 Mae fawr i'r gweithio am y 14 ymydd yw'r yglwbwyd 19 yma yw'r Cymuned Cymru yn 2023. Alec Riley oedd gwybod i'r cyfnodau i gynhyrchu ar y ddym ni, ac rwy'n fawr i'r Jacqui Bailie, sy'n swyddfa am y dyfnyddio ar y dyfnyddio. this morning we will continue to require it into the NHS recovery of dental services. I would like to welcome to the meeting David McColl, who is chair of the British Dental Association's Scottish Dental Practice Committee. Douglas Stain, chair of the Scottish Dental Association and Dr Asif Bashear, chair of the Scottish Dental Practice Owners. Thank you for giving up your time to join us this morning, gentlemen, and thank you for your written submissions. Mydwch, wrth myf deyrnasedd bethau hyn, y trafodaeth, angeu rhywun 1000 defnyddio'r debyg a ddefnyddio'r teimlo llาย Alydd headseth, ac arfod mwyfodol iawnrayn i fadeuny arlŽ ar bod dweud gynyddiadau ddisadoli ac gorit diweddellol i… Felly, ddych ynieu i ddfieldöyearnau, am sawer y gallur yn f fantastol, mae fail yn ei ddifur amfotach yn d� y m diningfadig sy'n autectaill. Howevero, mae eu bobl ogoi amser oedd â'rwnien diolch o le可 demonstrations hynny. ynghylch i gael. Sarwadda, rwy'n anhygoel i ddweud eich sutwch, ac rwy'n gweithio arfer y ddechrau caer i'n yapu. Rwy'n anhygoel i ddweud eich sutwch, introducedddo i chi. Rwy'n anhygoel i ddweud eich sutwch ar yr unig, ac yn cyhoeddwyr ffrifpeitiau, fitnddwn i'n gwirio rhoi wgwlinnol oherwydd yr Ysgolwch Dental Practise the Scottish Dental Association. We represent the practice owners that deliver the service of mhs dentistry to the people of Scotland The facilities through which the delivery of the NHS is happening to the Scottish people. The BDA represents, so we don't, in the Scottish dental practice owners group, the only criterion to be a member is that you need to be a practice owner. You may be a dentist, you may not be a dentist, you may be a nurse or a therapist, but you have to be a practice owner. David, would you like to explain the BDA? I'll give you my background. I've been working in Govan Hill in Glasgow in an NHS practice for, this is my 37th year. I'm a member of the BDA. The BDA has a committee called the Scottish Dental Practice Committee that is an elected committee from all of the areas in Scotland, and we represent all non-salaried general dental practitioners. The Scottish Government has a legal obligation to negotiate on items pertaining to the funding of NHS dentistry with the Scottish Dental Practice Committee. My background, I'm a dentist working in Cumbernauld. I've been a practice owner there for over 20 years. The Scottish Dental Association was born out of the pandemic, dentists are not BDA members for various reasons. We thought there was a gap in the market to represent their interests, so we've spent the last few years creating the SDA. We're a work in progress, we have 800-900 members at the moment, but we're early days for us. You're not splitters? No. Are you starting to work out what the relationship is between all three of you? I think it's a situation where dentists have been quite apalysical and disinterested in the politics of it until the crunch came, and now maybe there's scope for us all to band together at some stage, but we're looking forward rather than a splinter. I suggest, again for your information, that not every dentist or dental care professional in Scotland is a member of the BDA. The pandemic was difficult for everybody. What we're trying to do is to best represent ourselves so that we can best support the people of Scotland. Can you move on forward? Okay, thanks. I just want to understand where everybody was, and that's been very helpful. If we move on to the substance of the inquiry, we're really interested in looking at the impact Covid has had on dental services across Scotland. I was reading the submission from the BDA, so I'll ask Mr McCall this question first of all. You have a very striking statistic in that where you say that dentistry has lost over half 52 per cent of its capacity since lockdown. My first question, therefore, is how long is it going to take us to get back to where we were, if ever, and what needs to happen to ensure that we do. There's so many facets to answering that. It really hinges on reform. That's where we need. Pre-Covid, the system of delivery was unfit for purpose, and if Covid showed anything that the current system we have was broken, what we need is proper root and branch reform. We need to move away from an item of service delivery model, because it's not fit for 2023 healthcare delivery. That's where we need to be. We have a real recruitment and retention problem, because the NHS is not being seen as an attractive place to work. We cannot recruit dentists, let alone any other staff, to work in NHS practices. Are you talking specifically about NHS practice as opposed to private practice? So there's not a recruitment issue in private practice? No, absolutely not. We have spoken to students now who know, even going through university, that they do not want to work in the NHS. The reform we are looking for is not just payment reform, it has to be holistic, complete, root and branch reform, because we need to try to people to work in the NHS as a career. Don't really have to repeat what other people say, but if you have anything you want to add, please come in. I think that the split between NHS and private practice is an infallible split. Our practice is very largely NHS based. All patients are NHS registered and 80 per cent of the treatment we do is NHS. Other practices can have fully NHS registered patients who opt for the majority of their treatment to be done on a private basis. Other practices will have some NHS patients and some fully private patients. The recruitment issue is most acute in the more NHS end of the spectrum, where we've lost two associates, two fully private practices over the past two years. There's nothing you can say to young dentists who want us to work in a private practice and see 10, 15 patients a day for a sensible level of remuneration. Please stay and see 40 patients a day in this crazy treadmill because it's better for you. It's just not until that situation changes and people want to work in our practice. As they have done for the last 20 years, the recruitment issue within the NHS end of the spectrum is going to remain as bad as it is, if not worse. Just before Dr Bashir, can I just follow something up? You've raised some really interesting points. From our committee's point of view, what we're looking at specifically is the impact of Covid. To what extent has this happened because of Covid, or is this happening anyway? I found 2018-2019 that the NHS was coming about as much as I could tolerate, but there was no real change in sight. There was no body of dentists that I thought seemed interested in pushing for reform. Covid gave everyone a chance to reflect. It was the early stages of Covid when there was a brief panic across the profession that no-one really knew if we were going to be supported, how things were going to pan out. We closed our practice up in March 2020. The health board wanted to use the practice as a Covid hub for Covid positive patients. We had no idea where we were going from there, so social media took over and we knew hundreds, thousands of dentists were crying out for some kind of body to support them and some kind of leadership. That was really where the problem came from. Initially, it was a twiddle drive to get reform in the NHS and other more practical minded people realised that moving