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Modernising NHS Dental Services in Scotland: Analysis of Responses

CHAPTER 6: HOW SHOULD DENTISTS' CONTRACTUAL ARRANGEMENTS LOOK IF THEY ARE TO SUPPORT THE DELIVERY OF THESE SERVICES?

The consultation stated:

There are two main systems currently in operation for the delivery of NHS Dental Services - independent contractor dentists and salaried arrangements. For independent contractors, there is a complex system of fees and allowances as set out in the SDR with over 400 items described and priced. It is largely a piece work system, with some elements of capitation and allowances. There is no minimum NHS commitment required of independent contractor dentists, although remuneration reflects what they actually provide. They do not have to provide NHS treatment at all. If they do wish to be on an NHS list then they must provide NHS treatment to at least one patient every six months.

There has been an increasing emphasis in recent years on the wider dental team, including the PCDs (hygienists, therapists, nurses et.) and managerial and support staff. It is suggested that, as with other aspects of primary care services, the focus for the future should be more on the whole practice - with the right skills and good quality infrastructure (premises, equipment, etc). And, indeed, there might also be a greater drive to support practices working or joining together and also more closely with other parts of the NHS. As with other primary care services, the emphasis would increasingly be on the local NHS Board having the responsibility to secure dental services either through contractual arrangements with practices or by direct provision through salaried staff.

Independent contractor dentists are responsible for providing the staff, premises and equipment needed to deliver services and this past investment has to be recognised in any future changes. These facilities are directly provided by the NHS for salaried GDS and CDS practitioners and staff. While there has been some movement towards financial support to independent dentists through certain types of reimbursements and allowances, it has been suggested that there might be greater support from the NHS in return for defined NHS commitment.

For services delivered through contract, therefore, there may be a range of possible changes. These are not mutually exclusive, and could be seen as a possible "menu" from which to meet specific local needs.

For salaried staff, it is assumed that they will continue to be employed under national terms and conditions but with the same types of flexibility which will apply to other staff covered by Agenda for Change. It is also suggested that the "public health" dental services should be provided by clinical staff (dentists and PCDs) separately from the providers of practice based preventative and treatment services.

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

6.1 WHAT ARE THE VIEWS ON THE RANGE OF DELIVERY AND FUNDING OPTIONS?

Responses to this question were relatively unstructured and wide ranging in comparison with the remainder of the commentary provided. In order to harness views in a constructive fashion, commentary was separated into views relating to the range of delivery options and those relating to the range of funding options. The analysis of each is presented below.

VIEWS ON RANGE OF DELIVERY OPTIONS

Two issues dominated the 84 responses of relevance. These were firstly, the potential for an enhanced role for PCDs in the delivery of dental services and, secondly, the balance between a national framework and local flexibility in delivery.

Enhanced Role for PCDs

Views emerged largely from the responses of dentists and NHS Boards and Trusts. The overwhelming mood was one of support for training PCDs to take on a greater role in the delivery of dental services and the removal of current restrictions which curtailed any enhanced role.

An expanded role for PCDs within dental practices was seen as increasing the overall manpower available and enabling the dental practitioner to focus on the more demanding aspects of their profession (e.g. Dent 54, Bod 16, Pat Rep 10). Such increased resources were viewed as especially important in remote and rural areas where service delivery may be stretched (Dent 35). One respondent painted their vision of dentists as leaders of teams consisting of dentists, therapists, hygienists, nurses and clinical technicians (Dent 45). It was seen as important that PCDs received appropriate training prior to undertaking any increased role (e.g. Prof Rep 27, Dent 78, Dent 68, Dent 35, Dent 81). From a patient's perspective, it was considered that the competency of PCDs needed to be assured and, perhaps, the agreement of the patient should be required in advance of treatment (Pat Rep 6).

From the viewpoint of the PCD, an enhanced role was viewed as raising professional awareness and improving public recognition of their part in delivery of dentistry (Bod 27). One dissenting voice from a dental practitioner was that dentists may not want what was perceived as the added burden of responsibility for supervising enhanced PCD work (Dent 5). Two voices of opposition emerged from the public responses. One expressed concern that there should be no " dulling down" of expertise, by, for example, a hygienist undertaking fillings (Pub 14). Another member of the public viewed the notion of hygienists carrying out dental work as a " bargain basement remedy" to the delivery of dental services (Pub 21). Although expressed by a small minority of respondents, such views perhaps signal the care which may be required to "sell" such delivery options to the general public should this recommendation be taken forward.

