Doctors' and dentists' remuneration (DDRB) review body - 2022-2023 pay round: evidence

H. Specific Staff Groups – Pay, Terms and Conditions

H.1 General Medical Practitioners

Introduction

205. This section provides information relating to general practice (independent contractor GMPs) and the delivery of contracted services through the NHS Boards. This section provides additional background to developments with the GMS arrangements in Scotland, and the implementation of the new contract in 2018.

Background

206. The majority of GMPs working to provide primary medical services in Scotland are independent contractors, self-employed or partnerships running their own GP practices.

207. The General Practice – GP workforce and practice list sizes was published on 14 December 2021. As of 1 October 2021, there were 922 GP practices^[15] in Scotland and 84% were on the national General Medical Services contract. The number of practices in Scotland has decreased by 8% from 1007 practices in 2011, reflecting a trend towards larger practices with more GPs serving a larger number of patients. GMPs operating under Section 17C or 2C arrangements provide services based on locally agreed contracts, and any uplift in investment for these arrangements is a local matter for the Health Board.

208. As of 1 October 2021:

• 775 practices operated under the General Medical Services Contract;
• 90 practices operated under the 17C contract; and
• 57 practices operated under the 2C contract^[16]

Source: National Primary Care Clinician Database (NPCCD)

209. The headcount of GPs in Scotland is 5195. This is a slight rise of 74 GPs compared to 2019. Prior to 2018, the headcount of GPs had remained roughly constant at around 4,900 since 2011^[17]

210. As of 1 October 2021 , an estimated 39% of the GP workforce were male and 61% female.^[18]

211. The average (or mean) size of a Scottish GP practice in terms of numbers of registered patients was 6325 in 2021^[19] however there was considerable variation, ranging from under 200 patients for practices in remote locations or practices which addressed specific health needs of patients (e.g. those with challenging behaviours or homelessness), to practices of over 20,000 patients in densely populated urban areas.

2018 GMS Contract

212. The 2018 Contract came into effect on 1st April 2018. It was agreed through a process of collaborative negotiations between the Scottish Government and the SGPC.

213. The contract includes:

• Improving access for patients;
• Addressing health inequalities and improving population health, including mental health;
• Providing financial stability for GPs;
• Reducing GP workload through the expansion of the primary care multidisciplinary team;
• Increasing support for GPs and GP infrastructure;
• Increasing transparency on general practice funding, activities and workforce to assist strategic planning, commissioning and delivery of primary care services; and
• Making general practice a more attractive profession for existing GPs, junior doctors and undergraduate medical students.

214. One of the core aspects of the new Contract is the new funding model as the Scottish Government recognises that an appropriate and secure level of income is a prerequisite to attracting GPs to the profession and ensuring the future sustainability of general practice.

215. The new contract will be introduced in two phases. Phase One included:

• A new workload formula to better match resource to demand;
• Additional investment of £23 million to allow most practices to gain from the new funding formula, whilst the remaining practices have received an income guarantee to protect their income level to ensure no practice was destabilised; and
• From April 2021, a GP Partner whole-time-equivalent minimum earnings expectation. This means that no GP will receive less than £89,784 NHS income per year (including pension contributions) for a whole-time post.

216. These initial changes will be followed by Phase 2 dependent on a further vote from the profession. Phase 2 will include:

• Introducing an income range for GP Partners that is comparable to consultants; and
• Directly reimbursing practice expenses.

217. These proposals are based on evidence from the 2017 Review of GP Earnings and Expenses,^[20] and will be supported by the investment of £250 million in direct support of General Practice by 2021/22.

Pay and Contractual Uplift 2018/19

218. For 2021/22 the Scottish Government implemented the DDRB recommendation to uplift GP pay net of expenses by 3%.^[21] In total the Scottish Government uplifted the GP contract by £27.5 million. This also included a 4% uplift to practice staff expenses, and a 1.9% uplift to wider practice expense in line with CPI. This also included £2.1 million funding to cover population growth in 2020/21.

