UK: Vital Signs - Scotlands Oral Health: The Direction of Travel

Last Updated: 13 April 2017
Article by Andy Drane

In the UK the National Health Service can sometimes be seen as a badge of honour. Free access to healthcare at the point of need has been a defining feature of social fabric since the upheavals of World War Two.

But what happens when there's no one to provide that healthcare? This is what happened at the end of the 20th Century and the early years of the 21st Century for NHS dentistry. Many people found themselves unable to find a dentist to provide NHS care. This was particularly true in the rural parts of Scotland with people having the choice of paying for private treatment (if they could find it) or travelling long distances to find care. I have personal experience of this; when I moved to the Scottish Borders in 2000 I was told the nearest NHS dentist taking on new patients was in Newcastle. It is no surprise that for many these choices were unobtainable in equal measure which resulted in a de facto denial of dental services and a decline in the oral health of the population.

As we approach the end of the second decade of the 21st Century the position is markedly better. However, it is still far from perfect.

In late 2016 the Scottish Government issued its latest consultation on oral health; "Scotland's Oral Health Plan". According to the Health Secretary there are now more than 4.8 million people registered with a NHS dentist and over the past 8 years the number of NHS dentists has increased by approximately 30%. In part that increase has been due to overseas dentists moving to work in Scotland. My NHS dentist in Galashiels, Julia, is a migrant from Eastern Europe; very good she is too.

Of course, future oral health is as much impacted by preventing dental problems arising as alleviating existing problems. Whilst aspects of the Scottish diet are still imperfect it is clear that some of the messages are getting through in our education system. It seems reasonable to anticipate that many more of our young people understand the importance of looking after their teeth and that will sustain them into adult life.

However, whilst prevention will improve things over the coming decades, many Scots are still living with the consequences of the past. Some of those consequences arose from ignorance; some from lack of access to professional care. There are those in our elderly population for whom having your teeth extracted and replaced with false teeth was an acceptable – even desirable – coming of age present for a 21 year old. For some that will have been their own personal experience; a hangover from days when oral healthcare had more in common with torture than modern medicine.

The Scottish Government's most recent consultation put forward a series of proposals and invited views and comment on those proposals. At their heart those proposals look to modernise NHS Dental Services. A significant part of the modernising agenda is focused on how dental contractors (for which read dentists and dental practices) are remunerated. Remuneration is set out in the Statement of Dental Remuneration ("SDR"). The assertion is that the current system is complex, difficult to administer and manage, and hard to understand. For anyone who has had the misfortune to read and try to understand the SDR it's an assertion that resonates.

Even if a majority of the consultation's proposals are enacted, the impact for dentists and dental businesses is unlikely to be significant in the short term. However, over time the changes could be substantial. Indeed Scottish Government aspiration is that in the long term there will be a wholesale change in the nature of mainstream dental care and how it is paid for.

There is a key theme running through the current focus in oral healthcare on providing treatments to already compromised patients and the manner in which that focus is remunerated is not fit for purpose and needs radical amendment.

"It is [Scottish Government's] aspiration to introduce a preventive care pathway with more emphasis on maintaining or improving the level of oral health. Our vision for a new preventive dental culture requires a system of payments to dentists which reflects its positive nature and aligns payments to the needs of the patient whilst rewarding the time, effort and hard work that the dental team put in to promoting and maintaining good oral health".

There is an acknowledgement that this would need to be part of a process not a "big bang". The starting point would be to build on existing initiatives with children and young people but would then aim to move adults with stable oral health from an "item of treatment" pathway to a "preventative treatment" pathway.

Part of this will involve dentists probing into patients' lifestyles with questions being raised about issues such as smoking, alcohol intake and medication; all matters which can and do impact on oral health.

The potential for rather greater immediate changes for dental contractors lies in the nature of their legal relationship with individual health boards. Scottish Government proposals talk about moving to a formal contract between health boards and dental contractors. The apparent purpose of such a contract would be to "help ensure that the arrangements and obligations for each party are clear".

This is something which general medical practitioners faced up to in 2004. It was part of a raft of changes to doctors' terms and conditions underpinning all of which was a formal legal contract which set out the rights and responsibilities of both commissioners and providers. It is instructive that at a time when, in the case of general medical services, that whole system is the subject of protracted renegotiation, Scottish Government should nonetheless be looking to replicate it in the context of oral health.

