 Felly, wrth gwrs, a gweld ei chyfnod o'r 15 yma leifftrath o'r Cyfrifolau Cymru yn 2023. Alex Rowley yn ei ffordd o gyfrifiad i'n gwestiynau nhw, ac rwy'n gwybod i'r Jackie Bailley o'r cyfrifolau cyfrifolau cysylltu. Y gydigwyd Cymru yw ydw i ddechrau'r ystod o'r 5 yma, dwi'n bwysig i'r cyfrifolau cyfrifolau yw'r cyfrifolau cyfrifolau cyfrifolau? Felly, y gallwch yn gofynol. Mae'n gydigwyd yma. We agree to take on agenda number five and item. Agenda item number two, recovery of NHS dental services. This morning we will conclude our evidence taking on the inquiry into recovery of NHS dental services, and I'd like to welcome to the meeting Jenny Minto, Minister for Public Health and Women's Health. Tom Ferris, chief dental officer and deputy director for dentistry, optometry and audiology division. David Knopman, the unit head for dentistry, optometry and audiology division at the Scottish Government, thank you very much for joining us this morning. Minister, would you like to make any short opening remarks before we move to questions? Thank you, convener. I would. Thank you for inviting me to support the important work of the committee and provide an update about the Scottish Government's commitment to NHS dental services through the pandemic and sustaining provision and patient access to these services in the long term. I should be happy to answer any questions that the committee has in connection with Scottish Government's written response on 25 May. I am supported in this session, as you have noted, by chief dental officer Tom Ferris and senior policy official David Knopman, who have been imposed throughout the pandemic period and will be able to provide further information and policy context that may be of use to members. If I may, I would like to reflect briefly on the significant journey that NHS dental services have been on since the outset of the pandemic and the subsequent recovery of NHS dental services. The committee will be very much aware that NHS dental services were disproportionately impacted at the earliest point, with full cessation of services on 23 March 2020 being the immediate and necessary response to the emerging pandemic emergency, and that the necessary cautious remobilisation of services was similarly impacted due to the potential of coronavirus to be spread by aerosol generating procedures in the dental setting. During this challenging period, the Scottish Government put in place £150 million of emergency financial support and PPE when public health concerns and infection prevention control measures prevented the sector from operating normally. We see preservation of the sector the first stage in ensuring that we can adequately recover NHS dental services. The Scottish Government implemented a significant policy intervention in February 2022 that removed the basic examination fee and replaced it with an increased fee for an enhanced examination, including for under-18s. That policy change means that all patient examinations, including children, provide the dental contractor with a higher fee for a longer examination appointment resulting in a reduced need to deliver a high volume of care. That change was reflective of the sectoral representation to the Scottish Government during the pandemic and engagement in the development of the oral health improvement plan, OHIP, that clinicians were unable to provide the modern dental care that they felt their patients required under the high volume arrangements, as the payment model was not reflective of new techniques or clinical discretion. The effect of providing the enhanced examination is that clinicians are now able to spend more time with their patients and are able to provide patients with improved preventative care. The intention of that reform builds on OHIP to further support patients receiving the right care at the right time. The recovery of NHS dental services from the pandemic period is shown in official figures published by Public Health Scotland. NHS Dentistrade delivered over 3.8 million patient contacts in 2022-23. That compares to 2.8 million the previous year and 1.5 million at the height of the pandemic in 2021. While we are not where we would like to be, we have achieved a great deal. I also want to provide in my opening statement something of a context of recovery. While Scottish Government support has taken the sector some of the way towards full recovery, there are external economic workforce and capacity factors in dental labs that will require a longer timeframe to fully address. It is also worth reflecting briefly on the underlying conditions that play in the sector as the cost of materials and staff are impacting significantly on the ability of practices to remain viable. While the Scottish Government can and has made specific interventions, the committee should note that it is not within the gift of government to fully insulate NHS dentistry from those challenges. Our keystone is payment reform, which I know the committee will want to go into more detail about. We see that as a significant step forward. The Scottish Government is presently engaged in sensitive negotiations with BDA Scotland around setting fees under the reformed model that delivers the OHIP with a strong focus on preventative care. I would hope to be in a position to provide further details to the sector and the committee if that is helpful upon conclusion of that negotiation. Running alongside the implementation of payment reform are a range of mitigations with the main focus on island and rural areas. The committee will be aware of specific interventions through the Scottish Dental Access Initiative and Recruitment and Retention Incentives, which are targeted for certain board areas. We are also working closely with affected boards on different models of care so that we have greater resilience in the future. In summary, while we have made progress, the Scottish Government has still got the significant work to do to support the sector and is focusing on delivering reforms that ensure sustained and equitable services for the long term. With the help of committee members, I would like to explore the challenges and possible solutions as we move forward. Thank you very much, minister, for that extensive response. We are going to turn to questions now and we will hand over to model Fraser. Thank you. Good morning minister and good morning colleagues. We have been taking evidence for the last two weeks from various stakeholders that we have heard from NHS boards, we have heard from representatives of patient interests and we have heard from dentists in the profession. In your letter to the minister of 25 May to the convener, you say that the policy of the Scottish Government throughout the pandemic has been to preserve and protect NHS dentistry. In my view, we have successfully done this. I am bound to say that I do not think that the evidence that we have heard reflects that statement. For example, what we heard last week from the dentist was that there has been a loss of 52 per cent capacity in NHS dentistry since Covid. In fact, many of the issues with NHS dentistry existed pre-Covid but were accelerated and exacerbated by the problem. There are many areas in Scotland now where there are no NHS dentists at all. Kinross in the convener's constituency he will be familiar with is an area where you cannot now get an NHS dentist. New Brand Fife in my region as well is another area. There are lots of other examples. Even where people are registered with NHS dentists, they are waiting extreme periods of time to get appointments for routine work. We have also heard, for example, that although we have new entrants coming into the profession, graduates coming out do not want to do NHS work, they want to go into private practice because they have more time to spend with patients. The picture that we have painted for us is a very unhappy one. Would you like to advise your comment in your letter that everything is fine? Thank you for that very long question. The actions that the Scottish Government took going into the pandemic