219. In agreement with the Scottish General Practitioners' Committee, the contractual uplift was applied consistently across all general practices, meaning that there was no negative impact on practices.

Investment in General Practice

220. Investment figures for 2018/19 were published on 19 September 2019.^[22] They show that for the period 2018/19 the total spend on General Practice (including the reimbursement of drugs dispensed) was £992.5 million in Scotland, an increase of 6.53% from 2017/18. Total spend on General Practice 2018/19 (excluding the reimbursement of drugs dispensed) was £967.5 million in Scotland, an increase of 6.81% from 2017/18. From 2020, this series of publication has been discontinued.

Agreement to Publish GP Earnings

221. Following an agreement between Scottish Government and SGPC NHS payments to practices have been published since May 2015 beginning with the publication of 2013/14 data.

222. In 2019/20 the sum of NHS Scotland non-dispensing payments made to 935 General Practices was £894.6 million^23]. Investment had increased by £56.8 million (6.8%) when compared to 2018/19. .

• £747.6 million was paid to General Medical Services (GMS) contracted practices run by GPs;^[24]
• £105.2 million was paid to locally negotiated contracted practices (17C) run by GPs;^[25] and
• £41.8 million was paid to NHS Board run practices (2C).^[26]

223. Of the £894.6 million paid in 2019/20:

• The Global Sum was the largest payment amounting to £619.6 million to 935 General Practices.^[28]

224. In addition to the £894.6 million, £22.9 million was paid to 89 General Practices for dispensing services in 2019/20, similar to the previous year.^[29]

225. The new contract means an increase of data collection. This will include requiring all practices to provide data on earnings, expenses, hours and sessions. This data will be held confidentially and processed by NHS National Services Scotland Practitioner Services. Only anonymised, non-identifiable data will be provided to the government and NHS Boards for the purpose of analysis.

Patient Experience

226. The Scottish Health and Social Care Experience survey is carried out every two years, the 2019/20 survey was published in October 2020,^[30]

227. Over 160,000 individuals registered with a GP practice in Scotland responded to the 2019/20 Health and Care Experience Survey. The survey asked respondents to feed back their experiences of their GP practices and other local healthcare services: receiving care, support and help with everyday living; and caring responsibilities.

228. 79% of people rated the overall care provided by their GP practice positively, this was down four percentage points from the last survey.

229. 85% of people found it easy to contact their GP practice in the way that they want to and 77% were happy with their GP practice opening hours.

230. Around two thirds of people (67%) rated the arrangements to see a doctor positively compared with 79% seeing a nurse.

231. 92% of people were able to obtain two working day access to their GP practice; this is a slight increase from the previous survey. Around two thirds of people were allowed to book an appointment at their GP practice three or more working days in advance – a significant decrease from the previous survey.

232. The number of GP consultations estimated to have taken place in Scotland in 2012-13 was 16.2 million.^[32] This figure is likely to have risen in subsequent years.

Access

233. Most people (85%) found it easy to contact their GP practice in the way that they want, with half of people finding it very easy. This is a decrease of two percentage points compared to the previous survey. In previous surveys, respondents were asked how easy they found it to get through to their GP practice on the phone specifically and this was also rated very positively, with 82% of people saying they found it easy in both 2015/16 and 2013/14.

234. Respondents were asked what they thought of the opening hours of their GP practice:

• 77% of people were happy with them;
• 17% of people were not happy with the opening hours – for most of these people this was because it was too difficult to get time away from work during the practice's opening hours; and
• 6% of people were not sure what the opening hours of their GP practice were.

235. This is consistent with responses to this question in previous years

236. A review of patient access to GP services across the country in partnership with the British Medical Association (BMA) was included in the GP contract agreement for 2014/15, in order to support practices and NHS Boards to both better understand the challenges and to make any necessary improvements to access. This focus has been maintained in the new contract, which is underpinned by the principle of ensuring patients can see the right person at the right place at the right time.

237. In Scotland we are transforming primary care, including the development of multidisciplinary teams, supported by extra investment through the Primary Care Fund. This will put in place long-term, sustainable change within GP services that can better meet changing needs and demands, to ensure that patients can access the right person at the right time.

