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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.


    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.


    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.



    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.


    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.


    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

    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

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    For Further Information Please Contact:

    Matt Smith, Scottish Secretary
    UNISON House
    14, West Campbell Street,
    Glasgow G2 6RX

    Tel 0141-332 0006 Fax 0141 342 2835

    e-mail matt.smith@unison.co.uk

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