Suggestions were offered as to the nature of the work which PCDs would be suited for. These included:

• Oral health prevention/education (e.g. Dent 33, Dent 35, Dent 62, Bod 19, Bod 26, Bod 28)

• Some epidemiological examinations (Dent 30)

• Basic NDIP (Dent 35)

• School inspections (Bod 22, Bod 20, Prof Rep 28, Prof Rep 20)

• Therapists to be involved in examinations and limited diagnosis (Dent 19)

• Therapists to be involved in radiography (Dent 19)

National Framework and Local Flexibility

Many respondents made the comment that the idea of "one size fits all" was inappropriate in the context of delivery of local dental services. The consensus was for local flexibility within the overarching confines of a national framework for delivery. Although some concern was expressed as to how the details of this arrangement would pan out (Dent 78), and that accountability over local services should be central (Bod 7), there was much support for the development of a national overview expressed as a framework (e.g. Prof Rep 32) under which individual arrangements would fit (e.g. Bod 24).

For many consultees, the key to effective delivery at local level was flexibility (e.g. Bod 20, Prof Rep 28, Pat Rep 14, Prof Rep 20). This was seen as especially important to reflect the differences between urban and rural contexts (Prof Rep 13, Pat Rep 20).

Some respondents referred to the role of the local health boards in delivering a locally responsive service. Calls were made for a "strengthened" role for the health boards (Pat Rep 17), with a remit to determine local needs in partnership with professionals and patients (Pat Rep 9). Health boards were seen to need a more robust infrastructure to support dentistry (Bod 7).

A few consultees welcomed the suggested "menu" of services from which health boards could select and contract services according to local need (e.g. Dent 78). A further comment was that devolving funding for services to health boards would facilitate a more integrated approach to planning (Pat Rep 13).

NHS Dentistry

The funding of dental services is covered in more detail in the next section. However, some relevant comments on the future delivery of NHS dental services emerged in the discussion on national and local structures.

A vision outlined by a few respondents was for an NHS practice to remain in every town on the high street or in health centres (Pub 1, Bod 26, Bod 17, Educ 2). The future accessibility of NHS dentistry was raised as important by many and the underpinning of dental practitioner and/or PCD posts with salaries was seen as one way to achieving this vision (e.g. Bod 24). Another way was for health boards to be given the power to secure specific commitment, for example, through a standard, sessional contract with NHS commitment spelled out (Prof Rep 19).

Two respondents commented on the necessity to review the current arrangement whereby dentists remained on the NHS list by providing NHS treatment to at least one patient every six months (Pat Rep 8, Bod 29). Both were in favour of more stringent criteria for inclusion on the list.

Integration with Wider Health Team

One recurring theme to emerge was that of the need for dentistry to become better integrated within the wider healthcare team. The notion of separate oral and general health care was seen as flawed (Dent 58) and, perhaps, understated in the consultation document (Bod 15).

Several respondents advocated closer working between dental practitioners and other healthcare workers whether within secondary dental service provision or the wider healthcare field (e.g. Pat Rep 13, Pat Rep 17). One consultee recommended that dentists should be equal partners on healthcare committees and have the opportunity to share premises and patient bases (Dent 23). Other comments were that this approach would ensure integrated clinical pathways for patients (Prof Rep 13), and may generate opportunities for joint training between different healthcare professionals (Bod 14).

Views on Specific "Menu" Items

Of the items listed in the "menu" of options from which, the consultation paper proposed, items could be selected to meet local needs, two delivery options attracted particular comment:

Better peer support for isolated and single practitioner practices

Eight responses contained clear support for this proposal. One idea was for groups of dentists working together to avoid professional isolation (Educ 2, Bod 19). This arrangement was also seen as providing cover for dentists in case of their absence (Pat Rep 18).

Widening the range of dental contract holders to encompass corporate bodies or practice groups

Of the 5 responses of relevance, 4 were clearly against this proposal (Bod 4, Bod 28, Bod 21, Prof Rep 14), with one advocating its cautious consideration (13/2).

Other Relevant Comments

A small number of responses related to specific circumstances where special delivery arrangements might be required. One such scenario was the case of those affected by homelessness, with lives not currently conducive to settled living, dental registration and regular attendance. For this group of patients, it was suggested that outreach dental services should be provided (Prof Rep 10). Another target group which found difficulty fitting with the routine dental delivery system comprised drug addicts. One respondent recommended an incremental system may be appropriate for this group, commencing with "drop in" dental facilities, followed by "weaning" to CDS, then finally appointments with GDS (Dent 78).

