Oral health improvement strategy for priority groups

Chapter Five Making the best use of professional skills

This chapter considers the provision of services, both dental services and those provided by other health professionals and people working in the social care sector. It also highlights the National Care Standards and how they relate to dental health.

Traditionally, dental services have been provided by teams which could potentially include a dentist and a range of dental care professionals such as dental nurses, dental hygienists, dental therapists and dental technicians.

However, a number of new roles have emerged which have played a particularly valuable role in the prevention of oral disease in children. These are already starting to play an important role in supporting key staff and in improving the care of vulnerable adults outside the traditional practice setting.

Examples of new roles include:

• Dental Health Support Workers who reach into communities to deliver oral healthcare messages. This approach is still being evaluated for children within the Childsmile programme and is being developed to include working with older people.
• Clinical Dental Technicians who have undertaken training to develop their clinical skills and may make full dentures directly for patients and may provide a number of additional clinical devices to patients on the prescription of a dentist.

5.1 General Dental Services (GDS)

In Scotland, the majority of General Dental Practitioners (GDPs) are independent contractors, working within the NHS General Dental Services framework. Payments to dentists comprise item of service fees, continuing care payments and payments derived from a range of grants and allowances. Enhanced continuing care fees are paid for the provision of treatment to those with special needs and those over the age of 65. Under GDS arrangements, patients access NHS treatment from the complex item-of-service fee structure set out in the Statement of Dental Remuneration and, unless exempt from charges, contribute up to 80% of the total fee, up to a maximum of £384 at the time of writing.⁴⁹

At 30 September 2011, 3,053,394 adults in Scotland (75.6%) were registered within the GDS. Registration declined steadily from the age of 55.

In the 55-64 year age group, 67.8% of adults were registered, declining to 53.5% registration amongst those over the age of 75 years.⁵⁰

From 1 April 2010, dental registration became continuous in Scotland,⁵¹ ending lapse from registration "by default", a situation which had the potential to impact significantly on those who may not have fully understood the process and obligations of dental registration. These changes should assist continuity of care for all patients, particularly the vulnerable.

A range of dental treatment is available under NHS terms and conditions.⁴⁹ This includes examination and advice, oral hygiene instruction, the application of fissure sealants and fluoride, periodontal treatment including scaling and polishing, all of which may be provided within the GDS. The current list also includes a wide range of restorative and surgical treatment.

Dental practitioners can provide treatment at home (domiciliary care) to patients who have special care needs and who cannot reach a dental surgery. However, provision of this service by general dental practitioners has gradually declined.¹⁸ In the years between 1992-93 to 1999-2000 domiciliary treatments by general dental practitioners accounted for approximately 30,000 visits per year. However, this declined sharply between 2000 and 2007-08, when only 13,771 visits were carried out.¹⁸ Figure 3 shows this reduction for the whole of Scotland.

Figure 3. Number of domiciliary visits undertaken by GDPs in Scotland

Source: Scottish Dental Needs Assessment Programme. Domiciliary Dental Care Needs Assessment Report. October 2010.

Reasons for the gradual decline are thought to include: the level of current remuneration, the constraints of the physical environment, lack of portable equipment, together with the need to transport an extensive range of emergency drugs and oxygen. Concerns about infection control have also been identified as a potential barrier to the provision of domiciliary services through general dental services.¹⁸

5.2 The Salaried Dental Services

The Salaried Dental Services include both Salaried General Dental Practitioners (GDPs) and the Community Dental Service. It is a directly managed salaried service. The role of the modern Community Dental Service includes the delivery of a Public Health role, including screening for oral disease, health promotion and preventive programmes for children and adults with special needs. The service provides annual inspection of children's teeth as part of the National Dental Inspection Programme. The Community Dental Service provides a safety net service to those who have special care needs and cannot access General Dental Services. Salaried GDPs provide general dental services in areas where there is a gap in provision by general dental practitioners.

The Salaried Dental Services play a key role in delivering care to the most vulnerable people in the community, particularly when care is required at home, or in the care home setting. It has also played a central role in many of the priority group pilot programmes ongoing across Scotland.

The Community Dental Service makes a significant contribution to the provision of domiciliary services in Scotland. The number of domiciliary visits carried out by Salaried GDPs has risen from 396 in the year 2000 to 1,246 in 2008, as shown in Table 2. However, this is still a relatively small proportion of the overall GDS provision of domiciliary dental care.

Table 2. Number of domiciliary visits undertaken by GDPs, non-salaried and salaried, for year ending March (Scotland)

Year	Non-salaried	Salaried	All
2000	30,316	396	30,712
2001	27,108	366	27,474
2002	24,494	266	24,760
2003	23,495	342	23,837
2004	21,008	511	21,519
2005	18,915	333	19,248
2006	14,898	446	15,344
2007	13,272	933	14,205
2008	12,525	1,246	13,771

Source: Scottish Dental Needs Assessment Programme. Domiciliary Dental Care Needs Assessment Report. October 2010.

