An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland

AN ACTION PLAN FOR IMPROVING ORAL HEALTH AND MODERNISING NHS DENTAL SERVICES IN SCOTLAND

1. INTRODUCTION

The fundamental objectives of a modernised NHS dental service for 21 ^st Century Scotland are to improve oral health and provide accessible services focused on prevention and high quality, effective treatment.

Learning the essential skills to secure and maintain good oral health in childhood, lays the foundations for a healthy mouth for life. High quality dental services, utilising the skills of the whole dental team are a key part of this process, supporting individuals in maintaining their own oral health and providing additional care and advice when it is needed.

The current remuneration system for paying dental professionals and the consequent charging system has remained largely unchanged since the establishment of the NHS and is now outdated and in need of reform.

The professionals who provide dental services need to feel that a career in NHS dentistry meets their aspirations, provides job satisfaction, professional development and a fair reward. If we are to improve oral health and health services, we must both attract and retain the dental workforce which we need.

The public needs clear information on how to achieve and maintain good oral health, information on what services they can reasonably expect, and what responsibilities they have in return.

Meeting our objectives can best be achieved by taking steps to improve both oral health and health services. This will require a genuine partnership between a well-informed public and committed professionals.

Ten key principles underpin the way ahead:

• Oral health as an integral part of overall health improvement, underpinned by a free dental examination for all population groups.

• Services for children and young people should be focused on prevention and meet the oral health needs of those in the most disadvantaged circumstances.

• Patient led standards ensuring high quality services.

• A strengthened salaried dental service targeted at those in most need.

• Simplification and improvement of the current remuneration system with more transparent information for patients.

• Better support and incentives for practices demonstrating commitment to the NHS through the provision of NHS services.

• Further support to encourage recruitment and retention of all dental team members.

• A dental workforce trained to deliver dental services in a way which is effective and complements and supports a preventive approach to care.

• Closer integration of dentistry within the wider NHS family, through a national framework with local flexibility.

• An education and training plan to deliver more high quality dental professionals.

1.1 The Context

Oral Health in Scotland

Oral health has improved steadily for adults, with only 18% of Scots identified as having no teeth at the last Adult Dental Health Survey in 1998, from a previous low of 44% in 1972. However, for children, progress has been relatively static, with 55% of Scottish 5 year olds showing some signs of decay in the latest survey of Primary 1 children in 2003. This is unchanged from previous levels of decay found in this age group in the 1999/2000 Scottish Health Boards Dental Epidemiological Programme Survey.

Dental Services in Scotland

Currently, 49% of Scottish adults and 66% of children are registered with an NHS dentist, with additional numbers of children and adults accessing primary care services through the Community Dental Service and some doing so under private arrangements.

Dental health services are delivered in a range of settings, with input from a wide range of potential dental team members: dentists, hygienists and therapists, dental nurses, receptionist/managers and dental technicians. Each has a key role to play in the delivery of patient care and there is agreement that maximising the potential of the dental team is of critical importance in tackling both oral health improvement and dental service improvements in Scotland.

Data from Information and Statistics Division (ISD), Scotland, indicate that, at September 2004, there were a total of 2,161 dentists working in General Dental Services in Scotland, including salaried and non-salaried principals, assistants and vocational trainees. A further 605 dentists provide care in the Community Dental Service and Hospital Services.

The General Dental Service (GDS) provides the majority of dental services (accounting for approximately 75% of the costs of all NHS Dental Services in Scotland).

General Dental Practitioners (GDPs) are independent contractors who, while working under existing NHS arrangements, treat children and adults under a hybrid capitation and continuing care arrangement, supported by an item of service fee structure. While some practitioners undertake only private work, many GDPs undertake a mix of private and NHS treatment.

The salaried dental services have a vital role to play in meeting the need of disadvantaged groups and those with special needs, and NHS Boards may commission salaried services in accordance with their resources to meet local priorities, including the need to complement GDS provision. Salaried GDS practitioners provide the normal range of NHS general dental services.

Unless exempt, patients receiving treatment under GDS contribute up to 80% of the charges up to a maximum of £378 per course of treatment.

Currently, within GDS, there are over 400 different items of service and an equivalent number of patient charges for adults. Until 1990, dentists' payments were made only on completion of a treatment/course of treatment and this represented over 90% of the dentist's earnings. The introduction of capitation and continuing care payments in 1990 has changed this marginally, as have the more recent additional payments of practice allowances in Scotland. However an estimated 70% of dentist's earnings remains on payment of item of service.

The Community Dental Service (CDS) provides dental services and a safety-net function for those unable to access GDS, including services for special needs groups. In addition, the CDS undertakes screening for dental disease, notably for children in Primary School, as part of the National Dental Inspection Programme. Screening takes place in Primary 1 and Primary 7 and the information obtained identifies those at high risk of dental disease.