to support the dental area and dental services were absolutely needed. I think that if that work had not been done, if that investment had not been made, then I cannot imagine where we would be sitting now. We still have a lot of dental practices. Perhaps, yes, I would accept that there are some concerns. However, what we are trying to do in discussing with the dental groups is the need to stabilise the profession, and that is exactly what our discussions have been around. I can remember seeing the cues, and I think that that was referenced by some of the evidence that you received the cues around dental practices 20 or so years ago. I do not believe that we are at that point. I am reflecting on where we have gone to, the support that has been given to dental practices throughout the pandemic, and building on the evidence that we have received from dentists when we did the survey, the OHIP work. There is a recognition that we need to continue to work with the profession to ensure that we get the right levels of treatment and the right access for people. I think that that is what recovery looks like when we can see that we have the right number of dental practices providing the right services so that people can get access to that, and we stabilise the profession. I believe that that is what my colleagues have been working incredibly hard with the dental sector to ensure that we have. I think that the introduction and the connection that we have within the NHS health boards and the support that we have provided them in various areas across Scotland specifically to try to maintain access to dental services is incredibly important. However, that is not happening, because all the evidence that we hear in the committee and as representatives locally is that access to NHS dentistry is still reducing. There are still practices that were doing NHS dentistry that are now stopped and there are people coming to us all the time saying that they want to get an NHS dentist and they cannot find anyone who will take them on their backs. I think that you also received evidence from NHS Borders that was very clear in the work that they are doing directly with practices and the support that the Scottish Government has been able to give through the SDAI grants to £100,000 for a new practice and £25,000 for other practices. There is work going on and I think that we have to be careful that we don't paint such a dark picture across the whole areas. I think that there are areas and the dental directors within each of the health boards have a very good relationship with their dental practices. That relationship with my officials ensures that we understand where problems are. For example, in Tayside, there have been specific requests in specific areas where they recognise that they need to attract more people. As a result, that work has been done and they are now included in the ability to get SDAIs. Where I accept that we have a distance to go in a lot of areas, I think that we are making progress. We will see if progress is being made in due course. If you look at the pattern of change, you are absolutely right. I might remember 20 years ago that there was a big issue, a lack of NHS dentists and there were queues outside practices. There was a big ramp-up in training and recruitment of dentists. A lot more dentists came into the profession and that was a great success. However, what has been happening over the last maybe five years or more is that there has been progress with NHS dentists increasingly moving to do more private work. What happened during Covid is suddenly that as accelerated and people are now having increasingly to turn to private dentistry because they cannot get an NHS dentist. People are in a fortunate position and perhaps they can afford to do that. There are many people who cannot afford that. Therefore, they are following through the gaps. We have a real issue of inequality. I suppose that my question would be what is the Scottish Government's vision for dentistry? We have always had a mixed economy. We have always had dentists doing private work and NHS work. The growth has been in private work and NHS work has shrunk. How does the Government see the profession going forward? If we are going to retain NHS dentistry, given that we know that a lot of young people coming into the profession are more attracted to doing private work, is that only going to be achievable with a substantial injection of additional cash? If so, where is that coming from? We need to remember that about 45 per cent of the population of Scotland can access dentistry free on the NHS. That is very important to remember. If they can find a dentist? There is also the ability to get dental care through phoning up your NHS boards. I know that the NHS boards, along with the directors of dentistry in each of the NHS boards, are looking to improve that facility. It was a SNP manifesto commitment for free NHS dentistry. In the policy prospectus, what we have said is that we want to stabilise the profession and make it sustainable. That is where we are going. It is still a commitment. Given that we are in really quite difficult financial circumstances, I would hope that we can move towards a free NHS dental service, hopefully within the length of this parliamentary session. It is important to recognise the fact that we have been taking steps to achieve that by allowing free dentistry for people up to the age of 25 or under 26. We heard from the dental practice owners that under-25s are coming forward wanting cosmetic treatments such as teeth whitening, which is putting a burden on them. I wonder whether that is the best use of limited resource. You mentioned the commitment for the extension of free services for everyone. How credible is that that will be delivered? Clearly, the whole system is creaking at the seams at the moment. There is not enough money to fund what we are offering at the moment. Is it realistic to think that within three years we can give free NHS dental care to everyone and that that will be accessible and will be the dentist to deliver it? With regard to the teeth whitening, as I understand it, that is not a normal piece of treatment for people under 25 to be able to get on the NHS. It would only be in specific circumstances. I was slightly surprised when I heard that piece of evidence as well, so I wanted to understand what was behind that. As I have referenced, we are in really difficult financial constraints just now, but I think that our vision has to be that we have the best oral health that we can have. From my perspective, if we can ensure that we can provide that to the people of Scotland, then that is a really important preventative way to avoid additional spending later on. My job is to try and work out the way to find that, to ensure that that happens. I have my officials working with me and the dental sector to look at different ways that we can perhaps achieve that. I will move on to Jackie Baillie and prevent the dentist in child smell. Thank you very much, convener, and good morning to the minister. Child smile, I think that we would all describe as a flagship programme introduced by the last Labour Scottish Government and continued helpfully by the SNP. What we are seeing is a growing inequality gap between the least and the most deprived areas, particularly when it comes to children's oral health. Before Covid, I think that there was a problem, but that problem has been exacerbated by Covid. What we are now seeing is that registrations of very young children have dropped dramatically. Only 25 per cent of 0 to 2-year-olds are registered, which is desperately worrying, because that has an impact on later life. Child smile, we do not think, has returned to pre-pandemic levels. In relation to children's oral health, what are you doing to address those concerns? Equally, we know that that extends into adults as well. What specific measures are you taking to address inequalities in adults' access to dentistry? I was concerned as well when I saw the level of young children that