AN ACTION PLAN FOR DENTAL SERVICES IN SCOTLAND

August 2000

Contents

Introduction
Context
Needs and Supply
Contributing to Public Health
Preventing Disease
Service Availability and Access
Quality and Standards of Service
Responsive Services
Human Resources and Teamworking
Infrastructure and Environment
Resources
Conclusion

Introduction

1. This paper outlines an action plan for dental services in Scotland. It recognises the vital contribution which dental services make to health improvement and patient care, as a service in its own right, as part of the wider NHS system, and in its links to other Scottish initiatives. It confirms the importance of planning now to meet the changing needs of the people of Scotland, of the nature of the services required, and of the professionals who deliver these services. The prime focus of this plan is on primary care dental services (PCDS) where 90% of patients receive their care and treatment, but it makes reference to the relationships with other aspects of the service.
2. There are two main components of PCDS — general dental services (GDS) provided by "family" dentists and community dental services (CDS) provided by dental officers. General Dental Practitioners (GDPs) are nearly all independent contractors, most of whom provide a mix of NHS and private services, from (generally) small practices. Community dental staff are employees of trusts whose main target populations are disadvantaged groups and those with special needs (including children, people with learning difficulties, elderly in residential care); in addition they provide a safety net for those who are unable to access GDS. Both the GDS and CDS are supported by members of the professions complementary to dentistry.
3. The hospital dental service see referrals from both dental and medical practitioners and from other hospital services. The main specialist areas are oral and maxillofacial surgery, oral medicine, orthodontics, restorative dentistry and paediatric dentistry. The dental teaching services are located in two dental teaching hospitals at Glasgow and Dundee. They see a range of both primary care and secondary care patients to give students a wide range of experience in clinical areas as well as teaching all aspects of the curriculum.
4. There is no "guarantee" of access to GDS in the same way as there is to general medical services. In the latter, a local health body can, ultimately, assign patients to a GP to ensure that care is provided. There is no direct parallel for dental services, although local health bodies do all they can to ensure as comprehensive services as possible. Dental practitioners can set up practices anywhere provided they are appropriately qualified and their premises and equipment are of a suitable standard. In GDS practitioners have to raise the capital for and continue to invest in their practices to provide the locus for these services.
5. It is also recognised that a number of other organisations have an important role in contributing to the improvement of oral health and oral health care services and to the achievement of health targets:

• Health Boards and Primary Care Trusts for assessing the needs of their population and ensuring the provision of dental services; for promoting dental health through prevention and health education programmes; and for developing joint working with local agencies and organisations to ensure a consistent and co-ordinated approach.

• The dental profession for their role in diagnosing and treating dental and oral disease; their prevention role through educating their patients towards better oral health; their "missionary" role in persuading the public to recognise oral health as a priority for action in Scotland; and for raising dental health issues across the national agenda.

• The medical and other health professions including health visitors, pharmacists, school nurses, midwives and dieticians, for the influence which they can bring to bear on wide sections of the population to promote dental and oral health.
• Local authorities for ensuring that oral and dental health is given priority in health education and health related policies in schools.

• Schools, nursery schools and playgroups, for their direct impact on children through the vital early years, teaching good oral hygiene and encouraging a healthy low sugar diet.

6. This document concentrates largely on the contribution which PCDS make to dental and oral health, but working in close co-operation with specialist hospital services, university teaching hospitals and others both within and outwith the NHS.

