Dental Health Services
The next item of business is a debate on motion S2M-2708, in the name of Roseanna Cunningham, on behalf of the Health Committee, on access to dental health services in Scotland.
Members of the Health Committee, like members throughout the chamber, have been concerned by the extent of the anecdotal evidence of a perceived decline in access to national health service dentistry services. The committee thought it appropriate to have a more objective assessment of the situation than was available, so in April 2004 it commissioned researchers from the Guy's, King's and St Thomas' dental institute in London to conduct a survey of Scottish dentists. Their remit was to identify the contribution of dentists to the provision of NHS dental services in Scotland and to identify areas where the availability of services is insufficient to meet need or demand. The report and conclusions were published on 1 February 2005.
On behalf of the Health Committee, I thank Professor Tim Newton, Professor Alison Williams and Dr Elizabeth Bower for their comprehensive piece of work, which I hope will form the basis of a serious examination of some of the real difficulties and shortcomings facing NHS dental provision throughout Scotland. I also thank the clerks to the committee for all their assistance and hard work.
The research is extremely thorough. I will take some time to present the main findings of the report to the chamber, with a detour here and there, as members might expect, into my experience as a constituency MSP who receives complaints from constituents who are unable to access dental services.
The purpose of the exercise was to find the facts behind what we knew to be the reality of some of our constituents' experiences. Stories abound of queues down the street when a dentist announces that he or she is taking on NHS patients or, worse, restricting his or her NHS list on a first-come, first-served basis. There was just such a story in The Herald on Tuesday. The sole remaining NHS dental practice in Stranraer announced that it was going private and would be offering NHS treatment only to children and existing NHS patients. That dentist had nearly 3,500 patients, a great many of whom queued outside the surgery to join the private scheme, which has been restricted to only 1,000 members, leaving 2,500 people disappointed. The question is where those people are to go. Of course, Stranraer is not alone in experiencing such a situation.
The report identifies a number of problems in relation to access to dental services and flags up the difficulties that could arise with the implementation of the Executive's policy on free oral health checks unless dentists can be encouraged to increase the amount of time that they spend treating NHS Scotland patients over the next two years. Frankly, there is little sign of that happening, either from past performance or from indications for the future. In the past two years, just over one in 10 dentists in Scotland have increased the number of NHS hours that they work, while more than a quarter have decreased their NHS hours. Only 3.5 per cent of primary care dentists have stated that they intend to increase the amount of time that they spend treating NHS patients in the next two years.
It may come as a surprise to members that insufficient information is available at health board level on a whole range of indicators, such as numbers of dentists; the number of dentists who are accepting new NHS patients; distances travelled by patients for primary and secondary dental care, which is pretty fundamental, especially in rural areas; the availability of evening and weekend appointments; access for groups with special needs; demand for dental services; and recruitment and retention of all dental staff. That is all basic information, yet it is not readily available.
We know some things, however. The researchers established that the dentist to population ratio for Scotland as a whole was 5.57 NHS dentists per 10,000 population, although when part-time provision and the provision of private services were taken into account the figure fell to 3.52 NHS dentists per 10,000 population. However, there are significant variations. Surprisingly—I say that because most committee members were surprised—the highest dentist to population ration was in greater Glasgow and the lowest was in Dumfries and Galloway. Presumably, the news from Stranraer means that the figures there have got even worse.
Roseanna Cunningham will remember that those statistics relate to health board areas and that in committee I made the point that, on a local authority basis, Aberdeenshire was more badly hit than any other area.
Yes. There is an issue with how the figures operate, because they relate to health board areas, not local authority areas or, indeed, constituency areas.
There is also wide variation in the proportion of time that dentists in different health board areas spend providing NHS services, ranging from 99.5 per cent in the Western Isles to 64.5 per cent in the Highlands. In the recent past, 26 per cent of dentists have decreased their NHS time. Significantly, that proportion was greater in general dental practice. Members might think that that is stating the obvious, but the research report states:
"Registration rates were significantly higher in areas where there were more GDS dentists available, suggesting that increasing the dentist to population ratio in an area is a way of improving the utilisation of services in that area."
That means that the more dentists there are, the more likely people are to go to the dentist. Given the appalling state of Scotland's dental health, that has to be an immediate area of concern.
Scotland has a slightly higher dentist to population ratio than the United Kingdom as a whole, but that has to be seen in the context of our far higher levels of remoteness and rurality. When we compare ourselves with other European countries, there is no need to adjust the figures to take those factors into account. In Denmark and Norway—the two countries in Europe that are most comparable to Scotland in terms of population and geography—the dentist to population ratios are more than twice that in Scotland. We have a long way to go to catch up.
When we turn to accessibility issues, we find that 58 per cent of primary care dentists are offering appointments to new child patients. That is all well and good, but it means that 42 per cent are not. Moreover, only 37 per cent are accepting all categories of adults as new NHS patients. Again, that varies throughout the country, with Orkney dentists accepting the highest proportion and Borders dentists accepting the lowest proportion of new NHS patients. More than 80 per cent of Borders dentists are either not accepting new patients or have a waiting list.
There are problems with access to NHS specialist services in rural and urban areas, with long waiting times for some specialties in Lothian, greater Glasgow, the Borders and Dumfries and Galloway. More than half of specialist practitioners are not accepting new patients or are using a waiting list. The point must be made that the public are prepared to travel for specialist services, but they are not prepared to wait for them. As I said, only 3.5 per cent of primary care dentists intend to increase the amount of time that they spend treating NHS patients in the next two years. It is worth thinking about that in the current context.
No single incentive to increase NHS commitment from dentists was favoured by an overwhelming majority of practitioners. The most frequently endorsed incentive was a significant increase in the fee per item of treatment. Moves to a salaried contract or a capitation arrangement are less popular and there seems little likelihood of retired dentists being attracted back into work. That means that the significant increase in NHS provision that is required to meet pledges to make free NHS check-ups available to all by 2007 is unlikely to be achieved with the range of incentives that are currently available.
The report provides a summary of the performance of each health board in relation to NHS dental services, in terms of availability, accessibility and accommodation. I have no doubt that members went straight to that information as they tried to figure out how provision in their constituencies compares with provision in the rest of the country. If members have not found that information, I can tell them that it is on pages 6 and 7, just before the brightly coloured map that will help to orientate them.
Of course, everything is relative, as Mike Rumbles suggested. Tayside, where my particular interest lies, appears on paper to be better served than some areas. However, I will give an example of what can happen in one of the so-called better-served areas. I have a constituent who needed to have a front crown replaced. She cannot afford to go private. Because she works in Stirling, she called dentists in Stirling, Dunblane, Bridge of Allan and Perth, with no success. She managed to get her family placed on the waiting list of a practice in Perth, but she was told that she would have to wait at least until August before anything came up.
Eventually, a week after her tooth had fallen out, she called the dental hospital in Dundee but, because the crown pin had fractured, the hospital advised her—wait for it—to get a dentist. She sat outside the dental hospital calling dentists in Dundee until she finally found one who was taking NHS patients. She had her crown fixed at a third of the private price. She is relieved about that, but now faces a long round trip to take herself or her children to the dentist. Given that she works in Stirling, she will presumably have to take most of a day off work. Simply put, the best that there is—Tayside is one of the better-served areas—is just not good enough.
On 17 March, the Executive published its "An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland". In a letter to me on 4 April, the Deputy Minister for Health and Community Care welcomed the research report and provided the Executive's response to its findings. I have three questions arising from that, which I hope that the minister will address either during the debate or afterwards.
First, the minister acknowledged that better information is required at a local level to address supply and demand issues for NHS dental services. The Executive's action plan gives NHS boards responsibility for planning and securing the provision of NHS dental services, including improved information. The main focus is to be on those people with the greatest need—that is, children and older people. My question to the Executive is: how is greatest need to be assessed, in the absence of adequate information?
Secondly, the minister indicated that the availability and access issues that are raised in the report will be addressed in the national workforce plan to be published in June 2005. Would she care to give an indication of how quickly she believes the plan can be expected to have an impact on dental services in Scotland?
Thirdly, on recruitment and retention, the Executive has indicated that it plans to increase Scottish dental schools' output of dentists and to offer dentists incentives to return to Scotland. The minister also wants to recruit from outwith Scotland and intends to increase the remote areas allowance from £6,000 to £9,000. Once again, I ask whether the minister can give us a timetable for when those plans will begin to have a real impact, because that will be important to people's perceptions of what is happening throughout Scotland.
The research that the Health Committee commissioned offers a comprehensive snapshot of the views and experiences of NHS dentists in Scotland. Ministers and members would do well to reflect on what it tells them, particularly about incentives. I highlight a comment from one respondent on incentives:
"Stop access money for young dentists to allow them to set up a new practice around the corner from the retiring practitioners desperate to sell."
There must be logic in the way in which the incentives are applied.
The Health Committee recognises that, through the development and publication of the action plan, the Executive has begun to take action on the issues that are identified in the report. However, I am concerned that that action is not enough to tackle the depressing picture that is painted in the final summary of the report. As the report says, the Executive's pledge of free check-ups for all by 2007
"is going to be difficult to fulfil".
Plans to use retired dentists are
"unlikely to be successful".
Moreover, the significant increase in NHS Scotland provision that is required to meet the Executive's pledges is
"unlikely to be achieved with the type of incentives currently available".
Finally,
"a broader national strategy is required to ensure that the majority of practitioners receive adequate incentives to commit to NHSScotland".
We are all aware of the problems with access to NHS dental services. By commissioning the research and sponsoring today's debate, the Health Committee hopes to highlight the issues that require to be addressed and to make a positive contribution to the solutions. We will continue to monitor progress.
I move,
That the Parliament commends to the Scottish Executive the research report, Access to Dental Health Services in Scotland (SP Paper 277), commissioned by the Health Committee; draws the Executive's attention to the problems of access to services that the report identifies and their implications for the introduction of free dental checks, and urges the Executive to use the report to inform the implementation of its dental strategy.
We all agree that Scotland has a continuing need to improve oral health, especially among children and in deprived communities. Indeed, in deprived areas of Scotland, more than 60 per cent of children have dental disease by the age of three. That is simply not acceptable.
As members know, last month I launched in the Parliament a three-year action plan for improving oral health and modernising NHS dental services in Scotland, which is backed up by new and additional funding of £150 million. That is the single biggest investment in NHS dentistry ever—no Government in history has invested so much in Scottish dental care. The results will speak for themselves: by 2008, Scotland will have 200 extra dentists; an additional 400,000 patients will have access to an NHS dentist; and there will be more dental professionals in training in Scotland than ever before.
However, improving our country's oral health is not just about more money and more dentists. To make a real impact, we must give priority to preventive measures. We have consulted on the case for adding fluoride to water and it is clear that views in Scotland are strongly polarised. We have developed a practical action plan that leads the way on dentistry in the United Kingdom and includes the biggest supervised toothbrushing programme in Europe.
In countries such as Denmark and Sweden, specialised dental health educators supervise children's toothbrushing sessions. Will the minister expand on the plans in Scotland? Who will supervise such sessions and train teachers on how to provide information to children?
That is a good point. At the moment, there is a variety of ways of supervising toothbrushing. In some schools, dental hygienists supervise it, but we are conscious that, if the programme is to be rolled out to all nurseries—and, indeed, into the early years of primary schools—we need to consider using training supervisors who are members of the core school staff, such as support workers and teachers who manage nursery schools and early-years provision. I need to be able to work with my education colleagues to ensure that that is rolled out. Also, in the context of health-promoting schools, we need to ensure that the toothbrushing schemes form part of the assessment of the schools' effectiveness in promoting health. The schemes are hugely important, but we need to ensure that there are adequate training and support.
