be looking at the model for how dentistry works next week anyway so um we will be expanding us listen i'd like to thank you all very much for giving us your time this morning um if there are any other issues that you want to raise with us the the clerks will be happy to tell me is with you oh sorry Declan my apologies no um apologies i should maybe just get me the opportunity a moment to go to say i know this is a discussion about reform and what have you but i think i'd be a mis if um i just didn't take the opportunity to comment about what was touched upon earlier on in terms of the you know the dangers and the difficulties that our colleagues faced at the height of the pandemic um you know again i think Anthony had mentioned that you know we're most at the most at risk professional perceived to be um and you know many of our colleagues put themselves at the front line and difficult and uh works you know at times but you know the danger perceived danger seemed to be particularly high and an awful lot of news coverage of how many people were were dying from from Covid infection and what have you so um i think it would be nice just to at this point mention how our colleagues stepped up at a difficult time would continue to provide services um at their own personal risk and uh you know it would be good if that was acknowledged absolutely and i would and everybody in this committee would absolutely concur with that um as i said earlier i was at mone dentist they were matt hasdup completely it was it must have been horrendous so your your point is duly noted to okay that concludes our public part of the meeting we intend to continue next week's evidence session and we will hear from the scottish government on the 29th of june so i suspend this meeting till i witnesses to leave and we will move into private thank you