These services work together to meet the very diverse needs of both urban and rural communities, often in circumstances where access to services may be compounded by isolation.

Recent efforts to provide uniquely Scottish solutions to these very significant challenges and to encourage recruitment and retention of a suitably skilled dental workforce have had some success. However, the current dental system has been criticised as overly complex and increasingly limited in meeting the needs of both dental professionals and patients, particularly children. Consequently, in response to growing public and professional concern over these issues, it was considered appropriate to consult the Scottish public and key interests in Scotland on how future services might best be developed and how oral health, particularly for children, might be improved.

1.2 The Consultations

"Towards Better Oral Health in Children", published in September 2002, set out the facts about the oral health of children in Scotland and outlined a range of possible measures to encourage improvement. It also sought views on how to enhance preventive treatments, the promotion and practice of healthy eating and ways of using fluoride, including the issue of water fluoridation.

"Modernising NHS Dental Services in Scotland" launched in November 2003 was prepared to support the delivery of the undertaking in the White Paper Partnership for Care that we would "take forward proposals for changes to the system for rewarding primary care dentistry in order to promote prevention, improve access to services and improve recruitment and retention." It also addressed the commitments in the Partnership Agreement relating to dentistry.

The wide-ranging responses to these consultations have helped to shape the Executive's plans to address the issues raised.

1.3 Action Plan 2005-2008

This paper sets out an action plan to improve oral health in Scotland, with a particular focus on improving the oral health of our children, and presents our proposals for modernising NHS dental services in Scotland over the next 3 years but with implications for oral health and dental services to the end of the decade. This will set change in progress over the next 3 years and have further implications on changes in oral health and dental services into the next decade. There is no single solution; it is only by a combination of actions that we will be able to improve access to services and patients' dental and oral health.

2. WORKFORCE

It is essential that if we are to achieve our aim of securing improvements in oral health and health services, we must act now to ensure that current workforce issues do not restrict our ability to deliver the comprehensive service to which we aspire.

Although the number of dentists in Scotland has increased by 70% since 1975, and continues to rise steadily we do not have enough dentists to meet our needs; we estimated in 2003/04 that there was a shortfall of over 200 dentists and we have already begun to address this by recruiting an extra 50 dentists, through a range of recruitment and retention initiatives. However, we also believe that a comprehensive approach, which maximises the contribution and skills of all dental professionals is vital if we are to meet the challenges of securing appropriate access to services.

We have already undertaken a range of measures to encourage and support dentists working in Scotland. This has included supporting practices through practice improvement funding and the recently introduced general dental practice allowance, and providing additional financial support to those working in rural and remote communities. By encouraging young dental graduates to remain in Scotland through the provision of "Golden Hellos" we have signalled very clearly our intention to support young dentists.

However, we acknowledge that more could be done to support those in training. We need to extend current measures to support dental students in training, linking this to commitment to NHS dentistry for a period following graduation.

We are currently expanding training capacity for dental professionals in Scotland, both by expanding the intake of dental students by 15%, to guarantee an output target of 135 by 2006 and by radically reviewing the dental training model.

However, we believe that 135 dental students per year is the minimum we need to secure our expansion of the dental workforce and we will keep this figure under review.

In this way we will ensure that we maximise the very real potential that exists for training both dentists and Professionals Complementary to Dentistry (PCDs) within a range of community settings, through dental outreach.

Taking forward our Partnership Agreement commitment to extend existing outreach capacity in Scotland by establishing a dental outreach training facility in Aberdeen by 2007, we will consult on further expansion to a full dental school after assessing outreach benefits in 2007 and considering whether the annual figure of 135 dental graduates is sufficient to meet the requirements of the Scottish dental workforce.

In recognition of the very valuable role that professionals complementary to dentistry can make to oral health and health services and the quality of those services, we have already taken significant steps to increase the number and scope of these professionals training in Scotland from the 18-22 hygienists completing training annually in Scotland in the late 1990s (Edinburgh and Dundee only produced one cohort every 2 years), to an annual output of 30 clinical PCDs per year by 2008, most of whom will be dually qualified hygienist/therapists. In addition we will further expand the numbers of the clinical PCDs beyond current plans, to an annual output of 45, a 50% increase by 2010. This will mainly be hygienists/therapists but also includes others such as clinical dental technicians.

These professionals are able to undertake a wide range of clinical duties, including prevention of dental disease and oral health education. They work as key members of the dental team and have the potential to increase the amount of care delivered. The potential contribution of PCDs is often underestimated. For example, a therapist can increase a dentist's output by 45% and a hygienist can increase daily output by 33%.

The total number of dental professionals in training will exceed any previous numbers in Scotland by 2010.