VIEWS ON RANGE OF FUNDING OPTIONS

This aspect of the consultation attracted the most comment of all issues raised, with two-thirds of responses (133) containing relevant comments.

Some comments were general in nature:

Others argued for a nationally based funding scheme (Prof Rep 14) to " avoid a postcode lottery" (Dent 35). A small number of respondents suggested that if funding was to be delegated to health boards to administer, then at least this should be ring fenced to avoid funds being used for other purposes (Pat Rep 5, Pat Rep 7).

A substantial volume of respondents called simply for increased funding to a more realistic level that adequately reflected the true costs of treatment and allowed for quality time with patients. One comment was that dental practitioners ran businesses not charities (Dent 42).

Most respondents expressed a view on at least one of the main funding options highlighted in the consultation document: fees per item, salaried, capitation and sessional payments. Pros and cons were outlined for each of these with no clear option emerging as an overall preference. Indeed, many consultees recommended a mix of funding systems, depending on local circumstances. The comments on each option are summarised below.

Fee Per Item

The overwhelming consensus was that current fees were inadequate. Respondents (the main body of which were dentists) remarked on the "ridiculous" (Dent 37) and "derisory" fee scale which was wholly inadequate to support modern dentistry (Dent 56). The current level of fee was seen as perpetuating the "treadmill" effect and providing perverse incentives (Dent 58) with an outstanding need to factor in allowances for oral health preventative work (Dent 51, Dent 74, Bod 9, B/T 1, Bod 12, Prof Rep 15). Several respondents suggested levels to which the fees should be adjusted. These ranged from 15% to 300%.

The current fee scale was also criticised by a large volume of respondents for being overly complicated and cumbersome. Whilst a small minority suggested scrapping the existing scale (Dent 34, Dent 86), many others were more moderate in their views, recommending, for example, that the scale be simplified, banded and rationalised.

A few consultees commented that the Fee Per Item system had not kept pace with modern technology and published evidence (Bod 17) with, for example, time away from the practice penalised (Educ 2, Bod 19, Bod 26).

Several respondents remarked that the system did not sit well with an emphasis on prevention. One suggestion was that "oral hygiene" should be added to the list as a separate item (Bod 9).

A minority view was that the system should remain unchanged (Pat Rep 14) as its concept was easy to understand (Dent 42), easy to administer if computerised (Dent 38) and was good for generating data (Prof Rep 19).

Despite such perceived drawbacks of the current Fee Per Item system, there was much support for retention of its framework following increased funding and simplification. Indeed, a few respondents went so far as stating that it was the only way forward (Dent 59, Dent 69, Dent 78).

Salaried Service

There was much support from respondents representing a variety of sectors, for funding NHS dentistry with a salaried service. Recommendations ranged from an entirely salaried service, to salaries in certain circumstances. Most commonly cited circumstances were services for children (e.g. Dent 36, Dent 54, Dent 78), in remote and rural areas (e.g. Prof Rep 13, Prof Rep 14, Bod 3, Bod 17), and in cases of special needs or vulnerable patients (e.g. Dent 19, Bod 7, Pat Rep 11).

Many respondents commented that a salaried option was probably the most expensive to support, but on balance this was outweighed by its significant advantages. Amongst the merits which consultees associated with this funding option were increased flexibility for dental practitioners, especially women who may require some flexibility in working (Dent 36); an assured service for vulnerable groups (Bod 7) or areas where services were difficult to access (Pol 1); and a closer fit with a renewed emphasis on prevention:

" piece work payments will put undue emphasis on shoddy workmanship to get the job done in minimum time to maximise profit. A fully salaried profession also makes it easier to integrate with other primary care operators" (Pub 21)

However, amongst the responses was a substantial minority which expressed concern that a move to a salaried service would result in a decreased output (e.g. Bod 28, Dent 35, Dent 42) or would simply replace one treadmill with another (Dent 21, Dent 52). Some suggestions to tackling the first of these were made, such as to incorporate effective management (Dent 35), or introduce tight monitoring along with the system (Bod 8).

A minority of respondents also raised the issue of salaries for PCD staff. All of these were in favour of introducing salaries for such practitioners. Two also suggested that practice managers be appointed, fully funded by the NHS (Dent 68, Prof 5). A suggestion was made that a reasonable salary for a trained therapist would be around 25k - 30k (Prof Rep 4).

