The Scottish Government

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Main Findings

• The consultation was welcomed as timely and necessary in view of what were seen as the current and increasing difficulties in the delivery and funding of NHS dentistry. Overall, current NHS dentistry was seen as being out of step with current and future demands and expectations.
• A general view was that the exercise provided an opportunity to work out Scottish solutions to these difficulties in parallel with those being developed south of the border. There was a confidence that Scotland could formulate its own way forward, learning lessons from the English pilots and other such initiatives.
• Three key problematic issues raised by respondents were difficulties with access to NHS dentistry, lack of support for NHS dentists and a lack of appropriate financial incentives.
• The consultation responses were characterised by their diversity of views even from within respondent sectors. Such variety suggests that the issues are not clear-cut with merits and drawbacks associated with each of the options available.
• A recurring theme was that in view of the wide range of geographical contexts within which any new system must operate, and the diverse needs of different groups of patients, one size of system will not fit all requirements. A call was made for local flexibility nesting within a standardised, national framework for NHS dentistry.
• Many respondents highlighted their concerns regarding inequality of access to NHS dentistry with innovative ideas put forward for incentives, rights and responsibilities for dentists and patients to remain within the NHS framework and standardise provision across Scotland.
• Several respondents referred to parallels in medical practice and called for compatibility of salaries, funding, practice and other operational issues across different primary care services.
• A common plea was for better integration of dentistry within the body of primary care. The perceived isolation of dental practice from the mainstream health care provision was seen by some as the root of many of the current problems.
• A sea-change in favour of facilitating an emphasis on prevention emerged as a key priority. An overarching view was that current funding and delivery systems were stacked against the promotion of prevention and that the funding of NHS dentistry required to be much more closely aligned with strategic oral health priorities in this regard.
• A central problem was perceived to be a shortage in the dental workforce linked to difficulties encountered in the retention of trained staff. A host of suggestions were made to tackle the problem including greater use of outreach placements during training and offering new graduates a time-limited salary in their early years of practice in return for a specified NHS commitment.

Introduction

The consultation on Modernising NHS Dental Services in Scotland took place between 20 November 2003 and 2 April 2004. During the course of the consultation over 5000 documents were distributed. After a launch distribution of around 2000 copies, further documents were issued in response to requests, and more copies were distributed along with invitations to a series of consultation events around Scotland. The consultation was also made available on the Scottish Executive website.

The consultation paper strove to promote a mature, constructive and inclusive debate to inform future policy. It cautioned, however, that no change is possible without some degree of risk to the stability created within the existing framework. The paper raised a series of issues and questions around each of 3 broad themes:

• What sort of dental services should be provided under the NHS?
• How should dentists' contractual arrangements look if they are to support the delivery of these services?
• How should patients contribute to the cost of the service?

The written consultation attracted 203 responses with some of these representing combined views of groups of consultees.

The written consultation was supported by other consultative mechanisms including a series of consultation events held around Scotland, a seminar and panel discussion attended by the Deputy Minister and informal meetings between officials from the Scottish Executive Health Department and key organisations.

Aims and Objectives

The aim of the research was to analyse the comments contained in written responses to the consultation on "Modernising NHS Dental Services in Scotland", to present the findings of the analysis and to identify any gaps in respondent sector.

Methodology

Responses to the consultation were sent to the Scottish Executive consultation team either in hard copy or via e-mail. The consultation team sent copies of each response to The Research Shop for analysis.

An electronic Excel database was used to store and assist analysis of the responses. The main challenge for the analysis was the relatively large quantity of detailed free text material submitted by professional stakeholders.

Although responses tended to follow the broad framework of issues and questions for discussion set out in the consultation paper, some introduced further topics or focused on one specific aspect of NHS dentistry and expanded on that. The Excel database fields used to record the material were based largely on the topics set out in the consultation paper but also included a small number of additional fields to accommodate the further themes which arose.

A small team of researchers worked through all responses using a well established set of ground-rules which served to promote consistency in handling and recording of the comments contained in the responses. Relevant comments from each response were extracted and entered into the Excel database under the appropriate field.

The analysis of comments was then undertaken based on the extracts contained in the database and reference to the original submissions as required. Most of the analysis was qualitative in nature although where scope for quantitative analysis existed, this was exploited.

The views presented were not vetted in any way for factual accuracy. The report may, therefore, contain analysis of responses which may be factually inaccurate, but nonetheless reflect strongly held perceptions.

What sort of dental services should be provided under the NHS?

The consultation paper posed a number of specific questions about the future extent and nature of NHS dental services.

Overarching views were that there should be a consistency about, and a national standardisation of, future NHS services. Such services should be evidence based and clinically effective. It was considered that any proposed model should enable patients to pick from a menu of both NHS and private treatments in a manner which focuses on patient needs rather than professional demands.

A common view was that a core of dental treatment should be available under the NHS, but differences emerged between respondents in their views of what the core should comprise.

Views showed the greatest diversity in relation to the extent to which the NHS should provide cosmetic dentistry and orthodontics. For some these fell outwith the NHS remit. Others saw the need to provide them in certain circumstances. Overall, respondents considered that the new system should allow for some flexibility in accommodating technological advances and changing trends in public expectations.