towards a more private way of operating was a way to go. Going from almost zero activity to rebooting the service, the private side for a lot of people was just taken off from there as a way to serve patients and as a way to make their own lives better in a way that they probably hadn't previously had the chance to do. Again, as David said, there's been an unhappiness for a long time. I don't think anyone thought there was a chance to change things. Covid gave us that chance. There was a brief hope that reform could happen. We seem to have lost that window now. We're back on the treadmill and stopping everything again for a second time, moving to a third system in the space of as many years. It isn't going to be easy for anyone and so many people have jumped ship and it's going to be very difficult for us to get back on board. So the question was how has the pandemic affected our NHS recovery? I think that what we need to understand is that we are serving to the Scottish people. Dentists in Scotland are delivering a low fee—that's not important, but the bit that's important is the high volume and the other part that's important is the disease-centred model. We're delivering this high-volume, low-fee, disease-centred model to the Scottish public. This is the vehicle through which we are operating. The Scottish people going into the pandemic and to lockdown, they weren't dentally fit enough as a consequence of that delivery model that we were utilising. Then the pandemic happens. We have locked down for two years, which then results in a bigger backlog. Instead of changing what we do, we just go back to using that same model to try and fix the backlog—this high-volume, disease-centred model, which is a very, very dated model. As Doug has said, we've been working on this high-volume treadmill for many, many years. The thing that is stressful for dentists and is stressful for the support staff is that that's not the important thing. The important thing is that it traumatises the patients, because patients don't get—if you're delivering high-volume dentistry with such an invasive, which creates anxiety to the people of Scotland, what are you doing to them? You're traumatising them. Now that we have lockdown, lockdown happens. People were anxious about going to the dentist before lockdown, then they can go for two years, and they start to worry. I haven't been for two years. I've got all these problems that are happening—my teeth are breaking, etc. That gives them even more anxiety. Then they can get an appointment to see the dentist. Some people just step away, so they don't access the service at all, so we're seeing that more. Some people try to access the service, and then they can't access the service, which I think is really bad. It's really bad for the Scottish people. What we need to do—the backlog is related to the size of the backlog is related to the type of delivery that we were doing. So, in terms of coming back out of this now, it's going to take more than two years to get rid of the backlog. The practices that have more NHS commitment or more NHS patients is going to be more difficult for them, wrongly so than the ones that have private patients, and that for me is not a good situation for the people of Scotland. I have a lot more questions, but on your last point, Dr Beshear, you said that it would take more than two years to get out of the backlog. I'm interested to get David and Douglas's perspective on that. David, you were taking a much more pessimistic view in terms of whether we'd get out of the backlog at all. What I would say about the backlog is that the patients are currently seeing our high treatment need. There are not people who just came in and it's just a couple of visits. This is going to take a long, long time to see them. We're probably all the same. The first check-up appointment will probably be three months away, but it's okay to see someone for a check-up. You need to point them for treatment. We need to work flexibly, and the current system we're working in does not allow us to work flexibly, and it doesn't allow us to skill mix within the practice. Not everyone needs to see a dentist, so we have therapists and hygienists and trained DCPs that could be doing some of that work, but the system we are working in does not allow us to do that. We need significant reform to try and get through that. So finally, without reform, will we clear the backlog? No. Okay, and that would be your view all the way? Essentially, that's the situation. If we see a patient, as I saw, a 14-year-old girl yesterday is a new patient, which is quite rare to have space to see a new patient, she needs a couple of fillings done. That's going to be four months away for the next available appointment, and probably another couple of months for the next appointment following that. So the time we spend doing her exam, what we remunerated for that when the course of treatments completed, five or six months from now, her situation, unfortunately, is going to get worse over these intervening months. So then the treatment may end up being more complex. So again, that's even no longer before we see any remuneration for work we've done, and it's going right back to when the multiplier and treatment was at 1.7. We'd started doing treatment but offered this much, and by the time the course of treatments completed, the multiplier's dropped down to 1.1, so we're actually being paid less than we originally thought we were being paid. And there's that big window where we've committed the time, the manpower, the materials, and received nothing in compensation whatsoever. Also, while that's happening, patients have not been seen for three years, the registration fee drops off from £1.20 a month to £12 a month or thereabouts. So the continuing care payments which make up about half of the practice income have dropped off a cliff. That drop was suspended for the first couple of years during Covid. It's now active again, and one of our associates who's off on maternity leave, her income from that is more than half since she put off on maternity. So, again, that's a baseline figure which the practice allowance has calculated. So it's just a compound loss of income while still working hard. As you treat more anxious patients with greater needs for less return and almost the more you do it, the worse off you get. It's an impossible situation. In terms of recovering the backlog, is this never going to happen while the situation is going on? I'm sorry, I'm really conscious of time. I'm going to move on, and Jackie, if you'd like to pick up where we are on staffing please. Thank you very much. I'm going to pursue some of the issues that Murdo started off with you, but relating specifically to staffing. Douglas Tham, you said that you referred to the treadmill in reference to NHS dentistry. Can you unpack that a little so that people understand? Yeah, I mean, I think it's probably touched on there a bit. It's a case of we're working at a pace and you simply can't slow down. We've got lots of patients with needs and they have to be seen within a realistic time frame. And that's why we're busy doing this. It's impossible to kind of step aside, reform, do something better. But any example, tomorrow I'll get into the practice just to see patients with toothache. And the bulk of them will be patients who've not been in the practice in the last three or four years, which means we've had a monthly commitment of 12 pence from them for their registration. I'll be taking teeth out for £16 a tooth. We'll