Context

7. The key aim of an overall oral health strategy is to provide the opportunity for everyone to have a healthy functional mouth throughout life. This can be achieved by access to dental treatment, oral health care and by use of preventive measures.
8. The White Paper ‘Towards a Healthier Scotland’ identifies dental health as a key health topic on which action needs to be taken. It pointed out that levels of decay are strongly related to deprivation: the poorest 10% of children have 50% of the decay in surveys of the dental health of Scottish 5, 12 and 16 year olds. Adult dental health also remains poor. The White Paper set a headline target that 60% of 5 year olds should have no experience of dental disease by 2010, and a second rank target that less than 5% of 45-54 year olds should have no natural teeth by 2010.
9. The current thrust of health care policy is to design services to meet individual and population needs. It also needs to provide high quality, evidence-based services, making best use of the skills of team members. Patients need to be better informed about, and more actively involved in, decisions about their care. All of this is directly relevant to PCDS. In particular, access to GDS is difficult in some parts of Scotland. Some of this has been caused by a reducing commitment to the NHS on the part of some GDPs. In some areas, especially the remoter ones, it has been difficult to attract dentists. The CDS is under increasing pressure to meet the needs of the priority classes, particularly with the continuing development of care in the community. At the same time, it has had to act as the ‘safety net’ where GDS are not readily accessible.
10. Inequality is, therefore, a major issue for PCDS. Not only does it exist in terms of dental health, particularly of children, but in access to services, which is very uneven across Scotland and within specific areas. There is also recognised variation in quality of services and in the way in which team working operates within PCDS.
11. It is important that PCDS are not viewed in isolation within the NHS. They are part of a spectrum of primary care services available to the population and they require access to relevant specialist services. On a broader front, they need to interlink with other agencies, for example, education (in relation to the dental health of pre-school and school children) and social work (particularly arising from care in the community). The opportunity to work together comes not just from using the same physical setting (which may not be appropriate in many circumstances) but from improved communication. The new organisational structures — (in particular Primary Care Trusts and Local Health Co-operatives) — give the impetus to look at different ways of delivering services in a more co-ordinated way.
12. There is a range of factors — some applicable to the NHS as a whole and some more specific to PCDS — which need to be taken into account in considering the future of PCDS:

a. changing patterns of health service provision e.g. more care being carried out in a community setting;

b. changing demography e.g. people living longer;

c. changing public expectations e.g. about ready access to services, information and involvement;

d. different patterns of supply of services across the country e.g. the distribution of dentists varies greatly in Scotland;

e. different use of skilled support staff;

f. development of centres of excellence where specialist staff can offer specialist services.

 

Needs and Supply

13. The dental health of children and adults in Scotland is a cause for concern and compares poorly with other areas in the UK. While there have been improvements over the years, around 56% of 5 year olds have signs of dental disease and 18% of adults have no teeth. There are now one million more people in Scotland with teeth than there were in 1972. In addition, there has been a four-fold increase in the number of 65s and over with teeth. In five-year-olds, only 8% of tooth decay has been restored, 20% has been extracted, and over 70% remains untreated. These statistics alone suggest the need for changes and improvements in service provision.
14. The nature of the service itself has changed considerably, not least because of technological advance. There are now effective prevention measures and treatment interventions are more sophisticated. Diagnostic equipment is more widely available and safer. There has been a major reduction in the use of general anaesthetics, and changes to the use of alternative techniques such as sedation.
15. Some 65.8% of children are registered with GDPs and a further 10% receive care from the CDS, leaving nearly 25% with no ongoing dental care at all. Only 49% of adults are currently registered with GDPs, and even allowing for a number of people (estimated in the 1998 Adult Dental Health Survey at some 14% of adults in Scotland) who may be receiving care on a private basis (willingly or because there is no real NHS alternative available), there is a large section of the population not receiving regular dental care.
16. The current level of GDS varies across Scotland. During the year ending March 2000 there were on average 36 GDPs per 100,000 population. The distribution of dentists varies greatly in Scotland: on the mainland from 407 (45 per 100,000 population) in Greater Glasgow to 33 (31 per 100,000 population) in the Borders. The pattern of service also varies, reflecting at least in part local needs.
17. The CDS provides services to a range of priority classes, including children, people with learning difficulties and elderly in residential care. They are a major service provider for the dentally anxious; this includes sedation, general anaesthesia and behavioural techniques. They provide a safety net service for those who are unable to access GDS. As with GDS there is a significant variation in staffing and level of service across Scotland.
18. The hospital dental service in responding to the referrals from primary care has been under pressure in some areas to meet targets for waiting lists and times. The development of these services needs to take place within the context of the Acute Services Review and clinical networks. The dental teaching schools have had their activity and outcome reviewed and benchmarked against all other UK dental schools. There should be a continuing and increasing emphasis for dental students on primary care where the majority of graduates will work, and better integration with teaching of the professions complementary to dentistry.
19. Consultants in Dental Public Health have a key role in providing public health policies in Scotland. The Public Health Review gives a clear direction for the development of this speciality within public health in Scotland, linked closely to the future role of Health Boards.
20. From the patient point of view, the wish is to see a universally available, good quality and effective service, with choice where practicable, and the right balance between prevention and treatment. It is to be recognised that greater health gain is more likely if resources are targeted to tackle the inequalities identified both in terms of dental health and access.

