Modernising
NHS Dental Services in Scotland
The Draft UNISON Scotland
Submission to the Scottish Executive Consultation: Modernising NHS Dental Services
in Scotland
March 2004
Executive
Summary
UNISON
is Scotland's largest trade union representing 150,000 members working in the
public sector encompassing the majority of NHS employees and dental staff.
UNISON
Scotland welcomes the consultation paper on modernising dental services in Scotland.
Dental services have been ignored for too long.
UNISON
supports the series of pledges outlined in the White Paper Partnership for Care
and the Partnership Agreement, promoting a more preventive approach to oral health.
The recommendations
do not sufficiently emphasise the need for more NHS salaried dentists.
UNISON
Scotland applauds the Executive's initiatives designed to encourage young dentists
who have trained in Scotland to remain here, and more experienced dentists to
stay on in practice. However the measures that have been introduced are far from
adequate.
The
consultation does not fully recognise the importance of the dental health team
and the vital role they have in providing quality dental services.
UNISON
is disappointed that the workforce planning does not recommend consultation with
trade unions. As the main trade union representing NHS workers and dental staff,
UNISON Scotland would expect to be consulted on plans for dental staff.
UNISON
supports the legislative changes required to allow NHS Health Boards to locally
commission dental services, on the understanding that employees' pay and conditions
would not be negatively affected, or that this would not become an enabler for
PPP or PFI to be introduced in public services.
Introduction
UNISON
is Scotland's largest trade union representing 150,000 members delivering public
services in Local Government, Health, further and higher education, energy (gas
and electricity), water, transport and the voluntary and community sector. We
represent the majority of staff in the National Health Service in Scotland.
This
paper constitutes UNISON Scotland's response to the consultation document issued
by the Scottish Executive on Modernising NHS Dental Services in Scotland.
Response
The
Scottish Executive's consultation on Modernising NHS Dental Services, follows
on from Westminster's consultation entitled, "Modernising NHS Dentistry",
published four years ago in 2000. (1) The Scottish consultation, however, does
not acknowledge the fact that dental services south of the border have not improved
much. There is still a severe dental crisis in the UK, as hundreds queue up desperately
trying to find a dentist. (2) If the Scottish Executive is seriously determined
to make real changes in Scotland, then they will have to do much more than their
counterparts south of the border. The concern is, that this consultation is a
paper exercise, merely following Westminster's lead.
The
Executive's title, "Modernising Dental Services" is vague. The term,
"modernisation", can have many different meanings when used by policy
makers. So far, in its time, "modernisation" has stood for cost cutting,
privatisation, and the signal for the introduction of PFI and PPP in public services.
UNISON is firmly opposed to PPP or PFI. As the largest union in the public sector,
representing workers serving the public, UNISON Scotland is wary of yet more attempts
to "modernise" public services. UNISON Scotland advocates a revitalisation
of public services. Public Service Organisations (PSNs) are a far more effective
way of providing public services.
PSNs
are essentially an agreement between public service providers to work jointly
on a project usually by pooling resources and working to a common action plan.
The overall aim is to encourage a spirit of co-operation, communication and mutual
support across Scotland's public services. A concept severely damaged by the introduction
of market forces to our public services. In a changing environment, networks are
a more rapid and effective method of responding to change, than constant boundary
reviews and statutory reorganisation. PSNs can also bring together the fragmentation
of services brought about by privatisation and the growth of un-elected public
bodies. They offer co-operation not competition and the opportunity to make effective
use of ICT and economies of scale without centralised control. While public bodies
can engage in networks that involve various organisations, the prime focus should
be in forging networks of Public Service Organisations (PSOs).
Little
Progress
The Scottish Executive's consultation
includes the gloomy statistics of oral health in Scotland. This could be interpreted
as an attempt to pre-empt any blame. This does not prevent us, however, from pointing
out failings. There has been a funding shortage in dental services both in England
and Scotland, not least following the years after the English consultation first
appeared in 2000. Dental services have been severely under-funded and ignored
for years. In 1988 a paper by Helen Finch reported that,
"Anxiety
and issues around the clarity and levels of charges for dentistry were the principal
concerns of patients, followed in importance by patients' failure to perceive
a need to attend, and the attitude and communicative abilities of the dentist".