238. The Primary Care Fund is also supporting and accelerating the use of digital services by GP practices, such as by funding the development of web GP and online appointment booking to improve patient access.

Care and Treatment

239. When asked to rate the care provided by their GP practice overall, 79% of people rated it positively. This shows a decrease of four percentage points compared to the previous survey and a decrease of eleven percentage points compared to the first Health & Care Experience Survey in 2009/10.

240. The most positively rated statements were 'I understood the information I was given' and 'I was listened to' (both 95% positive).

241. The statement with the lowest positive rating was 'I knew the healthcare professional well', with less than half of people (46%) rating it positively. This statement also has a significantly higher negative rating (28%) than the other statements. However, those who had contacted their GP practice more frequently in the last 12 months were more likely to respond positively to this statement.

Vacancy, Turnover and Attrition Rates

242. According to the Primary Care Workforce Survey Scotland 2019^[33] workforce survey, 32.3% of GP Practices reported that they had vacant GP sessions from 1 April 2018 to 31 March 2019, in comparison with 24% of practices in 2017.^[34] The overall vacancy rate was 7.7 vacant GP sessions for every 100 total GP sessions. The vacancy rate varied by NHS Board. Discounting the Island Boards rates which are subject to volatility due to small numbers, the vacancy rate ranged from 5.6 vacancy sessions per 100 GP sessions in Forth Valley, to 11.4 vacancy sessions per 100 GP session in Dumfries and Galloway.

NHS Board *1	Percent of Responding Practices Reporting a Vacancy	Vacancy Rate *2
Ayrshire & Arran	33.3%	7.3
Borders	20.8%	5.9
Dumfries & Galloway	56.3%	11.4
Fife	41.2%	8.9
Forth Valley	31.6%	5.6
Grampian	34.4%	8.0
Greater Glasgow & Clyde	23.2%	6.0
Highland	29.5%	10.2
Lanarkshire	39.6%	8.3
Lothian	33.3%	5.8
Orkney	20.0%	3.6
Shetland	0.0%	0.0
Tayside	31.0%	10.2
Western Isles	25.0%	15.2
Scotland	32.3%	7.7

1. Figures for Island Boards may be impacted by small numbers

2. Vacancy rate is the number of vacancy sessions per 100 total GP sessions

NHS Health Board	Estimated Number of Sessions
	Sick Leave	Maternity Leave	Parental Leave	Special Leave
Scotland	29,967	33,483	380	4,393

1. The estimated number of absent sessions (in the absence of a 100% survey response rate) was based on scaling the sample headcount from the survey to match the national head count from NPCCD. For more details see the methodology section.

Recruitment and Retention

243. Between 2008 and 2017 the headcount of GPs remained roughly constant at around 4900. In 2017, Scottish Government committed to increasing numbers by at least 800 over the next ten years.

244. In 2021, we remain committed to that target with the number of GPs increasing by 150 over the last two years, to a total of 5,195, as at 1 October 2021, which was a record number of GPs working in Scotland

245. As we strive to meet our 2027 recruitment challenge we recognise it will require concerted and sustainable effort over the medium term to achieve significantly improved fill rates. This includes taking forward a number of initiatives to make general practice a more exciting and attractive specialism. This includes:

• Continuing to offer the £20k bursaries for GPST posts in "hard to fill areas" in the further 2020 recruitment round.
• Expanding training opportunities within Primary and Community-based practices.
• Enhancing roles of GPs via Fellowships.
• Reviewing the trainee selection criteria to ensure it is fit for purpose.
• Enhancing the GP Returners Programme to encourage those who have left the profession to return.
• Increasing exposure to primary care at undergraduate level

246. Trainee recruitment in 2021 has been the most successful year of the last five with 98% of GP training posts filled and we continue to develop our strategy for both recruitment and retention of our workforce.