Contributing to Public Health

21. The White Paper ‘Towards a Healthier Scotland’ stressed the importance of dental health and the need to tackle Scotland’s poor record, particularly focussing on children. This was seen as part of a wider agenda, and the demonstration project ‘Starting Well’ (targeted at children from pre-conception to school entry) which has commenced in Glasgow will include the promotion of dental health, as well as nutrition, healthy diet etc.
22. Fluoridation of the water supply, where practicable, offers the most effective means of improving dental health, particularly for children in disadvantaged circumstances where disease is most common. The importance of full and informed consultation on this issue is recognised. Where it is not possible to consider fluoridation of the water supply, alternative measures such as fluoridated milk may be appropriate.
23. Encouraging very young children to register with a dentist, with advice to parents on tooth brushing and reduction of sugar in the diet of infants, is another important element in the promotion of oral health. This will be achieved effectively only with the co-operation of other health professionals in the community (health visitors, GPs etc) and other agencies such as local authorities. It is important that PCDS dentists play a key role in developing policy both with local health services and with local education and social work services to ensure a co-operative approach throughout all communities on issues such as diet and oral hygiene.

Preventing Disease

24. In addition to the measures listed above, there are specific actions within PCDS which can be taken to prevent dental disease, again targeted specifically at children.
25. The early years enhanced capitation scheme was introduced in 1998 to provide enhanced monthly registration payments for GDPs to undertake increased preventive activity for 0-2 year olds, with a sliding scale to recognise the greater challenge faced by dentists in more deprived areas, and for 3-5 year olds with the highest levels of dental decay. As a result, registration of 0-2 year olds has increased appreciably.
26. A Scottish Intercollegiate Guidance Network (SIGN) guideline (in press) on targeted prevention for 6-16 year olds confirms the effectiveness of fissure sealants in the reduction of dental caries. While some fissure sealant work is already undertaken in Scotland, it is not sufficiently targeted at those with the greatest needs.

Service Availability and Access

27. In 1999/2000 £171.3m was spent on GDS in Scotland of which some £50m was paid directly by patients. There are 1,833 principal dentists in Scotland, practising within the GDS as independent contractors. Around 200 community dentists work in CDS.
28. As independent contractors, GDPs are free to decide whether or not to provide NHS services, who to provide them to and what level service to give. The DDRB report for 2000 recommended that the Health Departments, in consultation with dentists, introduce a financial scheme to reward a high level of commitment to the NHS.
29. At 31 May 2000, there were over 1.9m (49.3%) adult patients registered with a GDP in Scotland. In addition a number of adults attend GDPs on a regular basis but outwith the 15 month registration period. Even allowing for this and a number of people who may be receiving care on a private basis, there is a large section of the population not receiving dental care. A small number of patients (30,000-50,000) attend dental teaching hospitals for their primary care dental services. Some 753,000 (65.8%) children were registered with GDPs and a further 10% receive care from the CDS.
30. Dental access schemes have already been put in place to tackle dental health needs and current demand for GDS. These have produced so far 6 offers of grant for new dental practices and 21 for extensions to existing practices, plus 2 for ‘return to work’ schemes.
31. A number of salaried GDP posts (now 40) have been approved to meet specific local requirements, particularly where access to GDS has proved difficult. In remoter areas, joint GDS/CDS posts have been established which allow a flexible approach to changing local needs. These are now seen as a permanent part of PCDS in Scotland.
32. The CDS targets adults with special needs, as well as specific groups of children, sometimes using mobile clinics. There are, however, some groups of disadvantaged patients who continue to have difficulty in securing dental care.

Quality and Standards of Service

33. There is already in place a range of measures to promote and assure quality within PCDS. Vocational training is a requirement for newly qualified dentists, and there are now 100 VT places in Scotland, including 10 new VT posts in CDS developed in 1998. The trial of General Professional Training, which offers young dentists the opportunity of clinical experience in GDS, CDS and the hospital dental service, has produced good results; the trainees have gained a valuable multi-service perspective before moving into primary care practice. There is a significant amount of continuing professional education (CPE) undertaken by dentists, and the General Dental Council (GDC)’s "Lifelong Learning" proposals have the objective of making continued registration conditional upon regular participation in CPE. There has also been a growing commitment to clinical audit in PCDS, building on the earlier peer review arrangements. Within both GDS and CDS, there is a well-established complaints system. Most areas have a system of GDS practice inspections, although implementation has not been consistent.
34. The renewed emphasis on clinical quality within the NHSiS will be directly applicable to PCDS. Clinical governance, building on existing patterns of self-regulation, will promote and support continuous improvement. There will be national standards and guidelines produced for PCDS both from SIGN and other bodies. The Clinical Standards Board for Scotland will play a key role in the future, linking to standards and guidelines produced by other bodies. Local Dental Practice Advisers are increasingly important in helping dentists implement guidelines, undertake audit and identify training needs. The relevant bodies at national and local levels are making strenuous efforts to develop ways of identifying poor performance and the remedial action needed. The General Dental Council is the lead body for these developments working in close collaboration with the NHS and specialist professional organisations such as the Faculty of General Dental Practitioners.