are not registered at dentists, and I would like to commend everybody who has worked on child smile, because it clearly has made vast improvements. I was pleased to see that the Scottish Government invested a further £1.9 million over two years. That allows about 400,000 packs to get into child settings, whether it is nurseries or dental practices, to ensure that children are getting that important lesson education. Let us not forget the baby box, which also supports in oral health. I think that your question was specifically about what specific targets have we met. I have talked earlier about the improved fee to dentists, which allows them to see children, and that is incredibly important. I think that there was over 600,000 child examinations carried out, which is a really good start. When you were taking evidence from Public Health Scotland, there was some indication that, perhaps, going out into nursery schools had not ramped up to the same pre-Covid level, so that is clearly something that we need to ensure happens. We cannot forget the Community Oral Health Challenge Fund, which has specifically focused and targeted on communities of greater need. In Ayrshire, for example, the child services there have done specific work with children with additional needs to get them using their being aware of their child, their hygiene, oral hygiene as well. I think that it is these relationships directly into communities that are going to make the difference. In so many areas of the role that I carry out, it is that relationship between Government and the professions and the third sector organisations. I think that the third sector organisations have played a very important role. I know that you took some evidence with regard to inequalities and ethnic minorities. Again, I know that the health boards and their directors of dentists have been working very carefully and closely with them. I think that it is that tripartite relationship that will improve how we get on. It is the investment, but it is also the advertising to ensure that that happens. That is where we are making improvements. Given that you have described the kind of interventions that you are making, particularly for children, do you think that that is enough to restore registration levels? If you do, have you set a target for what percentage of registrations you expect and by what time? Obviously, targets drive improving performance, and have you equally set targets for closing that inequality gap, which is in fact growing? As I understand it, registration has increased, certainly, amongst adults. I would hope that the work that we are doing with regard to ensuring that oral health care and brushing etc. is happening in settings where children are and that that would have a knock-on effect. I am not aware of any targets being set, but maybe Tom can... Sure. We do have the national dental inspection programme, which is a programme that goes out every year to measure the oral health of children in primary 1 and primary 7. We have targets of 75 per cent of primary 1 children by 2024, which would have no sign of obvious decay in 80 per cent of primary 7s by 2024. The most recent measure that we have is in 2022 for primary 1s, and it is 73 per cent. The pandemic may have an impact on that, and it may dip a bit, but we do have a target. We were working on something called the slope index of inequality, where we look at the difference between the most affluent quintile and the most deprived quintile, and we would want to see that reducing across boards. That was just for the very early work, and that will commence with the next school term as we ramp child smell back up to where it was. As you say, it is almost back to where it was, but there are still some schools and nurseries where it is not quite happening, so we need to build the relationships again with those individual head teachers. If we have issues, I have education policy colleagues in the Scottish Government. We also have worked previously with the directors of education in COSLA, who are really helpful in driving the attention towards schools working with us to improve oral health. I suppose that what I am trying to do is get a sense of the urgency of this, because if we are still sitting at zero to twos at only 25 per cent registration, that is going to have a knock-on effect. We know that if you do not prevent it, it costs you more money to treat disease later on. I am keen to get a sense of when you expect those targets to be achieved. Is there any kind of additional remediation that you are doing because of Covid and to try and recover them? Child smile has an arm where they work with new parents just after the child is born. It is usually referral by a health visitor. Those families are facilitated to register with a dentist, so that should be happening again. Equally, any young child who attends NHS 24 because they are in pain will be followed up by the local health board to make sure that the family get into care either by registration with a general dental practitioner or by going to the public dental service for care. Any child who, through the school inspection process, is identified as being at high risk, will be followed up by the health board or the health improvement teams to make sure that the family has the support to get into child smile, but equally they get registered with a practice or with a public dental service. There are various touch points where we contact families and engage with families to get registration. I accept that zero to two registrations are low. They are always the lowest cohort of the population, but it is not great where it is, and we need to put a lot of effort into that as we go forward. It is even lower just now than it has ever been. Can I talk more widely about prevention? The dentist we had before us talked about prevention virtually with every breath that they took, which I am very much welcomed. What they described was a funding model—let me get this right—that was high-volume, low-fee, disease-centred, and they felt that they were not able to do the kind of prevention work. Let me give you one example. One dentist raised with us the ability to bring a group of children together to do education work on prevention, but the fee model does not allow them to do that. I am keen to know what improvements you will make that would enhance the ability of dentists to actually do prevention and what you as a Government will do beyond the touch points that you have described at population level to improve access to dentistry so that we can ensure that there is more preventative work taken. I watched that evidence. That is one of the key things that we have to talk about, is the flexibility of staffing within dental practices and what that would allow them to do perhaps on a different scale. If I go back to what I said earlier, the thing that we have to move forward on positively is getting the right fee structure, and, as I have said, we are in negotiations with the BDA about that. I suppose that a child smile is given in dental practices as well, and I think that that is important because it is already introducing children to a dental practice, so that you will hopefully avoid the anxiety that some children have when it comes to visiting the dentist. I am happy for our discussions with the BDA and other dentists to move into that area, looking at the flexibility of staff, because I think that that is incredibly important, but that is a longer term look at how we structure support for dentists. I was very aware that prevention is absolutely one of the key things, and I referenced that earlier in my introductory notes, that if we do not get the prevention right, it ends up costing us in the longer term. I think that I will stop there. Just so that I do not want to put words in your mouth, what I seem to hear from you is that the ability to be more flexible around about prevention is not in the current discussion about fees. The current discussion about fees is looking at the volume of the fees and how we can make that more