The provision of dental services throughout Scotland remains a challenge; Roseanna Cunningham mentioned some specific challenges. The number of dentists in Scotland has increased by 70 per cent since 1975, but we still need to do a lot more. We are training new staff in the professions complementary to dentistry, such as dental hygienists and therapists—again, Scotland is leading the way in the UK on that. However, the demand for dental services is also changing and people expect much more in terms of what dentistry can offer. People are living longer and more people are retaining their teeth into older age. The nature of treatment is changing and much more complex treatments are required.
I put on the record my support for dentists who are committed to NHS dentistry—that remains the majority of dentists in Scotland. In recent months, we have seen a small number of dentists turning their backs on the NHS. Roseanna Cunningham mentioned the dentist in Stranraer going to work in the private sector.
The minister was due to visit that dentist but she cancelled the visit. Would it not be appropriate for her to go ahead with it, if necessary to talk to the dentist to find out his reasons for leaving the NHS and, more important, to talk to some of the patients who are stranded in Stranraer with no access to an NHS dentist within a reasonable travelling distance?
I will be absolutely frank with the member. I thought that it was important, on my visit to Dumfries and Galloway, to meet dentists who are committed to the NHS. Frankly, I was appalled by the behaviour of that dentist. What he did seemed to me to be no more than a political stunt. It is not good enough for the people in Stranraer to be treated in that way. It is not good enough for dentists to be able to train at the expense of the public purse, to build up an NHS list, to build up the trust and confidence of patients in Stranraer and then to walk away. Patients deserve more than that. I went to visit a dentist in Castle Douglas who works with the NHS and is an excellent example of the dentists who are committed to NHS treatment in Scotland. I make no apology for doing that.
Some dentists are selective in choosing whom to treat under the NHS. For example, some dentists force parents to go private before agreeing to provide NHS dental care for their children. That is simply not good enough. It is not good enough for dentists to train at the taxpayer's expense to build up that confidence. Patients deserve high-quality treatment under the NHS.
I know that the vast majority of NHS dentists are committed to their patients and to the NHS. I thank them for that. Their loyalty will be rewarded through the record £150 million package of measures that we announced. We want to restore the balance, so that patients who want NHS care can receive it from dentists who are supported by, and committed to, the NHS in Scotland.
The challenge before us is to secure a dental workforce to meet the demands for NHS dental services. We will do that by increasing the supply of dentists and the supply of people who work in professions complementary to dentistry. As well as expanding the salaried dental workforce in the NHS, we will continue to offer financial incentives to secure dental practices in rural areas and in areas of deprivation. We will also set national care standards for private dentistry and for independent health care. We will seek to protect the interests of patients in whatever dental services they seek under the NHS.
In that context, I very much welcome the report "Access to Dental Health Services in Scotland", which the Health Committee published on 1 February. The information in the report is a helpful addition to the work that the Executive is undertaking on workforce issues. The report also complements our major consultation on modernising NHS dental services in Scotland. The Executive has already taken action on one of the report's main recommendations, which is on the need to adopt a broader national strategy for dental care in Scotland.
On the other issues that the report raises, we entirely agree with the report that better information is required at a local level if we are to address the requirements for NHS dental services, particularly high street services. That point was also made by Roseanna Cunningham. As part of our action plan, NHS boards will be given clear responsibility for the planning and securing of the provision of services to address local needs and will be required to improve the information that is available. Those requirements will be reinforced by health ministers through the performance and accountability review process.
How can the Executive ensure that the £150 million of resources that have been allocated will meet the priorities, given the distinct lack of information that the Executive was working on, as is confirmed in the report?
There is no doubt that we need to get better at acquiring information, but we have enough information at the moment to be able to plan with NHS boards. We are only too aware of the shortfalls that exist in areas such as the Highlands, which the member represents. During my visit to Inverness, I learned at first hand about the plans for an outreach training centre to ensure that young dentists can train in the Highlands and, we hope, choose to work there in the longer term. We have information at the moment, but we need to get better, smarter and more detailed information.
In recent weeks, I have made a series of visits around Scotland to hear at first hand how NHS boards intend to improve dental services in their areas and how they will play their part in dental outreach training in Scotland. The dental outreach programme will be hugely important for Scotland's more rural areas. It will allow dental students and students in professions complementary to dentistry to gain first-hand experience of working in rural communities. It will create opportunities for an enriched working experience both for the dental professionals involved and for the students. NHS Grampian is on course to meet our partnership commitment of establishing a dental outreach training centre in Aberdeen during 2006. It is also working actively on recruiting more dentists to improve access.
In the past year, NHS Highland has been successful in recruiting 16 NHS dentists and is developing outreach in Inverness. Moreover, NHS Dumfries and Galloway is currently putting together a business case for the establishment of a multisurgery dental centre in Dumfries. The dentists whom I met in Dumfries the other day told me that, within the next couple of years, the multisurgery dental centre will be able to have 13,000 patients on its books. In the longer term, that figure could be doubled, but talks are continuing. Those are only a few practical examples that demonstrate the importance of having local commitment to NHS dental services that is backed up by national support.
The Executive acknowledges the report's findings on variations in registration rates and the problems of access to NHS dental services in parts of Scotland, particularly in rural areas. To provide support for dentists in rural areas, we have increased the annual remote areas allowance from £6,000 to £9,000 as of 1 April this year.
We acknowledge that workforce planning is vital to the successful delivery of dental services in Scotland. We have put in place arrangements for such planning at national, regional and local level. It is intended that the national workforce plan 2005, which should be published in June, will be followed by plans for all NHS boards and for the three regions.
Although the number of dentists in Scotland has increased by 70 per cent since 1975, we estimate that we have a shortfall of around 200 dentists. In part, that is a result of the Conservative Government's decision to close the Edinburgh dental school in 1996. A number of measures that are unique to Scotland have already been introduced to improve the recruitment and retention of dentists in the short to medium term. Those measures are starting to pay dividends, as an extra 50 dentists have already been recruited.
Although professions complementary to dentistry are not dealt with specifically in the report, they are mentioned as an important element in workforce planning. We believe that a comprehensive approach to dental services that maximises the contribution of all members of the dental team is vital to improve access to services. Given the report's suggestion that the employment of dental therapists can improve dentists' output or productivity by 45 per cent, the contribution of such professions is hugely important.
The need for local flexibility is recommended by the report to allow problems of access to be addressed at local level. From 1 April, NHS boards have had authority to appoint salaried general dental practitioners directly. That should provide the additional flexibilities that the report suggests.
I am aware that, as Roseanna Cunningham mentioned, the report expresses concern that we will find it difficult to fulfil our pledge to provide free dental check-ups for all by 2007 without a significant increase in the number of dentists who provide NHS services. There is no doubt that the target is challenging, but I am convinced that the measures that I have outlined will mean that we can recruit and retain enough NHS dentists to meet the pledge.
The additional £150 million that I have announced means that, by 2007-08, we will spend some £350 million on dental services in comparison with the £200 million that we currently spend. That represents an increase of 75 per cent. Over the three years, that funding will build up from the current base to £245 million, £300 million then £350 million. Cumulatively, that amounts to nearly £300 million extra. That record investment is backed up with a comprehensive action plan that will take forward the work on improving oral health and dental services.
I have also announced further measures to support NHS dental services. From April, we have doubled the general dental practice allowance, which supports practice costs. This year, we are providing £5 million of practice improvement funding. In addition, we will provide recurring financial support for existing dental premises and for information technology.
To sum up, we do not underestimate the challenge in securing better access for patients to NHS dental services. However, the measures in our action plan represent the most substantial programme of work ever undertaken to address our poor oral health record. I welcome today's debate and look forward to working with the Health Committee on this important issue.
I pay tribute to those who worked on the report and to the committee clerks for their input. The report is an excellent piece of research, which has informed the committee's thinking and provided important statistical evidence on the challenges that we face in tackling the crisis in NHS dentistry.
The report found that 42 per cent of primary care dentists who currently treat children are not accepting new child patients or are using a waiting list. A quarter admit to scaling down their NHS commitment and only 3.5 per cent of primary care dentists say that they intend to increase the amount of time that they spend treating NHS patients over the next two years. If one statistic in the report should make us sit up and take notice, it is that one, because it shows what the future holds unless the situation is turned around.
As Roseanna Cunningham said, the report concluded that the Executive's flagship pledge to give free dental checks to everyone by 2007 will be difficult to meet without a significant increase in the number of NHS dentists. The report also made it clear that the minister's plans to use incentives to lure retired dentists back to work in the NHS were unlikely to be successful. It stated:
"A significant increase in NHSScotland provision required to meet pledges to improve access to dental services is unlikely to be achieved with the type of incentives currently available".
That is a very strong message to the minister.
Since the report was published and since the Scottish National Party held a debate in the Parliament on NHS dentistry, we have had the long-awaited response from the Executive to the consultation, much of which was to be welcomed. The investment promise for NHS dentistry was certainly welcome, because one of the key problems has been the chronic underinvestment in NHS dental services over the years, including the years of this Executive. Nevertheless, the investment that has been announced is welcome and I hope that it will deliver improvements in the areas in which we need to see improvement.
The crucial question is whether the negotiations with the dental profession will result in agreement being reached to recruit people to, and retain them in, NHS dentistry. The negotiations on the fee level are particularly important, because the issue comes down to a basic economic argument that, unless NHS dentistry becomes more attractive and rewarding, more and more dentists will leave the NHS to go to the private sector where they can do less for more money. The intemperate language that was used by the minister in attacking the dentist in Stranraer who has left NHS dentistry is not at all helpful. We need to persuade dentists to remain within the NHS. Persuasion is the way forward, rather than launching an attack on an individual dentist.
Does the member approve of the actions of the dentist in Stranraer last weekend? Does she approve of the ultimatum that he gave to loyal patients, who had to queue in the rain to get back on a reduced list? Does the member approve of his actions? Yes or no?
That is not the point. If we are to persuade dentists to stay in the NHS and persuade dentists who have left the NHS to come back, it is not helpful to castigate those dentists and put them all in the same boat by saying that they have deserted the NHS. The minister has a job to do to persuade all those dentists to come back. The Scottish NHS Confederation stated:
"more of a challenge will be persuading established and more experienced GDPs to return to or to continue treating NHS patients."
How will the minister's intemperate language achieve that?
The minister has announced £150 million of additional funding, which is the biggest-ever investment in NHS dentistry. Within a few weeks of that announcement, a dentist declares that they are going private. Does the member support the action of that dentist, following the announcement of £150 million? Yes or no? Or does she support the patients?
The minister misses the point. The individual dentist is not the issue. The issue is those who have gone before and those who may come after and make the decision to leave the NHS. The minister must get to grips with that issue, rather than shout at an individual dentist. That is not the point: the issue is dentists who may leave in the future. The minister must focus her priorities on persuading dentists to stay within the NHS. Her language today has not helped.
I agree with Shona Robison's comment about the language that has been used. I will address that in my speech. Does she agree that the endless stream of dentists who appear to be opting out of the NHS has less to do with money and considerably more to do with working conditions, bureaucracy and regulation?
The two go together. Those dentists do not have quality time with their patients and they are run off their feet. If dentists can do less work for more money in the private sector, that situation must be addressed; if it is not, the problem will continue.
