Most of us hoped that the legal branch of our tree would flourish and bring some cover to our practices. This seems unlikely for now, but not all, not even most, is lost.

What hope is there left?  With a legal challenge, we hoped to right the wrongs inflicted on us by the Scottish Government. Not just during the pandemic, but for years. The endless conveyor belt that NHS dentistry has been for decades, now feels akin to the battered, lifeless soil left after the bulldozers rage through an intensive forestry farm that has seen the cheapest, quickest growing trees planted for decades, with absolute disregard to quality, not only of the resulting product but of the necessary ecosystem that surrounds it.

In a day and age where sustainability and not exploiting the ecosystem is everyday talk, the Scottish Government need to stop using dentistry as a commodity where the highest output at the lowest cost is all that matters.

Things can change. We need a sustainable, quality-based dental (eco)system. This will pay off, in the long term, if the Scottish Government is willing to look past short-sighted politics and immediate savings.

Problems for dental practice owners in Scotland didn’t start during the pandemic, and they won’t end after it goes away (and it will go away).

New dental practice owners are faced with tremendous challenges when setting up their business, often with nobody around them to help. Having a support network for those taking their first steps into dental practice ownership could make all the difference in the long term.

Even those owners that have been established for a long time can sometimes feel alone in their challenges. It has been suggested that the SDPO Telegram group is “just a support chat”, but even then, we know this has provided immense value to some owners during this crisis.

When it comes to finances, SDPO is working to obtain membership benefits from different groups and companies and we are already looking at finance related courses for our members. Only dental practice owners can truly understand the financial needs of their businesses.

And, of course, we still believe SDPO deserves a seat at the negotiating table. We represent a highly important stakeholder in Scottish dentistry, and as such we will keep pushing the Scottish Government to consult with us – as per their own regulations. It is the QC’s opinion that this will come as the group becomes more established.

Professional lobbying and PR will also play a role in improving the future for practice owners. No other organisation is willing or able to fulfil this role.

All these branches can – and need to – flourish. They just need care, and time. If we all give a little of it, so some don’t have to give it all, we will have a shelter big enough to cover us all.

Not so long ago the Scottish Chief Dental Officer undertook a nationwide touring roadshow to gain information and ideas for wholesale changes to oral healthcare delivery. The resulting Oral Health Improvement plan (OHIP) was formulated and was launched on 24th of January 2018. The Health Secretary is quoted as saying,

“Record numbers of Scots have access to NHS dentists, and as a nation our oral health is improving. But poor oral health is entirely preventable and we need to ensure we do all we can to tackle it, and break the link between oral health and deprivation.

“The Oral Health Improvement Plan will support the profession to spend more time on what they do best –providing excellent care for the patients who need it most. We will continue to work closely with them as the recommendations are implemented. It will ensure people get the personalised care they need, when and where they need it.

“We will reach out beyond dental practices to support communities to find innovative ways to support people lead healthier lives –particularly in deprived areas or among older people.”

I vividly recall a meeting at which the CDO was guest speaker after the plan was formulated. There was great unrest that dentists would be left to explain all the complexities of the changes to the public, with all the time, arguments, stress, etc that this would involve. She assured all in the audience that funds would be made available to communicate to the public the changes to NHS oral healthcare by way of leaflets, media, posters, etc.

However, since then the OHIP seemed to have been pushed into a siding. The shelving of the plan seems to have occurred shortly after someone asked, “where is the money coming from?”

Roll forwards a year and the OHIP is mentioned in the job description for candidates for the vacant CDO position in 2019.

So if you were the CDO with a job description including “You will be expected to lead the implementation of the Oral Health Improvement Plan.” How would you go about it?

The fundamental problems, identified over 2 years previously, still remain, and can be summarised as follows.

Quality vs. Quantity

For decades the emphasis has been on quantity of treatment. Budgetary pressures from the Government have forced practitioners to work faster to maintain viable businesses. Despite this the BDA and others identified a 30% reduction in average practice income since 2009 due to a combination of real-terms reduction in NHS fees and increased costs associated with ever tightening regulation. Part of this regulation comes from the GDC, who warn the profession against saying there is a difference in quality of treatment between NHS and non-NHS treatment. But faced with the stark reality of the inadequacy of the SDR and the changing emphasis on increasing quality from the NHS, it is difficult to escape the reality of the inverse relationship between quality and quantity which exists in all business worldwide.

A cynic would point out that on one hand, the GDC would take an individual dentist to task if he suggested he could devote more professional time to give better quality to an NHS patient if the patient paid privately. On the other hand, if the NHS says it wants to structure things to give a better quality of treatment, the GDC wouldn’t take the NHS to task in its admission that it has been actively promoting a poor standard of care.