Dentists have always been seen as more entrepreneurial than doctors and more focused on achieving optimum commercial outcomes. That has been only encouraged by the way dentists are remunerated under the SDR. In simple terms the more treatments provided the greater the remuneration; inevitably that drives behaviours.

Scottish Government believes that the introduction of a formal contract would facilitate a move from payments based solely on treatments to payments which also take into account quality of service delivery and achievement of outcomes. The proposals sound remarkably similar to those which were introduced in general medical services at the time of their "New Contract". In that case those proposals manifested themselves in the Quality and Outcomes Framework ("QOF"). What is notable in that sector is that QOF has now been abandoned. Part of the reason behind that is that whilst it improved some aspects of service delivery there was no or only minimal improvement in actual patient outcomes.

The consultation also explores other proposals which would impact significantly on dentists and the business of running an NHS dental business. For instance, one proposal is that GDC-registered practice owners or directors would have to provide a minimum number of hours of NHS clinical care per week in each practice location. It is not entirely clear what the drivers are behind such a proposal but it would clearly affect the pattern seen in recent years of dentists buying up multiple practices and running them as a mini-corporate operation.

The consultation is now closed and Scottish Government are considering which of their proposals to adopt as official policy. However, given past experience around the time of the 21st Century, they would do well to beware being too hasty and to try their utmost to take the profession with them. If they do not then there must be a risk dentists simply refuse to follow. The profession "has form" in this regard.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on

Click to Login as an existing user or Register so you can print this article.

In association with
Up-coming Events Search
Font Size:
Mondaq on Twitter
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
Email Address
Company Name
Confirm Password
Mondaq Topics -- Select your Interests
 Law Performance
 Law Practice
 Media & IT
 Real Estate
 Wealth Mgt
Asia Pacific
European Union
Latin America
Middle East
United States
Worldwide Updates
Check to state you have read and
agree to our Terms and Conditions

Terms & Conditions and Privacy Statement (the Website) is owned and managed by Mondaq Ltd and as a user you are granted a non-exclusive, revocable license to access the Website under its terms and conditions of use. Your use of the Website constitutes your agreement to the following terms and conditions of use. Mondaq Ltd may terminate your use of the Website if you are in breach of these terms and conditions or if Mondaq Ltd decides to terminate your license of use for whatever reason.

Use of

You may use the Website but are required to register as a user if you wish to read the full text of the content and articles available (the Content). You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these terms & conditions or with the prior written consent of Mondaq Ltd. You may not use electronic or other means to extract details or information about’s content, users or contributors in order to offer them any services or products which compete directly or indirectly with Mondaq Ltd’s services and products.


Mondaq Ltd and/or its respective suppliers make no representations about the suitability of the information contained in the documents and related graphics published on this server for any purpose. All such documents and related graphics are provided "as is" without warranty of any kind. Mondaq Ltd and/or its respective suppliers hereby disclaim all warranties and conditions with regard to this information, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. In no event shall Mondaq Ltd and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use or performance of information available from this server.

The documents and related graphics published on this server could include technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Mondaq Ltd and/or its respective suppliers may make improvements and/or changes in the product(s) and/or the program(s) described herein at any time.


Mondaq Ltd requires you to register and provide information that personally identifies you, including what sort of information you are interested in, for three primary purposes:

  • To allow you to personalize the Mondaq websites you are visiting.
  • To enable features such as password reminder, newsletter alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our information providers who provide information free for your use.

Mondaq (and its affiliate sites) do not sell or provide your details to third parties other than information providers. The reason we provide our information providers with this information is so that they can measure the response their articles are receiving and provide you with information about their products and services.

If you do not want us to provide your name and email address you may opt out by clicking here .

If you do not wish to receive any future announcements of products and services offered by Mondaq by clicking here .

Information Collection and Use

We require site users to register with Mondaq (and its affiliate sites) to view the free information on the site. We also collect information from our users at several different points on the websites: this is so that we can customise the sites according to individual usage, provide 'session-aware' functionality, and ensure that content is acquired and developed appropriately. This gives us an overall picture of our user profiles, which in turn shows to our Editorial Contributors the type of person they are reaching by posting articles on Mondaq (and its affiliate sites) – meaning more free content for registered users.