3. THE WAY FORWARD - WORKFORCE

Targets

From a baseline of March 2004

By March 2008

Dentists:

• Increase the total number of dentists working in NHS dental services by at least 200 at an average rate of 50 per year, in salaried and independent practice

• Increase the number of dental students by 15% to deliver an output of 135 per year

• Increase the number of vocational trainees to 135 per year

Professionals Complementary to Dentistry:

• Increase the number of therapists in training to 45 per year

• Increase the number of dental nurses in training to 250 per year

To reflect the targets above each NHS Board will by 2006 identify and set a target for increased numbers of dental professionals.

Several factors are likely to have a direct influence on the increasing demand on oral health services in future, notably:

• More people keeping their teeth in older age.

• Increased early retirement of dental professionals.

• Increased part-time working.

• Increase in non-NHS working.

Modernised services, with innovative approaches to education and training will allow greater flexibility to support oral health care needs, particularly in remote communities.

3.1 Education and Training

There are 2 dental schools at Glasgow and Dundee which train new dentists. In addition, Dundee and Glasgow are developing additional flexible teaching options in a range of settings for students, known as "dental outreach schemes". The schemes offer experience in primary care services. Outreach training offers an opportunity to provide a range of dental training settings, outwith the conventional "dental school" model.

In addition to these measures, the Edinburgh Dental Institute currently undertakes postgraduate dental training and training of dental hygienists.

And 2 new dental therapist schools opened in Glasgow and Dundee, in 2003 and 2004. A further training facility is to open in Edinburgh in 2005. Rapid expansion of the dental therapist workforce will impact on the dental workforce from 2006 onwards.

Current action includes:

• Expanding the intake of dental students by 15% to guarantee an output of 135 graduates per year from 2006.

• Setting an output target of 35 qualified hygienists and/or therapists per annum for the next 5 years to be achieved by extending Scotland's dental hygiene schools in Glasgow and Dundee and establishing a conversion course at Edinburgh Dental Institute for existing hygienists.

• Supporting dental outreach training in Glasgow, Greenock and Dundee and reviewing current arrangements with a view to expanding dental outreach training in Inverness, Dumfries and Inverness.

• A commitment has been made to support new centres in Aberdeen and Inverness for therapists. Student training will come on stream from 2006 and 2007.

• 'Golden Hellos' have already been introduced to encourage retention of dental professionals in Scotland.

• Access grants are available for dental premises in specific circumstances.

The total number of dental workforce students, including PCDs, will exceed any previous output. But more needs to be done. We will put in place a package of measures which are intended to recruit professionals into the NHS and retain them there; in particular:

We will:

• Implement changes and additions to the current recruitment and retention measures, including an extension of the remote areas allowance.

• Introduce a new scheme to retain older dentists by offering more flexible contracts/employment arrangements.

• Support dentists with special interests in primary care through additional contractual arrangements.

• Implement an improved career structure for primary care dentists and PCDs to recognise special interests.

• Improve the return to work and keeping in touch schemes for those wishing career breaks.

• Introduce a bursary scheme for students which brings commitment to NHS dentistry for a period of 5 years after graduation.

• Implement outreach teaching for dental and clinical professionals complementary to dentistry students, at centres in Aberdeen, Inverness and Dumfries.

• Ensure that each year all the additional dental students have a VT/GPT place in Scotland.

• Increase incrementally the numbers of PCDs, particularly joint hygienist/therapists, beyond current plans to an annual output of 45 therapists per year, a 50% increase, and 250 dental nurses per year.

In combination these measures will address the shortfall in dental workforce and radically improve access to NHS dentistry in Scotland.

4. ORAL HEALTH

4.1 Children's Oral Health

Successive national oral health surveys have revealed very high levels of dental decay in young children in Scotland, with children from the most disadvantaged communities commonly demonstrating the highest levels of decay.

• By the age of 3, over 60% of children from areas of deprivation have dental disease.

• By the age of 5, over 56% of all Scottish children have dental disease.

• By the time they are 14, 68% of children have suffered from dental caries in their adult teeth.

The problem often starts at a very early age. If we are to tackle the problem, we need to ensure that children from all communities in Scotland access care regimes which emphasise the importance of good dental health and healthy eating habits from early childhood. This requires a partnership between a range of professionals and the parents of young children.

4.2 Adults

Dental health has improved for many Scottish adults over the last 30 years. One million more of the adult population of Scotland now have some teeth compared to 1972.

The improvements that have been achieved in oral health are the result of more positive attitudes to prevention of oral disease and improved dental services.

However, despite these improvements, oral disease is still a problem for many Scottish adults and access to dental services is increasingly problematic in many areas of Scotland.

The 1998 Adult Dental Health Survey revealed that:

• The average adult aged between 35 and 44 years of age had lost 8 adult teeth and had 10 teeth filled.

• 41% of Scottish adults reported some dental pain in the past 12 months.

