Dental Services (Grampian)
We now come to the members' business debate on motion S1M-1347, in the name of Mike Rumbles, on access to national health service dental services in Grampian. The debate will be concluded, without any question being put, after 30 minutes.
Motion debated,
That the Parliament recognises that improving access to NHS dental services is a public health priority, welcomes the publication by the Scottish Executive of An Action Plan for Dental Services in Scotland as a first step in this process but recognises that in the Grampian Health Board area, as in a number of rural areas of Scotland, more needs to be done to ensure access for all to NHS dental treatment.
I am pleased to open this evening's debate, which is designed to highlight the problems of accessing NHS dental treatment, particularly in the Grampian area.
My attention was first drawn to the problem of accessing NHS dental treatment by the difficulties my local dental practitioner faced when he attempted to recruit a dentist to serve the people of Alford. For about 18 months, he tried to find someone who was willing to come to the rural north-east—but to no avail. The local health authority then tried to cover the area with a salaried dentist, so that NHS treatment could be provided. Six months down the line, the health authority could not recruit a dentist either.
I am concerned that people in rural areas are finding it increasingly difficult to get NHS dental treatment, either for routine work or for more specialist treatment from a consultant. I congratulate the Executive on taking NHS dental treatment much further up the political agenda. I also welcome its publication of "An Action Plan for Dental Services in Scotland".
I know that the Executive recognises that we have real problems with dental care provision in Scotland. Statistics from its document demonstrate that one third of our children are not registered with general dental practitioners and 25 per cent are left entirely without continuing dental care. However, the issues that I am raising this evening go much wider. Non-exempt individuals—for example those who are not children and who are not in receipt of benefits—are simply not able to access NHS dental provision.
After taking up the Alford case, I soon found that the health authority solution was to tell people that they could access NHS dental provision because an NHS salaried dentist was available in the city of Aberdeen, but anyone who knows the north-east will know that travelling such distances is not a practical solution, especially for people on a low income.
When I pressed health authorities to provide information on the level of NHS dental provision in the north-east, I was amazed to discover that no such information exists—no one could tell me how widespread the problem of accessing an NHS dentist in rural Aberdeenshire is. I conducted my own survey by asking the 10 dental practices in West Aberdeenshire and Kincardine whether they provide NHS access to new non-exempt patients. I found that only half do, so half the people in my constituency cannot register for a local NHS dental service. I cannot believe that the problem is confined to my constituency; it must be a wider problem in rural Scotland. Good schemes, such as the one for salaried dental practitioners that is identified in the action plan and is designed to address this problem, work only if a dentist can be recruited.
I will give some pertinent statistics that were provided to me by the Grampian local dental committee. Nationally, there is one dentist for every 2,500 people, but in Aberdeenshire there is one for every 4,500 people. That means that the problem is double for people in Aberdeenshire. In greater Glasgow, there is one dental consultant for every 100,000 people, but in Grampian and the Highlands and Islands there is only one consultant for restorative dentistry for every 900,000 people. Guidelines suggest that there should be one consultant for every 300,000 people, so the problem for people in the north-east and the Highlands is three times as bad. There is a waiting time of up to five years for restorative dentistry in Grampian.
I received a letter today from Alec Cumming of Grampian University Hospitals NHS Trust. He told me that
"the waiting time for a routine first appointment with the Consultant is indeed around 56 weeks at present. Following an initial appointment, some patients will have to wait up to four years for treatment."
There is no doubt that there is a shortage of dentists, in the north-east in particular. The problem is exacerbated by the fact that half the dentists working in rural Aberdeenshire do not take new NHS non-exempt patients. Those two issues need to be addressed. I will suggest two possible solutions, which I hope the minister will address.
First, the target of 120 graduates per year for the next five years should be increased. Scotland was producing up to 160 graduates before the Edinburgh dental school closed. The Grampian local dental committee has suggested that a link could be established with the Dundee dental hospital, building on the current expertise in the region. That would help to increase the provision of dentists and bring them into the region in the first place.