Capitation System

Views on a future system of capitation funding were mixed with support balanced by criticism. A commonly cited concern was that a capitation system might lead to under treatment (Dent 78) with the potential for "sponsored" or "supervised" neglect (Dent 5, Dent 33, Dent 79, Bod 17, Pat Rep 11). A specific concern was that a reduction in the level of laboratory work may result from the system (Prof Rep 6). Another worry was that those affected by homelessness may not fit within the system (Pat Rep 10).

However, these perceived drawbacks were balanced by support for such a system if funded at a realistic level (e.g. Dent 85, Dent 86) and if accompanied by some system of quality checking (Dent 33).

A small number of respondents outlined their support for a system of funding which combined capitation with Item of Service payments and other added services (Dent 32, Dent 67, Bod 23, Bod 7, Bod 29, Pat Rep 17, Prof Rep 32). A small minority highlighted their preference for a combined capitation and sessional funding system (Bod 28, Bod 21).

Patient Registration System

Within the context of considering the capitation system, several respondents commented on the current patient registration system. All criticised the system, the main comment being that it was poorly understood by patients (e.g. Bod 22, Prof Rep 29, Dent 85). Some consultees highlighted particular circumstances in which the registration system was wholly inappropriate. These included the cases of elderly people with dentures who may not require frequent, regular dental visits (Pat Rep 7), carers or those with mental health problems who may not have the opportunity to visit the dentist at the frequency required by registration (Pat Rep 18), people affected by homelessness (Pat Rep 10) and asylum seekers with no understanding of the system (Prof Rep 12, Prof Rep 21). The registration period was described as "arbitrary" (Prof Rep 13) and inconsistent with other healthcare practice (Prof Rep 14).

Suggestions were made for various extensions to the current period (e.g. 2 years (Dent 49, "life" (Bod 23)), with a few respondents advocating scrapping the system altogether (e.g. Dent 79).

Sessional Payments

Comments regarding sessional payments focused on specifying circumstances in which such payments would be appropriate. These comprised:

• For sedation (Dent 49, Bod 15, Bod 21, Prof Rep 5)

• For emergency treatment (Dent 49)

• For special needs patients (Prof Rep 5)

• Where time was a factor, such as prevention, specialist dentistry (Dent 49, Prof Rep 32)

• Where the case was challenging on account of the patient's chaotic lifestyle (Prof Rep 12, Prof Rep 21)

Two consultees commented that a sessional payment system was more likely to produce a quality service (Dent 5, Dent 46). A few others suggested combining sessional payments with capitation and/or Fee Per Item systems (e.g. Dent 15, Dent 62).

Funding focused on Practice rather than Individual Practitioner

Of the 13 responses in which a clear view was expressed, all but one were generally in favour of practice based funding. One view was that a practice based system permitted practices to negotiate with their local NHS organisation and allowed for validation of the whole practice team as opposed to simply monitoring an individual practitioner (Bod 8). However, the one dissenting voice considered that funding by practice might destabilise working relationships within a practice (Anon 1).

6.2 ARE THERE SPECIFIC ISSUES ABOUT FUTURE FUNDING OF INFRASTRUCTURE, E.G. PREMISES?

Around half of respondents offered some comment in response to this question. A general view was that owning and running a practice was now a considerable burden for some dentists (Dent 34), with many happy to sell to the NHS if offered an appropriate price (Dent 50). NHS funding support was viewed as lessening the risk in an otherwise high risk business (Bod 15). One recommendation was for an infrastructure strategy to be developed (Dent 58). Another dentist, commented, tongue in cheek, that GDPs were unique within the NHS for having to pay a hefty admission fee (practice costs) to join (Dent 73).

Dental Practitioner Infrastructure Costs

Many respondents identified increasing and new infrastructure costs which they claimed that dental practice owners now had to face. Most commonly cited were those relating to:

Information Technology

Mentioned by around one quarter of those who commented, there was general agreement that practices should put in place, as a priority, new, robust and comprehensive IT systems. A few consultees recommended that new IT systems should be linked to the existing NHSnet in order to promote better communication between healthcare workers (Bod 26, Bod 7, Bod 29, Prof Rep 32, Bod 18).

The overwhelming majority view was that dental practice owners should receive some financial support for the hardware, software and training associated with such new computer systems. Where dentists had already invested in IT, it was suggested that they be awarded financial recompense retrospectively (Dent 72).

Dealing with Cross-Infection, Waste Disposal, Ultrasonics

Eleven respondents highlighted what they saw as the increased costs to practice owners of complying with new professional and legal obligations such as handling waste and using disposables. Most were dentists who claimed to have experienced at first hand the financial implications of responding to what they saw as an increasingly regulated profession.