Suddenly the Government want to change the emphasis to quality of care, but with either no increase or a reduction of the budget. This has therefore been firmly placed in the magic top hat for a bizarre illusion for the current CDO to perform. A magic trick befitting the best illusionists in the business. It is analogous to the attempts of alchemists to transform base metal into gold.

There are obviously costs associated with the desire to improve quality

• More time needs to be taken to provide higher quality
• If more time is being taken, remuneration needs to be increased to keep pace
• If more time is being taken, there has to be a commensal increase in manpower to enable the same volume of treatment to take place.
• An increase in workforce entails increasing the provision of university places for dentists, college places for DSAs, increased training spaces for hygienists and hygiene therapists
• If a greater workforce is required, there has to be an increase in physical buildings and surgeries.
• There is still the cost of keeping the public and profession informed of the changes, as promised by the previous CDO

The costs of all this need to be factored into the OHIP. Otherwise the same pot of money has to be spread more thinly.

So one major obstacle for the CDO is to conjure up the money. How can this be done?

Well Governments from time in memorial have always sought to force through their plans while everyone’s attention is in other directions. A kind of smoke and mirrors and misdirection one would normally associate with the best stage magician.

Under cover of covid, the CDO and Scottish Government seem to have unilaterally changed the SDR and other legislation with little (and at times) no consultation with the profession. On the face of it this is, of course welcome, as it provides some security of income to help keep practices afloat. It is after all practices which deliver the overwhelming bulk of NHS dental treatment far cheaper than any alternative. However, having implemented emergency funding, the confusion and arguments over various issues (funding the private element of practice income; provision of PPE;SOPs; legality of forcing practices to close fully to patients; reduce numbers of dentists which need to be paid by having no graduates or student intake; etc) the ideal environment for laying plans to finance wholesale reform of oral healthcare exists.

By softening up the profession with this misdirection and seeking to divide it, the way is opened to save money by making unilateral changes to implement the OHIP with minimal energy or resources left within the profession to resist.

Over the years the Government has manoeuvred the BDA/ SDPC (who they regard as being a dental trade union) and groomed them into a weaker position than they had decades previously. It wants to replace the open chequebook of the SDR with a greater means of budgetary control. It has seen how this was done in England with the imposition of UDAs and they certainly don’t want to discuss or negotiate, now, with practice owners. They would much rather keep practices under the financial thumb and force them to accept some new deal as part of the OHIP.

The usual means of doing something like this is to keep applying financial pressure, gradually strangling their target; depriving them of income (the oxygen that is needed for all businesses). Then make any increase in funds look like a huge favour; a gasp of relief from their victim. This happened with the enforced closure of practices, where the initial offer was 20%of the previous year’s IOS, making the intended 80%seem more generous than it was. The fear being that any words of dissent roundly criticised by the Government in public with phrases such as “Grasping dentists” aimed at alienating the profession and bringing on public scorn. After all the rest of the country is suffering; why should these pesky dentists think they should be a special case?

A magic trick befitting the best public stunts of Davids Blaine or Copperfield is then complete. Smoke and mirrors, misdirection of profession, Parliament and public and hey presto! A new structure of oral healthcare miraculously appears at little or no additional cost to the taxpayer and a completely malleable, impoverished, demoralised and divided profession.

The CDO has been employed as a magician

Magic, of course, is just illusion. To see how it is done requires a refusal to be misdirected. Not to look at the side issues and stay focused on the actual movements of the magician, whose aim is to get from point A to point B by layers of deception, with point B coming as a complete surprise finale.

We seem to be in the middle of a massive illusion. The problem is, we started at point A –contracts with Health Boards, with item of service supplemented by a complex and nebulous system of grants and initiatives. Point B has yet to be revealed. Just what the structure of oral healthcare will look like at the end of the trick remains a mystery. At the moment the magician has created the illusion and has introduced smoke and mirrors. He is halfway through a disappearing act.

• Practices are getting over 20% less than last year and are in a state of confusion through misdirection through slight of hand.
• The CDO magician reveals that more money has been created from thin air, to be spent on dental services and to keep the profession afloat during the crisis
• Some PPE has been miraculously pulled from up his sleeve. (Close observation has shown this to be as ancient as pulling an old string of handkerchiefs from a sleeve... and just about as moth-eaten)
• The public are totally bewildered, as routine care has vanished but the magician tells them (via a radio broadcast) that it is still there.

The problem is that the magician himself does not seem to have a clear vision of what point B is. What will be the structure or budget of the profession at the end of the trick?

If even the magician does not know this, he can’t possibly lead his profession through various stages to get there. If there is no destination, how do you get there?

This makes the CDO look less like David Copperfield, and more like Tommy Cooper.