patient and helpful, but also looking at how it is easier and less bureaucratic for the dentists. David, do you want to say something? I will say a little bit more about, without alluding too much to the negotiations that are currently going on, that the payments model is, in my view, a radical revision of what we currently do in dentistry. It has got a great deal more focus on prevention than we currently have, so we are going to be looking specifically at a more preventative focus within the fee per item model, so I should say a more preventative focus than we presently have. My sense is that, yes, there are discussions that are currently going on, but we are also being cognisant of the need to be more prevention-focused, and that is being reflected in the model that we are developing. I will stop here, convener. The dentist described that model as preventing them from doing the kind of dental work that I have described, so we just need to wait and see what you come up with. Probably following on from that, it said in your letter before we started the inquiry that the Scottish Government takes the view that the present blended system of payment comprising fee per item, capitation allowance and direct reimbursement payment should remain. I mean, certainly what we have heard, and I know that Mr Knopman used the word radical just now, but it has been suggested, I think, that the dentist is more that this is just tweaking the system, and they really would like something more radical. One suggestion is to move on to a system more like the GPs. Now, I speak to GPs, they are not entirely happy with their system, but they seem to be a bit happier than dentists are. Would that be an option? I think what the Government has said is that we want to continue the blended model, which does have an element of capitation, so the dentist gets paid per patient that is registered. I acknowledge that if the dentist has not seen that patient for, I think, three years, then that fee per patient does reduce. I think that that is a strong model, and then it is a fee per item of work that is done. That is what we are looking at changing, simplifying, making it less bureaucratic for the dentists, and that is the right way to go. I note your point about GPs as well, but with regard to dental care across Scotland, we have to look at the models that are across Scotland, and the blended model, we believe, works best for the practices across the length and breadth of Scotland and our islands. David, do you want to add anything? I accept the point that is being made. Our view presently is that, if we look at the empirical evidence, a purely capitation-style model inevitably leads to an undertreatment problem. We have got empirical evidence across the UK from the early 1990s when that was done in dentistry, but we have also got empirical evidence from the Covid period. We did the right thing in March 2020, we suspended the fee per item model, and we allowed an emergency support system to support dentists, which is effectively very similar to capitation. The difficulty we find is that, if you pay individuals, economic agents and their independent contractors, regardless of what they do, we go to the bottom in terms of actual patient care and treatments. The disadvantage of the fee per item model is that, if we accelerate that too much, we tend to get an overtreatment of patients. The reason why the Government narrative is a blended system of fee per item and capitation and allowances is because that way we get the strengths of each individual component of payment without unmitigating the weaknesses. It would not be our position to move across to what is described as the general medical services model on the basis that a pure capitation model on dentistry review would lead to a reduction in NHS treatment and a very significant and perpetual increase in oral health inequality. The payment model has to be a blended system of payments to ensure that we can maintain treatments to NHS patients, and we can only do that through fee per item, a retention of the fee per item model within that wider construct of different payments, including capitation. That is essentially in a nutshell our argument. The other thing I would venture to the committee is that we need to be incredibly careful. We have over 1,000 dental practices in Scotland, all of whom have different business models, many of whom are wedded to the present payment system that the Scottish Government offers. Radical change in terms of moving away from fee per item and replacing with capitation would be financially very destabilising. There are around 4 to 500 practices in Scotland that have over 90 per cent NHS care, and that would be potentially very destabilising to the sector and lead to a set of outcomes that we do not even want to consider, and it would have been within our discretion. That is essentially in a very quick summary of the Government's position with respect to capitation. At the risk of going over this ground again, the minister said that we have a strong model, and he said that it would get a lot worse if we moved to a different system. However, the reality is that my dentist has not been in touch with me since before Covid until I wrote to them and asked them. They have stopped doing reminders. My dental care cannot get any lower, and that is in Glasgow, in a city. We had people along here from Shetland who said that their system is not working. They have one practice, and they have a director of dentistry. How do you need a director of dentistry for one practice? I do not understand that. We have been hearing evidence that the present system is not working. You suggest that it would be worse if we moved to the capitation model, because practices would move away from the NHS, perhaps, or it would be destabilised. However, from what we are picking up, there is a strong drift away from the NHS, not necessarily in the numbers, but a practice like the one that I go to, which has stopped sending out reminders, and others have deregistered the one that I go to so we seem to be getting that across the board. When we hear people speaking to GP or medical students, they are not wondering whether they are in the NHS or not, they are wondering whether they are going to hospital or GP practice, and that is an issue, but when people are speaking to the dental students, they are saying that they do not even want to go into the NHS. Do you not accept that there is something fundamentally wrong here? I accept that we have challenges, absolutely. I think that what I would say is that the national picture presently, when we talked a little bit about registration, we have retained a very high registration of NHS patients. I would argue that that is the base position with regard to access. We have also seen something of a recovery. We did put in place short-term recovery measures through Public Health Scotland, and we have seen across the key treatment groups a very significant increase in these key treatments. The minister has already referenced the fact that we are up at around 4 million patient contacts against around five to five and a half million before the pandemic. That gives you the context of where dentistry is. In terms of participation, which is the numbers of patients that see a patient in a two-year period, we are now on track to a very similar position before the pandemic. The point that I would make to you, and I say this with the greatest respect to the committee, is that I would not describe the national picture in the darkest possible terms. The national picture is reasonable. It is not without challenge, but we do have some very serious local challenges. I accept that, within certain parts of Scotland, we are seeing a more significant challenge to accessing dental services than across the nation as a whole. It is the job of the Scottish Government to put in place that national framework to support boards in that local provision. That is what I think we are trying to do. I accept that there are different narratives playing out here, but I