Responding to the Disability Discrimination Act

Nine responses were particularly relevant. Those from older dental practice owners reflected personal experience and their concerns that their practices would be "unsellable" on their retirement because they did not meet the new standards required by the Act (Dent 37, Dent 49). A few commented that in reality, many dental practices were established in older properties, perhaps not on the ground floors of buildings (Pat Rep 7, Pat Rep 18) making it very expensive to adapt to meet to the standards required.

In the case of each of these pockets of expense, the general theme was that provision should be made for financial support from the NHS for IT, for helping practices meet new regulations and for assisting practices adapt to the requirements of the DDA in order that some level of NHS dentistry could be undertaken at these premises.

Views on Current Grants

There were mixed views on the grants currently available for dental practitioners. Most comments referred to the Practice Improvement Grant and the Practice start up grant. Whilst the former tended to be welcomed, with calls for it to be expanded to impact on a longer term basis rather than as a one off (e.g. Dent 34, Dent 69), the latter was viewed by most of those who responded as unfair and discriminatory (e.g. Dent 7). A call was made for both of these grants to be available equally to GDS or salaried dental practices (Bod 22, Bod 20, Prof Rep 28, Prof Rep 20).

One suggestion for strengthening the Practice Improvement Grant was to link it to practices' work towards IIP or Good Practice Awards (Dent 5). Another was for linking it to level of NHS work carried out (Dent 13).

Most of those responding called for the start up grant to be abolished. It was seen as unhelpful for already established practices (Dent 7, Dent 31, Dent 64, Dent 80) and contributed to their difficulties in persuading new Associates to join them (Dent 40).

Financial Support for NHS Commitment

The notion of attracting NHS funding in return for providing NHS dentistry services found favour with a substantial volume of respondents from different respondent sectors. In addition to assisting dental practice owners with costs of premises, staff, training, equipment, IT and health and safety adherence (e.g. Dent 15, Bod 24), this arrangement was viewed as beneficial to patients in that NHS services were likely to be more accessible (Pub 17, Pat Rep 11).

In particular, it was envisaged that NHS would be able to exert greater control over the location of NHS dental services (Dent 30, Bod 19). A further advantage identified was for newly graduated dentists, for whom NHS funding in return for commitment would help them cope with any debt incurred whilst training (Dent 84).

Models of NHS Assistance with Costs of Premises

Several responses referred, generally, to the perceived need for NHS financial assistance with the costs of dental practice premises (Pub 15, Prof Rep 30, Bod 22, Bod 14, Prof Rep 8, Prof Rep 9).

Others were more specific regarding their vision of a future dental service, co-located with other health professionals, within purpose built NHS premises (Dent 69, Dent 70, Dent 85, Pub 16, Pub 21, Prof Rep 35, Bod 23, Bod 20, Prof Rep 28, Prof Rep 1, Prof Rep 12, Prof Rep 20, Prof Rep 21, Dent 79). This arrangement was seen as offering many benefits such as providing a forum for more joined up oral health promotion work (Prof Rep 35), raising professional standards and making a wider range of services and emergency treatment available (Dent 21). Such centres were also seen as able to mix dental practitioners with PCDs, Vocational Training functions and student placements, with patients made aware that these were NHS establishments (Dent 71).

Another recommended model of working was for the NHS to buy out dental practices which were, for example, proving difficult to improve because of planning restrictions (Bod 24, Bod 27). It was suggested that many dentists would be happy to lease space within NHS owned premises (Dent 15, Dent 27), along with other dentist practices and with a shared practice manager (Dent 71).

Other ideas were that the Scottish Executive should buy up practices where the owner wished to retire, with the NHS selling these on to willing dental practice purchasers at a later date (Dent 23); that Local Enterprise Companies should be involved in the establishment of new practices (Bod 19, Prof Rep 14); and that the plans for new housing estates should be required to accommodate space for a purpose built, multi-disciplinary health centre, to be owned by the NHS and leased to practitioners (Dent 9).

Compensation for Past Investment

Although the general mood was one of welcoming a greater level of NHS funding to support dental practitioners, a small number of respondents expressed concern that those practices which had already invested substantially in their premises should not lose out with funding, on account of their investment being retrospective rather than prospective (Dent 68, Bod 6, Prof Rep 1, Prof Rep 5, Prof Rep 14, Dent 80, Dent 85).