• 56% of Scottish adults over 65 years had no teeth.

4.3 Services to Improve Dental Health

Improvements in oral health, particularly for children, cannot be achieved solely by those providing dental services. They require a multi-faceted approach, involving other sectors within the NHS, other statutory agencies, such as education authorities, and by tackling the broader determinants of poor oral health such as diet and smoking. Oral health improvement also needs commitment from the population - communities, individuals, patients and parents. However, high quality, accessible dental services available to those who wish to use them are a key component for sustained improvement. Services should offer an opportunity for regular comprehensive assessment of oral health needs and for preventative care, advice and appropriate treatment.

5. THE WAY FORWARD: ORAL HEALTH IMPROVEMENT

Targets

By 2010

5 yr olds (Primary 1)

• 60% of children will have no signs of dental disease

11/12 yr olds (Primary 7)

• 60% of children will have no signs of dental disease in permanent teeth

Adults

• 90% of adults will have some natural teeth

• 65% of adults aged 55-74 yrs will have some natural teeth

Oral Cancer

• Reverse current declining trends in oral cancer 5-year survival, for males, by 2015

5.1 Children

The results of the consultation on children's oral health provided evidence from a wide range of Scottish interests and have helped to inform the way forward towards improving children's oral health in Scotland.

• People agreed on the central role of diet in oral health. Good dietary habits should be established from the early years with home, school and community all playing a major part.

• Effective oral hygiene practice should be established at a young age, supervised by parents and carers.

• Schools should enable and facilitate good oral hygiene practice through the day with much support for extending free toothbrush and toothpaste schemes throughout Scottish schools.

• Opportunities exist for better diet promotion in the community with health professionals requiring to present a greater consistency of message and joined up approaches.

• A wider range of measures could be implemented in schools to reduce the availability of unhealthy food and improve healthy options.

• The public require improved education on healthy eating with clear, consistent and achievable messages.

• Dental services should be underpinned by a preventive philosophy, supported by a suitably modernised service.

In summary:

• People saw a clear need for a robust and overarching strategy for children's oral health.

• Schools and shops were seen as contributors to poor oral health whilst having significant potential to combat the problem.

• Schools and communities have a major role in developing good dietary and oral health habits.

• Dental services need to be supported in becoming more pro-active in improving oral health, including undertaking more outreach work and adopting a modern and friendly image.

• Big improvements could be made to reduce the availability of sugary produce in schools and promote healthier diets.

To achieve sustainable oral health in our children requires co-operation and partnership across Scottish society. We will introduce a range of measures to ensure that oral health is prioritised and is integral to the health improvement agenda in Scotland.

5.2 General and Crosscutting Measures

The benefits of a multi-disciplinary approach to oral health are well-recognised. Benefits include improvements to both general health and well-being and to oral health. In order to tackle the causes of dental disease, it is essential that all those with responsibility for the care of children are clear on their responsibilities. Health services and local authorities and individuals all have a key role to play. The introduction of the new Community Health Partnerships which will build on the work of Local Health Care Co-operatives, offers a real opportunity to ensure that key agencies work together to ensure an integrated approach to improving oral health and securing the type of integrated care essential to improving the oral health of children.

We will:

• Establish a comprehensive preventive care system for children and young people which includes enhanced services for those in most need.

• Increase the number of dental professionals trained in Scotland, especially those whose main role is to support preventive care.

• Ensure that oral health is seen as an integral part of health improvement actions in particular in children and young people with programmes such as Sure Start, implementation of the Scottish framework for nursing in schools, health promoting schools programme and community based health improvement programmes.

• Empower professionals across all public services to contribute positively to oral health improvement through education and training.

• Give a responsibility to Community Health Partnerships to achieve a more co-ordinated approach across community based services, to assess needs and respond through multi-professional and multi-agency action.

• Ensure dental teams are responsive to the needs of children and that all dental services are child friendly.

Within dental services, we will:

• Implement new schemes to promote registration and associated preventive activity from birth, with the intention that registration is ongoing and not time-limited.

• Introduce new enhanced services for those with extensive caries i.e. those with more than 3 diseased teeth requiring treatment: preventive treatment payment and weighted outcome payment on completion of treatment.

• Concentrate community based orthodontic treatment on those children and young people who are assessed under the Index of Orthodontic Treatment Need (IOTN) as having clinical needs.

5.3 Infants and Preschool Children

Targets

By March 2008

• All children will have access to dental care on starting nursery school and together with their parents and carers will have access to dental advice

• The number of children aged 0-2 yrs under dental care/supervision will increase from 35% to 55%

• The number of children aged 3-5 yrs under dental care/supervision will increase from 66% to 80%

• All pre-school children in areas of greatest need will be offered dietary advice, dental advice, support and preventive packs through community based organisations

• All nursery schools will offer supervised fluoride toothbrushing schemes and support healthy eating and drinking water policies

5.3.1 0-2 years - Pre-nursery

It is during infancy and early childhood that the foundations for good oral health are established. Early contact with appropriate health professionals during pregnancy and in the first 2 years of life provide an opportunity to offer advice on weaning and oral hygiene practices and to establish the necessary skills, such as toothbrushing, essential to good dental health throughout life.