The number of domiciliary visits carried out by the CDS across Scotland, shown in Figure 4, has stayed relatively steady between 1996-97 and 2006-07, averaging around 25,000 visits per year.

Figure 4. Number of domiciliary visits undertaken by the Community Dental Service in Scotland

Source: Scottish Dental Needs Assessment Programme. Domiciliary Dental Care Needs Assessment Report. October 2010.

In 2006, the Taylor Report⁵² carried out an extensive review of the role, remit and structure of the primary care salaried dental services, recommending a New Scottish Public Dental Service, with a merged Community Dental Service and Salaried GDS Service. The review found that such an approach would be able to provide an enhanced service, and would enable better use to be made of the skills of the professionals complementary to dentistry, and enable improved targeting of services in areas where need is greatest.

A revised service could work in partnership with the general dental services, offering enhanced flexibility. Such a service would potentially be more responsive to the needs of priority groups such as the elderly, the housebound and those with special needs.

5.3 Hospital Dental Services

Hospital dental services in Scotland are responsible for the provision of secondary care services, normally confined to more complex dentistry which is beyond the scope of primary care. Services are accessed via referral from primary care. In addition to the provision of complex care, hospital services may be involved in undergraduate and postgraduate teaching and dental research.

5.4 NHS Hospital In-patient Services

In the urban setting treatment to hospital in-patients is provided by the CDS. Such patients do not require to pay for services. Delayed discharge of patients from hospital has the potential to impact on the provision of dental services, as extended in-patient stays are likely to increase the need for dental treatment whilst in hospital. Significant efforts have been made to address this issue in Scotland and data indicate that delayed discharge has declined substantially over the last 10 years.⁵³ However, this situation has the potential to impact on service use if recent improvements in delayed discharge are not sustained.

5.5 Dental Care Professionals

Dental Care Professionals (DCPs) play an important role in the care of vulnerable individuals and encompass a wide range of professionals, including: dental nurses, dental hygienists, dental therapists, dental technicians and clinical dental technicians. Their roles are complementary to that of the dentist. DCPs must register with the General Dental Council (GDC). At June 2010 there were 5,798 DCPs in Scotland:⁵⁴

Recently, the GDC acknowledged the need to shift the focus of DCP education away from highly prescribed topics and subject-based training to one which focuses more on desirable educational outcomes.⁵⁵ In practical terms this provides for a much more flexible approach to the delivery of clinical services through enhanced roles which have considerable potential to contribute to the needs of priority groups, including frail and dependent older people. For example, the range of duties for dental nurses may now include the application of fluoride varnish to the teeth, a measure which may be important in developing preventive programmes for priority groups.

The roles of dental hygienists and dental therapists have undergone significant changes within the last 10 years. Since 1 July 2002, subject to completing the necessary training, dental hygienists and dental therapists may now carry out a wide range of clinical duties including scaling and polishing of teeth, the application of fissure sealants and fluoride as a preventive measure and deliver oral health education.

Dental therapists may carry out a range of restorative procedures for children and adults work in general dental practice as well as the Salaried Dental Service.

Post-qualification training for DCPs includes a number of courses directly relevant to the provision of services to vulnerable people. In 2009, 18 DCPs participated in training to achieve the Certificate in Special Care Nursing, 34 attended training to achieve the Certificate in Oral Health Education and nine attended courses to achieve the Certificate in Dental Sedation Nursing.⁵⁴

5.6 Working Across Disciplines to Improve Oral Health

A number of organisations and professions other than the dental team also have a valuable role to play in helping to support good oral healthcare for vulnerable people and in the prevention of oral diseases. Local authorities and NHS boards have a particularly important role in ensuring a joined-up approach to care though the development of Single Outcome Agreements, and through the process of shared assessment and the development of Health and Homelessness Plans.

Local authorities also have responsibility for the delivery of education and training to frontline care staff through the Scottish Vocational Qualification (SVQ) Programme, complementing that of NHS Education for Scotland as the main provider of education to medical, dental and nursing professionals. The Care Inspectorate is responsible for regulating and inspecting care services in Scotland.

5.6.1 Staff who Care for Adults Vulnerable to Poor Oral Health

The provision of oral health training for care staff varies considerably throughout Scotland. To obtain long-term changes in practice⁵⁶ it is important to ensure that staff training for those who care for vulnerable people is ongoing and that staff understand the value of oral healthcare and the difference which it can make to the quality of life of clients. Oral and dental health is not consistently included in needs assessments or admission and discharge protocols, which potentially compromises oral health and continuity of care.

It is important that a national preventive programme for those who are dependent or who have special needs supports the training needs of frontline care staff and raises awareness of oral conditions and the actions required to maintain good daily personal oral care. This includes the carrying out of an assessment of residents' oral health and care needs, both on first admission and on an ongoing basis. The development of oral care plans is an important part of this process as the ability to understand when it is appropriate to refer to an oral health professional. The documentation of daily oral care is important to show when oral hygiene has been carried out and also acts as a useful prompt to undertake care.