The British Dental Association has made it clear that unless there are major changes in remuneration for work that is done, there will not be enough dentists to implement the report's proposals, which are very good. How are the negotiations going with the dental profession on the fee level? They are crucial to the delivery of the many good things that the minister announced last month.
Many premises urgently require to be improved, and another mechanism to encourage dentists to remain or do more within the NHS is to provide assistance with infrastructure costs. For many dentists, the overhead costs do not make it financially viable to do more NHS work. That issue must be addressed. The Executive's commitment to provide more assistance for premises is certainly welcome. We must ensure that that is delivered as quickly as possible.
We must increase the dental workforce. Comparison with other small European countries, such as Denmark or Norway, which have double the dentist to population ratios that Scotland has, shows that Scotland is lagging behind. The BDA estimates that at least 215 additional dentists will be required if the Executive is to keep its pledge on free oral health assessments. We have had a commitment from the minister on the number of salaried dentists. How many additional salaried dentists does she hope will be delivered by the end of the year and what progress will be made after that?
We need to expand the workforce numbers, not only of dentists but of professionals complementary to dentistry, because they can take on much of the work—particularly the preventive work that we have all been talking about—and leave dentists to do the more complex work. Investment in training and education is required to achieve that.
Workforce shortages are the key. I was particularly pleased to see the golden handcuffs proposal to commit dentists to working for the NHS in return for being given a bursary during their training. That is exactly what the SNP proposed for medical students, but the proposal was criticised and dismissed by the Deputy First Minister. I am glad that the Executive has changed its mind on that and has seen the sense of the proposal.
Will the member take an intervention?
No. I am running out of time.
The SNP believes that more needs to be done to expand the workforce and therefore supports the development of a third full dental school in Scotland. If we require evidence of the need for that, the total number of applications for entry to dental schools in 2005 was 1,044, but 152 places were available. There were 550 applications for 85 places at Glasgow dental school and 494 applications for 67 places at Dundee dental school. Those applicants are all potential dentists of the future. It is clear that they are qualified to train as dentists, but they cannot do so because of a lack of places at dental school. That highlights the need to secure an extra dental school. The SNP is committed to doing that.
The preventive measures that the minister outlined in her plan are important. I highlight one that jumped out at me, which is to
"Implement new schemes to promote registration and associated preventive activity from birth".
We need to get children registered with a dentist at as young an age as possible, but that will happen only if there are more NHS dentists to do the work. The situation is a classic catch-22, which the minister and the Executive must resolve in order to deliver some of the good things that are in the plan.
I joined the Health Committee as the report was being published. I commend the committee for commissioning the report, which gives a clear snapshot of current dental services.
The debate comes at a time when NHS dentistry has reached crisis point in some parts of Scotland. In Grampian, it is virtually impossible to find a dentist who is willing to take on new NHS patients—even children. Dentists are still leaving the service this week, as we have heard from several members this morning.
My dentist went private six months ago. He did so not to make more money, but in the hope of losing around 200 patients from his practice list so that he could get off the treadmill of drilling and filling teeth and devote more time to his patients' oral health. At the same time, he could gain a more stress-free life.
Once dentists have moved out of the NHS and found a better quality of life, they are unlikely to return. A dentist who had moved out of the NHS recently told me that they now have a well-run practice and a manageable number of patients, whom they have time to care for. Most important, they have stability and no longer depend for their living on the whims of Government policy, which can change from election to election every five years or so. They said that they would never go back to the NHS.
What is the Conservative party's policy on private dentistry?
Dentists are contracted to the health service. It is up to them whether to work for the NHS or opt to go private—that has been a long-standing situation. If it were to change, getting dentists into the NHS would be even more difficult.
The report that was commissioned by the Health Committee revealed an astonishing lack of data at health board level on adult oral health, the recruitment and retention of staff, the demand for general, community and hospital dental services and other matters. Without such basic information, it is hard to see how supply and demand issues for NHS dental services—particularly for general dental services—can be properly addressed.
The report confirmed that there are particular problems with accessing NHS dentistry in rural areas; that only 3.5 per cent of primary care dentists intend to increase their NHS commitment over the next two years; that there is a problem with retaining dental nurses; and that 62 per cent of retired dentists—many of whom have retired early—could see no incentive that would induce them to return to providing NHS Scotland dental services. Furthermore, the rising proportion of women in the profession, with their desire for career breaks and shorter working hours, is an increasingly important consideration in service planning and delivery.
On top of an increasingly female workforce and the pressures of early retirement, too many dental graduates still leave Scotland once their training is complete. In addition, the current complex system of charging certainly needs to be replaced by a new system that is easy to operate, transparent, easy to understand and less bureaucratic. The short-term measures that the Executive has introduced recently to try to alleviate the current crisis have not solved the problem. Urgent measures are needed if NHS dentistry is to survive in Scotland.
The Executive's pledge to provide free dental checks for everyone by 2007 sounds attractive, but it is generally accepted that the pledge is unlikely to be met by the dental workforce that is currently available. Modern dentistry—which goes far beyond the identification and repair of holes in teeth to include lifestyle and preventive advice and the needs of the patient as a whole—is time consuming, and that time has not been funded by the NHS.
The aims of the dental action plan, which were announced by the minister in March, are admirable and try to address issues that are raised in the report. By March 2008, every child in Scotland is to have access to dental care when they start nursery—that means an extra 50,000 children every year. The aim is to have the largest supervised toothbrushing programme in Europe, which is fair enough; 200 more dentists by 2008; and 400,000 more people—that is, nearly half a million people—registered with an NHS dentist by March 2008. Red tape is to be slashed in general practice, with hugely simplified item-of-service fees for dentists. There should be more professionals complementary to dentistry, a new form of remuneration for dentists and improved practice allowances.
Some £150 million of extra funding over three years for NHS dentistry in Scotland has been promised. That is a large sum of money, but I say to the minister that it is just around half of what the profession considers to be necessary to put things right. The action plan was described by Dr Lamb of the British Dental Association as
"a patchwork of measures which lacks clarity".
He also said that
"it is difficult to see at this stage how the Executive's admirable aims will be achieved."
Many other dentists have said that there has been too little, too late and that what has been done will not resolve the crisis in the service. Dr Lamb has requested answers from the Executive with regard to concerns about funding for training dentists and about how the immediate shortage of dentists will be solved.
Are enough trained staff available in the colleges to provide the training for the significantly greater number of dentists and professionals complementary to dentistry that the Executive has identified as required? I asked that question on the day that the minister announced her action plan and Mary Scanlon repeated it. Why did we not receive an answer? Furthermore, given the recently identified lack of sufficient patients for current dental students to train with, where will the Executive find patients for the extra dental students and therapists that it has promised? Will they be found through the promised outreach centres? Will there be enough? Is there an assumption that all the extra students will make the grade, or will there be pressure to pass students in order to meet the Executive's targets at the risk of compromising quality? Those questions are important and they need positive answers if the Executive's aspirations are to become reality.
Only time will tell whether the action plan is effective in averting the crisis in NHS dentistry. Initial reactions suggest that, at the very least, its aspirations are over-ambitious given the resources that are available. I hope that the plan will attract new recruits into the NHS, but I am afraid that I do not think it will bring back those who have already left the service, either through retiring early or for the rewards and independence of private practice.
This is a welcome debate on the problems that NHS dentistry in Scotland faces. The failure over many years to ensure that everyone in Scotland—regardless of where they live—should have access to an NHS dentist has been nothing less than a scandal. Several years of campaigning have been required to reach the position in which the Parliament is at last on course to address that appalling situation.
The material in the report that we are debating comes as no surprise to me or to the Liberal Democrats, on whose behalf I speak. It highlights the fact that access to dental services is a problem throughout the country. The problem started around 10 years ago, when the previous Conservative Government closed the Edinburgh dental school and cut the number of schools that service Scotland from three to two. I followed what Nanette Milne said about training places. The Conservatives are, and have been, negative about dental training in Scotland. All that they seem to be interested in doing is cutting and cutting again.
Access to dental services is more of a problem in some places in Scotland than it is in others. Grampian has the second-lowest number of dentists per head of population in Scotland. Earlier, I said to Roseanna Cunningham that the report does not mention the fact that the Aberdeenshire local authority area has the lowest number of NHS dentists in the country. My constituency has been heavily affected by that. When a dental practice opened last year in Stonehaven, which is in my constituency, it was no surprise to see 1,000 people queueing outside the dental centre simply to get on the practice register.
Will the minister give way?
I am not a minister, but I will certainly give way.
Mike Rumbles mentioned the Edinburgh dental school. Does he acknowledge that the Conservatives recommended the postgraduate dental institute in Edinburgh, which is a centre of excellence for postgraduate education and training?
It would be wiser for the Conservatives not to push the issue, because they have done a lot of damage. They set in train the damage to the NHS dental service in Scotland and the difficulties that we face.
We should remember that the Health Committee asked the Parliament more than a year ago to commission the research on which the debate is focused. Time and events have moved on. The report has now been published and, since its publication, the Executive has made the action plan announcement. Therefore, we are in a rather unique situation. We have the report, which identifies the problems and suggests ways forward, and we also possess the Executive's action plan to solve the crisis.
The study provides detailed insights into the problems that are associated with accessing dental services throughout Scotland and is a valuable contribution to the debate on solving the nation's dental crisis and how we can move forward. It predates the Executive's announcement and makes a couple of points that I want to focus on, as they have already been highlighted.
The study says that the pledge of free check-ups for all by 2007 will be difficult to fulfil without a significant increase in the number of dentists who provide NHS treatment. It makes the broader point that a national strategy is needed to ensure that the majority of dental practitioners receive adequate incentives to commit to the national health service.
The Executive's action plan addresses the points that are raised in the report. The Executive will abolish 90 per cent of the red tape that dentists have to deal with, to which Alex Fergusson referred; that will reduce the so-called items of service from 450 different items to about 45 standard items. It will establish a comprehensive oral health assessment in addition to the standard dental check; that assessment will be free for everyone. The Executive is rolling out a major expansion of salaried dentists, while establishing a new range of incentives for practices that are committed to taking NHS patients. It will also introduce bursaries for dental students who commit to the NHS for five years.
All the practical issues that were raised by Andrew Lamb and BDA Scotland, including the issue of incentives, have been addressed in the report. The only remaining issue is the amount of investment; I will come back to that in a moment.
I am interested in Liberal Democrat support for what we might term golden handcuffs for dentists who are going into training and education. Does Mr Rumbles have the same support for those who would train to be general practitioners? Does he agree with the golden handcuffs plan for them?
It is not appropriate to refer to golden handcuffs. However, I am certainly in favour of this concept for dentists and I think that it could be expanded for many other professions.
At the time of the commissioning of the report, the Executive estimated that it was short of some 200 dentists. We aim to end that shortage by 2008. The Executive has already increased dentist numbers by about 50 and is well on its way to bridging the gap with several measures, including increasing the places in our dental schools from 120 to 135 a year.
For the past five years, I have pressed for the establishment of an outreach training centre in Aberdeen. That centre, followed by the establishment of a dental school, is now on the cards. We pushed the issue and got it into the Liberal Democrat manifesto at the last election.
Will the member take an intervention?
I have already given way to the Conservatives.
The outreach centre will open soon and the Executive has agreed to consult on whether there is a need to turn it into a fully fledged dental school.
