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Modernising NHS Dental Services in Scotland: Analysis of Responses

ANNEX 1: CONSULTATION TEXT: SECTION 6

6. CHANGES TO THE SYSTEM

6.1 Introduction

Any effort to reform dental services must inevitably consider the balance between the requirement for change and the extent to which existing systems have been effective in meeting the needs of the public and dental health professionals. No change is possible without some degree of risk to the stability created within the existing framework.

For the profession, there is a need to ensure that future services evolve in a way which continues to protect stability and investment whilst building on a culture of quality within the NHS. It is important that new arrangements incentivise and support dental professionals in the delivery of services at all stages of professional life.

For the public, there is a need to have a clear understanding about what the options are for a modernised dental service, what these would look like, how they would gain ready access to these services and how dental charges would fit within any new arrangements.

There needs to be clarity about the scope and extent of a modernised NHS dental service, the arrangements for delivering a service, and the consequent system for patient charges.

This section briefly considers each of the following issues in turn and raises questions about them. It must be stressed that there is an inevitable inter-relationship between the three elements. The issues presented, particularly about delivery, are not mutually exclusive and should not, therefore, be seen as separate options. There is unlikely to be a single solution which fits the circumstances in all parts of Scotland. However, decisions will have to be taken about -

6.2 The Extent and Nature of NHS Dental Services

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 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 any other aspect 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 issues in this section are:-

6.3 The Delivery of NHS Dental Services

As described earlier, 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 etc) 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 service should be provided by clinical staff (dentists and PCDs) separately from the providers of practice based preventative and treatment services.

The issues in this section are:

6.4 Patient Charges

The current system of patient charges for NHS dentistry requires individuals (who are not exempt or qualify for help) to pay 80% of the treatment costs, subject to a current maximum of 378. Because a course of treatment may comprise a number of individual items, each with a different fee, the system is extremely difficult for patients to understand (and complex for dental practices to manage). There is also some limited charging for services provided through CDS (and the hospital dental service).

Changes to the remuneration system for contractor dentists and greater integration of GDS and CDS into primary care dental services would mean changes to the patient charging system. Successive administrations since the early 1950s have taken the view that patients - unless exempt for specific age, condition or income reasons - should contribute to the cost of dental treatment. Income from dental charges is currently over 50m in Scotland.

Consumer groups and professionals have pressed for simpler charging arrangements which are also seen to be as fair and equitable as possible. Suggestions for change have included:-

The current system for exemption from and help with charges would continue (with the addition of the Partnership Agreement commitment on free dental checks).

The issues in this section are:-

6.5 Financial Implications

It is important to recognise that changes to the current scope of NHS dental services may have an effect on the funding required, from the Executive and/or from patients. Any additional expenditure from the Executive (beyond that already planned) would need to be considered against other Health Department priorities.

6.6 Legislation

Changes to the nature of NHS dental services, to the responsibility of NHS Boards, to funding arrangements, and to patient charge arrangements, may require primary legislation. The results of the consultation will help to inform and shape any legislative changes needed.

ANNEX 2: RESPONDENT LIST

This list contains details of non-confidential responses to the consultation. To protect confidentiality, the Scottish Executive has only made the responses or personal details of individual respondents publicly available where they have given their explicit permission to do so. Where responses have been received from individuals on behalf of groups or organisations, the Scottish Executive has made the name of the group or organisation publicly available, but has only made the response itself available where explicit permission has been received to do so.

Dental Practices/Practitioners

Plus a further 49 dentists who did not give permission for their personal details to be made public.

Individual/Members of Public Responses

R Borland
T Honeyman
A Dey
J Fleetwood
M Grant
P Stewart
E Plant
J Heaney
L Sharp
G O'Donnell
B Fagg

Plus a further 13 individuals/members of the public who did not give permission for their personal details to be made public

Educational/Research Organisations

British Association for the Study of Community Dentistry
Royal College of Physicians and Surgeons of Glasgow
Royal College of Surgeons of Edinburgh

Dental Health Services Research Unit

NHS Boards/Bodies

NHS Shetland
NHS Ayrshire & Arran
NHS Borders
Dumfries & Galloway PCT
NHS Fife
NHS Forth Valley
Glasgow Dental Hospital and School, N Glasgow University Hospital NHS Trust
NHS Grampian
NHS Greater Glasgow Primary Care Division
NHS Greater Glasgow
NHS Highland, Public Health and Health Policy
Inverclyde & Renfrewshire Division of NHS Argyll & Clyde
NHS Lanarkshire
NHS Lothian
NHS Argyll and Clyde
Lomond & Argyll Division of NHS Argyll & Clyde
NHS Orkney
NHS Western Isles
Scottish Dental Practice Board
Woodside/Maryhill LHCC
Practitioner Services Division of the Common Services Agency
NHS Quality Improvement Scotland
East Kilbride LHCC

Professional Representative Groups and Bodies

Forth Valley GDP Sub-Committee and LDC Committee
Scottish NHS Confederation
East Kilbride LHCC and Advisory Group
Lanarkshire Local Dental Committee
Tayside Area Dental Advisory Committee
Area Dental Committee of Greater Glasgow NHS Board
Glasgow Local Dental Committee
British Association of Dental Nurses
British Association of Dental Therapists
British Dental Association
British Dental Hygienists' Association
Dental Technicians' Association
Fife ADC and Fife GDP Subcommittee
Highland Area Dental Committee
Glasgow Local Dental Committee
Scottish Association of Clinical Dental Directors
STUC
Unison Scotland
Dental Protection
Scottish NHS Confederation
Clydebank Oral Health Action Team
Scottish Adult Dental Health Survey Scoping Group
Dept of Oral and Maxillofacial Surgery, Southern General Hospital
Fife Oral Health Steering Group
NHS Ayrshire & Arran Community Dentists
NHS Lothian, Salaried Primary Care Dental Service
West Lothian Oral Health Strategy Group
Dental Division Executive, NHS Lothian
Glasgow Dental Hospital Staff Association
NHS Shetland Salaried Dental Service
Tayside Local Orthodontic Committee
West Lothian GDPs
Woodside/Maryhill GDPs
Dental Division Executive, NHS Lothian
Consultants in Restorative Dentistry, Glasgow Dental Hospital and School
Maryhill/Woodside Oral Health Action Team

Patient Representative Groups/Organisations

Alzheimer Scotland
Ardlarich Patient Participation Group, Inverness
Argyll and Clyde Health Council
Borders Local Health Council
Civil Service Pensioner's Alliance Scotland
Consumers' Association
Disability Rights Commission
Fife Health Council
Glasgow Homelessness Network
Greater Glasgow Health Council
Orkney Local Health Council
Patient Participation Group, Culloden Medical Practice
Scottish Borders Elder Voice
Scottish Civic Forum
Scottish Consumer Council
Scottish Council for Single Homeless
Scottish Pensioners' Forum
Shetland Local Health Council
218 Project Woodside Health Centre

Political

S Stevenson MSP Peterhead

Local Government

Highland Council

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