247. The NHS Recovery Plan highlights that the recovery of staff is intrinsic to our collective ambitions for renewing our NHS and highlights the £8m of investment this financial year in measures to support the physical, mental and emotional needs of the workforce, including:

• the National Wellbeing Hub and National Wellbeing Helpline;
• investment of £2 million in targeted support to the primary care and social care workforces;
• the Workforce Specialist Service, which is a confidential multidisciplinary mental health service with expertise in treating regulated health and social services professionals;
• Specific GP Coaching for GPs thinking of leaving the profession
• additional funding to NHS Education for Scotland (NES) for the provision of psychological interventions and therapies to the Health and Social Care workforce;
• guidance to promote effective wellbeing conversations;
• enhancing occupational health provision;
• improving access to quality assured peer support and reflective practice; and
• the launch of a new National Wellbeing Programme with workstreams covering specific areas of work including ICU, nursing, primary care and social care.

248. Seniority Payments for Scottish GPs are set out in chapter 10 of the annual Statement of Financial Entitlements (SFE).^[35] Seniority Payments reward experience, based on years of reckonable service adjusted for superannuable income factors. Seniority Payments are made to the practice for payment to individual GPs.

229. Presently a GP has to work for six years before any seniority payment is made; for 6 years to achieve a payment of £600 per annum, for 21 years to achieve a payment of £5,129 per annum, for 36 years to achieve £10,258 per annum, with the maximum of £13,900 per annum payable being made at the 47 year point.^[36] The contractor has to have been in an eligible post for more than 2 years in order to be able to apply.

250. The Scottish Government's annual bill for seniority payments to GPs was £17.3 million in 2019/20.^[37] This is an increase on the £17 million in the previous year 2018/19.^[38]

251. 'Golden Hellos' for Scottish GPs are set out in chapter 11 of the annual Statement of Financial Entitlements (SFE). Golden Hellos are a lump sum payment to doctors who are starting out as GP performers in their first eligible post. Posts are considered to be eligible if they are attracting payments for remoteness, rurality or deprivation. Golden Hellos can also be paid to new GP performers if the local Health Board believes the practice is experiencing significant difficulties around recruitment and retention. These are just for GPs in GMS practices with the exception of Golden Hellos for remoteness and rurality which are for all practices regardless of contractual status.

Figure 3 - Table setting out the rate of Golden Hello payments

Reason	Payment
Recruitment Difficulty	£5,000 (minimum)
Remoteness or Rurality	£10,000;
Deprivation	£7,500 - £12,500

252. The rate of payment for part time GPs, with a time commitment fraction of less than 4 sessions per week is 60% of the full payment.

Salaried GPs

253. The Primary Care Workforce Survey Scotland 2019 estimated that 76% of GPs were Independent Contractors.^[39] It estimated that there were around 998 salaried GPs (22%) and 75 GP retainees (2%). .

254. The survey also found that Performer GPs, who had an average of 0.86 WTE per GP. Performer Salaried (0.67 WTE per GP) and Performer Retainer (0.45 WTE per GP) were more likely to work part time.

255. The document sets out a breakdown of the GP workforce by gender, however we do not have current data to indicate whether these GPs were independent contractor or salaried GPs.

GP Expenses

256. Scottish Government is currently collecting data on GP expenses. Until this exercise is complete, the availability of data on GP income and expenses remains that which is provided annually by NHS Digital on behalf of the four countries^[40] , and which, for the tax year 2018/19, was published on 10th September 2020. We invite DDRB to consider this report in its entirety, but for the purposes of independent contractor GPs in Scotland the report showed that:

257. The average taxable income for contractor GPs in General Medical Services in the UK was £121,800 in 2019/20. In Scotland the average taxable income for contractor GPs was £106,100.

