Scottish Government: Creating a Fairer Scotland: What Matters to You

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1 Scottish Government: Creating a Fairer Scotland: What Matters to You Social Justice Conversation Paper The British Dental Association (BDA) in Scotland is the professional association and trade union for dentists practising in the UK. Its nearly 19,000-strong membership is engaged in all aspects of dentistry including general practice, public dental services, the armed forces, hospitals, academia, research prison dentistry and has more than 2,000 student members. The BDA welcomes the Scottish Government s leaflet on Creating a Fairer Scotland What Matters to you. In response to the section Where we are today, We are Living Longer, Healthier Lives People from our most deprived areas live on average 10 years less than those in our least deprived areas, the comments received from BDA members and committee members who are involved from all aspects of dentistry in Scotland are provided below: Childhood Caries in Deprived Areas The BDA would suggest that whilst the Childsmile Programme is recognised as a successful initiative in addressing caries in children, there is still a high rate of childhood caries in deprived areas in Scotland leading to tooth extractions. We have called for the Scottish Government to build upon the success of the Childsmile Programme and expand coverage, and for administrations across the UK to take heed, and invest in prevention. The Chief Dental Officer (Scotland) has set up a Short Life Working Group and part of its remit is to make recommendations for the medium to longer term on extending the Childsmile Practice philosophy to children aged 6 years and over. The BDA would bring to your attention to the general health benefits which come from the Childsmile Programme. Whilst the main area of emphasis is on caries prevention, trained dental care professionals (DCPs) within dental practices also highlight the benefits of a healthy diet to patients and encourage them to reduce snacking on unhealthy food and drinks. Due to the one-to-one relationship dentists and DCPs have with patients, dental staff are able to answer specific questions raised by parents and explain food labelling and in particular what to look for and what to avoid. The BDA would suggest this communication is leading to better diets, which will help assist in tackling childhood obesity in the short term but might also lead to a reduction in diabetes and heart issues in the medium to long term. The BDA opposes marketing of unhealthy foods aimed at children, and is particularly concerned about the exposure of children to advertising and product placement of high in fat, salt and sugar food and drinks The BDA would urge Scottish Government to seek to reduce the proportion of Scottish children who grow up in poverty, with all of the disadvantages this brings to their lives, not just poor dental health. Quite apart from the economic imperative, we believe Scotland must tackle 1

2 poverty because of the blight and strain it places on individuals lives, on the communities in which they live, and on society in general; we believe Scotland has a proud history and ethos of being a compassionate nation with a strong sense of social justice and addressing the needs of the vulnerable, and we want to embrace this ethos on the basis that it is simply morally unacceptable that over 20% of our children still live in poverty. The BDA refers to Taking Forward the Government Economic Strategy The purpose of the discussion paper was "to create a more successful country, with opportunities for all of Scotland to flourish, through increasing sustainable economic growth." High Cost of Dental Treatment 1a. Restorative Dentistry for Elderly Patients BDA Scotland would suggest that dental health education/preventive measures are key so that fewer restorations are required, but more importantly helping people to see the value of looking after their teeth and having a sound dentition from cradle to grave. The BDA would like to see the profile raised on the importance of good oral health and motivation to achieve the latter. Programmes such as Childsmile will help establish dental awareness and good habits early in life. In some instances tooth extraction for elderly patients is the right decision hence the importance of individual treatment planning to suit the individual patient, however, restorative dentistry is expensive and this is unlikely to change. BDA Scotland believes that there are elderly patients opting for tooth extraction due to the high cost of restorative treatment. Hospital and care home staff also need to be educated on the importance and maintenance of good oral hygiene instruction particularly for the elderly. Good nutrition in residential and care home settings is also fundamental to the health and wellbeing of residents. There is also a requirement to address the domiciliary needs of elderly people who are unable to attend their dental practice for treatment. In this respect, the Chief Dental Officer (Scotland) has set up a Short Life Working Group, one of the outcomes will be to look at recommendations for a model of domiciliary care for those in their own home or resident in a care home. BDA Scotland met with the Care Inspectorate in 2014 at which time the BDA expressed the need for regulatory changes to be made in order to require residential care providers to ensure that all residents are registered with a dentist. 1b. Restorative Dentistry for Head and Neck Cancer Patients Patients affected by head and neck cancer who are rendered edentulous (having no teeth) as a result of disease or treatment (including surgery, chemo/radiotherapy) also generate high cost treatments. 2. Young Patients High costs are not only restricted to elderly patients; young patients with severe hypodontia (multiple genetically missing teeth), in particular cleft palate patients can put severe pressure on budgets as they have numerous missing teeth through no fault of their own. In these instances prevention is not an alternative. The introduction of the Public Dental Service and the requirement to use GP17 forms to record dental treatment has meant that reaching an adequate permanent solution has been prevented for these patients who are frequently from less affluent families and require care which cannot be carried out under the Statement of Dental Remuneration. 2