(3)
Again, in 2000, Tracy Land published
a report on similar issues, adding that,
"Access to care was now a primary concern. Over this 12 year time interval,
it may be concluded that while the original concerns of the 80's have been largely
unaddressed, there has also been a failure to reinforce the confidence of either
the public or the dental professions in the availability and standards of NHS
dentistry." (4)
These two reports
were quoted in the Department of Health report entitled, " A Modernised Service
for Patients in the 21st Century," published in 2002. The Department of Health
themselves admitted that,
"Health
policy on dental services has lagged decades behind other health sectors. Over
the decade since 1992, dentists' commitment to the NHS has reduced, leading to
access difficulties." (4)
Westminster's
response to the House of Commons Select Committee on Health's report also acknowledged
the serious problems with dental services in UK back in 2001 (again, attempting
to pre-empt criticism),
"We have
received extensive written evidence and we are quite clear that urgent action
is required. We consider that dentistry has never been fully integrated into the
NHS and as a result major health inequalities exist. We believe that the present
arrangements for accessing NHS dentistry are inequitable, uncertain and getting
worse; patients do not know where they stand. Unregistered patients find it hard
to get any form of care. Registered patients can lose that status without redress
and often without knowing they have done so…We believe there are serious concerns
and that Modernising NHS Dentistry lacks the weight to alter fundamentally
what is a deteriorating situation. " (5)
The
Crisis Continues
These repeated admissions
both by Westminster and by the Scottish Executive, are not enough to appease a
nation whose dental health is decaying year by year. In the UK, the number of
adults registered for NHS treatment, though now stable, is still 1.5 million lower
than in 1998 and 5 million lower than its peak in 1993/94. (6)
A
third of children in Scotland and half of all adults are not registered with a
dentist. People in Scotland suffer poorer dental health than many of their European
neighbours. Scots have higher levels of tooth decay than people living in England
and Wales. By the age of 14 most children already have decay in their adult teeth.
In Glasgow the main reason for admitting under 12's to hospital is to have rotten
teeth removed under general anaesthetic. (7)
The
availability of dental services has reached a crisis point, especially in some
parts of the country, where it is practically impossible to get any NHS treatment.
In parts of the Highlands and Islands and south-west Scotland between 70% and
80% of dental practices refuse to treat any NHS patients. (8) The scale of the
problem was highlighted recently when hundreds queued for up to seven hours to
join a new practice in Stonehaven. Initially the single-handed dentist had the
intention of accepting the first 300 NHS patients, but ended up with double that
figure, and many more had to be turned down. (9)
The
reasons given for the state of dental care in the UK are many. Fewer dentists
being trained, fewer salaried dentists, fewer full-time dentists, more dentists
taking early retirement, more dentists leaving the country, more dentists becoming
independent contractors, and less dentists taking on NHS patients. The Department
of Health maintains that part of the problem is the complex and poor remuneration
system in place. (4) This discourages preventative dental care and the continuing
maintenance of good oral health. The House of Commons Select Committee reporting
results of an Inquiry into access to NHS dentistry acknowledged inactivity,
"
The system has been reviewed comprehensively in the past, and both this Committee
and the DoH developed options for alternative systems. Yet it remains unchanged.
In the light of this history we do not advocate yet more reviews for their own
sake, but rather action: we believe the time for reform is ripe." (5)
Again,
to reiterate, this report was published in 2001. The Scottish Executive will have
known about the problems long before this consultation was published, and it is
unacceptable that so little has been done for so long.
Solutions
Legislation
UNISON
Scotland acknowledges the difficulties involved in changing an administration
that has been in place for a long time. We support the proposal to introduce legislation
enabling local NHS Boards to fund dental arrangements. This does not mean however,
that we would agree to PPP or PFI arrangements, which could be made easier to
set up as a result of these legislative changes. One of UNISON Scotland's policies
is to support public service networks, cross-boundary trading, best practice and
service provision, which should be quicker and more effective than boundary reviews
and reorganisations. They can also take advantage of economies of scale, while
retaining local accountability.
Workforce
Planning
The Executive's consultation
does not adequately emphasise the importance of the entire dental health team.
UNISON represents dental nurses, technicians, hygienists, therapists, administrative
staff, domestic staff, maxillo-facial technicians and dental surgery assistants.
UNISON Scotland advocates a holistic study of the dental team, not just the dentists,
in order for quality improvements to be made. Improvements for staff should include
pay and conditions, particularly in terms of equality, discrimination, training,
NHS superannuation, and pension rights. Imposing contractual obligations on NHS
dentists to respect the working conditions and terms of service of their staff
would go some way towards improving quality.
UNISON
Scotland supports initiatives that would increase the skill level and pay of our
members. For example the Scottish Advisory Committee on Dental Workforce (SACDW)
and NHS Education Scotland (NES) recommend training for dually qualified hygienists
and therapists to take on wider aspects of dental work such as fillings. As the
largest trade union in the NHS, we would expect to be consulted before any changes
were made to the work, pay conditions, and training of dental staff.
Supporting
NHS Dentistry
The consultation document
does not adequately address the need for more salaried NHS dentists. Ideally UNISON
would prefer an entirely salaried NHS dental service. Under the current circumstances,
however, as many as possible of the dentists who have left the NHS, should be
encouraged back into the NHS. Dentists should be reimbursed for their staff costs
at Whitley Council rates and terms of service. This would be an incentive for
dentists.