The magician's Magic Circle looks more like a wonky Ferris Wheel which hasn't passed a safety inspection. Each carriage contains a different element of the profession and the whole assembly is getting ever-more rickety as time goes on. There is a growing list of casualties due to lack of care and maintenance and proper investment to the structure.

• Final Year students may not graduate
• VTs didn’t complete their year and some are unemployed
• Universities are planning on no First Year intake
• Associates are leaving practices, and some leaving the profession
• Dental nurses are being made redundant
• Skilled laboratory technicians are unemployed and lost to the profession
• Retiring dentists are not being replaced
• The promised openness of information to the public has been replaced with lies about availability of routine treatment and denial of a two-tier system
• Practices are closing

In reality, the magical transformation of dentistry is one big disappearance act.

Be under no illusion, if you compare the CDO to Moses, the trick of the parting of the Red Sea is not happening. The CDO looks nothing like Charlton Heston and he is not leading an exodus to an OHIP Promised Land of milk and honey. The exodus is from the profession.

So ‘clawback’ stands according to the CDO’s letter to the BDA dated 17th September. We’re still working in this parallel universe where patients who normally pay, get their treatment for free, subsidised from support payments supposed to keep practices afloat. There are problems with VDP contracts. We’re still waiting for a response to our request for test data on revalidated masks, sent weeks ago. Patients are still confused and angered by the two-tier system that has developed. The list goes on……….

Our historic lack of unity means we have no representative body with the strength or resolve to tackle these problems. As a collection of individuals, we are powerless.

This is in stark contrast to other professional groups like doctors, pharmacy owners and optician owners who unite behind representative bodies and enjoy far more favourable outcomes than we do.

We need to acknowledge and address our unity problem. This is the first and most important step in improving the way we are treated. We should have a well-supported group with the strength and resolve to represent and protect our interests. We believe that the owner’s group is best placed to meet this need. No other group will represent owners as well as we can represent ourselves.

SDPO has the potential to be a game changer. If we can get the support of 80% or more of Scottish practice owners, government will have to engage with us. There has been some talk of legislative change that may be necessary for SDPO to get ‘a seat at the table’, but the SDR already states that Scottish Government must consult with ‘organisations representative of the profession’. An organisation with 80% plus of Scottish practice owners would be hard to ignore, and would have the resources to challenge Scottish Government policy.

We are making headway. With unity and support from Scottish practice owners, SDPO are confident that we can deliver change. Please spread the word, encourage others to join the group, support the work of the committee and stay engaged as we move forwards.

We deserve better/Our teams deserve better/The public deserve better

United we can achieve better

SDPO

SDCEP published another rapid review on 25^th September 2020. There was a lot of hype ahead of its release, I may not be over exaggerating if I compared it to the release of a Hollywood blockbuster! It goes to show, that these days, our lives revolve so much around new documents, guidance and guidelines related to dentistry in the pandemic era. In a way it is being nervous of what Facebook language calls FOMO (fear of missing out, for those unfamiliar!)

SDCEP quotes in the opening statement of its rapid review, ‘It is important to stress that this document does not have the status of guidance. It is provided primarily for use by policy makers and those who are developing clinical guidance relevant to dental care delivery during the COVID19 pandemic’.

We are all trained from our days at University to refer to guidelines with quality evidence, in an era of Evidence Based Dentistry. We understand there is not enough time, amid this pandemic, to synthesise evidence via meta analyses or systematic review…we are not in an ideal world!

So much expectation was drummed up in the official communications from the CDO that they will base their further decisions on the findings of this rapid review, for future dental workforce and service planning. I am confused to say the least. I was under the impression SDCEP was meant to give reliable guidance in its well-known format to help CDO. Ball is back in your court dear CDO…!

The SWLG report established by NSS Scotland reported the minimum ventilation requirement based on a document published in 2006. However this was never a mandatory requirement in the years to follow and during routine inspections hardly any emphasis was placed on ventilation, although our operating surgeries are heavily contaminated with variable concentrations of bacteria, viruses and potentially harmful chemicals, within the splatter and aerosol that every power tool creates.  I am not even referring to deadly SARS-CoV-2.

SDCEP recommends 10ACH as a standard which will lead to fallow time of 10 mins. I do not quite understand how the magic number was reached and why is it not 15 or 20ACH? What will happen in surgeries with windows, or no windows but with similar ventilation mechanics? SWLG mentioned 20min right?

What is even more puzzling – is 10ACH the minimum requirement that guarantee dental practices against disease transmission on its own accord? Not so sure. Especially when the risk of seeing an asymptomatic Covid +ve patient is about 1:20000. How much viral load is there in an asymptomatic patient and with all the precautions and risk assessments is there a real risk of disease transmission?