Responsive Services

35. The GDS system has not changed significantly since the inception of the NHS, and is regarded by many as being somewhat inflexible and focused more on treatment than prevention and more on quantity than quality. In addition, increased specialisation is not easily accommodated within the current arrangements. Within GDS the mix of NHS and private arrangements is generally accepted, but it does cause some confusion to patients, and the NHS commitment of some practitioners on dental lists is extremely limited.
36. A general dental practitioner who registers a patient under the NHS is obliged by their terms of service to provide or arrange for emergency treatment for their patient. While there is no formal requirement for Boards to provide emergency services for unregistered patients, a number offer such a service although this is somewhat patchy.
37. The new organisational arrangements within the NHSiS bring GDS and CDS within the ambit of PCTs (and IHBs). The formation of LHCCs, with their emphasis on the needs of local populations, is a further stimulus to more active involvement of PCDS in the wider primary care arena. There are already encouraging examples of cross-disciplinary working e.g. in out-of-hours services. Networks with hospital dental services can be further developed in some areas to offer patients integrated local services.

Human Resources and Teamworking

38. The education and training of dental practitioners and the professions complementary to dentistry is vital to the continued development of PCDS. This needs to be linked to sensitive manpower planning to ensure that the right numbers of professionals with the right skills are available to meet the changing needs. The closure of Edinburgh dental school resulted in a loss of over 30% of dental graduates in Scotland. Since 1990, the number of student hygienists has been reduced by over 30%.
39. There are few resources available for the basic education, training or continuing professional development of the professions complementary to dentistry. Less than 50% of dental nurses have any qualifications, no postgraduate resources are available specifically for these professions and dental technician training has slowly reduced to a point where only 2 centres now offer such courses. In the 1970s the number of dental therapists was expanding with 35 working in Scotland; the number has now reduced considerably with only 7 working in Scotland.
40. In May 1999, the GDC agreed fundamental changes (yet to be statutorily implemented) to the role of professions complementary to dentistry (PCD), including the introduction of statutory registration for all members of the dental team, and extending the permitted duties of existing dental professionals to allow them to undertake aspects of dental work. The HR strategy for the NHSiS ‘Towards a New Way of Working’ encourages experimentation with different skill mixes; these may help to alleviate problems with access to services in areas where there are shortages.
41. Dental teams need to work with others in the community, particularly other primary care professionals. Health visitors have a role in providing information about oral health and diet to the parents of infants. Community nurses and pharmacists can provide information and support to carers of the elderly, including issues of oral health, which help improve quality of life.

Infrastructure and Environment

42. Many dentists feel somewhat isolated from other parts of the NHS. The new organisational arrangements in Scotland provide a positive opportunity for enhanced integration. This would include an improved flow of clinical information, so that dentists have greater knowledge of relevant medical etc. conditions, and so that other professionals are aware of the implications of dental care. Communication links can also enhance the efficiency of the whole system. Electronic data interchange, for submission of forms etc, between dentists and the CSA is about to be rolled out. New technology can also help support remote and rural practices and make a contribution to better patient information.
43. The importance of practice inspections was earlier stressed as a vital element in maintaining and enhancing standards. GDPs and Trusts (on behalf of the CDS) have a responsibility to ensure that their premises, equipment etc are fit for purpose and meet all statutory requirements.

Resources

44. £171m is currently spent on GDS in Scotland. We know in great detail the quantity of service which is delivered across PCDS, and, increasingly, something of the quality. But the remuneration system for GDS in particular relates very largely to quantity. Additional funding has already been made available to support the dental access schemes and the PDS pilots, and more will be required to ensure full implementation of this plan.
45. As with all NHS expenditure, we need to ensure probity and take action where systems are abused. The CSA and Health Boards already take action in such cases, some of which can be complex and time consuming.

Conclusion.

46. This plan provides a co-ordinated approach in the short to medium term to improving the dental and oral health of the people in Scotland. Its implementation needs full discussion with the professions, the service and patients if it is to be delivered effectively.