I welcome the new announcement from the SNP's health spokesperson this morning of support for a new dental school for Scotland. I am used to Richard Lochhead jumping on the bandwagon as it goes by—it is a pity that he is not here, or he would jump again on the same bandwagon. However, it is good to see the SNP officially adopting Liberal Democrat policy. I sincerely hope that Shona Robison will include that policy in the SNP manifesto for the next Scottish parliamentary election, as my party included it in its manifesto for the last election. It is nice to see the SNP catching up at last.
To fund all this, the Executive is to increase funding from £200 million a year to about £350 million a year over the next three years, a substantial increase of some 75 per cent.
There is no doubt that there is a crisis in dental provision in Scotland, which the report has highlighted. There is also no doubt that the Executive has produced an excellent plan that will solve the crisis if it is fully implemented. The Parliament's role now is to ensure that the action plan, as outlined by the Executive's ministers, is delivered.
In north-east Scotland, access to dental services is an issue of key concern. There are real problems in registering with a dentist and particularly in accessing NHS dental treatment. Recently, there have been further instances of dentists making the regrettable decision to cease NHS treatment.
The problem in the region is highlighted in the report that was commissioned by the committee, which shows not only that Grampian has the second-lowest number of dentists per head of population but that dentists in Grampian are below the average in terms of the percentage of time that they spend on NHS work. The concern that is felt in the region is perhaps evident in the fact that Grampian NHS Board had the highest response rate from dental practitioners to the questionnaire for the report, with 90 per cent responding.
Too often in this debate, members have complained about the problems and bemoaned the situation rather than offered practical solutions. That is why the Executive's announcement last month was so important. The action plan is comprehensive and will make a real difference in improving access to dental services in Scotland; of course, it is backed by the investment of an additional £150 million over three years, which shows Labour's commitment to tackling the problem.
This debate, which was brought forward by the Health Committee, and the report that the committee commissioned into access to dental services are invaluable. Not only do we have the opportunity to highlight the concerns, but the depth and quality of the research in the report should inform the Executive's decisions on how its action plan will ensure that the significant extra funding is spent effectively.
The report is important because it offers clear data on how assessment can be made of where need is greatest and how the impact of investment in more services and staff can be most accurately assessed. That wealth of data must be used by the Executive to ensure that the right priorities are chosen for investment through the new action plan. The report highlights the fact that on measure after measure—I outlined only two—Grampian is assessed as having particular needs and particular problems with access to services. The report also emphasises the extra hurdles to access that can affect those who live in rural areas; again, that is an issue in the north-east.
It would be churlish of me not to note that the Executive has already identified Grampian as an area that requires special and immediate action to improve access to dentistry. When I met the minister in Aberdeen earlier this month as she visited the GDENS service, I was pleased that she announced that there will be an immediate award of £500,000 to the health board to improve dental services and that some £2 million will be awarded to the health board for that purpose over the next two years.
Such action follows the appointment of salaried dentists by Grampian NHS Board. Further new appointments are planned and there is a comprehensive action plan to improve dental services, a key part of which is the establishment of a dental outreach training centre. The centre will treat thousands of patients, as well as helping to recruit dentists to work in the area.
Grampian has been singled out as requiring investment and action to address problems with access. The report highlights why such action needs to be taken and why that focus will continue to be required.
I welcome the report's acknowledgement that the determinants of oral health extend far beyond access to dental services, because that is a key point. Education and prevention are also vital issues. I am pleased that some of the extra funding is linked to requirements providing prevention.
I was pleased that Rhona Brankin visited a toothbrushing scheme at a nursery in Aberdeen. Expanding that kind of provision and emphasising to the young that they need to look after their dental health are crucial in improving oral health and thus reducing the pressures on services and helping to improve access.
Another issue that the report raises is how we encourage dentists to continue, or return to, NHS work. It is unfortunate that the report indicates a lack of willingness in parts of the profession—a minority, as the minister said—to engage in NHS provision. I hope that the minister's recent announcement of increased remuneration for dentists for NHS work will help to address the situation.
The profession and its representative bodies must engage in constructive dialogue with the Executive to play their full role in improving access to NHS services. We have an opportunity through the action plan and the new investment to make real improvements to access. Using the data, the report gives us an even better opportunity to ensure that the investment and the action plan work and provide the kind of access to dental services that we all want.
The situation in Grampian and the north-east is at crisis point. If one considers the range of measures that Roseanna Cunningham helpfully told us are on pages 6 and 7 of the research report, one will see that, where there is a direct measure of access to services, the north-east is in the worst possible category. As Mike Rumbles and Richard Baker pointed out, we have a real problem.
How do we address that problem? I was delighted to attend—with both the aforementioned gentlemen—the start of the postgraduate dental arrangements in Aberdeen, which are a cross-party matter. I believe that we need a third dental school, so I hope that what is happening in Aberdeen will be the start of such a school. It cannot happen overnight, much as we would like that. Dr Milne was correct to say that we will need to ensure that we have people who can train not only the dentists, but the professions that are ancillary to dentistry.
Access to dental services relates not just to the presence of dentists, but to physical access. The implementation of the Disability Discrimination Act 1995 has had a major impact on provision of dental services: it has precipitated closure of a number of small dental practices that were considering whether to continue, and it has led to dentists' moving on when their facilities did not meet the standards that were set by that act and the costs of bringing them up to standard were prohibitive. I have no complaints about the act's provisions on access, which were well intentioned. However, it has had consequences that have not been helpful, given the fragile circumstances in which dentistry in Scotland finds itself.
Does that mean that the member welcomes the announcement of significant increases in dental practice allowances? That is the kind of support that will allow practices to bring their facilities up to the required standard.
I will go on to address such issues.
There is such antipathy from a number of dental practitioners to the continued provision of NHS services that the kind of welcome steps that the Executive has recently taken will not necessarily have the results that we all want. Confidence among NHS dentists has been shot, and I do not know whether they will have confidence in the system for the future, despite the welcome steps that the Executive is taking. I wonder whether the horse has bolted and whether we have lost the opportunity to rebuild confidence in NHS dentistry.
The problem goes back to the establishment of the NHS and the role of independent contractors, which was conceded in 1948. I am not sure that the independent contractor system is delivering for the NHS. Both the minister and Duncan McNeil, in his intervention, made the point that independent contracting must work for both parties. It is obviously working for dentists, but is it working for the general public? That is not just a philosophical question—it underpins the whole debate.
The report recognises that there has been an increase in the number of NHS salaried dentists and that some dentists—perhaps one in eight, which is a relatively small proportion—are interested in becoming salaried dentists. However, the report also suggests that NHS salaried dentists provide a less efficient and accessible service.
I ask the minister to let me finish making my point. I am not attacking her in any way.
I have a point of information.
The issue of access out of hours can be dealt with in the contract. I do not know whether we have evidence that there is higher throughput in private dentistry because of the greater profit motive or because NHS salaried dentists are starting to deliver the oral health programme that we hope all dentists will deliver, and are therefore doing less drilling and filling. I am happy to take an intervention from the minister now, if she can give me some information.
I did not mean to interrupt the member midstream.
Comparison of the productivity of salaried dentists and independent contractor dentists is not straightforward. Many salaried dentists take on a large number of complex cases and work with people who have complex special needs. I caution the member against taking an excessively simplistic view of the comparison between the productivity of the two groups.
I am happy to accept the point that the minister makes. If the reason for the difference is as she describes, that is welcome news. I find it hard to believe that someone who happens to be employed by the NHS, rather than self-employed, would work less hard. I was disappointed that the report seemed to some extent to imply that.
I want to highlight a case that has been brought to my attention by a pensioner in Aberdeen, who could not find an NHS dentist to deliver the dentistry that she required. She knew that she needed to have a tooth extracted and eventually found someone to do the work privately. Sensibly, she asked how much that would cost—her only income is a state pension. She was told that it would cost her £40 to have a tooth extracted. However, when she went along with her £40, she discovered that she would have to pay in advance for the examination. Because the lady had not visited a dentist for some time, much other work that was required was pointed out to her during the examination. However, she had only the examination and the extraction. She paid £40 for the extraction, but the private practice is now pursuing her for an additional £44.70. She is being threatened with legal consequences for failing to pay that sum, which she is not in a position to do. That is the kind of situation in which we find ourselves. Perhaps the oral hygiene of that 67-year-old pensioner cannot be readily restored, but she cannot get NHS dentistry, is being asked to pay for something that she cannot afford and is being provided with services that she did not seek. We cannot find such a situation acceptable.
We must do all that we can to persuade the 38 per cent of retired dentists who have not said that they will not come back into the profession to do so. The Executive has proposed a range of measures. There is no single magic bullet that will solve the problem. If 12 per cent of dentists are willing to become salaried, let them do so. Let us sort out the capitation arrangements. I wish the minister well in her discussions with the profession about producing a new contract that will provide the kind of financial and professional incentives that will persuade dentists to return to the NHS. However, I worry that we have almost reached the point of no return and that NHS dentistry may become a thing of the past.
I welcome the debate and the publication of the research report, especially because in my region—the Highlands and Islands—access to dental care has been and remains an issue of great concern.
The weighty research report is primarily about dental services, rather than dental health, but it is reasonable for me to touch on our oral health record. Richard Baker has already quoted the following statement from the report, but I will do so again because it is so telling:
"the determinants of oral health extend far beyond access to dental services … Dental service utilisation alone does not necessarily enhance or maintain oral health".
I found the tables in the report fascinating. Scottish Borders, which clearly does best in the league table that relates to tooth decay in children, even allowing for all the variables that exist, and Dumfries and Galloway, which is about fifth in the table, are among the areas that have the lowest dentist to population ratios, the worst access to NHS dentists for new children and adults, the longest distances to travel to dentists and the longest waiting times. However, those areas have middle and low deprivation rates, respectively. That is a really important issue. Dental health in children—there does not seem to be much information held centrally about dental health in adults, to which I will return—correlates poorly with the level of services, but absolutely with the level of poverty. We will not improve the oral health of our population unless we eradicate poverty. It is as simple as that.
However, it would be wrong to say that provision of dental services is not important: of course it is, as is universal access to those services. I welcome the various initiatives and investments that the minister has announced. I welcome particularly the fact that the Executive is considering having a greater skills mix in dentistry in our communities in the future by introducing to surgeries professions that are complementary to dentistry, such as more dental hygienists and other people who could deliver services that dentists currently deliver.
Alex Fergusson said in his intervention that retaining dentists is not just a case of throwing money at the situation, but is also about job satisfaction. The report looked to some extent at what would make dentists more interested in treating more NHS patients. It was interesting that although 55 per cent of dentists agreed that they wanted increased fees for services, there were many other areas on which there was no agreement. I suspect that it would be an interesting exercise to go into more detail with individual dentists to find out what makes working for the NHS less satisfying.
That reminds me of a psychologist with whom I used to work. We used to ask each other the "miracle" question, which was, "If a miracle happened and you went to work tomorrow, what would be different?" It might be that for some dentists the miracle would be that they would carry on as normal but would get more money for treating patients. I suspect that for some, the miracle would be that they would arrive in the morning at splendid, up-to-date and purpose-built premises that were provided, maintained and equipped by the health board, staffed not only by receptionists and dental nurses, but by a range of professionals who are allied to dentistry and who would help them to deliver services. Job satisfaction and working conditions are perhaps more important and less easy to define than money, but they make the job more worth doing.