be taking the pulse of teeth to start root treatments, again for which no fees payable until the course of treatments completed months down the line. And that's taken care of a very small percentage of our 20,000 patients who haven't seen us for a long time. We're also doing that with fewer dentists than before because the smart ones have jump ship. They don't have the obligation that the practice owners are left with. And a young dentist is getting into that before they know what they are in a similar situation, which is very akin to trying to really slow down you fall off the back and it's hard to get back on again. That's helpful, thank you. Can I ask David McCall that the BDA did a survey that suggested that 59% of dentists have reduced their NHS commitment and that's likely to increase and 34% are either retiring or leaving to start a new career. Can you kind of just rehearse for us why people are leaving, why they're reducing their NHS commitments? I think, Jackie, they're just not seeing the NHS as an attractive place to work. That's the big problem. When we talk to students and when the students tell me that they don't want to work in the NHS, that's really disturbing because we need an NHS dental service to survive. The Scottish Government's support at NHS dental practice is really well during Covid, but we need to move on from that. That support needs to continue and it's not just about payment reform, as I said. You need to make the NHS an attractive place to work. Private practice is a very attractive place to work because you can set your own fees, you can spend more time with your patients and what happened during Covid when, effectively, we were in a fully funded, capitated model not predicated on doing little bits of work for little fees, which is high volume, low margin. Dentists and teams like that, we could spend time with their patients and that's where we need to get back to. Patients deserve to have time spent with them and, as I said, you're in a disease management process, but we can't actually manage a disease, we're treating disease. We need to invest in prevention and that doesn't need to be done specifically by a dentist, it needs to be done by the dental team. We have a whole team that can deliver this, but we need to get the government to buy into prevention. Let me come back to you on one small point and then take us on to prevention because you didn't mention training at all. Are there sufficient training places in Scotland, but the destination of the trainees is the private sector rather than the NHS? There's no point in training more dentists that don't want to work in the NHS. Sure, I just needed to understand that so that we're clear about that. Let me go on to the model that is currently in place with the SDR for treatments and materials. That clearly you seem to be suggesting disincentivises people into NHS dentistry because, as both Douglas and yourself have described, the sheer pace of payment is not matched by the activity. How would you change that to a prevention model? My view is that we need to have a fully capitated model along the lines of general medical practice for us to deploy our teams because at the minute the only person that can produce any funding for the practice is the dentist, so the dentist has to be on the treadmill, as Douglas says. That is not the way to run any clinic in 2023. We need to move on from that. High-volume low-margin healthcare does not work. Anybody got a view to add to that? Jack, I would say that it's very, very important. If collectively we can get this one point across to you, it's that we all care about the NHS dental service. We all believe in it and we all want it to thrive. The thing is that we have worked for many, many years in trying to make this work, but increasingly, as David is saying, it's that younger dentists see the flaws in the system because it's a low-fee, high-volume, disease-centred model. We have to keep coming back to this word as a disease-centred model. We're not trying to prevent things, so we need to move to a more modern approach. The modern approach is a preventative model, so we're preventing disease. Instead of measuring how many treatments our dentist is doing, how many treatments are doing, why is that activity? If they're doing treatment activity, that's not good. That's not good. We should actually be measuring the reverse. We, for some reason, are wedded to this delivery model in Scotland. Actually, I do know why. It was ahead of his time, so the NHS we were brave when we created the NHS. It was something that no other part of the world had. Unfortunately, within dentistry, we've delivered the same model for over 70 years. That model is closer to being an antique than it is to being modern. Because it's closer to being an antique, you can't blame the younger dentist for not wanting to go into it, because it scares them. It scares them because they think, I'm going to have to go into NHS dentistry and I have to do this high-volume dentistry, which goes against everything that they're taught at university. The reason that they don't go into it is not about the money. It's about the actual type of delivery that they're doing, so they step away from it. What we absolutely need to do is we need to change that, flip that. As Professor Conway was saying in last week's meeting where he said that they spent £2 million on prevention and they had £5 million of treatment savings. So that's our model moving forward. Thank you very much for that. Other people will ask you about child smile, but I share your view of it. Can I take us on to dental corporates operating in the UK and now, indeed, some of them operating in Scotland? What impact do you think this has on NHS dental services? I don't know who wants that one. Corporates are coming into the market, increasingly so. Did the good or bad, I'm not sure, remains to be seen? Many practice owners, because of the challenges of trying to deliver the service, the NHS dental service, they are selling their practices. These practices are being bought in the main by corporates. Here's the problem. The thing is that the corporate then doesn't have the ability to buy the practice or to take over the practice, but there's a shortage of dentists, so the delivery isn't there. That's not a good thing. In my personal view, it would be good for Scotland to have corporate dentistry delivering the service. No, I think that it's much better to have individually owned practices that are headed up by a principal dentist that is controlling the delivery. I think that people will get a better, much better level of service, but that's what is happening. We have communicated this to the chief dental officer that there's a trend towards corporates taking over dental practices in Scotland. We don't think that's good, but if we want to change that tide, we need to make some bigger deform. I literally have seconds in which to finish up my session with you. I wonder if Douglas or David have anything to add. Can I throw in one final question to the mix because the convener won't let me back in? Do you think that the Government should collect and publish the NHS commitment of each dentist or each practice so that we get a more realistic picture of GDS coverage in Scotland? Douglas? In that front, I'm not entirely sure because there's a bit of a danger that becomes a witch hunt for dentists or doing more private work than NHS work. Not that I've got anything to fear in that front whatsoever. In terms of the corporates, the big difference is