3 Children who play sport can also be disadvantaged; for example, children who play rugby and who cannot afford a bespoke gum shield. 3. Cosmetic Dentistry There are some patients who seek cheaper unnecessary cosmetic dentistry abroad and expect the NHS to maintain or restore the poor quality dentistry. The financial burden of treating this group is worrying. Hospital Dental Services Front line hospital services are under financial restraint. Whilst all public services must seek efficiency it is impossible to do more with less. This will and does impact on clinicians' ability to carry out treatments optimally and has a knock-on effect on the public directly: In terms of access, treatment outcomes and in confidence in the NHS in general. This cannot be considered fair or equitable. Dental Care in Remote and Rural Areas BDA Scotland would highlight that access to dental care in rural Scotland is limited. It is understood there are large groups of patients who are not registered with dentists. In these areas access to routine dental care for patients should be available within a reasonable distance from their homes. It is recognised that there are geographical challenges, but would ask Scottish Government to commit to ending rural health inequalities. Water Fluoridation BDA Scotland endorses that communities strive to move towards the decision to choose fluoridated water especially in areas of deprivation. The move would be of benefit to both children and elderly people. It is suggested that water fluoridation would complement the Childsmile Programme which promotes tooth-brushing and the application of topical fluorides in children but would also reduce the overall burden of tooth decay and reduce dental health inequalities in the elderly. Sugar Consumption The BDA supports sugar reduction in fizzy drinks and sports or health drinks. A high intake of carbonated drinks, whether sugar-free or not, is damaging to oral and general health. The BDA suggest that acidic drinks and foods should come with a warning regarding the risk of dental enamel erosion. High sugar food and drinks should warn of the risks of dental caries, obesity and type 2 diabetes. The BDA is supporting the British Medical Association s latest call for a 20 per-cent levy on sugary drinks. The BDA suggests it is time government policy recognised the singular threat to public health. The BDA believes sugar consumption should be discouraged and manufacturers given a reason to cut sugar in drinks. The BDA supports the subsidising of healthy foods, and suggests food labelling with an integrated traffic light labelling to enable consumers to make informed and healthier choices. In relation to the labelling of sugar content, the BDA believes that greater consistency is required to prevent confusion between total and added sugars. Front of pack labelling must be supported by education to maximise the benefit to public health. The BDA believes that health education and preventive measures which are backed up by a support network would encourage and motivate patients to help to reduce their intake of sugary drinks. Raising the profile of dental health with posters not only in dental surgeries but in 3