Secondly, there has been a reduction in NHS work because the level of fees for basic treatments is unrealistic. If there were a properly funded core service, with full funding for treatments such as check-ups, fillings, extractions and dentures, but more complex treatments were made private, more dentists could be attracted back to NHS work and the problem could be alleviated quite quickly. Of course, there is a shortage of cash—there always is—but the idea is to focus funding on a fully funded core service. That would enable more patients to find an NHS dentist closer to home, rather than have to search for practices providing NHS services.
The radical views of the Grampian local dental committee are worth examining. The fees that are associated with NHS dental services are outdated and provide little or no incentive for preventive dentistry in general practice—general practitioners want to focus on preventive dentistry.
Although the Executive's action plan is very welcome, the problems of accessing NHS dental services are real, especially for rural communities in the north-east. Perhaps we need more radical action to address them.
I will be very interested to hear the Executive's reaction to the ideas that I have outlined today. What about a training link between Aberdeen and Dundee to increase the number of trained dentists? What about incentives to promote access to NHS dentists in rural Aberdeenshire?
Six members have asked to speak, so speeches should be around three minutes, please.
I welcome the opportunity to debate this matter and the constructive approach of Mike Rumbles's motion. He is primarily concerned with access to dentistry in rural areas; my main focus is on similar issues in the city of Aberdeen and the position of NHS dentistry as a whole.
In the bad old days of internal competition in the NHS, general medical practitioners in the Grampian Health Board area led the way in opting out of mainstream funding arrangements in favour of fundholding practices. Happily, because of local health care co-operatives, those medical general practices have come back into NHS structures based on consistently high standards of care across the city and region.
In general dental practice, NHS patients in and around Aberdeen have been losing out more than most, in much the same way as was the case with GPs, as more and more dentists have opted out of providing mainstream NHS services. It is a matter of record that the number of NHS dentists is 31 per 100,000 population compared with an average of 37 per 100,000 in Scotland as a whole. The situation is even more serious than those figures suggest because general dental practitioners continue to appear in the figures until they have removed the very last NHS patient from their list. So, for example, although the list of a dental practice in Aberdeen Central has dropped from 1,800 NHS adult patients five years ago to only 35 today and it has stopped accepting new NHS child patients, it continues to have an NHS number and to count as a provider of NHS services. That is typical of the situation in and around Aberdeen. When a dentist ceases to provide NHS services, typically he or she also cuts the total number on the list, seeing perhaps 60 patients on a private basis for every 100 seen on the NHS.
I support what Mike Rumbles said about how we address the issue. It is not that doctors and dentists in Aberdeen are greedy or less socially aware than those elsewhere, but that they face cost and other pressures to an exceptional extent. Because dental practices operate as self-contracted, self-employed, commercial enterprises, those cost pressures exacerbate the differences between levels of provision in one region and another. For the minister to find ways to increase NHS dental services, we need to address the status of general dental practitioners and how they relate to the NHS as a whole.
I congratulate Mike Rumbles on securing this evening's debate and on sporting a Highland outfit. I think it is fair to say that the subject of the debate was generated by a meeting of the Grampian dental committee that many of us recently attended. We were stunned by what we heard because none of us had appreciated how serious the situation in Grampian was becoming. Many of the concerns expressed then have been covered by Mike Rumbles and Lewis Macdonald; I share those concerns.
Cost is a barrier to people going to the dentist. One of the fuel protestors who came to the Parliament a few weeks ago said that it cost him £5 for petrol to get to his local dentist. The dentists we spoke to in Aberdeen said that they would get a better financial award as a vet taking out a dog's teeth. One dentist told us that he saw a 76-year-old man who had to pay 80 per cent of his own costs, which meant a £100 bill.
As Mike Rumbles said, we also have to address the very serious situation that is developing in hospital dental services. There are incredible pressures on that service in Grampian, and waiting list problems for all three hospital specialties have gone on for four years. Decades of funding neglect of hospital dental services in the north-east of Scotland is the reason for that. The few consultants who are delivering those services are run ragged; they are covering the jobs of a number of consultants. They say that local dental hospitals are around 40 per cent below the correct staffing level. As a result, patients are being passed from pillar to post. It is not just a problem of overworked consultants: ultimately it is patients who suffer.