I mentioned the lack of information on adult oral health. I found it fascinating to read in the report that there is a distinct lack of data about dental health and dental health services held either at health board or Government level. The work that was done in preparing the report from the 1,800 returned questionnaires that the authors received provides some valuable information, but only on a snapshot basis. The information should and must be collated and monitored regularly over time. For example, the report mentions that no information on adult oral health is held by health boards. How can we plan to meet the needs of the population when we do not know what its needs are? No information is held at health board level about numbers of whole-time equivalent dentists. That is incredible—somebody pays them so surely we know how many of them there are.
No information is held at health board level about the number of dentists who are accepting new NHS patients—again, that is crucial information. There is no information about distances that are travelled by patients to see dentists, which is a big issue in my area. There is no information on demand for access to dental services, there is no information about the need for community dental services to treat some of the most vulnerable people and there are insufficient data on recruitment and retention. Now that the huge information gap has been recognised, I hope that we will hear how it will be plugged.
It will be difficult to meet our dental care needs and to keep up with meeting those needs as they change if we do not know what they are. I look forward to the day when our children's oral health is much better, when we have tackled poverty, when we have removed fizzy drinks from schools, when we have improved children's diet and when we have improved toothbrushing and dental health awareness in general. However, our population is living longer, people keep their teeth longer and the dental health needs of older people will increase. That has to be considered.
I have made the point about free dental checks in chamber debates before. I accept what other members have said about there being difficulty under the present system in delivering universal free dental check-ups, but there is also an ethical problem. In medicine, it is an ethical truism that one does not screen for a condition unless one can treat it if one finds it. My worry is this: even if we can deliver free dental checks, if they show up a need for treatment, will we be able to deliver that treatment? If we cannot, it is almost unethical to do the checks. We need to look not only at meeting the need for free dental checks, but at meeting the increased treatment needs that the checks will show up.
I value the opportunity to contribute to this important debate on access to dental services.
The research report provides a clear snapshot in time of the challenges that we face in Scotland. I have campaigned on behalf of the constituents of Dunfermline East over many months on the vital issue of NHS dental services and withdrawal of NHS services by dental contractors. I have written many letters to, and met officials from, Fife NHS Board, as well as writing to and meeting the Deputy Minister for Health and Community Care. Therefore, I was especially pleased when it was announced in the statement to Parliament on 17 March that health boards are to be given the authority directly to appoint salaried dentists.
I represent towns that are among the poorest and most disadvantaged in Scotland and they need to be targeted for support in all aspects of health care, but in dental health care in particular. I have already asked NHS Fife whether it will appoint directly salaried dentists. If it does, that will help on the long journey back to NHS-provided dental services in my constituency. It follows that the Scottish Executive might need to consider additional resources for a board such as NHS Fife, which might find itself having to make more finance available in the interests of ensuring adequate dentistry provision, especially in areas of great need where NHS provision has all but disappeared.
The minister spoke of the daunting challenges of providing NHS dental services. The Executive has many aspects to consider, such as recognition of Scotland's changing demographics and the greater oral health needs of an increasingly elderly population, which must be incorporated into planning.
I do not have a problem with the golden handcuffs that have been mentioned by Shona Robison and others this morning because I believe that the bursary scheme for students should help significantly to attract young people to the dental profession. If we are going to provide finance for that, there is an onus on all of us—
The point is that, although we welcome that scheme, we would like it to be extended to medical students, a proposal that was unfortunately opposed by Jim Wallace. Does Helen Eadie now support that proposal?
I have never had a problem with that proposal, but my view is my view and I will try to persuade others of it. When we have a dire shortage of specialists in Scotland, we need strategies such as the bursary scheme. If it is right for dentists, the logic is that it is right for other medical professions.
Does the member accept that, because the golden handcuffs arrangement that the SNP promotes for medical students would be open only to graduates who are not domiciled in Scotland, the policy is potentially hugely restrictive and is likely to be viewed as discriminatory?
I was unaware of that, but if that is the case, I support the minister's view entirely.
The research report highlights training issues, about which Nanette Milne spoke. We are all well aware that there are only 13 dental schools in the United Kingdom, which produce just 800 dental graduates each year. As Mike Rumbles and others said, it is tragic that the previous Government chose to close the Edinburgh dental school. We miss it, so perhaps the health ministers will reflect on whether a dental school could be restored to Edinburgh. The BDA wants the figure of 800 graduates to increase by 25 per cent; I hope that Scotland will play its part in that challenge. I welcome what the minister's statement on 17 March said in that regard.
The research report and the BDA say that more must be done to encourage people who qualify here to practise here. Almost half the dentists who currently complete their training in Scotland opt to practise elsewhere.
I have concerns about the BDA in Scotland. The first is about the way in which dental contractors in my area unilaterally withdrew their services without warning or consultation, and through letters that left a lot to be desired. No diplomacy or courtesy was employed to advise local representatives of such a major change—patients simply received a letter and that was it.
My second concern is that when I visited the media section of the BDA website, I noted the reception in Scotland for the deputy minister's statement. That reception was lukewarm, to put it mildly. In the media release of the BDA in Wales, Stuart Geddes, the national director of the BDA in Wales said:
"The British Dental Association has today welcomed the National Assembly for Wales's announcement of an additional £5.3m for NHS dentistry. The new money, which will come over three years, is intended to improve access to dental services and to support dentists providing those services.
In addition, they have also pledged to increase funding for vocational training, with allowances for trainers rising by over 22 per cent and those for trainees rising by over 11 per cent."
Let us compare that with what was said by Andrew Lamb, who is the director of the BDA in Scotland. He said, following the announcement by Scottish Executive ministers:
"The British Dental Association has dubbed today's announcement on NHS dentistry by the Scottish Executive a disappointment and a wasted opportunity. Although the announcement held some good news for Scottish dentistry, many of the fundamental issues have been missed."
Let us just think about that. He said that following the minister's statement that the Scottish Executive will provide unprecedented financial support of an additional £150 million over three years, which represents the biggest-ever investment to support NHS dentistry in Scotland. In addition, the minister announced another £5 million to help dentists to improve their practices. She continued the good news by committing the Scottish Executive to increasing the remote areas allowance for NHS dentists by £9,000 a year, with a further £1 million to support emergency dental services. That has made me wonder about the BDA in Scotland. I would be happy to meet BDA representatives, but its press release raises questions in my mind about that organisation.
I am pleased about the moves that the Scottish Executive is making to improve dental services across Scotland. Such improvement represents a major challenge and ministers have my absolute and utmost support in all the work that they are doing to improve services.
I thank my colleague Jamie McGrigor, who was originally scheduled to take part in the debate but who gave way so that I could speak. He did so on the promise that I would mention the Western Isles—by saying that, I hope that I have fulfilled my commitment to him. He is very concerned about dentistry in the Western Isles.
The fact that I have not heard Dumfries and Galloway mentioned so much in a debate since the unhappy days of foot-and-mouth disease perhaps shows why I am so keen to take part in the debate. Anyone who saw the pictures of my constituents queueing in Stranraer last Monday to sign on with a dentist who has opted to leave the NHS could have been forgiven for thinking that they were looking at some scene from the great depression of the 1930s. However, the only thing that they would have had wrong was the date, because a great depression sums up exactly the mood of my constituents in Galloway and Upper Nithsdale when it comes to access to dental services. One has only to scan the excellent research report to see why—no health board area comes out worse than Dumfries and Galloway does.
Perhaps the only mistake that was made by Mr Barr, the Stranraer dentist who opted out on Monday, was that he did so during a general election campaign. Only a couple of months ago, a dentist in Castle Douglas opted out and, although he attracted much local criticism, he avoided the unnecessary and unpleasant political invective that has been rained on Mr Barr—bizarrely, from the very political party whose stewardship of the NHS in the past eight years has brought about the seemingly endless stream of dental practitioners who have had enough of the NHS as delivered by the Executive and who have taken what they feel is the only alternative that is left to them, which is to go private.
Does Alex Fergusson support the action that was taken by Mr Barr in Stranraer? Yes or no?
I shall come to that in just a second.
Mr Barr was quoted in Tuesday's newspaper as saying:
"We have been squeezed and squeezed by the Government. A steady erosion of funding and a huge increase in bureaucracy has prompted our move away from the NHS."
I agree with Alasdair Morgan, who pointed out—I assume that it was his only reason for coming into the chamber this morning—that it was a shame that the minister had changed her plans to meet Mr Barr and instead visited the one remaining NHS dentist in Castle Douglas, who is very good. She might have learned much more by visiting Stranraer that day, as she planned originally to do.
In answer to the minister's question, I say that I would infinitely prefer to see Mr Barr working in the NHS, but I totally defend his and any other individual's right to exercise their constitutional right. I also feel free to criticise—I do so in this instance—the Executive's stewardship, which has led Mr Barr and others to take that regrettable course of action.
Is the member going to answer the question?
I have absolutely answered the minister's question. I think that we should move on before the debate gets more heated than it already is. Duncan McNeil is speaking next, so I have no doubt that it will continue to become more heated.
In January, I was contacted by a constituent who sounded really excited to have got an NHS dentist in Dumfries to give her an appointment for a dental check-up at last. She is really looking forward to that appointment—next December. Only last Friday, I was visited in my monthly surgery in Newton Stewart by a constituent who has had open heart surgery and therefore requires regular dental checks to ensure that he is entirely free from infection. Only the chance mention that he was in receipt of pension credit gained him access to an NHS dentist, and that some 40 miles away. A general practitioner told me recently that the state of children's teeth in his practice is as bad as he has ever known it and is deteriorating. That is the reality out there. It takes more than a year to see an NHS dentist, if people can get one to see them, and our youngest generation looks set to increase the problem rather than to decrease it.
I accept and welcome the fact that the minister announced on 17 March actions to try to tackle those problems, however belated that action might be. However, I would like to quote from an e-mail from another constituent of mine—a former dentist who now acts in a consultative capacity and is highly regarded. Members must believe me when I assure them that he holds no brief for me, politically or otherwise, or for my party. He made that very plain when he came to see me. His e-mail said:
"I have just read the press release by the minister and it does not begin to touch on solving the problem either nationally or our own local problem."
He goes on to dissect the minister's plans dispassionately and logically. I shall forward a copy of the e-mail to the minister as a constructive criticism of her plans by a highly qualified and informed source.
First, does the previous Conservative Government bear no responsibility for the dreadful state in which it left the national health service by closing the Edinburgh dental school and leaving us with so few dentists? Secondly, on the point that he has just made to the minister, what initiative can Alex Fergusson come up with that the Executive has not taken on board?
Mr Rumbles will get the answer to his second question shortly, when I wind up my speech. In answer to his first question, the Government has had eight years to alter things since the last Conservative Government went out of power. He cannot go on for ever blaming the Conservative Government for all the ills of the current Administration.
My constituent finished his e-mail by saying:
"there is no point appealing to dentists' wallets in this way, the NHS dental service is no longer about money it is about working conditions. This smacks of closing the stable door after the horse has bolted … Will it have any real effect on the nation's NHS dental provision and public dental health? I hae ma doubts".
If he is proved right—many people agree with him—what is the answer? I believe that we need to consider the Canadian model of dental care, in which far greater use is made of dental assistants and allied professionals, which leaves the dentist free to plan each patient's treatment and to carry out in person only the most complex dental procedures. The minister referred to that, but she needs to go further. Dental assistants could be recruited and trained locally, which would hugely improve retention rates. Above all, they can be recruited and trained quickly.
