This article appears as part of the Inside the NHS newsletter.

Dentists in Scotland are waiting with bated breath for the outcome of talks on payment reform between Scottish Government officials and dental leaders.

The new framework, expected to take effect from November, has been framed by the profession as a do-or-die moment for the survival of NHS dentistry.

So what's the outlook?

The current model

Over the past three weeks, MSPs on the Covid-19 Recovery Committee have been gathering evidence on the current state of NHS dentistry and where the sector is headed.

Dental leaders, representing the British Dental Association (BDA), Scottish Dental Association (SDA) and the Scottish Dental Practice Owners group, were united in the view that a major overhaul is needed in the way that dentists are paid.

NHS dentistry is currently funded by Government via three separate streams: capitation (£1.30 per patient, per month, reducing to 26p per patient per month, if a patient hasn't been seen for three years), direct reimbursement (support to cover rent and business rates on their premises), and fee-per-item (the fixed sum dentists receive for work, such a tooth extraction or a filling).

Most practices are hybrid, providing both NHS and private care under the same roof. Of the 1000-plus practices in Scotland, between 400-500 generate around 90% of their income from NHS work.

However, the rising cost of materials means that the amount dentists are reimbursed for work ranging from denture repairs to crowns or root canals no longer covers their costs.

The situation is compounded by Covid backlogs.

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More than ever, patients have complex oral health problems requiring months of appointments, but dentists cannot claim for any of the work until the full course of treatment is complete – and even then may make a loss.

Against this backdrop, many practices are refusing to register new NHS patients and reducing both the number of appointments and types of treatment they offer on an NHS basis. Private dentistry is filling the space.

As of January to March this year, NHS dental activity remained 34% below 2019 levels. By September 2022, children from the most deprived areas of Scotland were 20% less likely to have seen a dentist in the previous two years than those from the most affluent postcodes. That gap has doubled from 10% in March 2020.

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Follow the money?

Dental leaders told MSPs the situation will only be reversed if Scotland adopts a GP-style model for dentists.

They want to scrap the "crazy treadmill" of fee-per-item which for decades has relied on dentists carrying out a large number of short NHS appointments each day in return for a comparatively low fee, with practice incomes propped up with a sideline of more lucrative private work.

For example, it would take around 130 NHS examinations to match the £2000 generated by doing a single dental implant.

This, they argue, is no longer fit for purpose.

If dentists were paid a more substantial fixed sum for each patient on their books under a "fully capitated" model they could afford to provide longer appointments to complex NHS patients and spend more time on prevention, instead of reacting once disease and decay emerges.

The Scottish Government is not convinced.

David Notman, the civil servant in charge of dentistry, told MSPs that such a system "would lead to a reduction in NHS treatment and a very significant and perpetual increase in health inequalities".

In other words, too many dentists would put their feet up and let the money flow in.

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Similarly, Mr Notman noted, if the government were to accelerate the value of the fee-per-item too much "you tend to get an overtreatment of patients".

The Government favours retaining the "blended model", albeit with tweaks. This looks likely to include a simplified Schedule of Dental Remuneration (SDR) – the list of services provided on the NHS – along with modest increases in fees and capitation payments.

David McColl, the chair of BDA's Scottish Practice Committee and the man leading negotiations with the Government, concedes that in any profession a minority "don't play the game". He said patients will simply vote with their feet.

"If practices don't want to treat patients and will just sit there and take funding and do nothing, they will not last because patients are not daft. They will go to another practice that will deliver the care, so the self-levelling will happen. Trust us for a few years and it will level out – and it will allow us to deliver the care to the cohort of patients that we have."

Perhaps politicians could be persuaded if a fully-capitated model also came with a commitment that mixed NHS-private practices had to ring-fence a high percentage of their opening hours to NHS work?

But the question then becomes what percentage, and how high would the capitation have to be to prevent a flurry of practices going fully-private instead (bearing in mind that fully private practices do not benefit from rent and rates relief, which is a substantial benefit to give up)?

For now though, it looks like "payment reform" will amount to little more than a modified status quo which risks doing exactly what the Government says it wants to avoid: reducing NHS treatment, and perpetuating oral health inequalities.

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