Mike Rumbles referred to waiting lists. For restorative treatments, people have to wait 66 weeks for their first consultation and four years for treatment. He raised my next point as well. The British Dental Association and British Medical Association recommend that there should be one consultant for every 300,000 people. Despite that, the same surgeon currently serves the Grampian and Highland areas. That combined area should have three consultants; it has only one.
For orthodontic services, the recommendation is one consultant for every 200,000 people; Grampian has only two instead of the recommended three. For oral and maxillofacial surgery, the recommendation is for one consultant for every 150,000 people; Grampian has only two instead of the recommended four. The conditions that require such treatment are debilitating and people need treatment quickly. It is important to remember that children receive orthodontic treatment at a certain stage in their development and that dentists play an important role in identifying mouth and throat cancers.
As Mike Rumbles suggested, the solution is a dental training facility. We have to build more training posts into the Grampian area and to provide incentives for people to move there to live. At the moment, it is very expensive and that is apparently putting people off.
I ask the minister to support a general review of dental services at general dental practitioner and hospital levels in Grampian. Please do not think that this is just Grampian MSPs coming along and asking for more funding for their area. Ours is a genuine case.
I would like to thank Mike Rumbles for giving us the chance to highlight the continuing problems in Grampian. His outline of the situation and his proposals are excellent.
I welcome the Executive's action plan strategy, but it is a simple fact that dentists are not being recruited into our region. Alford, my local village, lost its dentist and many of my neighbours have to drive to Aberdeen or even Banchory for treatment. As Mike Rumbles said, people sometimes have to travel up to 60 miles.
I could extol Aberdeenshire and its virtues all night, explaining why people should come and live there, but people are not coming. Young people are not leaving schools in Glasgow and Dundee to take up positions in the north. I urge the Executive to consider one of Mike Rumbles's proposals and to extend advanced training from Dundee into Aberdeen. In that way, dentists would at least start off in Aberdeen and Aberdeenshire. They might then decide that it is such a nice place to live that they stay. I also urge the minister to extend the loyalty bonus scheme that is paid to dentists to encourage them to stay with NHS patients.
The problem with the shortage of general dental practitioners is that it puts more pressure on community dentists in Aberdeenshire. They play a vital role with special needs and disadvantaged patients. The pressure on dentists is such that those patients, who need treatment, are being left out.
Dentistry problems in Aberdeenshire and the north-east as a whole are a special case. I know that, across Scotland, consultants in many fields are in short supply, but I urge the minister to consider some of Mike Rumbles's measures and to make a special effort to ensure that my constituents are not seriously disadvantaged when it comes to dental health.
I would like to thank Mike Rumbles for this members' debate, which allows us to put on record our concerns about the provision of dental services in the north-east. Oral health is an important part of overall health, and statistics on oral health in Scotland make pretty dismal reading. To improve those statistics, people will need access to dentists—that is the single most important thing that we can do to help improve dental health. How can we encourage people to go to the dentist if there is not a dentist within 50 miles?
The remuneration of dentists impacts on the number of dentists that we have. Most general dental practitioners, after they graduate, set up in practice and have to take on a large debt burden. We have to ask whether their remuneration under the current NHS system is adequate for them to repay that debt in a reasonable time and whether it is adequate to allow them to re-equip and to upgrade existing equipment as their careers progress. The option of salaried dentists has been considered and employed in Grampian to fill some of the gaps in general dental service provision. However, it has proved difficult to attract salaried dentists to work in the area; even with that option there is still a shortfall in the number of dentists.
Ben Wallace mentioned the on-going professional development of dentists and the fact that if we had the option of offering on-going training to new dental graduates in the north-east, we might persuade them to settle there. At the moment people must undertake postgraduate training elsewhere and people tend to settle where they have put down roots and made connections.
No one has mentioned the demographic time bomb. Many of our general dental practitioners are in their late 40s and 50s. When they retire, how will we replace them?