The minister's intentions are good, but I suspect that a more radical rethink of how rural dental services are delivered will be required. I urge the minister to think outside the box if the dental care of this nation is to be addressed properly and in a way that every member in this chamber would like.
I am sorry to disappoint Alex Fergusson, but given the recent debate, the minister's statement and today's subsequent debate, it is hard to generate any heat at all on the issue, which has been well discussed over the past few weeks.
As a member of the Health Committee, I welcome the interesting and well-researched document that has allowed this morning's debate to take place. One interesting factor that should inform us in today's holistic debate is that it is not necessarily true that if we provide more we will get a better result. Where there is a greater number of dentists and where there are increased opportunities for access, the result is poorer rates of dental health.
The report helpfully points out several aspects of that phenomenon. Availability and dentist to population ratios are important, but the proportion of time that dentists spend with patients, disabled and wheelchair access to local dentists and the distance to the surgery are also important factors. I suggest that there is perhaps also a culture of fear, which means that people leave it until the last minute to go to the dentist, rather than seek to prevent problems from arising. The dentist's accommodation is also important, as are waiting times and the availability of dentists in the evenings and at weekends. Easy access to services is high on people's agenda, because there is an expectation that people will not get a dental appointment.
Mike Rumbles, who is dashing back and forward in the chamber to have a conversation with another member while the debate continues, has said that although there is no doubt that the Executive's action plan, which seeks to reward dentists who are loyal to the NHS, is welcome—it certainly is welcome—rewarding dentists alone will not solve the problems that we face. As members have said, we must move the service away from repair to care. The education and training of the wider dental team, including professions complementary to dentistry—a term we had not heard until about six weeks ago—will help us to achieve that objective and will be important in increasing access, as the report's authors said.
The debate has focused on the recruitment and retention of dentists and on dentists' concerns, but there is a bit missing from the report—
Does Duncan McNeil accept that the researchers did what the Health Committee instructed them to do? The Health Committee did not widen their remit beyond the consideration of dentists.
Yes, I accept that the researchers' remit was to focus on those concerns. However, as members have said, we must build on the research and focus on the people whose skills complement those of dentists and who can and will make a difference to the quality of and access to NHS dental services. Dental hygienists can increase the productivity of dentists by 45 per cent, as has been said, and other professions can have an impact on productivity. I highlight the fact that there are 335 vacancies for dental nurses and hygienists, which represents a failure. I leave members with that thought. I hope that we can build on the research and address that serious issue. By raising the status of dental nurses and hygienists, we will make a real difference to the delivery of NHS dental services in Scotland.
I note, as I am sure do other members, that the Scottish Socialist Party, the most toothless party in the Parliament, is again absent from a debate that we would expect to be of particular interest to a party that trumpets its support for the disadvantaged in society. The matter is clearly too difficult for the SSP. However, the rest of us can have a serious debate, as is right.
The Health Committee did an excellent job in commissioning much new information and data. Members know that I always pore over numbers. I am always excited when I have a new source of data on which I will be able to draw for some time.
I received a letter today from the Deputy Minister for Health and Community Care, for which I thank her, which relates to a parliamentary question that I asked about dentists per capita. She says that in certain respects the numbers
"should be treated with caution."
That is probably wise. However, a broader issue is opened up, not just for the Opposition but for the Government, which we must try to discuss. I will return to that issue.
The British Dental Association has come in for a certain amount of stick in the debate. I am not an apologist for the BDA, but the organisation makes important points. Before the minister made her announcement on 17 March, the BDA sent a submission to the Health Committee, which was considered on 22 February. The BDA said:
"The existing dental examination Item 1(a) in the Statement of Dental Remuneration is insufficient to determine the needs of patients and to identify and discuss and agree with them the care regimes they should receive as part of a modern dental service."
I agree with the BDA and I suspect that the minister also agrees with its comment.
We must accept that the minister's announcement represented a move forward. However, after she made her statement, the BDA said in its press release:
"Today's announcement does little to tackle the fundamental issues facing NHS dentistry in Scotland. The BDA's hope is that this is not the final chapter and that the Executive will continue to look at dentistry as a priority issue."
Helen Eadie highlighted that point.
There are ways in which the Executive can demonstrate its good faith in treating dentistry as a priority. The minister has heard me compare and contrast health boards' obligation to find a general medical practitioner for a patient with the situation in relation to dentists. If a patient cannot find a GP, the health board must do so. Until we place an obligation on health boards to find an NHS general dental practitioner for a patient who cannot do so themselves, the dental profession will remain the poor relation of the medical profession. Of course, currently we cannot realistically deliver on that proposal and I do not suggest that we make such a change next week. However, we must make it our objective to be in a position to be able to do so.
Mike Rumbles talked about training. On 5 September 2002, I said that we supported the
"suggestion of conducting NHS training in the north-east."—[Official Report, 5 September 2002; c 13510.]
Mike Rumbles will be rather late if he congratulates the Scottish National Party on accepting that position.
The member knows very well that the only occasion on which the SNP's health spokesman has announced the party's support for the establishment of a third dental school in Scotland was this morning.
My comment of three years ago is on the record and I suggest that the member reads it.
There is particular value in training dentists in Scotland. The helpful research report, "Access to Dental Health Services in Scotland", indicates why that is the case: although 72.5 per cent of NHS dentists were born in Scotland, 88.8 per cent were trained in Scotland. The existence of dental training in Scotland is a key contributor to increasing the number of dentists available in Scotland. The 285 dentists who stayed in Scotland because they were trained here represent 16.3 per cent of NHS dentists. That is why training is so vital and why I, like Mike Rumbles, support every effort to provide additional training.
Over a time I have pursued concerns about the apparent inability to measure what is going on in NHS dentistry. There is an old management truism that what cannot be measured cannot be managed. The £150 million will help, but we do not quite know how it will help, because we are missing the figures. The minister has acknowledged that we do not have enough information on health boards to enable us to plan. That is a fair comment. However, although we pay NHS dentists by item and have statistics about how many dentists are making claims on the NHS and about dentists' activities, we seem unable to analyse the statistics and produce credible information about what is going on. I find that passing strange.
When I was elected as an MSP in 2001, I expected that there would be some privileges. Quite the most unexpected was that, for the first time in a while, I was able to get an NHS dentist, but only because I travel down to the central belt once a week and am able to get one down here. That is excellent for me but not the slightest help to my constituents.
As members know, I am one of the two mathematicians in the Parliament. A neat piece of mathematics describes the present situation: it is called catastrophe maths. It is represented by a folded curve on a graph and is illustrated by this example. If a bullet is fired from a gun, the action cannot be undone by pushing the trigger forward again; an entirely different solution is required. In a similar way, we cannot undo many years of neglect simply with money. Finding a solution will take time however much money is thrown at the problem.
A start has been made and I welcome that. However, more money is not enough. We must make the system more efficient. The Health Committee's report will give us something to chew over for some time to come—that is, for those of us who still have teeth with which to chew.
I still have all my own teeth, thankfully.
There are advantages and disadvantages to speaking this late in the debate. One of the advantages is being able to write a speech during the debate while listening very carefully to what other members are saying. One of the disadvantages is that everything has already been said. I will try not to be too repetitive.
I welcome the Health Committee's research report. As Duncan McNeil said, it offers us our third opportunity to discuss this issue in as many months. It is a very important health issue. The findings of the report do not surprise me. They are very much in line with evidence that committee members have heard on different pieces of legislation and during different committee inquiries. Some of that evidence has been anecdotal; to an extent, the report legitimises much of the thinking on the subject of access to dental services.
On one occasion, the situation was so bad in an area that a member of the public asked me to examine their teeth. When the Health Committee visited the Borders to take evidence in the workforce planning inquiry, we held a public forum in a hotel. A strong theme running through the inquiry was the lack of access to dental services and to NHS dentists. When we left the hotel, someone who had heard that the Health Committee was there to take evidence, but who had not been at the public meeting, complained about the lack of dentists and tried to get me to look at his teeth. He then pursued me and a clerk out of the hotel, with his mouth gaping. Discretion being the better part of valour, the clerk and I legged it to the car and drove off at great speed. I do not think that I would have had anything much to tell the man—although, from what I saw, it looked quite bad. I did not want to examine him any more closely. I am a city girl; perhaps what happened is just what men in the Borders do when they are trying to chat people up. I do not know.
We heard from Eleanor Scott about the lack of dentists to fulfil the commitment on free oral health examinations. In evidence on the Smoking, Health and Social Care (Scotland) Bill, the Health Committee heard the same point from some professional organisations. People may have much more to say on the subject when we discuss the stage 1 report on the bill next week.
As Eleanor Scott said—and this proves that I was listening while scribbling away—accessibility should not be judged on the supply of services and physical access to them. In table 1 of the report—which summarises access based on supply—the Borders comes low down or in the worst position on all but one of the indicators. However, children in the Borders have the lowest number of filled, missing or decayed teeth. The situation is reversed in greater Glasgow. It comes high up or in the best position in the table, but has the second-highest number of children with filled, missing or decayed teeth in Scotland.
The figures for access in Tayside are quite good, and the figures for decay are average to good. However, if the figures could be broken down, I think that Dundee would have high access to services but would also have a high number of dental health problems among children.
Understandably, most members have concentrated on the lack of dentists or on the lack of dentists who are prepared to take on NHS patients. I know that that is a real problem in many parts of Scotland, although it is not one that has been particularly brought to my attention in Dundee. However, it is at least as important to concentrate on ensuring that all people—especially children—use the available services, so that dental health problems are avoided through preventive advice and measures. I welcome the proposals that the minister announced a few weeks ago, although I would like even more effort to be made.
Children are already entitled to free dental services, and we can see from the report that 66 per cent of children in Scotland are registered. That figure is not as high as we would like it to be, but it is reasonably high. However, across Scotland, more than 50 per cent of children have significant levels of tooth decay. Clearly, although 66 per cent of children are registered, they are not all attending the dentist regularly. Those that do attend either are not getting advice or are not taking the advice that the dentist gives. The areas that have the best access to NHS dentists seem to have higher levels of problems with their teeth.
I am fairly satisfied that some of the minister's proposals will, in the medium to long term, improve the supply of NHS dentists. However, I am still concerned that not enough is being done to improve the take-up of services, particularly in deprived areas. I hope that more can be done to ensure that the Scottish Executive's fairly ambitious targets can be met or even exceeded.
We come now to closing speeches.
This has been an interesting debate, with a good number of good contributions.
Shona Robison spoke about chronic underfunding and underinvestment in NHS dentistry. However, in the SNP debate on dentistry not so long ago, she said that the SNP planned to increase funding by £40 million to £50 million, an—
A year.
Yes—a year. That represents an increase of up to 25 per cent. The Executive plans to invest £150 million, which represents an increase of 75 per cent—three times what the SNP plans to invest. I am glad that Shona has welcomed that investment.
Will the member take an intervention?
No. I think that we have said enough on the subject.
Brian Adam made a very constructive contribution, highlighting the real problems in the north-east. He was right to do so, and I also acknowledge Stewart Stevenson's speech. They were both positive and tried to move the debate forward. I am glad that the SNP is now supporting a third dental school in Scotland. The party's official policy is now aligned with our own.
I was somewhat surprised by Eleanor Scott's speech. She said that it was "almost unethical" to have free dental checks. I find that rather—
She did not say that.
She did.