Figure 4 – GPMS Contactor GPs – mean earnings and expenses by contract type, Scotland, 2017/18 and 2018/19 ^[41]

Contract Type	Year	Report Population	Gross Earnings	Total Expenses	Income Before Tax	Expenses to Earnings Ratio
GPMS	2018/19	3,300	£223,700	£122,400	£101,300	54.7%
		3,300	£241,100	£135,000	£106,100	56%
	Change	0	+7.8%	+10.3%	+4.8%	+1.3 Percentage Points
GMS	2018/19	2,950	£220,200	£119,300	£100,900	54.2%
	2019/20	2,900	£237,400	£131,600	£105,800	55.4%
	Change	-50	+7.8%	+10.4%	+4.89.7%	+1.2 Percentage Points
PMS	2018/19	350	£251,100	£146,800	£104,300	58.5%
	2019/20	400	£269,600	£160,800	£108,800	59.6%
	Change	+50	+7.4%	+9.5%	+4.4%	+1.1 Percentage Points

258. During 2017 the Scottish Government commissioned Deloitte to undertake a Review of GP Earnings and Expenses.^[42] This found that the average annual net income per Whole Time Equivalent (WTE)^[43] GP Partner (including NHS and Private earnings^[44] was £98,700. It also found that 70% of practice costs (on average) were staffing costs, followed by premises which accounted for 16% of practice costs.

Notes: Net income per partner GP is expressed in terms of Whole Time Equivalent; Source: Deloitte analysis based on Practices Accounts and Questionnaire.

259. There was some evidence indicating that partners in urban practices earned on average more than partners in remote practices. No correlation between average net income and deprivation was found. There was also some limited evidence that larger practices had a higher net income per partner GP than smaller practices.

260. The Scottish Government and SGPC agree that we need better information and evidence to inform both accurate recompense of expenses and options for the long-term overall development of GP pay in Scotland. To this end, the new contract mandates data collection. This includes requiring all practices to provide data on earnings, expenses, hours and sessions. This data will be held confidentially and processed by NHS National Services Scotland Practitioner Services. Only anonymised, non-identifiable data will be provided to the government and NHS Boards for the purpose of analysis.

Workforce Data for Scotland

261. The Primary Care Workforce Planning Survey Scotland 2019 captures aggregate workforce information from Scottish general practices and each of the NHS Board-run GP Out of Hours services. It provides the most comprehensive information available on the staffing cohort of general practice, both in hours and out of hours, but does not provide the cost. The costs of running a practice are a matter for the GP partners, including what pay they award employees. The 2019 survey was published in October 2021.^[46]

262. The 2019 results for Scottish general practices are based on survey data received from 830 responding practices. Of these, 76 did not fully complete the survey, 311 did not provide suitable unique identifiers (National Insurance Numbers) for their staff, and 40 practices submitted no GP data. The results include information on:-

• Estimated WTE numbers of GPs in post in Scottish general practices, along with information on patterns of sessional commitment by age and gender (a GP's week is typically defined in terms of sessions rather than hours, with a working day generally being comprised of two or sometimes three sessions).
• Estimated headcount and WTE numbers of nurse practitioners and other registered nurses employed by Scottish general practices, along with information on the age profile of these staff.
• Use of locum GP time and extra nurse time by Scottish general practices.
• Known vacancies for these professional groups in general practices from 1 April 2018 to 31 March 2019.

263. The 2017 results for GP Out of Hours (OOH) services are based on a survey of the GP OOH services in each of the 14 NHS Boards in Scotland. The results include information on:-

• The demographic profile of GPs working in GP OOH services in Scotland.
• The demographic profile of nurse practitioners and other registered nurses employed by GP OOH services in Scotland.
• The estimated GP (excluding Specialist Trainees) WTE increased from estimated 3,520 in 2017 to 3,613 in 2019, an increase of just under 3%.
• Routinely available GP headcount information^[47] indicates a slight increase in the numbers of GPs working in general practices.

1. Headcount from the NPCCD and excludes Registrar Trainee GPs

2. The Estimated WTE (in the absence of a 100% Survey response) was based on caling the sample headcount from the survey to match the national headcount from NPCCD. For more details see the methodology section.