6.3 ARE THERE ANY OTHER APPROACHES THAT MERIT CONSIDERATION?

In addition to the comments summarised above, a small number of other suggestions were made concerning future approaches to delivering NHS dental services. These are listed here:

• Greater focus on prevention by (a) incorporating funds for oral health development workers into funding applications for regeneration monies (Bod 1); (b) the appointment of an oral health worker for elderly people by each health board (Bod 1); (c) delivering preventative messages in ante-natal clinics (Bod 10); (d) rolling out good practice from the Oral Health Action Teams in Glasgow (Dent 79)

• Making more of the school location for the delivery of dental services by developing the role of the Community Dentist to provide a service as part of the School Health Service. Fitting community dental services around the school calendar, so dentists are available when children are able to attend the practice (LG 1)

• Enhancing the role of mobile dental units to provide a better service in rural areas (Bod 19, Pat Rep 4, Dent 78, Dent 68, Pol 1) and for the delivery of some paediatric services in city centres (Prof Rep 4)

• Resourcing NHS dentistry through tax on high sugar products (Dent 38, Dent 49, Educ 1)

• Better integration of primary care with secondary and tertiary services (Educ 3, Prof Rep 23, Prof Rep 25)

• More specialist posts to be created and perhaps located within GDS premises (Bod 22, Bod 20, Prof Rep 28, Prof Rep 20)

• Amend the fee scale to provide enhancements for difficult to treat children (Dent 27) and provide grant in aid for all prosthetic work (Dent 28)

• Group together individual GDS practices into co-operatives to enable them to bid for block contracts from local health boards (Dent 23)

• Introduce a Dental Advice Line as operating in Fife (Prof Rep 34)

• Consider a franchising arrangement with NHS Scotland as the franchiser (Prof Rep 33)

6.4 ARE THERE ANY OTHER INCENTIVES THAT MERIT CONSIDERATION?

In addition to the comments summarised above, a small number of other suggestions were made concerning future incentives that respondents considered merited consideration. These are listed here:

• Greater financial support depending on context with higher incentives in deprived areas, rural areas and other locations where accessibility of NHS dentistry is difficult (Dent 71, Dent 78, Bod 5, Bod 23, Bod 22, Bod 20, Bod 15, Prof Rep 28, Pat Rep 7, Pat Rep 17, Pat Rep 18, Prof Rep 1, Prof Rep 13, Prof Rep 14, Prof Rep 20)

• Greater financial support for handling special group caseloads (Bod 23, Pat Rep 5, Pat Rep 10)

• Better rewarding of quality of service (Dent 5, Dent 49, Dent 58, Dent 62, Bod 16, Bod 4, Bod 22, Bod 20, Prof Rep 28, Bod 28, Bod 14, Bod 21, Pat Rep 14, Prof Rep 20, Dent 79)

• Greater financial incentives to support training and/or career advancement (Dent 5, Dent 29, Dent 39, Dent 49, Dent 50, Dent 85, Dent 68, Bod 26, Prof Rep 1, Prof Rep 7)

• Financial incentives weighted towards delivery of prevention (Dent 5, Pub 15, Bod 10, Bod 16)

• Financial incentives weighted towards practice owners rather than associates (Dent 40, Dent 56, Prof Rep 30)

• Rewards for improving the patient base (Dent 5, Dent 66 - e.g. doubling the registration fee to encourage retention of patients)

• Extending incentives to cover PCDs (Dent 77, Prof Rep 4, Prof Rep 6, Prof Rep 10)

• Extending incentives to cover existing practice owners (Dent 4)

• Incentives specifically aimed at retaining older dentists (Dent 68) by providing retainers for largely retired practitioners in return for specified service (Bod 19) or permitting some pension along with part time work (Prof Rep 19)

• Better funding for maternity leave and for part time workers in order to retain women who may otherwise leave the service (Dent 78)

• Sponsoring dental students through courses in return for specified NHS commitment on graduation (Dent 30)

• Dental training scholarships (Bod 19)

6.5 HOW BEST SHOULD ANY NEW ARRANGEMENTS BE PUT IN PLACE?

Responses were divided between those which focused on the timing of the implementation of future change, and those which considered any particular supporting arrangements which they thought should be in place to facilitate the effectiveness of changes. Approximately one-third of respondents addressed one or both of these issues.

Timing of Change

The vast majority of those who commented advocated a phased, carefully managed implementation of new arrangements. A recurring theme was for evolution rather than revolution, with lead in times for changes in contracts of between 3 months and 12 months recommended.