The north-east is disadvantaged by the allocation of resources. Arbuthnott said that his formula was based on less than robust data. That is something that must be considered in much greater depth, in relation to the allocation of not only health service resources, but other resources.
I congratulate Mike Rumbles on securing today's debate and thank him for giving us an opportunity to discuss dentistry. I would also like to take the opportunity to say that he is looking very dashing tonight in his full Highland regalia.
The action plan that Mike Rumbles highlighted is excellent, but I refer him to another document: "Workforce Planning for Dentistry in Scotland: A Strategic Review". I am the first to criticise glossy documents, but "Workforce Planning for Dentistry in Scotland: A Strategic Review" sets out how to put the plan into action. It is an even better document than "An Action Plan for Dental Services in Scotland" because it takes the plan one step further. I have found it to be an excellent document.
Access to dentistry in Grampian depends on the training not just of new dentists, but of dental nurses, dental hygienists and dental therapists. There is no doubt that the two documents will increase the demand for dentistry in Scotland. We have a problem at the moment and if we are to fulfil all the recommendations in "Workforce Planning for Dentistry in Scotland: A Strategic Review"—which I fully support—we must increase the supply of training, to increase access to dentistry.
We need more training to ensure that dentists can fulfil the recommendations for their continued professional development. As a fellow of the Institute of Personnel and Development, Mike Rumbles will know all about that. We need such training not just for dentists, but for dental nurses, hygienists and therapists. We have never trained dental therapists in Scotland. The debate should not concentrate on dentists, because I understand that dental therapists will now be able to carry out extractions and fillings as well as other monitoring of patients. That may be one way of helping to fill the gap in dental services.
Given that training is so crucial in creating access to new dentists, I would like to highlight the fact that Dundee dental school—one of only two dental schools in Scotland—is currently facing a deficit of more than £250,000, in a health trust that is suffering a deficit of more than £19 million. That is one of the two dental schools that will have to provide funding, training and access for all the courses that I mentioned, as well as the consultant specialties that are needed to achieve the level of training recommended in the two documents.
Nora Radcliffe mentioned postgraduate training, which is a crucial aspect of the debate. I would like to take the opportunity to ask the minister to clarify an issue. Last week, the Dundee dental school was told that it was to be given funding for a postgraduate centre in the Frankland building, adjacent to the dental hospital. However, the next day, the school received a phone call from the management executive to say that it would not get that funding. I seek clarification on that issue.
I congratulate Mike Rumbles on securing this debate, and I am grateful to all members who have contributed to it.
During the debate on primary care dental services on 25 October, Iain Gray and Susan Deacon made it clear that we are committed to an effective and accessible NHS dental service for all who wish to use it. I acknowledge, however, that there are some problems with access to NHS dental services in some parts of Scotland that need to be addressed. Mike Rumbles referred to his own constituency in that regard this evening.
In the primary care sector, where around 90 per cent of dental patients are treated, most general dental practitioners are independent contractors to the NHS. I find it regrettable that in some parts of Scotland there has been a reducing commitment to the NHS by some general dental practitioners. Looking at the figures, however, it appears that the percentage of those who are registered with an NHS dentist in Grampian is only marginally less than the Scottish average.
Mike Rumbles referred to unrealistic fees. That is not the only issue, but I must tell him that increases in service fees have been recommended by the independent review body on doctors' and dentists' remuneration, which reaches decisions on increases, taking into account all the evidence submitted by the British Dental Association and the UK Department of Health. On a related matter, Ben Wallace suggested extending the commitment payment scheme for NHS dentists. That has just been introduced. The first payments were made this month, and more than £2 million will be paid this year. The same review body will comment on further remuneration.
The problem of access is one of a number of issues that will be considered by the implementation support group that has been set up to take forward the action plan for dental services in Scotland. The group had its first meeting on Monday, and comprises a cross-section of experts with an interest in dental issues.
To achieve improvements in dental provision, we need to have the people to deliver them—the right number of people with the right skills in the right place. Apart from the action plan, we issued in September a discussion paper on planning the dental work force, which proposes that the target for dental schools should now be an output of 120 graduates per year, which Mike Rumbles referred to. I remind him that that is a considerable increase over the past few years, and we are aiming to keep the output at 120. We have been able to arrange with the Scottish Higher Education Funding Council to implement that target.
