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Modernising NHS Dental Services in Scotland: Analysis of Responses

CHAPTER 5: WHAT SORT OF DENTAL SERVICES SHOULD BE PROVIDED UNDER THE NHS?

The consultation stated:

Dental services provided under the NHS in the community are currently defined in the 1978 NHS Scotland Act. The detail for general dental services is contained in the GDS Regulations and Statement of Dental Remuneration (SDR), and for community dental services in guidance and circulars. CDS could largely be described as GDS for special needs groups or for those who cannot access GDS through normal routes. The exception is the "dental public health" service set out in Section 39 of the 1978 Act which provides for the dental screening of school pupils by the CDS. If we are to make the best use of the workforce in the future, we should look at the full range of professionals working in the community and target the whole service to meet local needs in the most effective way. This implies a more cohesive and integrated approach to primary care dental service provision.

The current service is intended to promote oral health and "dental fitness". It now includes a range of prevention and treatment approaches, with a mixture of general and specialist services. Specialist services in the community are primarily orthodontics, with an increasing number of other specialist practitioners in e.g. surgical dentistry. Patients can be referred from other practitioners or services.

There are already restrictions on the range of services which can be provided under GDS; examples of excluded items include certain types of white fillings, tooth coloured crowns on molar (back) teeth, and dental implants. Technological change affects dentistry as much as other aspects of clinical care, and the current system is not adept at responding to these changes. However, any extension to the current service, through treatments new to the NHS, will have an inevitable cost impact, whether met directly by the NHS or by patients.

Equally, it could be argued that what is already available under the NHS is more than is essential to deliver oral health and dental fitness. For example, it has been suggested that aspects of orthodontic care and some crown restorations are cosmetic, and that treatments such as crowns and bridges go beyond what is absolutely necessary in this regard.

There is, therefore, a need to define what the NHS is there to provide and at what cost (directly or indirectly). There is also, as with other NHS services, a wish to focus more on prevention (where evidence based) in order to reduce the demand for "care and repair" services. This is not just an issue for children (although that has been the main focus to date) but increasingly for adults and particularly for older people.

The consultation paper posed a number of specific questions about the future extent and nature of NHS dental services. This chapter is structured to present the responses to each question in turn.

5.1 WHAT SERVICES SHOULD COME WITHIN THE NHS FOR THE FUTURE? SHOULD THEY BE PRESCRIBED AND LIMITED OR UNLIMITED?

Around one-half of all responses contained comments on future NHS services. Responses were extremely varied and ranged from a few words, to lengthy and detailed suggestions for change. An examination of the relevant commentary revealed that respondents interpreted this question in a number of ways. Whilst most focused on suggestions for NHS services, within the current framework (e.g. with patients contributing towards this), a few other respondents appeared to be focusing on the operation of a "free" service and provided comments on the nature of groups they considered should come within the scope of this.

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. However, 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 focused on patient needs rather than professional demands. In short, future services should be, " accessible, acceptable, available, appropriate and affordable" (Dent 79).

Who Should Decide?

A small minority of respondents commented that the question was not for them but should be directed at politicians (Dent 39, Dent 45); at patients (Dent 5, Pat Rep 17); or perhaps at a partnership "board" comprising membership from public, professional and management perspectives (Bod 7, Prof Rep 32).

Notion of "Core" Treatment

A substantial body of responses from a range of respondent categories referred to the notion of "core" dental treatment being retained under the NHS. However, a number of them raised the immediate issue of how to define "core". One view was that this was difficult to define in view of differences between patients in what could be considered essential for physical and psychological reasons (Dent 11). Others recommended not too rigid a definition (Pat Rep 17) to enable the relationship between oral and other health to be maintained. Broad approaches were offered, such as services which allowed the public to maintain a level of oral health which does not injure their general health (Dent 19); or treatment necessary to reduce or eliminate any existing pathology (Dent 62); or a basic level of treatment, as comprehensive as possible with some degree of flexibility (Dent 79). One view was that a "core" should be developed that was simple and straightforward for all to understand (Bod 24). One parameter suggested was that the core should comprise all services which could be delivered by a dental therapist (Dent 50).

