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Modernising NHS Dental Services in Scotland: Analysis of Responses
EXECUTIVE SUMMARY
A Scottish Executive Health Department consultation on Modernising NHS Dental Services in Scotland took place between 20 November 2003 and 2 April 2004. A consultation paper was issued to which 203 responses were received from a wide range of professional and lay individuals and organisations with an interest in the future of NHS dentistry.
The written consultation exercise 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 organised by the Consumers' Association, informal meetings between officials from the Scottish Executive Health Department and key organisations, and 3 additional meetings attended by the Deputy Minister to discuss the consultation issues with a variety of interests.
This report presents an analysis of the responses to the written consultation. The findings will inform the response by Ministers on possible ways in which to reform NHS dental services in Scotland.
The response to the consultation was encouraging in terms of the participation of a wide range of responding bodies from across a broad spectrum of stakeholder sectors, the detail of their commentary and the innovative, yet pragmatic ideas for change that they submitted. No obvious gap in respondent category was identified. However, possible "silent voices" were, perhaps, those of young people and those of members of minority ethnic communities.
The consultation document was structured around 3 main topics: What sort of dental services should be provided under the NHS? How should dentists' contractual arrangements look like if they are to support the delivery of these services? How should patients contribute to the costs of the service? These topics were further sub-divided into 12 specific issues for consideration. Consultees opted to respond to all or some of these issues.
OVERVIEW
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.
An overarching view was that the consultation was necessary in view of what were seen as the current and increasing difficulties in the delivery and funding of NHS dentistry. The exercise was seen as an opportunity to work out Scottish solutions to these issues in parallel with those being developed south of the border. There was a confidence that Scotland could formulate its own way forward, independently from England, but learning lessons from the English pilots and other such initiatives.
Many dental practitioners appeared to be proud of their past and current provision of NHS dental services but were concerned about the increasing difficulties they were experiencing, including the tension between providing what was seen by many as a public service whilst attempting to make a living and cover infrastructure and staffing costs.
Compared with other consultations, this exercise appeared to be characterised by diversity rather than consensus of views. Different views were expressed even from within respondent sectors. Such a variety of views suggests that the issues under consideration are not clear-cut and there may well be many different ways of going about delivery and funding, all of which may to some degree favour some and perhaps disadvantage others.
Another reason for the diversity of views could be that there appeared to be such a wide diversity of contexts within which the system has to fit. These ranged from geographical areas, to contexts relating to different patient types and needs. A recurring theme was that one size of system would not fit all contexts and local flexibility would be necessary, albeit nesting within a standardised, national framework for NHS dentistry.
The theme of standardisation emerged in several guises. Calls were made for any system of charging for dental care to be consistent nationwide across the General Dental Service (GDS), the Community Dental Service (CDS) and hospital settings with a standard approach to charging across primary care in general. There were requests for consistency in quality assurance targets and standards, with a few respondents also requesting standardisation of complaints and disciplinary proceedings. The perceived current inequality of access to NHS dentistry was considered by many to be unacceptable and innovative ideas for incentives, rights and responsibilities of practitioner and patient were put forward in an attempt to standardise provision across Scotland. Many respondents referred to parallels in general medical practice and called for compatibility of salaries, funding, practice and other operational issues across different primary care services.
A plea was made 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. There was a host of ideas suggested for closer working and sharing between dental and other health care professionals.
A sea-change in favour of facilitating an emphasis on prevention emerged as a key priority. Consultees described their views that current funding and delivery systems were stacked against the promotion of prevention. Responses clearly displayed willingness amongst practitioners, Professions Complementary to Dentistry (PCDs) and wider health care staff to tackle prevention, if supported by appropriate systems which incentivised this approach and did not leave them disadvantaged. In this respect, the need was seen for funding of NHS dentistry to be much more closely aligned with strategic oral health priorities.
Another issue raised by respondents and attracting many imaginative ideas was that of perceived dental workforce shortages. This was linked to difficulties encountered in the retention of trained staff. Again, many suggestions were made relating to training and retaining staff by respondents from several sectors. Suggestions tended to be pragmatic and represented both carrot and stick approaches. For many, simply providing more training places was not enough. These needed to be supported by a closer alignment of training with the reality of practice.
New graduates were seen by some to need a greater guarantee of income in their early years, perhaps by supporting them with a time-limited salary in return for a specified NHS commitment. Dentistry as a career was viewed as in need of an image make-over to attract aspirations even from school children in considering their future careers.