We will build on current action which includes:-

• Midwife and public health nurse contact and advice on health and dental care.

• Distribution of toothbrush, toothpaste and information to all infants aged 6-8 months, with additional distribution to older infants in communities with greatest need.

• Community based programmes providing dietary advice, water fountains and fresh fruit linked to the Diet Action Plan.

• All health professionals emphasising the significance and importance of breastfeeding and early infant feeding to health and dental health.

In addition to these measures, we will:

• Offer dental care to all children from the earliest stages.

• Offer parental advice on eating and drinking and provide a free oral health promotion pack. Those in the most deprived areas will be offered an enhanced preventive dental care programme.

• Promote good weaning practice and good early feeding practice linked to oral health improvement.

• Introduce a new programme targeted on areas of greatest need in Scotland, which often have the worst record on childhood oral health problems, encouraging through support from public health nurses early engagement and registration with dental services for those in most need. Uptake of this initiative will be monitored by NHS Boards using existing systems. This will be evaluated over 3 years and expanded, learning the lessons from that evaluation, across the rest of Scotland.

To support the new programme we will:

• Establish initiatives for local family dentists to provide care and advice and preventive treatment.

• Support joint education and training between dental teams, local community based support workers and public health nurses to enhance partnership working.

• Build on the lessons from Starting Well, the early years health demonstration project, established to act as a test bed for action and learning resource which combined intensive home visiting support for children (aged 0-3) and families with enhanced access to community resources.

5.3.2 3-5 years - Pre-school

During these years it is important to build on the opportunities afforded by nursery schools to develop key skills, work with health and education partners to support young children, especially those in greatest need. We now have in place, through existing toothbrushing schemes, and healthy eating initiatives, the capacity to deliver sustainable oral health programmes within our nurseries.

We will build on current action:

• Recently introduced distribution of a free oral health pack to all on starting nursery school.

• The provision of water and fresh fruit in most nurseries.

• Support material for this age group available from NHS Health Scotland e.g. "eating, drinking, brushing".

• Nutritional standards for food in the pre-school sector will be published for consultation towards end March 2005.

In addition we will:

• Ensure that all children starting nursery school will be offered dental care services and oral health advice including a daily toothbrushing programme. Those in areas of most need will be offered enhanced support services to prevent dental disease e.g. advice on the benefits of healthy eating and regular toothbrushing and offer of clinical preventive treatments.

• Promote early years access to prevention by issuing promotional oral health packs to all children starting nursery school.

• Offer extension of nursery toothbrushing schemes to all nursery children.

• Develop a new nursery school based preventive dental service, initially in areas of most need. This service will be complemented by treatment services which provide local community based treatment or care from mobile units. Evidence from these programmes will be evaluated, and used to inform the development of this programme across Scotland within 3 years.

5.4 School Children

Targets

By March 2008

• All children starting school will receive preventive packs

• All primary school children will receive a risk assessment and be offered oral health advice on starting and finishing primary school

• 90% of primary school children aged 6-12 years under dental care increasing from 75% to 90%

• 20% of primary schools with the highest need will offer supervised toothbrushing in P1 and P2

• All schools will demonstrate their support for healthy eating and drinking (water) policies through the Diet Action Programme

• All secondary schools will have an oral health promotion programme which links to holistic health promotional programmes for teenagers

5.4.1 6-11 years - Primary School

During this period permanent teeth (second teeth) grow into the mouth, and effective self-care and access to appropriate advice and dental services is crucial. We have already taken steps to ensure that both health services and education establishments play their part. Educational establishments already have a key role to play in reinforcing oral health messages, refining practical skills such as toothbrushing, and contributing directly to oral health policy, through implementation of the Scottish framework for nursing in schools.

Dental services provide an opportunity for children and carers to access expert preventive advice and to benefit from a range of preventive treatments care such as fissure sealants to protect newly erupted teeth. Dental professionals offer care, treatment and advice on the developing dentition, particularly important during the time when teeth are developing.

We will build on current action:

• Caries prevention, including fissure sealing, for those aged 6 and 7 years.

• School inspections on entry to primary school and in Primary 7, at the age of around 11 years.

• Scottish Health Promoting Schools Unit is established and provides professional support and guidance at local authority and NHS Board level to all those involved in the development of health promoting schools.

• Hungry for Success sets nutrient-based standards for school meals in Scotland the standards require to be implemented in the context of a whole school approach to nutrition and will be monitored by HMIE as part of their inspection of schools.