3. Previous survey WTEs (up to 2017) have been adjusted according to the NPCCD headcount to ensure a consistent trend. Previously this was estimated using population and differed slightly from the NPCCD (then GPCD Headcount) see table As of the 2017 publication)

4. One WTE is defined in this report as eight weekly contracted GP sessions

5. As at 31 March for 2019, 31 August for 2017 and 2015, and 31 January for 2013

264. The estimated number (headcount) of registered nurses working in GP practices in Scotland in 2019 was 2,465, an increase of 168 from the 2017 survey. The estimated WTE for all nurses was 1,690 (based on 37 hours or more per week being full time), representing a rise of 149 compared to the 2017 survey.

265. The largest group of nurses working at General Practices were General Practice Nurses, accounting for 73% of the estimated Nurse headcount and 71% of the estimated Nurse WTE. The next largest group are Advanced Nurse Practitioners (ANPs) and Nurse Specialists, accounting for 20% of the estimated Nurse headcount and 24% of the estimated Nurse WTE.

266. The figures from this survey do not represent the entire registered nurse workforce working in Scottish general practices. They exclude nurses who are employed by NHS Boards but who work in independent contractor practices.

1. Figures are estimates based on population of practices returning data

2. One Nurse WTE is defined as 37 weekly contracted hours

3. As at 31 March for 2019, 31 August for 2017 and 2015, and 31 January for 2013

267. Overall, 86% of all responding practices reported the use of a locum GP during 2018/19, with the estimated use of 273 Locum GP WTEs. This is lower than the 333 WTE estimated from the 2017 survey.

Figure 6 - Number of internal locum sessions required over 12 months, Scotland; 2013 - 2017 ^[48]

NHS Board	Percent of Responding Practices Using a Locum GP	Estimated Locum WTE
Ayrshire & Arran	66.7%	10
Borders	84.6%	7
Dumfries & Galloway	100.0%	11
Fife	88.2%	16
Forth Valley	73.7%	9
Grampian	93.8%	18
Greater Glasgow & Clyde	90.5%	79
Highland	75.0%	18
Lanarkshire	79.2%	25
Lothian	97.4%	57
Orkney	80.0%	2
Shetland	100.0%	1
Tayside	93.1%	17
Western Isles	100.0%	4
Scotland	86.4%	273

1. Locum GP WTE calculated as the total number of locum sessions filled during 2018/19 divided by 416 (the eight sessions that make up a weekly WTE multiplied by the 52 weeks in the financial year).

2. The estimated WTE (in the absence of a 100% survey response rate) was based on scaling the sample headcount from the survey to match the national headcount from NPCCD. For more details see the methodology section.

3. The WTE for Scotland has been estimated separately from the WTE for each Board, so the Scotland total is slightly different than the sum of the Boards' WTE

268. There were an estimated 627 (headcount) Health Care Assistants and 410 (WTE) working in Scottish general practice in 2019 (as at March 31). This shows a lower headcount (estimated 787 in 2017) but slightly higher WTE (399 in 2017) compared with the previous survey. For phlebotomists, there were an estimated 104 (headcount) and 54 (WTE) working at General Practices in Scotland in 2019. This shows a lower headcount (estimated 281 in 2017) and WTE (89 in 2017) compared with the previous survey.

269. The 2018 GP Contract mandates the provision of workforce data to be made mandatory. This will facilitate workforce planning in the future.

Working Hours

270. The Primary Care Out of Hours Workforce Survey Scotland 2019^[49] gathered information on GPs working in GP Out of Hours services.

271. Results from the 2019 survey showed that younger GPs were more likely to input fewer hours with the average for under 35s being 3 hours and for 35 to 44 year olds, 6 hours per week on average. This contrasts to those aged 45 to 54, contributing 8 hours, 55 to 59 year olds contributing 9 hours, 60 to 64 year olds contributing 11 hours and those aged 65 years and over contributing 11 hours per week on average.

272. GPs aged under 35 years made up 20% of the OoH workforce, but their combined hours accounted for just 10% of the total hours. Likewise, for GPs aged 35 to 44 years, while they made up 37% of the workforce, their combined hours accounted for only 31% of the total GP hours worked in Primary Care OoH services. GPs aged 45 years and over made up 43% of the OoH workforce, but their reported combined hours accounted for 58% of the total GP hours worked in Primary Care OoH services.