Comprehensive Service?

A smaller, but still significant body of respondents questioned the notion of "core" with the view put forward that such an idea was not prevalent in other branches of the NHS (e.g. a patient would expect a birth mark to be removed, so why not treatment for brown teeth? (Prof Rep 12, Prof Rep 21)).

A common view was that a "comprehensive" and appropriately funded dental service should be available within the NHS, although this was frequently qualified with specifications of particular groups which should be targeted, such as those with special needs (Bod 22, Bod 17); "learning disabled" patients (Dent 87); or "vulnerable groups" (Bod 5). Other views were that all current NHS dental services should continue (Dent 80, Dent 82); or that all services that dental practitioners had trained for should be included to prevent a "waste" of training (Pat Rep 6). (Although note one respondent's comments that what is available now is more than essential to deliver oral health (Dent 5.)) Another frequently expressed view was that all services for children should fall within the NHS in future (e.g. Dent 21, Dent 86, Dent 87, Bod 4, Bod 22, Bod 20, Bod 28, Prof Rep 20).

Proposed Aspects of an NHS Service

The majority of those who commented provided relatively pragmatic responses on what should fall within and outwith the scope of the NHS. Comments are summarised below.

Dental Assessments

Several respondents recommended that a regular dental assessment and diagnosis be incorporated into NHS care. The frequency of this varied from a one-off event (e.g. Dent 8) or twice yearly occurrence (Dent 22) to assessment frequencies dependent on clinical need (Pat Rep 11). The idea of an initial NHS assessment and course of treatment to make patients "dentally fit" found favour with a minority of respondents (Dent 27, Dent 29, Dent 85, Prof Rep 25) with one suggesting an added patient incentive of further NHS services as a reward for the patient's maintenance of oral hygiene (Dent 27).

Several respondents specified particular treatments which they considered should fall within the NHS or outwith. Figures below should be regarded as indicative rather than precise, based as they are purely on those who chose to comment.

Emergency Treatment and Pain Relief

A common recommendation from across many respondent sectors was for emergency treatment and/or pain relief to be included within the umbrella of the NHS. Several respondents suggested that NHS 24 could provide an obvious linkage between dentistry and other health services, with one single point of telephone access to the NHS (e.g. Educ 2, Bod 19, Bod 17).

Prevention Advice/Treatment

Around one-quarter of those who responded recommended that future NHS services should encompass preventative advice and treatment. One key benefit was envisaged as facilitating a greater quality of communication between dentist and patient.

Orthodontics

Views on the inclusion of orthodontic services within the NHS were mixed with no clear consensus emerging. Some respondents considered orthodontic services for children should be included as of right (Pat Rep 6, Pat Rep 15). Other respondents were more circumspect, however, advocating that NHS orthodontic services should be restricted to "severe" cases (e.g. Bod 22, Bod 15, Prof Rep 28, Prof Rep 20), or where the Index of Treatment Need (IOTN) indicated this as necessary (Dent 62, Dent 81, Bod 7, Bod 29).

Cosmetic Treatments

The provision of cosmetic treatments on the NHS also generated a mix of views, with respondents split between those who ruled out any NHS cosmetic treatment (e.g. Dent 21, Dent 49, Bod 17, Pub15) and those who suggested some cases may deserve NHS consideration (Dent 29 - to make people psychologically fit, Dent 30 - essential cosmetic treatment to maintain the welfare of the patient, Pub 16 - apply rules "sympathetically" where personal appearance is concerned).

The comments provided on orthodontics and cosmetic treatments reflected one of the emerging themes of the consultation: that of building into any new system the flexibility to facilitate current and future trends in new and advanced technologies and indeed in public expectations of dentistry services (e.g. Dent 78).