An overarching view was that any system used for reviewing and updating should be transparent and evidence based, with a few advocating that patients and other stakeholders be involved in the review and update system.

Balance Between Preventative and Repair Services

Respondents considered that a shift was required towards more preventative services, but that this change should be gradual to enable contemporary needs for repair to be addressed. However, the current funding system was seen as lacking in incentives to encourage an expansion in the delivery of preventative services.

A key theme to emerge was that health professionals outside dentistry had much potential to input to a future preventative strategy and indeed, may have more specialised skills than dental practitioners to promote such a message.

Role of Community Dental Service (CDS)

On balance, views were tipped in favour of maintenance of separate roles relating to the dental public health and the "family health" role of dentistry in the community. Many respondents considered that practitioners working in the CDS had specialist skills which were essential in the dental public health role.

A recurring theme was the call for a patient centred "seamless service" in which care could be provided by a range of deliverers as appropriate.

How should dentists' contractual arrangements look if they are to support the delivery of these services?

Dominating views focused on the potential for an enhanced role for Professionals Complementary to Dentistry (PCDs) in the delivery of dental services, and the balance between a national framework and local flexibility in delivery.

Views on Delivery Options

There was much support for the training of PCDs to take on a greater role in the delivery of dental services and the removal of current restrictions which curtailed any enhanced role.

In the context of the delivery of local dental services, it was considered that one size does not fit all. The consensus was for local flexibility within the overarching confines of a national framework for delivery. Respondents saw benefits in dentistry being better integrated within the wider healthcare team.

Views on Funding Options

A substantial volume of respondents called for increased funding for dentistry to a more realistic level that adequately reflects the true costs of treatments and allows for quality time with patients. However, no one preferred option for funding the delivery of dental services emerged from responses.

The current fees on the fee per item scale were viewed as inadequate; a salaried service was seen as expensive to support although having many advantages; a common concern was that a capitation funding system might lead to patient neglect unless underpinned by a quality checking system; and sessional payments were regarded as appropriate for specific, more challenging cases.

The notion of attracting NHS funding in return for providing NHS dentistry services found favour with a substantial volume of respondents.

Infrastructure Funding

Dental practice owners were seen as facing increasing costs including those for IT and responding to new professional and legal obligations such as the Disability Discrimination Act. A general view was that they should receive some financial support from the NHS to help them to meet these costs.

Workforce Issues

A common theme was to increase the volume of training places for dental practitioners and PCDs. Incentives to support the return to work of leavers and those who have retired early were suggested. Outreach training for under-graduates was supported as was the idea of requiring new graduates to work within NHS dentistry for a specified time period following graduation.

There was a call for the development of a career structure for dentists and PCDs which recognised and rewarded those with specialist skills.

Implementing New Arrangements

The majority view was that the introduction of any new arrangements should be phased and carefully managed, with piloting as appropriate. A recurring theme was the need for the new system to be underpinned by a framework of Care Standards, Guidelines and quality targets.

How should patients contribute to the cost of the service?

The topic of patient charging produced a substantial volume of responses relative to other topics. Views provided were a mix of those based on idealism and those based on pragmatism.

Principles

There were mixed views on the retention of charges for NHS treatment. Some consultees adhered to the principle of free NHS treatment at the point of delivery; others maintained that charges should remain in order to better regulate supply and demand of dental services and to provide an incentive for better oral health.

Most commentators were in favour of the plans for free dental check ups. There was overall agreement with the current exemption categories with the exception of pregnant and nursing mothers.

Most suggestions for patient charges recommended a mix of free, subsidised and charged dental treatment. Calls were made for a simplification of patient charges with greater transparency and fairness in pricing.

Views on Options for Patient Charges

There was much support for single (specific) charges for specific procedures. The balance of views was against changes to the percentage charged depending on the nature of the service or a patient's characteristics. It was also against the idea of a fixed charge for each visit to the dentist. Around two-thirds of those who commented favoured some form of insurance scheme as a way of charging patients for treatment.

Suggestions for a variety of other approaches for payment were made including a voucher scheme, smart or swipe card or regular savings card.

A recurring theme was for dentists to be protected against bad debts, perhaps by these being dealt with separately by another body.

Overview of Consultation

Overall, the responses to the consultation were wide-ranging, based on personal and professional experience and provided a depth of comment of much value to inform decisions on the future of NHS dentistry in Scotland. Although responses tended to follow the broad framework of issues and questions for discussion, some introduced further topics for consideration or provided commentary rather than any firm recommendations on potential changes.

The volume of responses was substantial with evidence of some respondents putting much effort into widening the consultative process by, for example, consulting a public panel of 500 people, collecting comments from workshops held at a staff meeting, issuing a questionnaire to collect comments from a particular target group, and discussions at various group and practice meetings. Many other examples existed of such wider distribution and discussion of the document and demonstrate a broad respondent base and significant depth of engagement with the consultation exercise.

No obvious gaps in respondents emerged. The consultation attracted a sizeable volume of responses from a wide spectrum of respondents representing a variety of perspectives. Remote, rural and urban locations were also represented amongst respondents. However, possible "silent voices" were perhaps, those of young people and those of members of ethnic minority communities. This observation is consistent with respondent gaps noted in similar consultation exercises.