We are also close to achieving the target of providing postgraduate vocational training places for all Scottish graduate dentists—that did not exist in the past. We can influence where that training takes place, and we will look at the north-east in that regard, which may partly answer Mike Rumbles's point about extending out from Dundee, although I hope to have other things to say about that in a moment.
I will turn now to the hospital sector, which was referred to in general terms by Richard Lochhead, and with specific reference to restorative dentistry by Mike Rumbles. Although 90 per cent of dental treatments are in primary care, hospital specialists are a vital part of the service. We are aware of the concerns in Grampian, in particular about the number of specialists in restorative dentistry. There are 22 such specialists throughout Scotland, or one per 230,000 population, which is better than the guidelines recommend. They are based in the four main cities, and provide outreach services to other health board areas. As with other dental specialties, there is a geographical imbalance between population and the number of specialists, and we need to deal with that through managed clinical networks. Those are currently being discussed for orthodontics and oral-maxillofacial surgery, and restorative dentistry will follow. Those networks ought to involve new links between Dundee and Aberdeen.
I welcome the minister's comments on the need for more consultants which has been recognised in Grampian. Does the minister also accept that for every new consultant we need new support services, such as nurses, and that that has to be addressed also?
The discussion paper to which I referred earlier proposed significant increases in the number of professionals who are complementary to dentistry to enhance the dental team. Clearly, we will consider those measures, and all the others in the discussion paper, in the light of the comments that we receive.
As well as getting the numbers right, we regard the quality of training as vital. Dentists can register to practise on graduation, but the NHS insists on one year's postgraduate training. In Scotland, we have successfully piloted two-year general professional training, and one of those pilots took place in the north-east. I can tell Mike Rumbles that we will consider making permanent and expanding that pilot, which would help to meet his point about making new links.
We have also funded 10 additional training places for the community dental service, which provides a substantial proportion of its services to remote and rural areas. However, many dentists prefer to remain close to the area where they did their undergraduate training. Although that is not an argument for a dental school in Aberdeen, it means that the local trusts in Grampian, with support from the board and the Executive, must make particular efforts to recruit and retain staff. To aid that, we are encouraging both dental schools to consider outreach training, which will give undergraduates experience in rural areas and in hospitals away from the dental schools. That could help to meet Mike Rumbles's concern about new links between Dundee and Aberdeen.
Mike Rumbles raised the issue of salaried dentists. The trust is working on proposals for a salaried post to provide two days of dental cover at Alford and three days in Aberdeen. That is in addition to the three salaried dentists who already operate in Aberdeen. It is open to the trust to apply to Scottish ministers to appoint further salaried dentists when and where the need arises. I referred to the Scottish dental access grants at last week's question time, when Mike Rumbles asked about dental services. Thirty access grants have already been awarded, and some have gone to practices in Grampian.
As Mike Rumbles and other colleagues may know, the trust has embarked on a series of consultations involving the public, local practitioners, the health board and Dundee dental school. One of the local health care co-operatives has been appointed lead for Grampian-wide primary care dental services. Several ideas are being pursued, including how to provide NHS dental services at Alford, to which I referred. Significant efforts are being made to recruit locums and permanent dentists to the area, including the major recruitment campaign that I highlighted.
Will the minister take on board the fact that members of Grampian Health Board have almost stopped advertising? Having spent so much money on trying to recruit dentists without any success, they have decided that, until they can find dentists to come to Grampian, the money is better spent elsewhere.
I hear what Ben Wallace is saying. I am told that an advertising campaign is going on and that, in January 2001, adverts will be placed, but I will check on what Ben Wallace has said about that.
To reply to Mary Scanlon's point, a bid will be put in for capital moneys for the Dundee hospital postgraduate centre for the coming year.
In the light of the recently published "An Action Plan for Dental Services in Scotland" and the associated on-going work, I hope that I have made it clear that we are determined to make a positive difference to dental services throughout Scotland.
Meeting closed at 17:43.