5.2 WHAT SYSTEM SHOULD THERE BE FOR REVIEWING AND UPDATING?

Thirty five responses contained specific reference to reviewing and updating systems. Amongst these, it was generally agreed that the need for review and updating arose from, inter alia, ongoing changes to population demographics, the emergence of new evidence on clinical effectiveness and changing disease patterns. It was noted that regular review contributed to keeping the service responsive and fluid (Dent 34). A variety of suggestions was made for the timing and structure of future review, but an overarching plea was for a transparent and inclusive system.

Frequency of Review and Updating

No consensus emerged amongst the minority of respondents who suggested a frequency for a future review and updating system. A few envisaged an ongoing exercise (Dent 29, Dent 68, Prof Rep 1). Others recommended an annual examination (Dent 34, Dent 84) perhaps supported by a 10 yearly study of impact on the nation's oral health (Dent 84). One response suggested a bi-annual frequency of review and update (Dent 19), and another a quinquennial exercise (Dent 50). One further recommendation was for a 3-5 year review (Bod 7, Prof Rep 32).

Evidence Based Review

Many of those who responded urged that any review should be evidence based. Indeed, two respondents suggested that the timing of the review should be linked to the arrival of new evidence (Bod 23, Bod 7). Other suggestions were for the establishment of a system such as that of the Scottish Intercollegiate Guidelines Network (SIGN) (Dent 30), with evidence made accessible for patients and healthcare providers (Educ 2). In the context of research based evidence, the Scottish Dental Practice Based (SDPB) research network was welcomed (Bod 22, Bod 20, Bod 28, Prof Rep 20) with a recommendation that review be carried out under the auspices of the SDPB, using their software (Dent 79).

Who Should Undertake the Review?

The suggestion of a role for the SDPB in review and updating has been mentioned. Other suggestions were made for appropriate review bodies. These included:

• Independent Review Body (Dent 46, Pat Rep 4)

• Scottish Executive in conjunction with dental profession (Dent 9)

• NHS/Quality Improvement Scotland (Dent 78, Prof Rep 14, Dent 79)

• Partnership Board (Prof Rep 32)

• Community Health Partnerships through the Performance Assessment Framework (Dent 79)

Further thoughts were that whatever the system, it should involve all those directly affected by NHS dentistry, - including patients, GDS and the Scottish Executive Health Department. Finally, one view was that the issue of review and updating was one for politicians, not this consultation (Dent 87).

5.3 WHAT IS THE RIGHT BALANCE BETWEEN PREVENTATIVE AND REPAIR SERVICES AND WHAT, IN PARTICULAR, SHOULD BE INCLUDED IN THE FORMER?

Seventy-eight responses provided comment on these issues with most detail emerging from the professional respondees. Overarching views were 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 continue. A move to more preventative services was viewed as a cost-effective strategy with long term gains to be had. Prevention was seen by many to be currently marginalised for a variety of reasons.

Future Emphasis on Prevention

Many respondents stated simply that a greater emphasis on prevention was required (e.g. Dent 7, Dent 23, Dent 29, Dent 34, Dent 67, Pub 15, Educ 2, Bod 19, Bod 5, Bod 15, Bod 17, Bod 7, Pat Rep 5, Dent 78, Dent 68, Dent 79, Prof Rep 32, LG 1 and others).

Several responses highlighted what was seen as a current lack of incentive to encourage an expansion in the delivery of preventative services. A selection of views provided by dentists is below:

• Ironically, although prevention was cheap to deliver, it took up considerable surgery time, which was a disincentive to dentists (Dent 22)

• There is no incentive for the dentist who has looked after the same patients for many years and, through good preventative advice now has a less lucrative caseload (Dent 33)

• Dentists do not get paid to advise/monitor, treat preventatively, but get paid to leave teeth until the damage occurs and then correct it (Dent 47)

What Should Prevention Services Delivered in Dental Practices Include?