just wanted to bring us back to the fact that the national stats show that we have done a great deal in terms of bringing dentistry back to a position that is not incomparable with what it was before the pandemic, but within our local sphere, I accept that some patients will be struggling with access and there are some local problems that we need to address. If I could just ask one other question on a slightly different tack, do we actually know what the state of the nation's oral health is? You have told us at primary level that, at primary 1, primary 7, you are actually checking at the kid's teeth that you know that a percentage has no decay or has decay. Do we know that for adults? We do not have an adult equivalent of the child inspection programme at all. However, that is one of the things that we are trying to build into the reform system. The greatest indicator of someone's risk of future disease is past disease. We are trying to build in some key indicators to the reform system that we can extract that data on an anonymised basis and use that to inform the clinician of the oral health of their case list. We can aggregate that up to practice level, to board level and to national level. We are trying to get that information with the least bureaucracy as possible and it is easiest if it is part of people's day to day work. We are trying to build in the key indicators that will come from the enhanced examination that they are currently doing. We extract that data, public health Scotland, use that data and then build out the stats from that. That is a weakness. We do not have that information. We have the Scottish Health Survey, which has self-reported stats about the number of teeth and dentures and attendance. It is fine as far as it goes but we need something better because we need metrics to prove, but we need outcomes. At the moment, we count virtually every widget that we do, but what is the point of a lot of that stuff? We really need to understand what is the outcome of doing those widgets. It is an outcome metric that we are looking for and we are working on that as part of the new reform. That is very positive. That is a good note for me to finish on. I want to come to you very quickly on something that you have just said. You are saying that across the country generally you have a lot of dentures that are wedded to the system that is there. We have heard that members of the SDA and the SDPO have been completely excluded from talks and negotiations about reform. Are you not hearing that people want reform? I think that there are two different things in a way. The point that I was making was that I think that a fee per item is a very strong incentive mechanism for dentists to provide NHS care. If we look at the stats we find that there is a large proportion of practices that have a high volume model. It gives dentists the discretion of income as well so that they can decide how much dentistry they want or do not want to do. From my perspective I think that there is a large proportion of practices in the Scottish population that want to provide NHS dentistry and the fee per item model provides the incentive for them to do so. Slightly separate question with respect to SDA and SDPO. We have very regular discussions with BDA Scotland. BDA Scotland is the representative body for the profession in Scotland. We also have intelligence through the boards with the directors of dentistry and we have quite a lot of networks within dentistry to give us that level of intelligence. With the oral health improvement plan in 2018, we had about 20 to 25 road shows in Scotland and we had a huge consultation exercise with all dentists in over 500 responses. Most of the oral health improvement plan is feeding into this discussion around reform and how we take forward the recovery of NHS dental services. We have a very substantial network across Scotland in terms of understanding the difficulties that dentists have. That would be my sense of things in terms of where we are with discussions with the profession. Are we right in thinking that the BDA does not represent all high street dentists? Government has to take a view. Our view is that the BDA is the representative body. It can provide us with what I would describe as a delegated mandate. It has a clear delegated mandate from dentists who are members of the BDA based on a membership fee to discuss with Scottish Government. Ministers have to set the line as to who they would regard as a representative body. It may very well be that the BDA does not have all GDPs, but they are able to provide evidence to us that they have a delegated authority from GDPs who are members. The Scottish Dental Practice Committee of BDA represents all primary care dentists because they come from the local dental committees of health boards. Membership of the LDC at the health board level is not dependent on being a BDA member, so there will be LDC members at health boards who are not members of the BDA, but they are local GDPs. There are subsequent elections forward on to the SDPC, and they form that representative body for us. They cover the length and breadth of all the boards and different areas of Scotland, so we get a full gamut of GDPs in that committee who come to us and bring their side of the story. It is important that there is a democratic mandate behind BDA that allows us to know that we are dealing with an organisation that is truly representative. We need to hear that from other organisations who would like to inhabit a similar space. Okay, it seems a very cluttered. If anybody was sitting listening to that just now, who didn't know anything about dentistry, they wouldn't have a clue what you were talking about, because there are so many anachronomies in there. Same for medicine in GDPs, just a substitute M for D. The only point that I'm trying to push here is that we've had people in front of us saying that they are completely unheard and excluded from the conversation, and I'm just wondering if that's something that might be considered after we've concluded our evidence and come back to you, that there are clearly people who are in the private dental practice who don't think, despite the fact that we've got NHS roles to play, that they are simply not being heard, and I think that's something that we should consider. Brian, I'll move on to you just now, thanks. Thank you. Good morning, minister. I've been listening with interest to what has been said today, and I think that I'm reflecting on the dentistry view that seems to be being portrayed here. I have to say that it's markedly different than the evidence that we've heard beforehand, and as a committee, we have to obviously assess the evidence that comes before us. As my colleague Jackie Baillie said, dentists repeatedly talked about wanting to go in, wanting to look at prevention, and you will know, minister, that's a passion of mine, but they also said that there was no immediate strategy or capacity to declare any backlog on immediate poor oral health. In fact, last week, we heard that under the current system, they thought the backlog would never be clear. For me, the concern here is the huge gulf between what the evidence we're hearing here today and the evidence that we've heard over the past couple of weeks. There are a couple of things that I wanted to mention. One, the fact that, because of the big gaps between being seen between appointments and what they're having to do with the dentistry, they're having to apply much more complex, which is obviously an indication of a problem, and also the fact that they get paid when the treatment is finished, and if it's taking longer to do that treatment so that there's an appointment and then there's a filling in three months and there's a filling in another three months, they're not getting paid for further six months, and they are saying that system, that system, it can't continue. So I think that if we're going to fix this, which I think we all want to do, it has to be, we have to understand what reality is. How do we, as a committee, help