that they're a business. They'll fulfil their contractual obligation to the letter, I'm sure, but spiritually there's nothing more. We've already seen Bupa off-road practices that don't make them any money. Corporates are there to make money. We're there to provide an NHS service. Ultimately, it's all going to end up corporate because independent people with me simply can't afford to bankroll very non-profitable business. Over the short medium term waiting for performed commitment at the other end, the corporates can afford to buy the practices funded the short-term shortfalls. If the NHS system is good, they've won. If the NHS system is bad, they go private and they've still won, but the owner-operators like myself stand to lose all-round short-of-selling to corporates, which isn't necessarily what we want to do for ourselves or staff-horror patients. Thank you, David. Just on NHS commitment, Jackie, to bench how you measure NHS commitment. Currently, NHS commitment is measured on a financial model. So, for example, if someone does an implant within a practice and that implant might cost £2,000, you'll have to do hundreds of check-ups to get the same measurement. That's what you would need to do. Hundreds of NHS check-ups. So, be careful with the measurement for NHS commitment. Okay. Thank the three of you very much. Thank you, Jackie. Brian, I'll move on to you just now, and we are looking at Theme 3.2, sorry if I was to recover, my apologies. Thank you. Good morning, gentlemen. I think, Brian, on the theme that I was going to go on, you've answered quite a lot of the issues that I was going to raise. So, I think some of the things that really are worrying, I think, especially on the preventive side of things, is potentially, we heard last week about the inequality within the service around the more affluent areas versus those in the SMD1 and 2. Can you tell us perhaps during Covid your experiences in that, I mean, and why is there such a, why does there seem to be such a disparity, an increasing disparity between the two? So, in patients who've had the most experience of dental disease over their lives, need the most maintenance and the most encouragement to maintain their oral health, and Covid certainly would cause them to suffer the most, but I can think of plenty of examples of the now prides of patients whose mouths have deteriorated terrible over the last three years in a way that, over the previous 20 years, they just hadn't. There's also the situation where they also require the more complex treatments, the root treatments, crowns, dentures provided in NHS, which currently are the least profitable, in fact, the most loss making items of treatment to do, and also the most time consuming. So, these people are losing out in the dentist that treat them, are finally increasingly hard to find a way to make things work for them. In a more affluent area where, for example, the enhanced exam fee allows people to be seen practices to make a greater profit from seeing these people on a regular basis, things are quite nice. If you see a patient who needs nothing done and it's just the case of an exam, see you in six months, and you can do that all day long, it works really nicely, whereas we do an exam, see you in six months to continue your course of treatment and we still haven't been paid for the exam. That's where the patients in more deprived areas tend to suffer more. What I would say to this is, look, I come back to the same point, and I'm sorry if I keep going over this again and again, but I just care about the people of Scotland. The thing is, we are failing them, right? We are failing them with this, because if they need treatment, we're failing them. This is why they have a bad feeling, they don't have a good feeling, the people of Scotland don't have a good feeling about going to the dentist, and that's, again, down to the delivery model, because every time they go, they get treatment. If you live in a deprived area, you're going to get more severe treatment, which is not going to actually make it easy for you to go, psychologically. So what we need to do is, we need to absolutely change the focus of what we are doing, because we are failing the Scottish people. By the way, what I would say is, back to what I said before, the current system of delivery does not allow us to skill mix within the practice. So within my practice, we've got 12,500 patients registered with a higher level of children, we've probably got over 3,000 children registered. The SDR at the minute doesn't allow me to get group sessions in for child smile delivery, and that's what I would like to do. There's no-one knows better than my practice what our patients need. Scottish Government don't know, the civil service team don't know, we need autonomy to deliver that service, and we can't do that under high volume low margin. You know, we have therapists that can deliver it, hygienists that can deliver it, trained child smile nurses that can deliver it, and we also have oral health educators that can deliver it. We can work in partnership with child smile nursery, child smile school to deliver that, but the NHS system we have right now does not allow us to do that. That's what we need. As I said, we need route and branch reform to make that work. I guess then, just to clarify, the outcome of that is increased number to children needing referred to secondary care for extractions and the likes, which is obviously more time consuming, more costly, and just back on the treadmill, I think that's the word that's going to stick with me in this session. Basically, I guess what this committee is called, Covid recovery. You're painting a realistic, if reasonably, bleak picture here of Scottish ancestry, so you've said that we're not going to get out of this under the current system. The backlog is not going to be dealt with under the current system. So, can I ask probably again, just so that from my own personal understanding, where do we need to go, what needs to happen to get out of this, to get us back onto a reasonable path? Dr Bishop, if you want to, Dr David is right. We need to meet the NHS more attractive, Brian. It's as simple as that. How do we do it? We need to get away from a treadmill effect. Low volume, high margin. Low volume, high margin does not work. So, younger dentists coming in, do they want to see 40 patients a day? Is it not high volume, low margin? High volume, the largest. I'm confused. I'm easily confused. I say it all the time. We need to get away from that, so we need to make it more attractive. Somebody coming into an NHS practice does not want to be seeing 40 patients a day. You don't want to be seeing that. We don't need to see 40 patients a day. We can recruit other members of the team that doesn't have to be a dentist to deliver that. Unfortunately, in my practice, I've lost two therapists, because the therapists do not want to work in the NHS practice. Now, for me to do that, you're actually paying them at cost, because we need to deliver it. What I will say, Brian, is where I work in Gavinell and Glasgow is the former First Minister's constituency. Because of the court of patients that we have, we are probably the highest referer for pediatric GA in Scotland, because of where we are. So what's really frustrating for me is the current waiting list, so we get a four-year-old that comes in, eight decay teeth, don't speak English as a first language, and we have to refer through our clunky Sky Gateway system that takes time for which there is no remuneration at