273. During 2017 the Scottish Government commissioned Deloitte to undertake a Review of GP Earnings and Expenses.^[50] Like the workforce survey this was also based on a sample of GP practices, and found that GP commitment ranged from under 10 hours per week to over 60 hours per week.

Figure 7 - Average weekly working hours by Partner GPs ^[51]

p5	p25	p50	p75	p95
9.8	31.6	37.5	43	60

Source: Deloitte analysis based on Practices' Financial Accounts, Questionnaire and ISD Scotland

H.2 General Dental Practitioners

Introduction

274. This evidence refers to General Dental Practitioners (GDPs) that provide General Dental Services (GDS).

275. GDPs are independent contractors who have undertaken to provide NHS dental services on behalf of NHS Boards. They can be either GDPs who are owners, directors or partners of a dental practice (principals) or self-employed GDPs who enter into arrangemetns with principal GDPs – which is neither partnership nor employment (associates). Independent contractors may engage assistant dentists, including vocational dental practitioners, to assist with the provision of GDS.

276. The evidence provided in this submission is similar to the previous year and is substantially truncated because of the ongoing situation with Covid-19 and the impacts of that on the pay position of the sector.

Background

277. The impact of Covid-19 on the NHS dental service have been prolonged and significant. In the immediate response to the pandemic all high street dental practices in Scotland were closed for patient access from 23 March 2020. Care was provided through triaging arrangements within the GDS to refer urgent dental care to NHS Board run Urgent Dental Care Centres. The Public Dental Service role throughout the pandemic has been to support GDS in managing urgent care, alongside some elements of their core functions.

278. The subsequent return of NHS dental services to patients reflects a precautionary approach in the use of Aerosol Generating Procedures (AGPs), which produce a fine spray of moisture droplets in most dental treatments. The last year to date has seen an increasing amount of care being provided by dentists within the payment structure that is in place at present, however, overall activity levels are significantly below those pre-pandemic.

279. NHS dental practitioners have been supported to deliver care through the provision of PPE to them and also mitigating measures such as access to funding to improve ventilation in surgeries and red-band hand pieces (slow speed drills) which reduce the potential for AGPs being produced.

Policy context

280. During the pandemic financial support arrangements have been in place to support dental incomes because the payment system is designed to remunerate dentists for actual treatments. The level of actual treatments has been impacted due to AGP and wider public health policy to prevent the spread of Covid-19. From the beginning of the pandemic the government has been making £12m per month emergency top-up payments to support dental incomes, as well as £2.75m per month as targeted support. In total the government to date has provided an additional £50m to dentist during the pandemic , plus over £35m to provide PPE to the sector.

281. For NHS dental contractors this means that the emergency top-up payments have guaranteed 85% gross individual contractor Item of Service baselined against 2019/20. The government has also increased by 30% the General Dental Practice Allowance alongside maintaining all other allowances paid to contractors, including capitation and continuing care. The link between payment for activity and value of payments was initially broken at the start of the pandemic due to the cessation of high street services and introduction of emergency top-up payments, however, over the last period actual activity has been increasing due to the government signalling the intention to bring these arrangements to an end from 1 April 2022. This is broadly in line with other sectors of the economy where pandemic related support payments

282. The government is focusing on supporting the NHS dental sector to recover patient access to care through the Item of Service payment structure as the main source of income available to contractors. Item of Service is crucial to ensuring that patients do receive care within the NHS as the fee structure supports remuneration for dentists in providing care to patients and also provides transparency within the system to show that payments are being made for necessary care and treatment.

283. The trend in recent months is that NHS dental activity has been gradually increasing, however, it remains substantially lower than pre-pandemic. The Cabinet Secretary for Health has set out to the profession that financial support arrangements are to end and this appears to have had a galvanising effect on the sector in terms of activity being undertaken. The intention to remove the emergency top-up payments from 1 April 2022 means that contractor income will be re-linked back into the level of activity being undertaken. It is not possible to confirm the final arrangements of the approach to payment structure at present due to live negotiations between government and the BDA on these matters.