The National Older People's Oral Health Improvement Group working in close collaboration with NHS Health Scotland, have recently produced a comprehensive training guide for oral health professionals, Caring for Smiles.⁵⁷ It supports oral health professionals working in care establishments, and has been disseminated to key interest groups across Scotland. The guide offers comprehensive information, guidance and practical support on caring for the oral health of dependent older people and guidance on patient risk assessment and the development of patient care plans. However, hands-on practical training is still required. This is best delivered by an individual appropriately trained in oral health.

The training guide also highlights some of the barriers which might be encountered when training care staff, and gives advice on the challenges of undertaking personal care for those who have dementia.

For homeless people, support staff in settings where homeless people stay have a valuable role in providing information for clients and in signposting clients to dental services. NHS Health Scotland and Dundee University are working together to produce a training programme to improve the oral health of homeless people called the Smile4life Intervention.⁵⁸ The guide is intended to be used by dental and social care professionals working with homeless people.

5.6.2 Social Care and Nursing Staff

The Joint Future Group was set up in 1999-2000 to agree a list of joint measures which agencies need to have in place to deliver effective community care services and identify and share good practice.

The principles and process of Single Shared Assessment (SSA) to inform basic health were subsequently outlined in guidance.⁵⁹ The SSA process includes an assessment of health, housing and social care needs, with a view to streamlining the process of care for individuals.

The core data sets provided in the guidance specify that oral health should be one of the components of assessment, and there is provision in the care plan data set for the meeting of oral health needs. Local SSA protocols for older adults have been developed in local authority/NHS areas but there is considerable variation as to whether oral health issues have been included.

In July 2002, the Scottish Executive implemented free personal and nursing care within the home and hospital setting,⁶⁰ subject to assessment of needs by the local authority, recognising that patients should not be forced to move prematurely into residential care as a result of having to pay for care in the home, where that care could be provided free in the hospital setting.

In Scotland, free personal and nursing care is now available free to everyone over the age of 65 who requires it, whether the individual is in their own home, in hospital or in a care home. The type of care provided is based on the Single Shared Assessment. Additional allowances, available only to Social Work-funded clients are available for enhanced care for the "elderly mentally incapacitated",^18,61 and "very dependent elderly". Payments towards residential care are complex and may require residents who can afford to do so to contribute to their care.⁶⁰

Several of the tasks which fall within the definition of "personal care" are of direct relevance in maintaining the oral health of those receiving care, notably, personal toilet, eating and drinking and management of prescribed medication. Therefore it is important that any future strategy addresses this issue.

Those entering care homes will increasingly be the frailest individuals for whom care at home is no longer a suitable option. For health planners, this should be reflected in a shift in the model of care from an institutionalised care model for older people to one which also reflects the needs of those whose care may be provided within the home setting, as older people encouraged to remain in their own homes for as long as possible.

A national care home contract has been developed for all local authorities. These make provision for toiletries, including toothpaste and brushes, to be supplied free of charge, However, the recent SDNAP Domiciliary Report¹⁸ has suggested that this policy not applied consistently across all establishments. The use of "own brand" products is expected to be self-funded. Loss of dentures is often problematic with inconsistency in denture marking contributing to the problem. Problems have also been reported with respect to facilities for oral care.¹⁸ Staff in care home settings should be aware of how to assist patients who may need to apply for financial help with dental charges.

5.6.3 National Care Standards

As a result of the Regulation of Care (Scotland) Act 2001⁶² there are now no legal differences between residential and nursing homes. The National Care Standards Committee was set up to develop national standards from the point of view of people who use the services. They describe what each individual person can expect from the service provider and focus on the quality of life that the person using the service actually experiences.

National Care Standards: Care Homes for Older People⁶³ include measures which are relevant to oral health. There is emphasis on a balanced nutritious diet within the standards but no specific reference to reducing sugar frequency. It is recognised that there is the potential for conflict between the oral health promotion agenda, which seeks to reduce sugar intake and the nutritional needs of older people. Addressing these issues must be balanced by the respecting the individual's freedom of choice.

The standards for care homes require staff to regularly review anything that affects clients' ability to eat or drink, such as dental health, and to arrange for advice. There is also a reference within the current standards to the need to maintain registration with a general dental practitioner and a recommendation that staff should help individuals to register as quickly as possible. The standards require that staff provide information about preventive healthcare, including screening.

There is no specific mention of the role of the Community Dental Services, who provide a "safety net service". This would be helpful in pointing staff to services for the most vulnerable clients, who may require more specialised care than can normally be provided in the general dental practice setting.

Standards for Care at Home, which were revised in 2005,⁶⁴ highlight the need for good nutrition, and require home care workers to obtain help obtain professional help for a client if it is wanted, if the ability to eat or drink is being affected by dental health.

Those in positions of leadership have a particularly important role and can play their part by creating a culture which encourages good oral health. Adopting policies within workplaces which support the efforts of staff working directly with client groups will help staff to value good oral health themselves and will motivate them to prioritise good oral health for client groups. Support for staff training is also essential if progress is to be made.