Specific ideas included running old and new systems in parallel for an initial period (Bod 19, Bod 4, Bod 26, Bod 17); or phasing the new arrangements for existing practitioners but introducing new arrangements immediately for those commencing their careers (Pub 16).

There were differences of opinion over whether the timing of change needed to be consistent across Scotland with the majority view being that one solution may not fit all circumstances and some variation should be accommodated (Pub 19, Bod 26, Bod 17).

A significant minority of respondents argued for a rapid establishment of new arrangements (e.g. Dent 29, Dent 50, Dent 83, Dent 84) with one consultee arguing that although this was not ideal, it was necessary to stem the flow of NHS dentists into private practice (Dent 86). Another view was that changes in fees required urgent action, but other aspects of change could follow at a more leisurely pace (Dent 79). One suggestion was that a think tank be established to oversee the implementation of the plan for change (Dent 50).

In Partnership

Many respondents stressed that any change should be undertaken after partnership work involving relevant professional groups (Bod 5, Bod 15, Bod 12, Prof Rep 1, Dent 81, Dent 82). One recommendation was for more consultation with patient groups (Dent 26).

Piloting

A recurring comment from dentists, NHS Boards and Trusts and Professional representative groups was that changes should be piloted prior to full implementation. However, one view was that there may not be time for this (Dent 49).

Care Standards and Quality Targets

A further recurring theme was the need for new arrangements to be underpinned by a framework of Care Standards, Guidelines and quality targets. Some responses referred to the need for quality targets in principle, but acknowledged the challenge of establishing a robust and meaningful system.

Many consultees expressed their welcome of the QIS draft quality standards and considered that these could be adopted as part of the new arrangements (Bod 22, Bod 20, Prof Rep 28, Bod 7, Pat Rep 11, Pat Rep 19, Prof Rep 20, Prof Rep 32). Other ideas for how quality should be measured were offered. One suggestion was that measurement should look wider than just treatment and perhaps move to the construction of an oral health index to monitor outcomes (Dent 45). Another was for quality to recognise, for example, a second registerable qualification, postgraduate activity and dental reference officer gradings (Educ 2).

Whatever, the system selected, one respondent reflected a general mood in advocating a consistent Scotland wide system with the ability to monitor and enforce clinical and service quality through a mechanism in the dental contract. This was seen as giving health boards a crucial method of scrutiny and accountability over the dental services provided to their local populations and might help recover the current lack of public confidence in the dental service (Dent 78).

Disciplinary and Complaints Systems

Two respondents highlighted the need to establish a more consistent and centralised disciplinary system (Pub 17, Bod 14). Another called for a clearer and single route for all complainers to follow (Pat Rep 11).

Other recommendations mentioned by a small minority of respondents are summarised here:

• Implementation to take into account of possible compensation and/or covering of risk for existing dental practices, particularly where previous investment has been significant (Dent 29, Educ 2, Bod 26, Bod 17, Bod 7)

• Should be open and transparent (Bod 5)

• Should have strong, professional leadership (Prof Rep 1)

• Should build as far as possible on current arrangements (Dent 67)

• Should be voluntary with dentists invited to change (Bod 28, Bod 21, Prof Rep 33)

• Should try to avoid excessive bureaucracy (Prof Rep 23)

• Should be accompanied by a major publicity campaign (Dent 62)

• Should try not to alienate existing staff or may lose them, especially older members (Dent 58, Prof Rep 12, Prof Rep 21)

6.6 WORKFORCE ISSUES

In the course of their consideration of the delivery of NHS dental services, many respondents provided more general comments on their opinions of current NHS dentistry workforce issues. Their responses are summarised below.

NHS Dentistry Not Attractive

Several respondents outlined what they saw as the reasons why NHS dentistry appeared unattractive as a career. Amongst the perceived disadvantages were the pressures of work, lack of financial security, burden of administration, lack of career structure, lack of clinical freedom, the "treadmill" effect, and lack of time with patients.

Workforce Planning

Five respondents referred to the need for smarter workforce planning (Pub 14, Bod 15, Bod 17, Bod 7, Prof Rep 19).

Increase Recruitment

A common theme was to increase the volume of training places for dental practitioners and PCDs. One view was that training places should be doubled (Pat Rep 2). Another consultee argued for a 30% increase in places (Dent 6). Training places should be available for young people and also older recruits on shorter, condensed courses, according to one respondent (Pat Rep 9). However, another view was that more dentists were not necessarily needed. For this respondent the problem lay more with retaining dentists within the NHS (Pub 8).