all. And the current waiting list is something like 96 weeks to get that scene. It's outrageous. This is not a new problem. This has been going on for more than a decade, and we need ministerial government intervention to do something about it. What you're describing there really is a system that needs to turn around, but it seems to me it's a bit of a tanker. Trying to turn a tanker, it's going to take time and planning to be able to deliver, because all of a sudden, you can't make it attractive for new identities into NHS dentistry. It could take a lot of time. And he's radical change? No, not just tinkering about with items in an SDR, and he's radical change. Faggot, does that mean the referrals for the children's extractions? In less extreme cases, where children need some teeth out of the age of four or five, six, it is quite doable in general practice to the right dentist, to the right mindset, given enough time, but it's so unattractive to anyone to want to do that for the feed they get. Because if you've got an anxious parent, an anxious child, an anxious nurse, and four patients complaining in the waiting that you're running late, no one wants to do it. If we're paid in a way that made doing that in general practice, doable, people would do it. I mean, a lot of some associates in our practice that have started doing that and gradualised, it's just too much for them. Again, it comes back to, I could put this, a capitation-based payment model, something that allows dentists time to do what they're good at, rather than being forced to do items of service just to generate enough money to stay open. Again, children's dentistry, at that basic level, should be a basic skill that we're all good at and proud to do, but it's not something that carries much kudos in the profession anymore, which is a shame. So just to give you some practical things that we can do in the here and the now, is that one thing that we could do is we could take the current item of service model and we can take out the things that aren't needed to secure oral health. That would then make working within the NHS dentistry a little bit more attractive, a little bit more attractive. We need to go back and say, okay, what is it that we want to deliver on the NHS for the people of Scotland? What does the Government want to deliver? Do we want to deliver a service that secure oral health, or do we want to deliver a world-class dental service to the Scottish people? That includes everything. So everything that the dental need that that patient might have is met on the NHS. Currently, that doesn't happen anyway. That's one of the reasons why patients have to, in my view, wrongly, so step out of the NHS and access private care because that item that they want is not available on the NHS. Currently, the system is deficient. I'm saying, okay, let's reduce it to a system that secures oral health in the first instance using the same budget that we have and use any surplus income to push that into a prevention. So that's one thing that we can do. The second thing that we could do, and this would make it more attractive for dentists into the NHS. So the second thing that we could do is that we could change the contract. So the contract is between the health board and the dentist, and we can shift that from the health board to the practice owner. Because one of the issues that we have is that we can't get, I can't get, the associate in my practice to do more NHS work than he or she may want to. So we want them to do more. It's up to them whether they do more or they don't do more. If they want to do more private, so we lose this control. You lose this control. So that's a second thing that you could do. So that's two very simple things that the Scottish Government could do to make the delivery more accessible and make the model a little bit more attractive for new dentists coming into the system. So many, I know so many reasons. John, could you go to... Yep, thank you. I mean, I think we're all on the same theme now about reform, so stick to that. I mean, I like the bullet points you had, Dr Bushier. I like bullet points. So you certainly covered a lot of ground, and one of them right towards the end is we are not asking for extra money. But I mean, all I'm hearing so far is this is going to cost a lot of money. Cos if you go from seeing 40 patients a day to 10, you need presumably four times as many dentists or other staff. So there's got to be a big increase in money. Has there not? Yes, if you maintain the same items of service. So we work off a menu. It's a big menu, and we have all these items of service that we can provide. But what I'm saying is look, we don't need... But from the Government's point of view, the Government's writing a check and the moment it's items, now if it changes, is the Government going to have to write a bigger check? No, not on the short term. So the thing is, is that you can... We need to make the system more effective for the Scottish people and more attractive. So there's two things we need to do. Make it more effective for the Scottish people and make it more attractive for dentists to work in, so we can retain them on the NHS. Right, so we... I hope we all agree that this system... Is there anybody in the room, can I ask? Is there anybody in the room that actually agrees? So I'm going to put the question to you. Is there anybody in the room that actually agrees that we should be delivering a high volume disease-centred model to the Scottish people? Well, I think the answer to that is... I'm also speaking to GPs. You've said you'd like a system like the GPs, but the GPs are totally unhappy as well. They can't recruit GPs, people stay in the hospitals, they can't recruit staff, they can't get locoms, et cetera, et cetera. So there's a huge amount wrong with the GPs system. Now one suggestion is let's employ all the GPs by the health board. So that would be another possibility. Let's have the health board employ all the dentists. Would that work? Yes, I think anything is better than this model, because we've been utilising this model for 70 years. I want to see a Scottish population that is the healthiest, the smileiest in Europe. That's what I want to see. That's my vision, and I think that that should be our vision. We're saying, and I think David, the BDA and the SDA have probably communicated to the Government that our proposal was to go to a more affordable, so take the items of service. I do want to let the others in as well, because you've said quite a lot. Mr McCall, are you speaking to the Government? What are the Government saying? Yes, we are speaking to the Government about a blended model of delivery. Where we are at the minute is that NHS practice is unsustainable under the current model. I think it does need more money in it. What it will tell you is that currently the NHS budget in Scotland is £19 billion. Six years ago it was £12 billion. That proportionate has not gone into primary care, and that's the problem. That's why you have no problem with the GPs that they can't recruit, because they can't see a future down the line here. Primary care has always been a subset of healthcare. All of that funding has gone into secondary care. We need to address that. Mr Tain, I don't know if you're aware of what's happening in other countries, because one of the suggestions is that we should have a world-class health service. Where is the world-class dental service? Is someone here? On your point about employment, maybe employing dentists if the country would then discover