If the member had been listening, he would know that I said that it was unethical to do a check if we could not then carry out the treatment that the check had revealed to be necessary. That would be similar to screening for a condition that was untreatable. If not unethical, it is certainly a very undesirable state of affairs. There is no point in telling somebody that something is wrong with them if we are not then able to treat them.
That is exactly what the Executive has consistently said, and is the whole point of having the action plan. Eleanor Scott gave the impression that the Executive was not addressing the issue, which is far from the truth.
Helen Eadie made some interesting comments on the response of the BDA to the Executive's action plan. She quoted Andrew Lamb as saying that the plan was a
"disappointment and a wasted opportunity",
and that many of the opportunities had "been missed." I take the opportunity to ask the BDA which initiatives it feels have not been taken up. I know that all the initiatives that the BDA asked for are being taken up—every single one of them. The issue is a simple one: it is about investment. I am surprised that the minister's announcement of the biggest-ever investment, which sees an increase of 75 per cent in funding from £200 million a year to £350 million a year, is not enough. Certainly, it seems that it is not enough for the BDA.
Although I am disappointed by the BDA's response, we need constructive engagement with it. The BDA and the Executive need to work together to ensure that the Executive's action plan, which is excellent, is properly implemented. There must be a partnership between the professionals who are involved in NHS dentistry across Scotland and the Executive. I hope that the BDA and the Executive will take that point on board.
I turn to Alex Fergusson's comments—although, unfortunately, he is not in the chamber to hear them. I intervened during his speech on the question of initiatives, but the only one that he came up with is what he calls the Canadian model. Under Alex Fergusson's Canadian model, a dentist gives the patient a comprehensive oral health check, after which the treatment is carried out by the appropriate person to do the work, whether that is the dentist, a dental hygienist or some other person. I wanted to say to Alex Fergusson that that is exactly what the Executive proposes to do under its action plan.
I return to my earlier point about the BDA's comments on the Executive's initiatives and repeat my request to the BDA to give us an example of an initiative that the Executive is not examining. All I can say is that I have not found any. Clearly, I upset Duncan McNeil in some way, as he did not seem to like my intervention on Alex Fergusson.
Stewart Stevenson alluded to the complete absence of the SSP in the debate; the comment was an appropriate one to make. Kate Maclean gave us details of her professional involvement in oral health assessments. I hope that she is a member of the BDA. If not, perhaps she will discuss it with Andrew Lamb at some future date.
I say at the outset that it is obvious from my interventions on him that Mike Rumbles is totally unaware of the postgraduate centre of excellence in Edinburgh and its responsibilities for postgraduate education and training.
As Duncan McNeil said, there has been no shortage of debates on dentistry in recent months, in addition to which we have also had a ministerial statement on the subject. I welcome the dental hygienists and therapists who are coming through the colleges. I think that the first cohort is due later this year. I welcome it and all those of future years.
The Conservatives are fully aware of the problems in this area, many of which have been highlighted in the debate. People in Nairn can wait up to four years to see an NHS dentist. Many dentists no longer take NHS patients. That means that pregnant women and pensioners have to pay for dental treatment because they cannot find an NHS dentist. For many people, having to pay £250 a year for a private dental plan is simply outwith their financial capability. "Good Morning Scotland" reported that some people in Wick were pulling out their own teeth.
However, today is different. Today, we are debating a report that examines the causes of those problems and confirms why the Executive simply throwing money at the problem is not the full answer and will not work. Unfortunately, instead of examining the problem and focusing expenditure accordingly, the Lib-Lab Executive tends to measure its performance by the millions of pounds that it spends on a problem.
The report by Professor Newton, Professor Williams and Dr Bower that is the subject of today's debate is thorough and extensive. As other members have said, the bottom line is contained on page 1 of the executive summary, which refers to
"no information on adult oral health … a lack of information on the numbers of Whole Time Equivalent (WTE) NHSScotland dentists working in all fields of dentistry at a Health Board level … little information at a Health Board level on … the numbers of dentists accepting new NHSScotland patients, distances travelled by patients for primary and secondary dental care, the availability of evening/weekend appointments, and access for groups with special needs etc. This applied to all sectors of dentistry."
It continues:
"More information was also required at a Health Board level on the demand for access to general dental services. Data on the need and demand for community dental services at both a national and a Health Board level was also lacking. In the hospital dental sector, more information was needed on the utilisation and need for services at both a national and a Health Board level. There was a need for data on the recruitment and retention of all dental staff."
I understand that there was one month between publication of the report and the announcement of the Executive action plan. How was it possible for the minister to gather all the information in the report and put it forward in the action plan just one month later?
We know that the average waiting time for routine treatment in Glasgow is the lowest in Scotland, yet Glasgow has the worst record in Scotland of five-year-olds who have missing, decayed and filled teeth. Kate Maclean raised that point when she spoke about the situation in Dundee.
We know that, over the course of their working life, women work on average more than six hours a week less than their male colleagues do. Therefore, having more women in the profession requires more dentists in the profession.
The problem that we are faced with is that the minister has pledged £150 million over three years—not each year for three years as Mike Rumbles suggested—to solve Scotland's dental problems, yet the report confirms that information about the country's dental problems is simply not known.
The report confirms on page 106:
"The pledge of free check-ups for all by 2007 is going to be difficult to fulfil without a significant increase in the number of dentists providing NHSScotland treatment, particularly in areas of low access. Furthermore, very few dentists anticipate increasing their NHSScotland provision of services."
Will the member give way?
I will finish the point, because Mike Rumbles did not listen to what Eleanor Scott had to say. I have included the point in my speech so, with my teacher hat on, I ask Mike Rumbles to listen when I say again that it is not enough to provide a dental check-up when there are not enough dentists to provide the treatment. What is the point of having a dental check-up every six months if people cannot afford treatment and we have an insufficient number of dentists to provide it?
Surely we must learn from this exercise that ministers should work with committees and wait for research and reports to come out before they make decisions. Ministers should make decisions that are based on findings instead of making announcements about spending money when it is obvious that the information to enable them to make rational choices about the optimum allocation of resources was not available. Instead of demonising the dentists who choose to go private, the minister and others should listen to their reasons for not continuing to provide NHS treatment.
I commend the report, which is a sound and thorough one. I also praise my former committee. I miss all its members and I suppose that they miss me a little—who knows?
The report was an important piece of work to commission. Indeed, the Health Committee is an important committee and I am pleased to see that it is continuing to hold the Executive to account by pushing forward on this important agenda for the public. All members' in-trays contain many examples of contacts from people who cannot access NHS dental care.
The minister said that we will have an extra 200 dentists by 2008. Is that a net figure? I am concerned about the number of dentists who will have retired by 2008 or who may have quit the NHS. The minister may be able to clarify that point in summing up, because this is an important issue. Mary Scanlon and Eleanor Scott made the point that there is not much point in people having a free dental check if they cannot then have a follow-up, but the report goes even further in saying:
"The pledge of free check-ups for all by 2007 is going to be difficult to fulfil".
There may be too few dentists for people to have a check-up, let alone any treatment thereafter. Recruitment and retention are important.
An important point that Mary Scanlon made about the action plan is the complete lack of national data. That fact thunders through the report. We all have snapshots of what is happening, and the minister, who seems genuinely concerned, wants to turn round the failures within our dental service—I was going to say the "decay", but I must avoid such puns. However, we need rigorous data. I hope that that will be acted on. If I may use the horrendous expression "golden handcuffs"—from which Mike Rumbles is backing off—there are in fact no national criteria under the SNP scheme for medical students. The scheme is open to all and, as we have pledged for a while, an e-copy of the information on our consultation is on its way to the minister now. We would be happy if she would respond.
Shona Robison and others raised the issue of the chronic underinvestment in dental services. I am glad to hear that there are negotiations with the profession on fee levels. As Brian Adam said, dental practices are businesses; they have to pay for overheads, staff and equipment, while delivering services to the public. That is where the gap has occurred. I will deal with some instances of fee levels that were recently brought to my attention by Borders dentists. The SNP fully supports the outreach centre in Aberdeen, which gained cross-party support. I will not make party-political capital out of it, as I acknowledge that Mike Rumbles—along with Richard Lochhead, Brian Adam and other members—has long pursued dental issues in the Parliament. The centre was fully supported, locally and nationally, by the SNP, and it is referred to in our general election manifesto, which is on its way to Mike Rumbles. We are very good—everyone is getting information from the SNP.
Mike Rumbles commented on the £40 million to £50 million increase that the SNP proposed. That is an annual increase, which—strangely enough—exactly matches the £150 million that was announced later by the minister. We were ahead of her. I am quite happy to produce the evidence beyond reasonable doubt for Mike Rumbles. Stewart Stevenson's point was interesting. Dentists have felt isolated from other NHS professionals and do not feel as if they are within the embrace of the integrated national health service that we all want. The fact that bad teeth can affect other areas of health has been brought to my attention by dentists. The Health Committee is considering legislation to integrate dental services—not before time.
I, too, visited dentists in the Borders, and I notice that the report mentions that Dumfries and Galloway and the Borders are the worst off. Not only are 80 per cent of dentists in primary care not taking new patients there; they no longer have waiting lists. That means that people must make a round trip of 100 miles—if they are lucky—to get to an NHS dentist in Edinburgh or over the border in England. That is not easy and I am not surprised that the Borderers, with their usual determination and perhaps desperation, pursued Kate Maclean in the belief that a member of the Health Committee would do if they could find no one else. Heaven forfend that that is where we end up.
To get back to the business side of the issue, the Borders dentists described to me the effect of changes. Let us take a simple thing such as root implements, which are now to be used only once. Each implement costs between £26 and £28, but the piecework figure is £30. As a result of the rigorous standards—fully supported by dentists—being introduced on decontamination of premises and equipment, dentists are simply not making enough money to keep in business and to keep treating NHS patients, much as they want to. Dentistry is becoming quantity driven, rather than quality driven. It means that someone receiving NHS treatment will not get some of the sophisticated treatment—better for them and better for their teeth—that they would get if they went private, because dentists simply do not have the time. It is a case of in the door, out the door. Dentists have to drill and fill as fast as they can.
There are a lot of data that we require. For instance, I would like to know—this is a point that was put to me by a dentist—how the Scottish Executive communicates with general dental practices in Scotland. The Executive seems to be out on its own most of the time, or lobbying its MSPs.
We have to ask why we are where we are. Heaven forfend that I blame anybody, but we have had 18 years of the Conservatives and eight years under London Labour. For six of those eight years, the Liberal Democrats have been in collusion with Labour, so Mike Rumbles should aim his fire elsewhere. One thing is true: it wasnae us on this side of the chamber.
I conclude on a more conciliatory note and congratulate the Health Committee on the report, which is just a beginning. Duncan McNeil was right—it needs to be taken further and should not now just rest on a shelf.
I have listened with interest to the various points that have been made by all parties in the debate. In my speech, I shall endeavour to answer the questions that were raised.
I acknowledge that there are problems of access to NHS dental services in many parts of Scotland, particularly in rural areas, and attention has been drawn to specific issues today. That is why we announced such a radical shake-up of NHS dentistry in Scotland over the next three years. We believe that that shake-up is ambitious and challenging but that it will reap long-term benefits. Despite steady improvement in the oral health of adults, the oral health of our children remains a major challenge, as Kate Maclean said. That is why we are investing so heavily in attracting new NHS dentists and encouraging committed practitioners to stay. In fact, some of the allowances that had been developed before the recent announcement are already kicking in. Around 50 new dentists have already been attracted to Scotland, and we hope to be able to attract more.