In addition we will:

• Ensure that all children starting primary school will receive a dental inspection and an oral health promotion pack. All children finishing primary school be offered a dental inspection and dental care. Those attending schools in the most deprived areas will have additional school based preventive dental services.

• Provide early-years access to prevention by issuing promotional oral health packs to all children starting primary school.

• Extend toothbrushing schemes to those primary schools with the poorest record of oral health.

• Develop a new primary school based preventive dental service, initially in the most deprived areas of Scotland and areas in which there is a significant problem with oral health. This service will be complemented by treatment services which provide local community based treatment or care from mobile units. Evidence from these programmes will be evaluated, and used to inform the development of this programme across Scotland.

5.4.2 12+ years - Secondary School

As children become teenagers, with growing independence and freedom of choice, we must ensure that we enable them to make the healthy, informed choices which will safeguard oral health. This is a key stage where participation in sport has a valuable contribution to make to general health and well-being. It is important that young people are given appropriate advice at this time on preventing dental trauma and protecting teeth from injury.

Most importantly, we must ensure that health and education partners work together with young people to raise awareness of good oral health and that they are fully informed of the impact of smoking and alcohol on oral health, particularly in relation to oral cancer.

We will build on current action:

• Around 68% of 13-17 year olds are registered with a dentist and 5% receive treatment from the community dental service.

• Hungry for Success and Health Promoting schools applies to all secondary schools in Scotland.

• Good practice with secondary schools developing healthy vending practices.

In addition we will:

• Ensure that all secondary schools will be offered as part of the health promoting schools ethos, an interactive smile for health programme, promoting oral health, good eating, no smoking and prevention of sporting injuries to teeth.

• Identify those children at greatest risk of oral disease through the national dental inspection programme ensuring that this is used to inform the school profiles and health plans.

• Introduce NHS Health Scotland promotional programmes aimed at increasing the number of teenagers registered and in care with dentists.

• Ensure that oral health will be linked to teenage health promoting programmes, concentrating on healthy smiles and link to smoking cessation and prevention, and self-esteem work.

• Extend the use of fissure sealants to older children aged 12-14 years; these are already part of the caries prevention programme for 6-7 year olds.

• Ensure awareness of good oral health and information on accessing dental services, through the Scottish Framework for nursing in schools.

5.5 Adults and Older People

Targets

By March 2008

All adults:

• A free dental check will be introduced for all adults by 2007

• NHS Boards will have available and use an oral health module for Scotland's Health at Work programme to promote workplace oral health

• NHS Boards will develop and deliver oral health care preventive support programmes for adults in most need such as prisoners and the homeless

Adults aged 60+:

• NHS adult patients aged 60 years and over will be offered a free oral health examination from 2005 onwards

• NHS Boards will have in place appropriate oral health care and support programmes for all elderly care homes and will introduce performance indicators to measure their compliance

• Registration levels for 65-74 year olds will increase from the existing level of 40% to 60%

• Registration levels for people aged 75 years and over will increase from 28% to 40%

• Older people with special needs will have individual care programmes

Oral Health in Scotland is known to be poorer than in many other European Countries and there are significant inequalities in oral health evident in some areas of Scotland.

Good oral health is the product of healthy personal choices and well-focussed professional care.

There has been growing concern in Scotland over the ability to access NHS dental services and recent evidence supports this view. Recent research carried out for the Scottish Parliament's Health Committee Study on dentistry highlighted problems of access to NHS Dental Services in Scotland, with some dentists refusing to provide NHS treatment to patients, and deregistration of patients. This has been further exacerbated by shortages of NHS dentists in many areas.

Patients should be able to obtain appropriate oral health care and advice when this is required, and thus the package of measures being taken to support NHS dentistry are critical in improving service access.

Recent surveys of the oral health of older people in the United Kingdom suggest that attitudes to dental and oral care have changed significantly in the last twenty years. There has been a gradual reduction in the number of people who have lost all their teeth, with many more older people keeping some teeth. A modernised service should reflect these changes.

For older adults, the pattern of dental diseases may vary from that seen in childhood. Root decay and gum disease are more common than in younger adults. Oral cancer is also found more frequently in older people. Improvements in oral cancer survival are linked to improved information and early detection and treatment of disease, accessed through suitable health professionals.

Dental registration is known to decline progressively with increasing age at a time when increasing vigilance is needed if oral health is to be maintained, and access to services is fundamental.

Reduced mobility and dexterity also present special problems for older people and need to be addressed through the provision of suitable services.

We will:

• Make registration a continuing and not time-limited system, with defined responsibilities for both dentists and patients.

• Ensure that the concept of registration applies also to all the salaried services i.e. patients would, for the first time, register with the Community Dental Service, reflecting the importance of continuity of care.