the true cost of what the dental budget should be to offer a salary of a level that would attract people to be employed NHS dentists and to find the sheer number of people who would take to work at pace that employees could work with without ending up resigning, going off sick, et cetera. Again, there are lots of other countries that have different models. Is a combination of state-funded and private funded? Do we know are there any countries with a completely state-funded system and no private or very little private? Not to my knowledge. No. Again, we've got a state-funded system which funds a comprehensive care which looked reasonable in 1990, probably the most recent. It's a comprehensive but outdated SDR. The best items of service we can provide aren't on SDR and simply never will be on the SDR, both in terms of sort of the dentistry implants, preventive dentistry, children's care. None of that is really done to give what's considered international best practice peridontum disease is another area where the NHS item of service is just a mile from where it should be. I mean, we've got a kind of McDonald's budget and we're trying to provide something and sit down meal on that. It's just not working. And is the Government listening to you or only to the BDA or what? There are no more lessons to me. Well, we're listening. Yeah, but I think that's, I mean, it's a thing but we're our own worst enemies. We've made it work as far as we could up until 2019-2020 and now I think the same thing. The goodwill profession has been lost in a lot of ways. People have lost faith that meaningful reform is going to come, that we can do the best for our patients. Patients are turning against practices. I think that's probably safe to say that in dentistry as well as healthcare. Generally, we get the blame for not seeing patients. We move our letters and people are not patients. We can form a complaints that we haven't seen them yet. I mean, it's a new level of complaint we have to contend with. I mean, last week, I can't remember exactly who we had last week, but we had kind of academic people and things like that. But I mean, when I suggested what we could move to quite a radical change, maybe like GP practices, they just said, oh, that's too huge, big a jump. I mean, is there any sense from the government? I know when we'd spoken to the G-10 officer about that in the past, he said the problem was they would know how to measure health outcomes in dentistry where as we can measure input. And that's been the barrier to it. I mean, they can see exactly what they do. So there are, there must be ways to measure that output. I mean, trust us for a few years, measure people's oral health, see what we've been doing, made things better, not worse. How do we measure their output? I mean, that's, is it not just the same problem? Yeah, but they seem to be trusted to do what they think is best. Okay, so do you want back in, Mr Buesha? No, I'll let David come in. I was going to say that we actually had that system during Covid. It was along the lines of general medical practice. The civil service team didn't measure it properly. And they weren't proportionate in the response for the practices. You weren't doing enough. 10% of any profession are aberrant. They sit out there and they don't play the game. You can't do anything about that. Seem as politics, maybe slightly higher in politics than 10%, but that's, that's just the way it is. So there is a measure you can there. So what happens if you have, if you have a fully capitated system that's weighted, then if practices don't want to treat patients and we'll just sit there and take funding and do nothing. They will not last because patients are not daff. They will go to another practice that will deliver the care. So the self-leveling will happen. Trust us for a few years and it will level out. And it will allow us to deliver the care to the cohort of patients that we have, because you can't have a panacea all across Scotland. As Brian has said, you know, you've got areas of deprivation one, two, and you get deprivation five. And it's not the same delivery model you need for everything. And during COVID, do you know much? Extra cost of the government to put money into the dental service? It depends how the government cost it. What they will is they'll try and pretend they spent a lot of money on PPE and that went into the dentistry. So they say they spent £150 million in addition. The problem was that they had to cover the charge, patient charge revenue, which is about £75 million a year. So that quirk in dentistry is, if you come in and get some dental treatment and you have to pay for it, you have to pay 80% of that cost. So what happened during COVID was that patient charge revenue of £75 million wasn't there. And in order to sustain NHS practices, the government needed to fund that. So you got extra money and you didn't see me because I haven't been to the dentist for three years? I didn't see you because I was busy seeing other people. Right, I'll leave it to that. Okay, thank you, John. Stuart. Okay, thank you. There's a few things have been said already this morning. Profit, loss making, it's business, but care about people. It's not a new problem. It's my problem for the last decade. We need to make it more attractive. So just a few questions around this, just in terms of making it attractive. So first of all, what is the average salary for an NHS dentist, in comparison to a dentist who does private work? I don't have those figures. But what I can tell you is that the averages associated in Scotland earnings are less than the averages associated in England. So it's not an attractive place to work. We also have higher tax in Scotland, as you know. So even trying to recruit people from England, we can do it. Don't do enough private work to have a baseline there, and I don't speak to enough dentists if we would drive it to, okay, how much of an opinion on what they made, but it's... Okay, I don't think... So much the revenue and the salary. I think it's more terms and conditions. And I think it's more what people are trained to do. We're in an area now where people want the teeth widened. They want complex abonding. They want the teeth straightened. This is where we are. When I met with your First Minister, when he was health minister, when they brought in free treatment for under 26-year-olds, I said the communication here has got to be key, because I don't want to have that argument with a patient coming in who wants straight-wide teeth under the NHS. And that's what we'll get for under 26-year-olds. So it's about conditions. That's where we are. We have to accept we're in this mixed market economy of what the NHS can deliver and what private treatment can deliver. And we've got to accept that, embrace it, and realise it's going to be deliverable through NHS practices. That's the only way forward. Because we can't have a two-tier system out there where you have a fully private practice and a fully NHS practice. We need to accept that that economy is there. I mean, I'm asking, I asked a particular question just because of the submissions that we have received. Now, John Mason just touched upon something a moment ago. So from Dr Bashir's statement, one of the bullet points was, we're not asking for extra money. And certainly Mr McCall, your statement, and I quote, and it was paragraph three from that. And it's with a contract that's unfit for purpose and are funded over stretch and facing the challenge of deep and widening oral health and