us here? How do we go from the gulf of what the evidence we've heard at the painting of a dentistry system here, where, as John Mason said, we have students saying that they don't want to work in NHS, and we also know that the current NHS dentistry is drifting towards private. How do we go from that? How do we close that gulf from what you're saying and the evidence to what we are hearing? I think that there's a few elements to that. I think that we've been quite clear that we do recognise that we have a distance to go to make the dental service the one that we actually want it to be. With regard to the backlog, I think that you've got evidence, and certainly I've experienced this from my own dental practice, in the six-monthly. I think that what we all grew up expecting was the normal time to return to the dentist. Actually, the dentist can make that decision, and it may be, actually, that you don't need to be seen for nine months or 18 months. Some people may need to be seen more regularly, so I think that the dentist has that capacity within their clinical decision making, and that may help reduce some of the waiting times. I think that we've also got to remember that throughout the pandemic, we lost a whole cohort of dentists in training, so they weren't able to do their practical experience. I think that we've acknowledged that we're back up to that level of 160 coming through, but it will take a few years to get back from that. The other thing, the work that we have done is looking at people where we can get other dentists from, and there's a bit of a roadblock there, so certainly in my area you would get a lot of dentists coming from the EU, but since Brexit that has reduced. What I have done is written to my fellow ministers for health in the four nations of the United Kingdom to say that we can find a way of speeding up the entrance of dentists in, and that will help with the capacity. The other thing that I've touched upon is looking at what other mitigations can happen, so the use of working with the health boards is their solutions there. I also touched on the flexibility of staff looking at what different members of the dental teams within practices are doing. Sadly, I don't think that we can fix it next week, but we have put in a number of mitigations to do that, including the additional funding that the director of dentistry from NHS Borders talked about in your last evidence session, the first evidence session that you did. Minister, it doesn't matter how many dentists are in training, if they do not want to go into the NHS dentistry it will make no difference whatsoever, and over and above that what we've heard as well is that a lot of dentists staff are moving to private practice purely for financial reasons because, in private practice, they can pay more. We have to understand what the problem is before we can fix it, and what my concern here is is that what we are hearing from one side of the argument and what we are hearing from you differs so much that I'm not sure that we're—I don't know what my colleagues think, but I'm not sure now where the reality is because we've heard that the NHS is under huge pressure across the board, and dentistry seems to be at the worst end of that, and to a point that one of them said that it's in danger of falling over. We have to accept where reality is, so this idea of, we need more dentists, we need more NHS dentists, how do we get more NHS dentists to practice? I appreciate that you've got evidence that said that young dentists don't wish to go into the NHS. We've had conversations and we hear the other side of that, so there is still a cohort of dentists that will wish to get their training in an NHS practice. We've got to be very careful about just painting that one side of the picture. There are people who wish to go into NHS, and I think that what we've been trying to do with regard to the payment reform is to improve the attractiveness, if I may use that word, for new dentists to come in. In my constituency, in Denun, in the hospital in Denun, there are two dental surgeries there, and they are working with fourth-year students from Glasgow coming in and getting support from a retired dentist. It's looking at those things, trying to be, as I've said before, flexible to ensure that we can bring them in, but we do believe that the negotiations that we're having with the BDA are moving to that flexible model to support NHS dentistry. We've heard that there can be a long delay in getting payment for treatments done. We've also heard that there are some treatments on the NHS that actually cost the dentist money to deliver. Is that something that you're looking at at the moment? Yes, it is, and we heard that as well. We are in a cost-of-living crisis with inflation, high inflation and the labs that are doing dental work. Their fees have gone up, so yes, and we have recognised that and worked with the BDA with regard to that. The other thing that we've got to remember, as well, is that things don't stand still. I was at a meeting yesterday talking about life sciences and the amazing work that's happening coming up with new technology to support. That will help in the preventative field as well, but that's expensive. In the long term, we would hope that that will reduce the requirement for additional care. I'm sure that we can all remember having to get putty in our mouths to work out what work was needed to be done, whereas now that can be done with a digital scanner, which will improve throughput. However, it's working out how we can do that, and that's also part of our conversations with the wider dentistry sector. Minister, on the number of dental students—you mentioned 130. Do the Scottish Government have any plans to increase that number? I'm afraid that I can't answer that question. I'll hand it over to Tom. Yes, we will be considering the intake of the dental schools, but we need to be mindful that it's a dentist that we need. David McCall, who sat in this chair, was quite eloquent about skill mix. Skill mix is something that we need to take seriously, and we haven't really embraced in dentistry. The regulations around it are a bit cumbersome, and we need to fix those, so it may be that we need more hygienists and therapists as well as more dentists. We need to get the number right, because I don't think that we just need dentists. We need more of all of the team, because dentistry nowadays is becoming a team sport, and I think that we need to be clear that we facilitate that in government. At the moment, there are quite advanced plans for a hygienist qualification to be delivered in an FE college in Lanarkshire. That's the first time that we'll have had a hygiene qualification in Scotland for a couple of decades probably, and that's really important. I've spoken to the therapy schools about could they increase input, and one of the models is based in UHI, and they do a hub-and-spoke arrangement, so they have small pockets of students, as the minister alluded to. Are there other areas of Scotland where there's a reduced dental workforce, and is that the best place for some of these schools to be? I think that that conversation is definitely having being had. There's also, at GDC level—in General Dental Council level—there are 5,700 international dentists wanting to come to work in the UK. The process to make that happen is hugely bureaucratic and cumbersome, and I think that's part of the conversation that the minister will be having with her counterparts to how do we speed that up and streamline it, and how do we get them to come to Scotland and give them an educational, developmentally supportive way into the NHS in Scotland, and in return for that, there would be an element of tie-in, I would imagine, to providing service to the population. I'll come back to the 5,700, because that's really interesting and helpful to know, but I ask the question because of the evidence that we've heard in terms of the number of dentists and practices that have went private and solely private. If notwithstanding what the