A variety of suggestions were made for the scope of preventative services which could be delivered within dental practices (e.g. Dent 19, Pub 15, Bod 5, Bod 15, Pat Rep 17). Some respondents provided detail of particular treatments. Most commonly cited were:

• Fissure sealants

• Topical Fluorides

• Fluoride varnish

• Xylitol gum

• Simple scaling

A small number of respondents referred to groups which they considered dentists should target when providing preventative services. These included children (Dent 70, Bod 14), new school entrants (Pat Rep 5) and older people (Educ 1).

Interestingly, a few responses advocated smoking cessation (Bod 9, Prof Rep 14, Dent 79) and healthy eating advice (Bod 5, Dent 79, Dent 86) as part of a preventative service package.

Delivery of Preventative Services

Many respondents emphasised that the delivery of preventative services need not be restricted to dental practices. One view was that professionals with much less dental service specialism could undertake this work - after all, cardiologists do not spend their valuable time lecturing primary school children on the effects of cholesterol (Prof Rep 19). Another comment was that attached to all dental practices could be a person with prevention responsibilities who could do outreach in addition to practice work (Prof Rep 21). Other respondents suggested what they perceived to be appropriate vehicles for the delivery of prevention. Most commonly cited were:

PCDs (e.g. Dent 65, Pub 15, Bod 15, Bod 17, Bod 14, Pat Rep 11)
Hygienists (e.g. Dent 50, Dent 78)
Salaried therapists (e.g. Dent 77, Educ 4)
Oral Health Action Teams (e.g. Bod 5, Prof Rep 5)

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 such as children and older people. Previous successes and lessons learned within Scotland were cited by a few respondents. For example, a risk-based holistic preventive care initiative for pre-school children working with health visitors (GETCAPP project in Dundee) (Educ 1). Learning from practice in other countries emerged as another theme in the consultation and was particularly pertinent to the issue of preventative services. Work in Denmark with children in rural areas and the adoption of the International Caries Detection and Assessment System advocated by WHO were also highlighted (Educ 1).

Two respondents considered that the new Community Health Partnerships could provide the opportunity to promote prevention via closer links between interested professional organisations and sectors (Bod 12, Dent 79). Finally, a small number of consultees recommended public awareness and educational campaigns to supplement preventative advice supplied by professionals (Dent 78, Dent 79, Pat Rep 17).

Requirements of a Preventative Focus

Although many respondents concurred with a greater emphasis on preventative services in theory, they were concerned that to make this a reality, various steps would be needed. A recurring view was that a preventative based service would require a far greater investment than at present (e.g. Dent 23, Dent 81, Bod 17, Pat Rep 10), with prevention specifically incentivised within the investment framework (e.g. Bod 29, Pat Rep 10, Pat Rep 14). The cornerstone of prevention - "talk time" (Dent 52) needed better financial support with the fee structure aligned to facilitate prevention as a strategy (Bod 9, Bod 23). A relevant view expressed by one respondent was that preventative dentistry was more likely to flourish under the NHS rather than within private practice (Pat Rep 21).

Further respondents sought more advice and guidance on the delivery of preventative services. Two responses referred to the need for the Scottish Executive to publish a formal response to the previous consultation on Children's Oral Health (Bod 22, Prof Rep 20). Others requested further guidance in addition to that provided in SIGN 43 (Bod 26, Prof Rep 20).

Views on Fluoridation of Water

Although views on future fluoridation of water were not specifically requested in the consultation document, several respondents made their views known in this issue, largely in the context of their consideration of future preventative services. A summary of these views follows.

In total, 25 responses advocated setting in motion the legislation to permit the fluoridation of water supplies in Scotland. Three responses referred to the need to remove VAT on fluoride toothpaste. Two respondents articulated their objection to proceeding with a fluoride in water regime.