equalities. And also just in terms of another bullet point from the Scottish dental practice owners, they're also business owners and entrepreneurs who invest in Scottish public health. So certainly what I've heard today and in terms of reading the paperwork, I do not doubt at all the three of you and also the people that you represent, the colleagues that you represent in terms of wanting to do the best for your patients. I don't think anyone would do that at all. But certainly much of what I have heard and the focus has been about money. And sure. I mean, I think we need to be realistic, right? So we are in a situation with the pandemic and COVID, et cetera, something that the world hadn't seen in recent years. It's how do we come out of that? Because it's how are we going to do it? So what steps, right? We don't want to ask you to be able to take a step that you can take. So it needs to be like small steps. So if we only have a limited budget, I mean, I don't know what budget you have. That's you have the budget or the government has the budget. You know, the thing is, is that if we only have that budget, then we have to find a better way of spending that, right? You know, it's public money, right? You know, so the thing is, is that we have to speak up, we have to tell you, the people that are running the country, actually this, as the providers at the front line, saying that this is not good enough, it's not serving the people of Scotland good, well enough. Right? Now, the thing is, is that, okay, if that's our only budget, then let's use that budget better, right? Better means let's trim down the items of service that we have on the NHS, but we don't go below this, securing people's oral health, right? So that's our line, right? So that's our marker, and any additional funds that we have left, we put that into prevention, right? So that's a way forward, right? It's a step forward, right? It should be much more than that, but I think that's the first step, so that's why that's the back, the narrative behind that statement. Let me see, and someone has popped into my head that I'd really like to ask. I'll come back to you. Dr Maciere, are you saying that there is too much choice on the NHS for the type of treatment and the fund that you have available? No, there's too much choice. I'll let David answer that. Currently, within our SDR, we have 600 items of treatment that have been there since before 1990, and none of them make any sense anymore. We don't even understand half of those items, so we've been working in the NHS probably for about 100 years between us, and we don't understand it. It's been, it needed to be reformed long time ago, so what they're currently trying to do is to try and whizz a load down to a few items that's workable under an SDR. But I think, as we've all agreed, none of us want to go back to an SDR. We need to go to a funding model that allows us to deliver what we can to our patients. Thanks for that clarification. Stuart, my apologies. Thank you. So, Dr Maciere, in terms of that narrative that you just told this committee, is that the narrative that's actually been put forward to the Scottish Government and officials within the Scottish Government? Because it certainly sounded very clear and a logical step forward. All right, but that's not what's came across. So, I would thank you, Stuart, for the question. You know, we are desperate, the Scottish Dental Practice Owners Group, are desperate to sit down with the policy makers, but who are currently being reviewing this NHS delivery model, but we are currently being excluded and have been told that they are already aware of the Scottish Dental Practice Owners Opinions. But I'm here to tell you, I'm here to tell you that they're not, because no one has asked us. So, the last statement on our submission was just simply this, listen to the profession. And I suppose David might be able to give you more of an insight, because they have been in negotiations or talks with the Government. And David, give your feedback to the committee. Yeah, it's obviously Stuart. I can't say anything specific about our negotiations because they're currently private and confidential, but our preferred model is not to go back to the ASDR. And we can't repeat that often enough. We need to go to a capitated, a weighted capitated model. We're quite happy to talk to the Scottish Government about that, but I think they have stated that their preferred method of delivery is a blended model of capitation, continuing care, alliances and item of service. So yes, so Government will say, we hear you, but we needn't to listen. Okay. And we need them to engage Stuart with the three organisations. With the three organisations. Okay. We've got a few other questions. Just in terms of the survey that was undertaken. So why did 30% of dentists according to your survey and 31% of the respondents to the committee's survey not apply for the additional funding throughout Covid? If I can answer that briefly on my own behalf, we applied for ventilation funding for our practice and were refused by our health board to have ventilation installed because the standard ventilation which was proposed by one of the contractors who's done a lot of practices didn't meet the standards they thought was appropriate for our building. They had several other contractors but for proposals nothing was done. There was seemingly a ventilation action group formed in Lanarkshire to look at how they could install ventilation. Nothing happened with it and the that has now disappeared in the year view mirror and we lost the patient access relative to other practices for the period from when we first applied until ventilation wasn't an issue. I assume other practices might be in similar situations maybe some people with ventilation installed in the first place but I do think there are questions over the science as to how appropriate the ventilation recommended and installed in what places actually was. Certainly Lanarkshire health board questioned the government's science in the front. The ventilation was a complicated issue it's not just a matter of putting in a fan one bit I'm sticking a fan out of the other bit. So if you look at that funding that funding it created to £5,000 per practice. My practice is in a health centre which is owned by Goethe-Gasconclyde health board. We at that time we had three surgeries there we now have five and so I got the state's department on the board to give me a quote for the ventilation system. The ventilation system for the three three surgeries is going to be £50,000. So £5,000 didn't even touch it. It wasn't even here. It needed to be more specific about what the requirements would be because as I said you can't just draw in from air in from somewhere and put it out somewhere else you need to get the HEPA filters involved. So what I ended up doing was I ended up just buying two HEPA filters per surgery which got me up to the requirement of 10 air changes per hour but this is going to be an ongoing problem not just within dental surgeries but I think within the whole of the NHS. Throughout the recent times the Oral Health Improvement Group had a suggestion to bring in directors of dentistry in each health board area and that has since happened. Has that been beneficial? It's been beneficial because I do have a working relationship with the director of dentistry in Goodagosco and Clyde but sometimes I feel he's hamstrung with the board because the board is very very heavily centric on secondary care and I've said for many