• Provide dedicated services for those patients with additional "special" needs.

• Expand enhanced capitation fees to recognise the more complex/frequent care needed for older people.

6. MODERNISING THE NHS DENTAL SYSTEM

We need to put in place a package of measures to modernise NHS dental services so that they can be readily accessed by those who need them. This package addresses the concerns expressed by professionals and patients during the consultation and the issues subsequently raised in the report "Access to Dental Health Services in Scotland" commissioned by the Scottish Parliament Information Centre for the Health Committee.

It is important to recognise that this is a complete package which will be implemented over the next 3 years. It seeks to support those who are currently committed to the NHS, to encourage a higher percentage of NHS work from "mixed practices", to sustain and develop the salaried services, and encourage entrants to the profession to see NHS dentistry as a rewarding career.

6.1 Remuneration

It has been acknowledged that the current dental remuneration system has become outdated and does not adequately support the development of the preventively-oriented services essential to improving oral health in Scotland.

A new form of remuneration system will be put in place for those undertaking to deliver nationally agreed services.

This will comprise a mixture of the following:

• A capitation system reflected by changes to registration arrangements.

• Allowances building on the existing general dental practice allowance.

• Item of service fees but with a much simplified and less bureaucratic system reducing the number of items from the current 400+ to around 50.

• Reimbursements to meet specified costs: premises, IT, staff and certain services, e.g. clinical waste disposal.

• Ongoing development of the career structure for salaried staff.

Allowances and reimbursements will be payable subject to the proportion of dentist's NHS earnings to total earnings reaching an agreed percentage. That point would trigger a payment which would step up incrementally based on the percentage of NHS earnings. Clawback provisions would also apply to those dentists not fulfilling the conditions.

6.2 Service Structure

NHS Boards will be given a clear responsibility for planning and securing the provision of NHS dental services to meet local needs. This will be reinforced by Ministers through the performance and accountability review processes. Community Health Partnerships will play a key role in promoting a more co-ordinated approach to community based services and supporting clinical networks. To complement national requirements, some services are best arranged locally as part of the direct responsibility of NHS Boards e.g. out-of- hours services.

We will:

• Promote a holistic approach to family dentistry while pursuing separate arrangements for specific services.

• Provide the facility for NHS Boards to contract locally for services which are not part of the national arrangements e.g. out-of-hours; oral surgery, special needs.

• Introduce for the first time a free, comprehensive oral health assessment, consistent with the Partnership Agreement commitment to introduce free dental checks. This would be done when a patient joins a dentist's list, and be followed by routine examinations and updating.

• Use the oral health assessment system to indicate care pathways to determine subsequent treatment needed and access to advanced care.

• Put in place a national system, involving the professions and patients, for keeping under review what is available under the NHS to recognise changing technology and advances in treatment.

• Ensure that public health functions such as "school inspections" currently carried out by the Community Dental Service continue but with a greater contribution from PCDs.

6.3 Infrastructure

A substantial programme of premises improvements and development is essential to provide facilities to meet professional standards and patient needs. This will include addressing health and safety, infection control and disability issues. In particular

We will:

• Provide recurring financial support for existing premises which meet agreed standards through a new reimbursement scheme to meet rental or equivalent costs.

• Provide improvement funding to bring existing premises up to standard and to provide child friendly practices.

• Support financially the move of practices to new premises, including 3 ^rd party developments.

• Develop incentives to open up new facilities or take over existing practices in areas of high need/demand.

The use of information technology is somewhat limited in primary care dental services. Extending its use is a vital component in improved clinical care and communications.

We will:

• Introduce a comprehensive programme of support for information technology in practices including the salaried services.

• Provide recurring financial support to practices for approved clinical systems.

• Connect all practices to NHS net.

• Fund the communication costs of practices using NHS net.

6.4 Responsive Services

Targets

By March 2008

• Everyone in Scotland will be able to access advice and support on dental health and dental services through NHS 24

• An additional 400,000 patients will have access to or be registered with NHS dental services

• All patients will be able to access urgent care within 48 hours

• All patients with a dental emergency will be linked with the emergency dental service within 1 hour

6.4.1 Access to Services - Routine and Emergency Care

Our commitment is that an additional 400,000 patients will have access to, or be registered with, an NHS dental service by March 2008. However, we acknowledge that this is a milestone on the path towards registration of all adults who may wish to do so. Our goal is to secure access to dental services for all who need them.

While better access to NHS dental services in Scotland depends on the effectiveness of the measures in all sections of this plan, there are some specific actions which build on initiatives that have already been put in place.

A key element in this is making NHS Boards more clearly responsible and accountable for planning and delivering dental services in their area to meet the needs of local populations.

We will:

• Increase the funding available to NHS Boards to provide emergency and out-of-hours services, with more flexible delivery options.