outcome may or may not be regarding the discussions, I fear that even if the discussions come to a successful outcome for both sides, I fear that the majority of these dentists will not go back into the NHS. We'll probably just remain private, so there will still then be a shortfall in the future in terms of NHS dentistry provision across parts of the country. In terms of increasing the number of dentists to come in to the scheme and to come in to provide those services, I think that that will be hugely important. No, no, no. I think that that's part of that international dentist work, about we need to make Scotland the attractive place to come and work, because if I'm honest, there is an element of some people who say that international dentists come across, they go into practices, not many come to Scotland currently, they go into practices and there's a bit of exploitation there, they're just seen as a bit of a work course, and I think that if they come to Scotland they need to know our system, they need to understand our system, they need to feel supported by our system, and I think that that's what we need to do in discussion with NHS education. We did it 20 years ago when we brought a cohort of 50 Polish dentists across, probably about half of them are still working in Scotland, and that was a great programme, so we learned a lot from that, and I think that we probably need to do that again. I must admit that I know that my dental practice is something from the EU, we're still there, which is good, I appreciate it. In terms of the 5700, what other aspects would you consider or have considered to try and taste people to actually come to Scotland? Those 5700 have applied to come and register as a dental therapist, so it means that they can do the bulk of what a dentist does, but not all of it, because that's the easiest way into registration and getting into the UK, so that would be great if we could do that. We then work with that cohort of dentists to make sure that they go through, that there's an exam they have to sit to allow them to then register as a dentist, but actually within Scotland we could always provide an educational programme to get them to that end point, because I think that's really important. If a young dentist has made the effort to cross continents to come and work in Scotland, we need to support them so that they can actually be the best dentists that they can be, and I think that we would want to do that. Another thing is, and I think that that's part of the conversation for ministers to have at UK level, is that if we actually had a notion of provisional registration, so yes, you're a dentist from overseas, you are provisionally registered to work in the UK, you work in Scotland, you build a portfolio, and if you satisfactorily provide evidence that you're working safely that you just automatically become registered as a dentist, that would be so much better than going through all the other hoops. And the other thing that we've been looking at is called an international BDS, and it's happening in a university in England, where you take an international dentist and they just do the final two years, 18 months of a British BDS course, and then they sit our final exam, and with that it brings an automatic registration to work in the UK. I think that's another really supportive and streamlined way of getting that international workforce into work in Scotland. So they're all up for discussion, I speak to the three other CDOs, we had the best way to approach this, and hopefully the ministers taking the lead and actually saying we need to get together at ministerial level will help to drive that forward. So these generally sound like useful tools in the irony to actually help to deal with the situation that we face, but going back to one of the points that the minister raised earlier on quite rightly is that the financial situation is tough. So how would these be paid for? I would be making a bid into Government for funding to make it happen, because if we need to grow the workforce, we have to find the resource to do it. It's not going to happen in any other way. The weird and wonderful ways of Government finance. On the directors of the industry this year, I asked a question last week, and I know that John Lennon touched on it earlier this year. What exactly is their role and what are they contributing? Because potentially are they costing a lot of money for very little by way of return? No, I could do a brief summary and then you can do the detail. No, I don't believe that they are a waste of money. I think that they are key to ensuring that the NHS boards understand the level of service that they have within their board areas, and they also have the connection with the work that actually happens within the hospital settings. So I think that, as David talked about, the Scottish Government is providing a framework to ensure that we have the right support for dentistry within the health boards. It raises up the profile of dentistry within the health boards as well, and I think that that's incredibly important. I've also met the BDA to talk about the operations that have to happen in a healthcare setting, so in a hospital. It's understanding the impact of the pandemic has had on them and on waiting lists. Again, by having that conversation, I raised it in the priorities for us to look at as a Government. I don't think that they are a waste of money, but I think that they are an incredibly important resource across Scotland. I would add that they were phenomenally helpful during the pandemic. They just came into being probably just before the pandemic, and they were probably barely used to the role before we were thrown into what's happening in the pandemic. It gives us a one-point contact at a health board, which previously we didn't have. If CDO needed to know something at a health board, he or she had to work out who was the person they had to go to, so now there is that single point of contact, and they know the system really well, so it improves communication backwards and forwards. In terms of Mr Mason, I think that you're a bit unfair about Shetland, because yes, there is one practice, but there's a public dental service in their hospital dental services, and they have to do everything. That director of dentistry in an island board probably has far more functions than perhaps someone in Greater Glasgow and Clyde who has a bit of a team to support them, so they are just as valuable in an island and a rural health board as an urban health board. Is it yourself suitable for the reprimand, John? One final question. On the issue of tie-ins, whether it's graduates or potentially folk from the 5700, what length of time would you consider would be the preferred option in terms of a tie-in for new dentists? I've thought that far ahead, but we currently have a bursary that's available to undergraduates, and I think they are tied in for the number of years they receive the bursary plus one, so that's the way we currently work it. The number of years of financial support you get plus one is what we currently use, and it may be something like that. Could that be increased, the tie-in? Well, I suppose that we could set it at any level. It's just whether or not it then becomes less attractive if the tie-in is greater. What you want is them to come and work in Scotland, enjoy it and want to stay. Stuart, I want to move on. We're over time at the minute, but a couple of supplementaries, if you're happy to hold on for a couple of minutes. I'm sure that's fine. Thank you. I'm just going back to something you said earlier, Mr Fass, around encouraging people to come in from overseas to come and work in. You said that we brought in 50 Polish dentists. I have an issue with that, I have a moral issue with that, and we are sucking talent from everywhere else, and while we're doing that, we're also allowing our own talent to leave and our own talent to work privately, not in the NHS dentistry. Do you see what I'm getting at? Should we not be focusing more on how we retain