many years what we're actually needed at board level as a primary care board to integrate with that. It goes back to the funding for everything going into secondary care and primary care just being left behind. Okay. Personally I can't see any significant benefit although it's been such an unusual time that's going to be an unfair comment. Okay. In terms of graduates how are graduates incentivised to actually work in the NHS? Incentivised. I think as David's already said that there is much of an incentive for them to go into NHS dentistry so this is becoming more and more unattractive for them and that's again relating to the delivery model you know so we need to shift we need that shift to happen it needs to be a preventive based model as opposed to a disease-centred model so there is no real incentive for them to go on to the NHS. Mr Cole. The government have incentives in forms of golden handcuffs, golden handshakes, bursaries they don't work that's a very short-term fix you know that short-term fix is doing our work but we need to make the NHS a long-term attractive place to work where people can go and have a career and currently if they go and work in a practice and they're possibly two dentists working in the practice and the most qualified person is two years there's no managed clinical network there there's no training there's no support that's why they don't want to go in there we need to have a practice model where we have that managed clinical network and support Mr Stain. You want to think that as a vocational trainer for 10 years having a new graduate in my practice for 10 years it's quite a soul destroying experience having to unteach them the best practice they'd spent their university career learning to teach in a way that things can be made to work in the NHS and you know I think even this that initial exposure makes a lot of people realise that the next career move is going to be very briefly NHS if at all I mean we used to have associates to stay with us for a good few years after doing their vocational training years how we'd developed our business but now that just doesn't happen at the same extent they know there's a better life out there they know there's a better way to do the right thing for their patients out there and they're not willing to sacrifice themselves for the NHS the way I think we all did without considering it a sacrifice at the time okay and my final question is just in terms of the dealing with the pandemic what funding or other measures would have I actually increased the capacity and the recovery for practices I'm going to come back to the any recovery hinges and reform and I think we've said that I don't know how many times in this session today you know we really need radical reform because tinkering about and rearranging the debt shares in the Titanic is just not going to work this time you know we need a radical rethink about how we deliver NHS industry and we all want NHS industry to work we have the goodwill in NHS industry between us we want to make sure that NHS survives and the patients get the treatment that they need we don't want to go back to people curing around the street for registering and that's not what we want to see we need it to work We're getting very close to finishing up I was going to say in terms of how things could have been improved but I think I've seen early 2021 we'd organised an online conference at which the chief dental officer spoke and there was a commitment to the SDR not returning a commitment to engaging with profession to get reform and I think at that stage there was actual enthusiasm amongst the profession to engage in creating something better so that once everything had ground to halt during Covid literally was a once in a career chance to start again doing something different and there was definitely goodwill there for people wanting to make that work I think and as times combine people have seen that not happen that's where a lot of practices and a lot of individual dentists have started to move away from providing NHS dentists to private and yeah when the trains left the station now so when people have just lost faith you know that the gesture it's going to take to get things back on track has to be bigger now than it would have been two years ago or a year ago Okay thank you Yep One final thing I would add is that I would ask you to use dentists on the NHS better so use them better so so you're using them as tooth mechanics really Well that's one final very fine I'm sorry we're already 10 minutes over time but one very final thing I want to ask you is there's an anomaly in some of the things that I'm hearing in the sense that you're saying we need to get a system of prevention rather than cure and yet we've got this backlog of people with diseased teeth so what does it take to bring those two things together and I know David you're going to say it's going to take reform but what does that look like? If we have reform we can then attract more people into our practice and our practice team to deliver it but without that we can't attract anyone in another minute If we have a fixed budget right now and I promise you this is not a gotcha question I'm merely trying to get my head around this we have a fixed budget you have this backlog of people with diseased teeth that need to be sorted but we also have the requirement to create a system of prevention How do you do that? Can you physically do that? What we need to do is be realistic about what we're delivering at the minute and the reason why we're delivering the type of care we're doing is because of the SDR that's why we need to get rid of that SDR David Douglas sorry When that is the impossible conundrum I think the truth is the only way to move forward is to have probably two separate trains of thought there The preventive side needs to be brought forward so that children growing up don't have a significant dental disease That was all about If it was, it's something that needs to be done more of, I'm taking boards I don't think the child's well worked but as long as we focus too heavily on catching up with the backlog then the preventive end is never going to become big enough to take over I mean that is the problem in an ideal world we need twice as many dentists for a couple of years all being paid enough to make them want to do the job and then we can get rid of half them that we don't need That's Pytons guy Atif you've got the last word on this So reduce the so what to do next reduce the SDR the 600 items as David's already mentioned reduce them to only items that will secure oral health right that's our first base right we've got to get to that that's us first base renumerate the people that are the providers better for what they're doing in the within the same budget and start to promote a preventive model when we do this we'll make it we'll make the NHS more attractive for dentists to work in and that's what we want Okay, gentlemen, thank you very much for your time this morning we have gone quite a bit over the time so thank you very much for that extra time if there's any other evidence you'd like to raise with the committee you can do so in writing and the clerks will be happy to liaise with you to do that We'll be hearing from the Scottish Government at our next meeting on the 29th of June which will conclude our evidence taking on this inquiry that concludes the public part of our meeting this morning so I suspend the meeting to allow witnesses to leave and we will move into private gentlemen, thank you very much