• Improve access to urgent care.

• Implement a revised "dental access scheme" to provide financial support to practices wishing to provide new or extended services.

• Give NHS Boards the authority to appoint salaried practitioners where that is the best solution to meet local needs, and ensure that NHS Boards provide the necessary infrastructure and support.

• Provide specific incentives, e.g. staff support, for those working in remoter areas where the main remuneration system is insufficient to sustain services.

6.4.2 Access to Services - Information

Patients need access to information on improving and sustaining oral health together with information on accessing dental services when they need them, particularly when urgent care is required. We will build on the expertise of NHS 24 and NHS Boards in delivering emergency dental care and will seek to support the development of new integrated dental emergency services.

We will:

• Provide better information to patients, including the use of NHS 24, about oral health, service availability, and about rights and responsibilities.

• Ensure that all NHS Boards provide a "help-line" for local people to help them access services.

6.5 Supporting the Dental Team

The consultation reinforced the importance of the contribution which PCDs and support staff make to the delivery of services, and a wish to see that more clearly recognised and rewarded. To ensure an appropriate balance within the dental workforce:

We will:

• Increase the number of PCDs being trained.

• Use to the full the flexibilities currently available for the use of PCDs and take advantage of the proposed extended role of PCDs.

• Implement recruitment/retention measures similar to those for dentists.

• Provide support for the training and development of staff, including practice managers.

• Give practice staff the opportunity to join the NHS pension scheme.

6.6 Quality Standards

6.6.1 Setting Standards - Quality Monitoring and Quality Assurance

Patients have the right to expect high quality services delivered by a range of well-trained health professionals in premises suitable for the delivery of that care. We will support professionals in delivering the highest standards of oral health care, based on the primary care dental standards developed jointly by NHS Quality Improvement Scotland and the National Care Standards Committee. We will ensure that patients benefit from the additional skills which PCDs can bring to patient care.

In addition to the support for dental infrastructure and premises outlined earlier;

We will:

• Provide payments to support quality through continuing professional development and audit.

• Ensure that NHS Boards inspect all dental practices within a 3 year cycle.

• Introduce an "accreditation" scheme for NHS dental practices and provide support payments to practices linked to inspection and accreditation.

• Support the development of specialist skills, so that practitioners with special interests can provide community based services.

6.6.2 Supporting Quality: The Dental Clinical Effectiveness Programme

It is essential that modernised oral health services and treatments are underpinned by evidence of effectiveness. There is already in place a range of published clinical standards and guidelines in dentistry. However, to support a rapidly changing service, a guideline initiative to address specific national dental priorities will be developed.

We will:

• Provide support for the development of a range of clinical guidelines for dentistry in Scotland. These guidelines will address the following key priorities:

• Dental disease in children.

• Examination and assessment of the adult patient.

• Oral health assessment.

• Emergency dental provision.

• Dental prescribing.

• Dental sedation.

• Decontamination and infection control.

• Clinical governance in dental practice.

6.7. Patient Charges and Patient Information

The consultation provided agreement that the current system was not satisfactory and that any new system should be simplified and clear, for both patients and staff. It was also felt that any system should reinforce and not undermine the promotion of good oral health.

Our current view is that some form of banding system linked to a simplified fee scale may be the most appropriate and further detailed work will continue on this.

In addition we propose:

• To maintain but not to increase the overall income from patient charges.

• That changes will encompass the Partnership Agreement commitment on "free dental checks" which will focus on the enhanced "oral health assessment". This will be implemented first for older people and then extended to all, subject to review.

• That patients and the general public will be appropriately advised on dental services, costs, access and their nearest NHS service.

7. MONITORING AND EVALUATION

It is essential that the changes proposed are monitored and evaluated. Building on existing work, we will put in place a programme for collection and analysis of core minimum data to be a major component of the monitoring and evaluation process.

In particular:

Standard information will be available on:

• Oral health.

• NHS dental services.

• Quality and standards.

• Dental workforce.

• Patient satisfaction.

Progress on all of these areas will be reported on an annual basis.

8. IMPLEMENTATION

8.1 NHS Boards

NHS boards will be key to delivering this action plan and the associated oral health improvement and enhanced services at local level. Boards in the past have mainly worked with the salaried dental service but will increasingly take responsibility for the delivery of all aspects of primary care dental services.

8.2 Special Health Boards

Quality, health and health improvement, education and training and information are core to this action plan.

In order to deliver these:

• We will develop joint action plans with National Services Scotland and the Special Health Boards such as NHS Health Scotland and NHS Education Scotland who have a direct remit for these functions nationally.

• We will also review the functions of the Scottish Dental Practice Board in the light of the changes to general dental services.

8.3 The action plan will be kept under regular review in order to ensure that it is meeting the targets set. This will involve close working with representatives of the service, the public and the professions.