DETAILED FINDINGS
General Comments (
Chapter 4)
A general view was that current NHS dentistry was out of step with current and future demands and expectations
Three key problematic issues raised by respondents were difficulties with access to NHS dentistry, lack of support for NHS dentists and lack of appropriate incentives
What sort of dental services should be provided under the NHS (
Chapter 5)
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
Some respondents considered that only vulnerable groups should have access to a comprehensive dental service provided by the NHS
Many respondents suggested that initial dental assessments should be provided within the NHS, although views were mixed on the treatment which the NHS should subsequently provide
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 these in certain circumstances
An emerging theme was that the new system should allow for some flexibility in accommodating technological advances and trends in public expectations
Systems for Reviewing and Updating
An overarching view was that the system for review and update should be transparent and inclusive
A common view was that the system should be evidence based but there were different opinions on the frequency of review and the most appropriate review body
Several respondents recommended 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 in the current balance towards more preventative services, but that this change should be gradual to enable contemporary needs for repair to be addressed
The current funding system was seen as lacking in incentives to encourage an expansion in the delivery of preventative services
One theme to emerge was that health care 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 to particular sectors of the population
A recurring view was that a preventative based service would require a far greater investment than at present, with financial incentives aligned with strategic preventative goals
Role of the 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
For many respondents, CDS had specialist skills which were essential in the dental public health role
Consultees requested a clarification of the CDS role
A minority view was that the dental public health and the "family health" role of dentistry should be merged as any divide between them was artificial and unhelpful
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? (
Chapter 6)
Views on Delivery Options
There was much support for the training of Professions Complementary to Dentistry (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 reflected the true costs of treatment and allowed for quality time with patients
No one preferred option for funding the delivery of dental services emerged
The overwhelming consensus was that current fees on the fee per item scale were inadequate, with many criticising the scale for being overly complicated and cumbersome
A salaried service was seen as expensive to support but as having many advantages
One common concern was that a capitation system might lead to patient neglect although there was support for this option if accompanied by a quality checking system
The current patient registration system was viewed as poorly understood, out of step with other healthcare practice and inappropriate in certain circumstances
Sessional payments were regarded as appropriate for specific, more challenging cases
The balance of views was in favour of practice focused funding
Issues of Infrastructure Funding
Dental practice owners were seen as facing increasing costs including those for IT, responding to new professional and legal obligations including the Disability Discrimination Act
A general view was that dental practice owners should receive some financial support from the NHS to help them meet these costs
Views on Other Approaches and Incentives
Many respondents welcomed the Practice Improvement Grant but saw the start up grant as unfair
The notion of attracting NHS funding in return for providing NHS dentistry services found favour with a substantial volume of respondents
Many consultees highlighted their vision of a future dental service, co-located with other health professionals, within purpose built NHS premises
There was some concern that practices which have already invested substantially in their premises should not be disadvantaged, compared with others, in any future funding support
Implementing new Arrangements
The majority view was in favour of a phased, carefully managed implementation of any new arrangements
Some thought that partnership work involving professional groups should precede any changes which should be piloted prior to full implementation
A recurring theme was the need for new arrangements to be underpinned by a framework of Care Standards, Guidelines and quality targets
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 if it was robust and well funded
Some suggested that new graduates should require to work in 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
Options for Change
How should patients contribute to the cost of the service? (
Chapter 7)
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 of those who commented were in favour of the plans for free dental check ups
Most suggestions for patient charges recommended a mix of free, subsidised and charged dental treatment
A call was made for greater standardisation in charging
Consultees wished to see a simplification of patient charges with greater transparency and fairness in pricing
There was overall agreement with the current exemption categories with the exception of pregnant and nursing mothers
Consultees emphasised that any charging system should be transparent and should not be open to different interpretations or disputes between dentist and patient
Views on Options for Patient Charges
There was much support for single (specific) charges for specific procedures
The balance of opinion was against changes to the percentage charged depending on the nature of the service or a patient's characteristics
The balance of opinion was against a fixed charge for each visit to the dentist
The balance of opinion was for separate payment arrangements for dental appliances
Around two-thirds of those who commented favoured some form of insurance scheme as a way of charging patients for treatment
Other Approaches
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 the health board, Scottish Executive or a debt collection agency
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