Recovery before reform

284. The Cabinet Secretary's letter of 21 October, has set out to the profession that it is essential that NHS dental services are allowed the opportunity to recover and stabilise in the medium term before the sectoral reforms are considered, in particular in the light of manifesto commitment to remove patient charges from the system. The policy position has evolved to focus on recovery and stability to enable improved conditions for the sector and public to more fully engage with the significant consultative process that will be necessary to discuss reform.

Pay Award for 2021/22

285. Scottish Ministers accepted the 3% DDRB pay award recommended for GDPs in 2021/22. In normal circumstances the award would be made on item of service and capitation and continuing care payments, with the government then paying the net fee and the remaining element met by patient charge payments. For 2021/22 it was possible to make the main element of the pay award in the normal manner, however, due to the nature of the emergency top-up arrangements an additional element was added to ensure that contractors were able to see the full value of the award.

H. 3. Consultants

286. A tripartite forum with MSG (NHS Scotland employers/Scottish Government) and BMA Scotland meets regularly to discuss matters of common concern and, where appropriate, produce joint guidance on these areas.

H. 4. Distinction Awards (DAs) and Discretionary Points (DPs)

287. Since 2010, no new DAs have been made, the only Consultants still receiving these are those who were successful prior to the freeze being imposed. We have been clear that that existing arrangements for DAs and DPs would remain in place and our position, since 2010 has been that to increase or restore DADPs would go against SPSPP.

288. The Scottish Government values the enormous contribution NHS Scotland staff makes to our health service. It is right that our aim is to attract and retain highly skilled and much sought-after staff. There is no evidence to suggest that an adverse impact has resulted from the freezing of the value of DADPs.

289. Although DAs are frozen to new consultants, the availability of new DPs increase in line with the number of consultants in post. Scotland continues to offer an attractive pay package for Consultants along with the continued guarantee of No Compulsory Redundancy.

290. We are therefore not seeking any recommendations from DDRB and distinction awards and discretionary points.

H. 5. Junior Doctors

291. Engagement with junior doctors continues through our regular tripartite forum (Scottish Government, Employers and BMA).

292. Following a commitment made by the First Minster, an expert working group was commissioned in 2017 by the Cabinet Secretary to explore options and changes necessary to reduce Junior Doctor working hours to a maximum of 48 hours per week without averaging.

293. Although the groups final report has concluded that "A 48 hour maximum working week (without averaging) for Junior Doctors "cannot be safely achieved within current service models and staffing establishments in NHS Scotland", the Scottish Government remains committed to this policy.

294. We acknowledge that implementation of this policy will not be easy and will involve system wide considerations. We also acknowledge that our immediate focus must be on supporting NHS Scotland in the recovery and remobilising of services. We are however already engaged with the BMA in order to identify and progress key issues and aspects, which can improve the safety, wellbeing, and overall effectiveness of Junior Doctors, and the service provide to their patients.

H. 6. Speciality and Associate Specialists (SAS) Doctors and Dentists

295. The Scottish Government declined to join contract discussions with the rest of the UK on SAS doctors. Instead, it was agreed we would seek a Scottish solution to reform the Speciality Doctor contract, including the potential development of a Senior Speciality Doctor grade.

296. As the COVID-19 pandemic hit in March 2020, it was agreed by Cabinet Secretary that pandemic response would be the priority, and that routine work would pause to allow resources to be deployed to support the NHS in the response to COVID-19.

297. The Scottish Government continued dialogue with employers and BMA Scotland, and in June 2021 the Cabinet Secretary for Health and Social Care approved a mandate for negotiations to begin.

298. Discussions have been constructive and all parties are pleased with the progress that has been made. Recognising the complexity of discussions and that it is important to reach an agreement that works for all, we have collectively agreed to extend negotiations in to early 2022 to allow us more time to agree a contract that works for all and ensures NHS Scotland remains an employer of choice for SAS Doctors.

H. 7. Locums

299. Due to the ongoing Covid-19 pandemic and response, we are unable to report on this aspect at this time.