Incentives to support the return to work of leavers and those who have retired early were suggested (Dent 13, Dent 49, Dent 68, Bod 12). A further idea was to import graduates from other countries (Prof Rep 22, Bod 26).

Training of Dentists

A small minority of respondents expressed dissatisfaction with the current level of dental school provision in Scotland. One respondent remarked:

" For the capital city of Scotland not to have a dental school and dedicated dental hospital I feel ….is an embarrassment" (Dent 22)

Another plea was made for the reinstatement of the former Edinburgh dental school (Pat Rep 9), with mixed views on the opening of an Aberdeen based facility (Pub 13 - pro; Bod 4 - against but advocated a more centrally based school).

Several consultees welcomed the notion of outreach training for undergraduates (Dent 6, Dent 35, Bod 19, Bod 26) especially as this was seen as preparing students for the realities of professional life (Prof Rep 33). In relation to the latter point, one issue raised as problematic had been:

"… the mismatch between the current under graduate education, their expectations and the actual needs of NHS dental practice" (Prof Rep 33)

For outreach training to be effective, a few respondents stressed that it should be educationally robust and well funded (Educ 2, Bod 7). Another view was that it may be possible to arrange outreach training for some aspects of course work, but the remainder will still need to be carried out at the dental school with the infrastructure not adequate at present to support any significant increase in students (Dent 68).

NHS Commitment after Training

Several respondents considered it reasonable to enforce on new graduates a commitment to NHS dentistry for a specified time. The time periods suggested ranged from 3 years to 5 years (Dent 22, Dent 70, Pub 6, Bod 29). The notion of dental cadetships was suggested (Bod 17) and the idea put forward of providing salaries for new graduates for their first few years in practice (Dent 34). One view was that dentists should be made to repay various training costs if they opt for private practice (Pat Rep 16).

Improve Conditions

Ways of making NHS dentistry more attractive as a career were suggested. Several respondents remarked simply that pay and conditions should be improved. Others suggested better marketing of the career in schools (Pat Rep 9) and developing the image of CDS as a more "vibrant" service in an effort to attract graduates (Prof Rep 34).

It was considered that NHS dentistry needed to become more family friendly as a profession (Bod 10) and perhaps learn from the example of retaining women doctors during their child rearing years (LG 1).

A significant number of respondents called for the need to develop a career structure for dentists and PCDs (e.g. Dent 44, 58, Dent 77, Bod 24, Bod 23, Bod 22, Bod 26) which recognised and rewarded those with specialist skills (Dent 45, Dent 50). A further recommendation was for greater flexibility to permit professionals to undergo further training without suffering financial disadvantage by doing so (Dent 44, Prof Rep 23).

6.7 OPTIONS FOR CHANGE

In the course of their consideration of the delivery of NHS dental services, around twenty respondents referred briefly in passing to the Department of Health proposed framework for reform of the dental services in England: Options for Change. Most of these comments were negative and it is not known whether more support may have emerged had the consultation document specifically canvassed for views on the proposals in England. However, in the interests of reporting the views documented, these are summarised below:

Criticism of the English Proposals

A few respondents were clear that the proposals south of the border would not be the appropriate route for Scotland to follow (Dent 13, Dent 54, Dent 69). One view was that this would precipitate an exodus of NHS dentists from Scotland (Dent 66); another was that for Scotland to simply follow in line would be bad for the image of dentistry in Scotland (Dent 79). It was felt that Scotland had to do more than that which proposed for England (Prof Rep 11).

More specific criticisms were that:

• what was proposed simply exchanged one treadmill for another (Dent 44, Dent 51, Dent 52)

• there were already signs in England of a destablising effect on NHS dentistry (Bod 7, Prof Rep 32)

• the system created more administration (Bod 7, Prof Rep 32)

• the system encouraged "supervised neglect" (Dent 32)

• the system was a back door route into privatisation (Dent 27)

• evidence from the pilots had demonstrated no improvement to the service (Dent 15)

• specific issues, such as practice compensation and the payment of associates were not covered by the proposals (Dent 5, Prof Rep 9)

On the positive side, it was suggested that the English changes offered Scotland the opportunity to learn lessons, particularly as there were pilot field sites (Dent 46, Dent 49, Bod 7, Prof Rep 32).

However, two consultees favoured the English proposals with one commenting that Scotland could be in danger of losing more dentists to the south, attracted by the merits of the English system (B/T 2Bod 14); and the other considering that the English model of quality assurance and clinical pathway development had merits (Pat Rep 11).

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