Brian Adam is worried that it is too late. I am not as pessimistic. We have the information that new dentists are being attracted to Scotland and I am confident that the measures that we put in place will attract more new dentists and encourage young dental graduates to come into the NHS. We very much hope that those measures will encourage people who have private treatment at the moment to come back to the NHS. We are confident that this is a good package for the workforce.
Several members mentioned the need to improve our collection of statistics. I agree, and that is an important issue for us. We already have information from the national dental inspection programme for schoolchildren, which allows us to access information on youngsters and to be able to plan to improve the oral health of children. The oral health inspection that we are in the process of developing will give improved information on the oral health of adults. Boards are now required to collect and use information about availability of dental services. We are looking to extend the registration period for patients. One of the challenges in the past has been when the 15-month registration period has ended and patients have become deregistered. It is also quite a challenge to get information about how many patients are being treated privately. There are particular challenges for us in collecting information, but I agree that we need to get better at it.
Our priority is preventive care for children. Kate Maclean and one of the Conservative members quite rightly drew our attention to health inequalities. Around six out of 10 children in Scotland have dental disease by the age of three. If we consider where that happens, we see that it is closely linked to health inequalities that we are aware of on the broader front. We have introduced a number of key preventive measures. We want to develop a comprehensive child dental service.
Prevention is at the centre of everything that we do. That includes the distribution of free toothbrushes and toothpaste, the supervised toothbrushing scheme that has been mentioned, providing free fruit to children in Scotland, work on nutritional standards and the development of mobile dental units for use not only in deprived areas but in rural areas. The effectiveness of such measures should not be underestimated, but parents, too, need to play their part in ensuring that children are encouraged to follow a healthy lifestyle and we need to support parents in doing that.
The development of a joint approach to the challenges is the key to improving oral health. The action plan that was launched last month will improve access. I mentioned my visits to NHS boards throughout Scotland, and I will continue to visit more of them to emphasise the fact that access to NHS dental services is a priority issue for ministers.
I recently opened Lothian NHS Board's state-of-the-art dental facility at Chalmers Street in Edinburgh, which will further improve access to NHS services, particularly for those in the Lothians who are not registered. I was impressed by the enthusiasm that all the members of the dental team showed and I have been hugely impressed by the enthusiasm of the dentists whom I have met throughout Scotland. However, other parts of Scotland are also facing major challenges and we have set out specific measures to address them. The committee's report is primarily about the workforce. Scotland will have 200 extra dentists by 2008, which means 200 more than we already have.
If the minister will let me intervene, I will tell her why that is not so.
It is clear that that is a net increase. We are increasing the number of dentists by 50 each year and we are increasing the number of students for professions complementary to dentistry by 30 this year, 35 next year and 45 in 2007.
I welcome the minister's recruitment plans and her action to recruit professionals complementary to dentistry, but will she acknowledge the point that I made earlier, which is that hygienists and dental nurses are leaving the dental service in great numbers every year? Has the Health Department examined the reasons for that in any detail? If it has not, should it not carry out a study to find out why those people are leaving and consolidate the position before we start recruiting?
Absolutely. I want to ensure that we have a comprehensive career path for all professions complementary to dentistry. That has included developing new degree courses. We need to examine closely particular issues with that section of the workforce, and I am more than happy to do that. We need a mixture of independent and salaried posts in the dental profession, complemented by therapists and hygienists, who can hugely improve dental practitioners' output.
As I have already said, by March 2008, an additional 400,000 people will be registered with an NHS dentist.
Will Rhona Brankin give way?
I want to get on, because I have to answer many questions that have been asked.
It would be helpful if Rhona Brankin took some interventions from Opposition members.
If Christine Grahame examines the Official Report, she will see that I have taken many interventions from the Opposition.
By March 2008, every child in Scotland will have access to dental care on starting nursery, and we will have the largest supervised toothbrushing scheme in Europe.
The number of item-of-service fees will be simplified from more than 400 items to around 50. That is what the dentists have asked us to do, and we have delivered it. We have also already given NHS boards the authority to appoint directly salaried dentists. By 2010 the total number of dental professionals in training will exceed any previous numbers in Scotland. Such measures develop and support the dental team and will contribute to improved access to NHS dental services.
However, we will not be able to solve all the problems overnight. Our poor oral health stems from generations of neglect in Scotland, and the current shortage in the workforce stems from bad decisions that were made in the past. The action plan sets out a series of measures to address our oral health inequalities with the aim of providing access for all who need dental services. Meeting our objectives will require a genuine partnership approach between the Executive, NHS boards, dental professionals and the public, but I firmly believe that the combination of our measures and unprecedented financial investment will make a real improvement to oral health in Scotland.
The debate has been good. Although it has not always been consensual, there is agreement throughout the Parliament that we have a duty to act to improve access to Scotland's dental services. As Kate Maclean said, the subject has been discussed on a few occasions over the past few months, and I was sorry to hear of her harrowing experiences in the Borders. The duty to act is the reason why the Health Committee decided to commission the research. I add my thanks to those of other committee members to the researchers and the Scottish Parliament information centre for their work on the report, which has richly informed recent debate on dentistry.
There is clearly a problem with access to dental services and there is also concern about the standard of oral hygiene in Scotland. It is incumbent on the Executive to work to tackle both those problems. We must not underestimate the scale of the problem. The consultation document "Modernising NHS Dental Services in Scotland" indicated that, by middle age, the average Scottish adult had lost eight teeth and had 10 fillings, but, as we have heard from the minister twice today, the more worrying statistic is that more than 60 per cent of children from areas of social deprivation have some form of dental disease by the age of three. As the minister also said, the nature of treatment is changing as people live longer, which means that they keep their teeth longer. My parents, who are in their late 70s, both have their own teeth, which would have been somewhat unusual a generation ago. In fact, the most recent adult dental health survey, which was carried out in 1998, showed that, in 1972, 44 per cent of adults had no teeth, compared with only 18 per cent in 1998.
Therefore, it is clear that the pressures for change in the delivery of dental services are significant. To judge by the debate, the most obvious pressures are the continued and, in some areas, growing problems of service availability and access. Our report was commissioned to examine that issue specifically and it clearly demonstrated the work that needs to be done.
Although availability and access are problems for many rural communities, we must also acknowledge that those who live in urban areas are affected too. My constituency falls within the Glasgow catchment. Although the catchment's figures on access are good, I have recently been contacted by a constituent who is concerned that his NHS dentist is focusing solely on private work and has left 2,000 patients without support. This experience is replicated throughout Scotland—we have heard much about Grampian and about Dumfries and Galloway from Alex Fergusson and others. If patients can find another NHS dentist who is willing to accommodate them, they are often placed on long patient lists.
However, as we heard from Duncan McNeil, access is not only about geography. When I was four, my mother took me on a mysterious visit up a close, as we say in Glasgow, which resulted in my being taken into a dentist's surgery and having a tooth extracted, which has led to a lifelong fear of dentists. The point that I am making is that in inner-city areas, where tenemental properties are prevalent, many dentists' surgeries are up closes and we must consider how to improve access for the elderly, the infirm and those with disabilities.
The report highlights the demonstrable variations in the provision of dental services throughout Scotland's health board areas and clearly shows that the problems that are faced in delivering services vary between health boards, rural and urban areas and primary and secondary care services. That has led the researchers to conclude:
"Solutions to the problems of access … are likely to be required … at two levels. While local commissioning of services should be sufficiently flexible to allow services to correct problems of access at the local level, a broader national strategy is required to ensure that practitioners receive adequate incentives to commit"
to the NHS. Part of the problem is that NHS dentists are becoming dissatisfied with the nature of their work within the current framework—we heard from Nanette Milne about the treadmill effect. We need to consider how much we are doing to encourage more dentists to promote dental health, as Richard Baker said. The action plan focuses on that area.
The remuneration system for dentists has been largely unchanged since the advent of the NHS and reforming it is vital if we are to encourage more people to take up careers in dentistry and improve access to services. As with any profession, dentists need to feel that a career in the NHS offers them professional development, job satisfaction and a fair reward for their skills. The report concludes that addressing recruitment and retention problems for GDPs and dental nurses is a priority. I fully agree with that. We must strive to ensure that we have a skilled workforce that is enjoying job satisfaction and is encouraged to develop its skills.
Another significant issue is the changing demography of Scotland. As we have heard, an increasingly elderly population presents challenges for the dental industry that impact on service delivery in other areas. Good oral health is important in the prevention and management of oral cancer. It is therefore imperative that we work closely with dentists to promote better dental hygiene.
I accept that many of the problems stem from decisions that were taken some time ago—although I will not rehearse that debate again—and are the result of decades of neglect, but the committee was clearly of the view that the Executive had to take action. Therefore, I was most reassured on 17 March, when the Deputy Minister for Health and Community Care announced in the chamber a huge and unprecedented investment in NHS dentistry over the next three years. As we have heard again today, the minister told Parliament that, thanks to that investment, an additional 400,000 people would be registered with an NHS dentist by 2008, through the recruitment of 200 extra dentists. By that year, every child in Scotland will be guaranteed access to dental care on starting nursery.
I was also particularly pleased to note the introduction of the largest supervised toothbrushing programme in Europe, with 120,000 children brushing at school each day. As we have heard a number of times today, prevention is much better than cure.
Does Janis Hughes agree with the point that I made when I intervened on the minister, which was that the secret of the success of such a programme of supervised brushing is the proper training of the supervisors?
Absolutely. If Mr Fergusson is patient, I will soon deal with some of the issues that he raised.
The Executive has previously put in place some short-term measures to tackle recruitment and retention. However, with the publication of the action plan, the Executive has taken more of a long-term view. As we heard from Shona Robison, it has introduced a new bursary scheme for dental services, subject to a commitment to NHS dentistry for a period of five years after graduation, and has given NHS boards the authority to appoint directly salaried dentists. I hope that those initiatives will ensure that the NHS is able to ensure a steady supply of dentists who will continue to work in the NHS in the coming years.
Similarly, it is important to make more use of professions that are complementary to dentistry, such as dental therapists, hygienists and nurses. As Duncan McNeil said, dental therapists can increase a dentist's output by 45 per cent and a dental hygienist can do the same by 33 per cent.
Alex Fergusson talked about the Canadian model and I agree with Mike Rumbles that that is what is being proposed in the Executive's action plan. It is important that we make as much use as possible of professions complementary to dentistry. They have a huge role to play not only in prevention but in providing on-going care for all patients.
The action plan also highlights the Executive's commitment to cutting red tape and offers dental practices access to a rental reimbursement scheme. The plan has been warmly welcomed in the chamber and throughout the country as evidence that the Executive is serious about improving dental health and access to dental services. We now have to ensure that the reality matches the rhetoric.
In the context of the professions that are complementary to dentistry, I should say that I am pleased that new dental therapist schools have opened in Glasgow and Dundee and that a further training facility is due to open in Edinburgh this year.
This is a vital issue and I am pleased that the Parliament has allowed the committee the opportunity to bring the debate to the chamber this morning.
I believe that, in commissioning the research, the committee had a role to play. That was done in the context of the action plan, which had been consulted on and was being produced by the Executive. The committee felt that the issue was important and we are pleased that the action plan has been outlined in the chamber.
I sincerely hope that the publication of the action plan has answered many of the questions that were raised by the report. I believe that the initial signs are encouraging. As always, however, only time will tell. A lot has been done, but there is a lot more still to do.
I commend the report to the Parliament.