Check this table which lays out clearly what is the potential risk of a dental practitioner coming across an asymptomatic patient in Scotland. Almost negligible but still we must follow the precautions, and that is entirely acceptable.

The review also quotes-  The role of asymptomatic cases in transmission has also been highlighted as a concern. At the time of writing there have been no confirmed cases of COVID-19 transmission in the literature linked to dental settings despite the potential risk of transmission in such environments….. So what is all the fuss about? Should we just get on with it?

Will there be a new Ventilation grant? Not all practices can have mechanical ventilation of 10ACH and getting to this target will be a considerable challenge. There are multiple hurdles in the process such as size of surgery, location of the practice, adjacent premises and complaints from the occupants of neighbouring properties. Theoretically speaking we are pushing more viruses into the exterior environment in the clearing up of our surgeries during AGPs. How relevant is this?

Also let’s face it , extractor fans push all the heat out and when we hit winter they blow out all warm air, effectively creating arctic conditions for the dental team to work in a safe but freezing environment.

HVE and rubber dam are not new inventions and are probably the main tools in risk reduction. It should not be a big issue optimising the high-volume suction to ensure it does the job.

They are still saying there is no evidence for air purifiers and pre op mouth rinse. It’s a shame that these two methods, used globally to manage risk of Covid transmission, are not being utilised at this stage, and we must now wait for more detailed evidence or studies to see their efficacy established. There was some allowance given to air purifiers in SWLG report and this is completely excluded here. Combined with mechanical ventilation they can increase the air change rate and their potential benefit seems logical.

Since the onset of pandemic and the lockdown of dental practices, this is not the first review published. Most recent reviews have been just reviews. What is hard to fathom is why do we not have analysis of quality of evidence? Whilst I understand the whole saga of the Covid pandemic is filled with uncertainties, unchartered territory for all of us, the expectations of SDCEP are high by default. There should have been a clear classification of evidence, on the basis of quality that we are traditionally used to. This will make it relevant not only to public authorities but also to the dental community, in making safe and appropriate decisions for patient care.

Wearing the hat of a primary care dental professional, it comes across to me as a big anti-climax and waste of precious time and money. We are 6 months plus down the road in this pandemic which seems never ending, and keeping our fingers crossed as to what comes next. Amid this anxiety, we are all overwhelmed by the plethora of government commissioned reviews and guidance.

The other fears expressed by colleagues and friends more informally are - will public health bodies use this review to impose new requirements based on unclear analysis of data, having spent substantial sums of money from its coffers on this rapid review.

It looks like we have more questions than answers. Let us hope for some favourable ruling by our bosses in St. Andrew’s House.

There does seem to be some confusion. Part of enhanced PPE for AGPs, we are told, is the wearing of a long- sleeved gown.

But why?

As a student more years ago than I care to remember, we wore long-sleeved white lab coats. However, for the last 30 or so years we have been told that wearing long sleeves hinders washing of wrists and forearms. We have therefore worn short-sleeved tops – commonly scrubs.

We are told that corona viruses are very easily killed by breaking its outer capsule using detergent. Hence the reason for the public told to wash hands regularly and often with soap and water. This appears to reinforce the message to us about having wrists and forearms exposed for washing.

So why, suddenly, has the 30 year old message about shirt sleeves been reversed?

One argument is that gowns are to protect clothes, and scrubs are classified as clothes. When we take off our scrubs, we might smear anything on the tops over our faces. This depends on how you remove the tops and some are modified in such a way as to have fastenings (poppers or velcro) so they can be removed easily Bucks Fizz-at-Eurovision-style. But this does not answer the forearm question.

Another argument is that nobody makes short-sleeved gowns. But this doesn’t answer why we are now instructed to wear long-sleeves. If we were asked to wear short-sleeved gowns, someone would make them. For example the Yorkshire PPE company came into the market and could have easily made short-sleeved gowns if the market demanded them.

I am sure you will have experienced a possible AGP being booked in, but discovered that an AGP was not required. (For example a patient reporting a loose restoration to the receptionist turns out to need an uncomplicated extraction. Not the AGP you had got togged up for). So you think you will just keep the gown on until the next AGP to avoid waste. But- hang on does the cuff prevent proper washing of your wrists? You could roll up the cuff to wash wrists and forearms, but when you roll the sleeves back down you will recontaminate your wrists with whatever was on them when you rolled them up.

It has been suggested to only wear the gowns with no scrubs underneath. This brings into mind a rather old joke

Q: “what do you wear under your kilt?”

A: “Nothing is worn under my kilt......everything is in perfect working order!”

Surely in the event of having no short- sleeved-gowns, it is better to either have short-sleeved gowns or roll up the long-sleeves? This allows for proper hand, wrist and forearm washing; continuous wearing until an AGP is performed and meanwhile anything that is “worn” underneath is protected.