our own talent within the NHS dentistry? We're doing both. The reform space that we're currently in, the point of that is to make it an attractive, financially viable place for people to want to work. Now, as someone said, the people who have left the NHS may not come back, some might, but hopefully it will stop further drift. That's what we want to see. We want to make it a decent NHS system that people will want to work in, but we also have a workforce issue. The number of dentists who used to come in from the EU made a significant contribution to our workforce, and we miss that because it is disappeared. If there are other dentists from overseas who want to come and work, and I understand your point, are we taking them away from the system, their own healthcare system? I've spoken to several people who have experience of education and training in healthcare overseas, and they say that it's really not a problem, especially in Asian countries. India, Pakistan and the Middle East train a significant number of dentists. They train too many dentists, so we're not denuding those countries of healthcare workforce. No, but we need to find a way to get them in, so if we can get the conversation with the other three UK jurisdictions about how we get international dentists in a streamlined pathway, then that's all to the good. They want to come and work here. There will be a benefit to them because we will provide education and training for them, and they will support our population by delivering care. We also support our population as well, which we need to increase. One final question. I presume that all four nations of the UK are having similar issues in terms of getting recruitment for dentistry. Tom, you said that there are 5,700 people potentially wanting to come here to practice dentistry at varying levels. What's the hold-up? We've got an urgent problem, so why is there a difficulty? The hold-up is probably the anachronistic legislative framework that the General Dental Council works within, and that's within the gift of DH. That's why we need to impress the minister down there with responsibility for dentistry, that needs to be fixed. England has just as many pressures in terms of dental workforce as we do. It may have some more acute workforce areas, especially its coastal areas. It has real difficulty in filling posts, so it's in its interests too that we find a streamlined quick way of getting that willing workforce to come and work safely for us. Thank you very much. I know I've gone over time, so I do appreciate your generosity in that. That concludes our consideration of this agenda item and our time with the minister. The committee will consider the evidence heard later in this meeting. I'd like to thank the minister and our colleagues for their attendance this morning, and I will now suspend the meeting. Thank you very much. I now bring this meeting back into session. Agenda item number three is consideration of the draft annual report for the parliamentary years from 13 May 2022 to 12 May 2023 and from 13 May 2023 to 12 May 2024. The purpose of the reports is to set out our activities in the relevant reporting periods. Members will see that we are considering an annual report for the previous parliamentary year as well as for the current one. The reason for this is, as members will be aware, that the Scottish Parliament agreed motion number S6M-09720 last night to wind up this committee. As a consequence, this will be our final meeting before the committee is formally dissolved on 14 July 2023. I will leave in general remarks about the reporting year until the end of the agenda item. First of all, I propose to go through the reports page by page for any corrections. If you have any comments on any paragraphs, please raise your hand when I come to the relevant section. Typo's have been picked up and will all be addressed at a later date. We will go through the report page by page. We are starting with Covid-19 recovery committee annual report 2022-23. We will look at page 1. It was just in paragraph 9 where it says tackling misinformation, but I wonder if we could add and disinformation, because I think that we looked at both, one being perhaps unintentional and one being intentional. Okay. All agreed? Yeah. Agreed. Page 5. Page 6. Page 7. Page 8. Page 9. Page 10. Page 11. Page 12. Page 13. Okay. We are now on to the next annual report, the Covid-19 recovery committee, Covid recovery committee annual report 2022-24. We will go through the same process. Page 1. Okay. Page 2. Page 3. Page 4. Page 5. Page 6. Everybody agreed? Thank you. I can confirm the annual reports are all agreed. The collapse will make minor revisions to the statistics and any other relevant factual information prior to publication and due course. I would like to really take this opportunity to thank all the stakeholders who have participated in the work of our session. Particularly, I have to say, from my point of view, the long Covid people who came in under great duress, they were clearly some of the more struggling and I just wanted to point them out. It greatly benefited our consideration of the issues we are scrutinised relating to Covid and recovery. I would also like to thank the current and former members of the committee for the collegiate way in which you have worked through our scrutiny. In the height of the pandemic, I think that it was a great benefit to the Parliament to have a dedicated committee to scrutinise the relevant legislation and our transition into our recovery period. Going forward, it will be for the other subject committees to take forward scrutiny of Covid recovery as it relates to their remits and we will make recommendations on that when we come to consider our legacy report. Does any other member wish to make any other remarks before we conclude this agenda item? I will first echo your thanks to everybody who has contributed to the committee, to our clarking team, to Spice and to all those who have helped us. I thank you, convener, for being a very short stint as convener, but you can put that on your CV for future reference. You convened a parliamentary committee, albeit just for a few weeks and for leading the committee in collegiate style. I should also thank our committee advisers who we have not seen that for quite a long time, but initially were regular attenders at the committee. That was Professor Peter Donnelly, Professor Susie Dunikey and Professor Helen Staggin. I think we will recall when they were coming more or less on a weekly basis to give us updates at the height of the Covid pandemic and their input was extremely useful to us. So I think we should record our thanks to them. I don't know if we're going to formally write to them to express our thanks to them, but I think we should do that. I would just reflect. Personally, I was the first convener of what was then the coronavirus committee in the last parliament, if I remember right, that we were set up. I think it was May 2020. The committee was established and here we are just over three years later bringing this particular journey to an end, which I hope is an indication that Covid is behind us. I hope that's not a hostage fortune in saying that, but I hope it's an indication that Covid is behind us. Nevertheless, there are very important lessons that we need to learn from Covid that a lot still needs to be done in terms of the public sector, public services that need to be put right post Covid. I hope that the important work that this committee has been doing will be continued by other subject committees as we go into the next parliamentary session. Indeed. I'd personally like to thank the clerking team. They have been absolutely brilliant. They've made me look almost competent. I'd also like to mention Alec Rowley. He's been a fantastic member of the team and, of course, the previous convener, Siobhan Brown, who was given a ministerial post earlier on, which is why I now sit in this chair. That concludes this public part of our meeting and I suspend the meeting to move into private. Thank you.