We are only able to provide the material on the Mondaq (and its affiliate sites) site free to site visitors because we can pass on information about the pages that users are viewing and the personal information users provide to us (e.g. email addresses) to reputable contributing firms such as law firms who author those pages. We do not sell or rent information to anyone else other than the authors of those pages, who may change from time to time. Should you wish us not to disclose your details to any of these parties, please tick the box above or tick the box marked "Opt out of Registration Information Disclosure" on the Your Profile page. We and our author organisations may only contact you via email or other means if you allow us to do so. Users can opt out of contact when they register on the site, or send an email to with “no disclosure” in the subject heading

Mondaq News Alerts

In order to receive Mondaq News Alerts, users have to complete a separate registration form. This is a personalised service where users choose regions and topics of interest and we send it only to those users who have requested it. Users can stop receiving these Alerts by going to the Mondaq News Alerts page and deselecting all interest areas. In the same way users can amend their personal preferences to add or remove subject areas.


A cookie is a small text file written to a user’s hard drive that contains an identifying user number. The cookies do not contain any personal information about users. We use the cookie so users do not have to log in every time they use the service and the cookie will automatically expire if you do not visit the Mondaq website (or its affiliate sites) for 12 months. We also use the cookie to personalise a user's experience of the site (for example to show information specific to a user's region). As the Mondaq sites are fully personalised and cookies are essential to its core technology the site will function unpredictably with browsers that do not support cookies - or where cookies are disabled (in these circumstances we advise you to attempt to locate the information you require elsewhere on the web). However if you are concerned about the presence of a Mondaq cookie on your machine you can also choose to expire the cookie immediately (remove it) by selecting the 'Log Off' menu option as the last thing you do when you use the site.

Some of our business partners may use cookies on our site (for example, advertisers). However, we have no access to or control over these cookies and we are not aware of any at present that do so.

Log Files

We use IP addresses to analyse trends, administer the site, track movement, and gather broad demographic information for aggregate use. IP addresses are not linked to personally identifiable information.


This web site contains links to other sites. Please be aware that Mondaq (or its affiliate sites) are not responsible for the privacy practices of such other sites. We encourage our users to be aware when they leave our site and to read the privacy statements of these third party sites. This privacy statement applies solely to information collected by this Web site.

Surveys & Contests

From time-to-time our site requests information from users via surveys or contests. Participation in these surveys or contests is completely voluntary and the user therefore has a choice whether or not to disclose any information requested. Information requested may include contact information (such as name and delivery address), and demographic information (such as postcode, age level). Contact information will be used to notify the winners and award prizes. Survey information will be used for purposes of monitoring or improving the functionality of the site.


If a user elects to use our referral service for informing a friend about our site, we ask them for the friend’s name and email address. Mondaq stores this information and may contact the friend to invite them to register with Mondaq, but they will not be contacted more than once. The friend may contact Mondaq to request the removal of this information from our database.


This website takes every reasonable precaution to protect our users’ information. When users submit sensitive information via the website, your information is protected using firewalls and other security technology. If you have any questions about the security at our website, you can send an email to

Correcting/Updating Personal Information

If a user’s personally identifiable information changes (such as postcode), or if a user no longer desires our service, we will endeavour to provide a way to correct, update or remove that user’s personal data provided to us. This can usually be done at the “Your Profile” page or by sending an email to

Notification of Changes

If we decide to change our Terms & Conditions or Privacy Policy, we will post those changes on our site so our users are always aware of what information we collect, how we use it, and under what circumstances, if any, we disclose it. If at any point we decide to use personally identifiable information in a manner different from that stated at the time it was collected, we will notify users by way of an email. Users will have a choice as to whether or not we use their information in this different manner. We will use information in accordance with the privacy policy under which the information was collected.

How to contact Mondaq

You can contact us with comments or queries at

If for some reason you believe Mondaq Ltd. has not adhered to these principles, please notify us by e-mail at and we will use commercially reasonable efforts to determine and correct the problem promptly.