4 doctors surgeries, medical/community centres, supermarkets, television and on social media also draw patient s attention to the risks. Head and Neck Cancer: Restorative Treatment BDA Scotland has raised the issue with Scottish Government about dental charges for patients who have oral cancer, both pre-surgery/radiotherapy, and in the rehabilitation phase, and have asked that patients with a diagnosis of oral cancer be added to the exempt categories to try and minimise this health inequality. Whilst some of the care is specialist in nature and led by a Consultant in Restorative Dentistry, a number of these patients rely on dentists in primary care, either in General Dental Services (GDS) or the Public Dental Service (PDS) to carry out basic periodontal treatment, caries prevention, restorations and extractions both pre- and post-cancer treatment. A number of patients need fast access to basic dental treatment to ensure they are fit to undergo cancer therapy and to prevent post-treatment complications such as osteronecrosis of the jaws (disease resulting from temporary or permanent loss of blood supply to the bones), or postradiation caries due to xerostomia (dry mouth). Due to the conditions of the NHS (GDS) (Scotland) Regulations 2010, Terms of Service, and recent changes introducing patient charges in the PDS, a number of these patients would be expected to pay for this necessary dental treatment, if they do not fall into an exempt category. No other form of pre-cancer treatment, or post-cancer rehabilitation requires patients to pay. Routine Dental Treatment for Prisoners From 2011, the oral health of prisoners in Scotland became the responsibility of NHS Boards and therefore dental treatment for prisoners is being provided by the PDS. BDA Scotland note that the Scottish Government s Oral Health Improvement and Dental Services in Scottish Prisons - Guidance for NHS Boards was published on 15 July However, BDA Scotland feel there are a number of issues which have still not been adequately addressed. Prisoners on remand or sentenced to less than 12 months can only access emergency treatment with no access to routine dental care; the need for more robust planning assumptions on throughput and productivity per session; the number of sessions required per week per number of prisoners and the need for investment in national IT systems which enables continuity of care as prisoners are transferred between prisons. The BDA suggests consideration is given to the nutritional standards in Scottish prisons. Orthodontic Treatment Orthodontic treatment is available to all patients subject to meeting the criteria based on the Item of Treatment Need system which is assessed by the clinicians involved in the treatment. It is becoming widely accepted by Orthodontists that retention treatment for patients is long term and possibly a life-long process due to the necessity of wearing orthodontic retainers. Currently, there is no provision by NSS National Services Scotland, Practitioner Services to pay for repairing retention appliances and there is only funding for supervising retention for 12 months. Obtaining funding within the 12 month period for repairing retainers is very difficult and often not forthcoming. After 12 months, there is no funding even for exempt patients and children also have to pay. The limited funding for the first 12 months after orthodontic braces are removed and zero funding thereafter is definitely disadvantaging poorer patients who need repairs or replacements and end up having no treatment leading to relapse. This does not provide good quality care for patients and is a poor use of NHS funding. 4

5 It is suggested for exempt patients that repairs of retainers which have been provided under the NHS, should be funded by the NHS. Regulation 9 applies to the replacement of lost or broken dentures, splints, bridges and orthodontic appliances due to an act or omission from the patient. Therefore an assessment must be carried out to decide if the patient should pay a deposit towards the replacement cost. In order for Regulation 9 cases to be considered as a primary care dental treatment, the patient must have lost or broken the orthodontic appliance. However, Regulation 9 procedure is interpreted differently by the different Health Boards, the BDA is aware that recently that almost every patient has had to pay. In some NHS areas patients are responsible to pay a contribution for the first replacement with an increased contribution for the second replacement and the full cost thereafter. A more balanced and fairer approach would assist exempt patients. With regard to replacements which are also subject to the 12 month rule mentioned above, it is suggested that these should be assessed on individual circumstances and not automatically provided free, although patients would need to be aware of this. It is thought the number of replacement claims has recently risen with the increased use of vacuum formed retainers which cannot be repaired once broken. It is unreasonable to expect dental practitioners to provide replacements or repairs without being funded. However, it is equally unreasonable for anyone else to fund repairs if the appliance that is provided is substandard and breaks within the first few weeks. The lack of proper retention leads to a loss of the planned orthodontic treatment outcome and can have a detrimental effect on the patient and also the effect of making the initial treatment of limited use or at worst, of no benefit. Some retainers are not repairable whilst others are lost. Should a replacement retainer be required, Regulation 9 applies as stated above, therefore an assessment must be carried out to decide if the patient should pay a deposit towards the replacement cost. In order for Regulation 9 cases to be considered as a primary care dental treatment, the patient must have lost or broken the orthodontic appliance. August