Those in favour of fluoridation of water comprised dentists, NHS Boards and Trusts, and Professional Representative Organisations. A member of the public and one dentist argued against fluoride in water. Fluoridation was seen as a cost effective measure which could have population wide benefits for oral health. For those against fluoridation, the disadvantages of this intervention were perceived as outweighing the potential benefits.

5.4 SHOULD THE "DENTAL PUBLIC HEALTH" ROLE OF CDS BE KEPT SEPARATE FROM THE "FAMILY HEALTH" ROLE OF DENTISTRY IN THE COMMUNITY?

Around one-third of responses commented on the future role of the CDS. Whilst a few respondents provided a very clear opinion on whether the public health role and the family health role should be kept separate, for most the picture was not so clear cut. One recommendation which summed up the views of many was for retaining the CDS function but nesting this within a more integrated dentistry service (Pat Rep 11). On balance, the views of those who commented were tipped in favour of maintenance of the separate roles relating to dental public health and family health.

Separate Roles

Those in favour of maintaining separate roles comprised respondents from a mix of sectors. For some, the 2 roles were quite different (e.g. Dent 68), with the CDS role "essential" (Prof Rep 30) and in continuing demand (Prof Rep 25). Maintaining a separation of roles was also seen as protecting the service to priority groups (e.g. Dent 54) and helping to retain the special skill base of the CDS (Prof Rep 27, Dent 78, Dent 68).

Several commentators remarked on the specialist skills of the CDS with one comment that the CDS is not simply a GDS for specific groups (Dent 11). An interesting view of another respondent was that those employed in the CDS may be motivated in a different way than that of other dental practitioners (Dent 58). A recurring theme was that the specific skills of the CDS made their provision of a "safety-net" for dental services less important than that of, say, dealing with vulnerable and difficult cases (Dent 44, Prof Rep 31, Pat Rep 15, Prof Rep 34).

Clarity of Roles

A small minority of respondents commented that more clarity was needed on the role of the CDS (e.g. Dent 84) with 2 questioning that the CDS could prove its worth (Dent 43, Dent 83).

Several consultees attempted to outline what they perceived to be appropriate roles for the CDS. Prominent amongst these were:

• Screening of patients

• Identifying "at risk" children

• Harmonising statistics/data gathering

• Dealing with cases not suitable for GDS because of behavioural problems

• Oral health promotion

• School dental inspections

• General Anaesthetic services

• Sedation

• Delivery of the National Dental Inspection Programme

In addition, one view was that maintaining specific roles for the CDS provided a greater variety of choice for employment for newly qualified dentists (Bod 23).

Combine Roles

Reasons provided by those who wished to see the roles combined were that the current divide was illogical (Dent 34) and artificial (Bod 22, Bod 20, Prof Rep 28, Prof Rep 20). The divide made for duplication of effort (Dent 79) with the roles inextricably linked (Dent 60). One respondent considered that the combination of roles would help to prevent an "Ivory Tower" attitude (Dent 81). For some, it made sense, particularly in rural and remote areas, for the dental public health and family health roles to overlap (e.g. Prof Rep 29, Bod 7). One suggestion was for a merger to form one single primary care salaried service but with some maintenance of specialism for certain functions (Prof Rep 32).

Seamless Provision

One theme to emerge amongst the arguments for and against the separation of roles was that of aiming for "seamless care" for the patient who may require both specialist CDS care and more general GDS or other services at various times. For several respondents, smooth transitions between different delivery mechanisms could be achieved by greater integration of services and more effort put into the development of complementary systems and interfaces (e.g. Dent 62, Pub 16, Bod 22, Bod 26, Prof Rep 11, Prof Rep 20). One comment was that this would require the removal of current professional and organisational barriers (Bod 17). Another view was that there should be a formal review of the links between the GDS and CDS in this regard (Dent 78). Closer links between CDS and more general health promotion services were also advocated (Educ 2).

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