There are not enough dentists
to meet the current needs of patients. One solution would be for the Royal Colleges
to review their yearly intake of students. There also needs to be an increase
in the number of training centres and programmes offered to dentists. UNISON Scotland
welcomes many of the Executive's new initiatives. For example, the initiatives
which encourage dentists to remain in Scotland, or move to designated areas, or
stay on in practice longer than planned. These initiatives, however, are not sufficient.
Measures should include realistic incentives for dentists to perform NHS work.
Dental premises must have sufficient accommodation, facilities and equipment for
the extended primary dental care team. Adequate funding of dentists' premises
could be given in return for NHS services. Auditing is necessary to ensure proper
use of public money. Funding for quality improvements to dental services however
must not come from the current health budget, but must be additional funding specifically
allocated for dental services. We concur with Lord Hunt, who stated at a BDA Conference
in May 2001,
"Dentistry needs
to be a core NHS service." (4)
Dental
health is not different from other health issues, and has been conveniently removed
from the rest of the NHS.
Community
Health Partnerships
UNISON Scotland believes that there
are advantages to public service networking and we encourage participation from
users, the community, staff and their unions. Community Health Partnerships (CHP's)
go some way towards achieving this goal. They build on Local Healthcare Co-operatives.
Dentists and their patients could benefit from CHP's, where GP's and others involved
in community and primary care work together to address local demand/ problems.
For instance it could allow 3 or 4 practices to hire extra staff between them.
This allows for decisions to be made locally to address local issues, and may
be able to pick up on health problems that the Health Board may not.
The
Scottish Executive's consultation focuses on health practices jointly working
together, and working more closely with other parts of the NHS. UNISON Scotland
supports partnership working. It does not mean, however, that we support PPP or
PFI in partnership arrangements. UNISON is concerned that there may be an ulterior
motive behind the government's recommendation for "joint working". Again
this may be the latest term used to signal the introduction of PPP or PFI. An
example of this is the Scottish Executive Consultation, entitled, "Consultation
on the use of Joint Ventures to deliver primary care/joint premises". (10)
UNISON endorses joint working when it means exactly what is stated; jointly working
between public sector organisations, in order to work more effectively for the
better of our public services. "Joint-working", however, when it means
working with the private sector (such as the English LIFT programme, currently
being introduced), is unacceptable.
Conclusion
Dental
services have been conveniently ignored for too long. After years of market forces
prevailing in dentistry, the country finds itself in an ever-deepening crisis.
Oral health is declining, and the gap is widening between those who can afford
to pay for dental services and those who cannot. The Scottish Executive have published
this consultation claiming that the answer is to modernise dental services in
Scotland. The term "modernise" however, is controversial and vague,
as is the consultation. Dentistry needs to be a core NHS service. UNISON acknowledges
that there are difficulties in changing a system that has been in place for a
long time. We welcome the current incentives that encourage dentists to stay in
the NHS or return to the NHS. Everyone should be able to receive dental treatment
on a fair and equal basis. Patients want updated facilities in appropriate premises,
with modern equipment.
The consultation
does not fully recognise the key role of the entire dental health team. UNISON
advocates a review of the whole dental team in order to improve oral health in
Scotland. The review should include the contractual obligations of NHS dentists
to respect the working conditions and terms of services of their staff, appropriate
training, and health and safety. This includes a review of their equality rights,
discrimination, NHS superannuation, and pension rights. As the largest trade union
in the NHS, we would expect to be consulted on workforce planning. Ideally, salaried
NHS dentists would be the solution to the country's dental problems. Failing this,
UNISON Scotland recommends a number of changes which we have suggested above.
These changes would make a real difference to the services offered. Scottish dental
services need to be improved. This consultation process must not merely follow
Westminster's lead.
References
1
Modernising NHS Dentistry, Implementing the NHS Plan, 2000
2
Hundreds queue as Scarborough NHS dentist fills gap in market, David Ward, Wednesday
February 18, 2004, The Guardian online, The
Guardian
http://society.guardian.co.uk/health/news/0,8363,1150282,00.html
3 Barriers to the Receipt of Dental Care, Department of Health, A Modernised Service
for Patients in the 21st Century, 2002 http://www.doh.gov.uk/cdo/optionsforchange/modern.html
4
Department of Health, A Modernised Service for Patients in the 21st Century, 2002
http://www.doh.gov.uk/cdo/optionsforchange/modern.html
5
Access to NHS dentistry, Government response to the House of Commons Select Committee
on Health's report. 2001
6 Dentists' private
income soars, BBC News online. http://news.bbc.co.uk/uk/1/hi/health/2625845.stm
7 Bid to tackle rotten dental record, BBC News online. http://news.bbc.co.uk/1/hi/scotland/3285785.stm
8
£6m boost for NHS dental treatment, BBC News online. http://news.bbc.co.uk/1/hi/scotland/2752277.stm
9 The Herald, Tuesday January 20, 2004
10
Scottish Executive Consultation on the use of Joint Ventures to deliver primary
care/joint premises http://www.scotland.gov.uk/consultations/health/cjvpc-00.asp
