Scotland's oral health plan consultation: analysis of responses

1 Analysis of Responses

Methodology

The consultation asked respondents a variety of questions relating to the proposals outlined in Scotland's Oral Health Plan. The majority of the questions were closed, inviting respondents to either agree, disagree, or neither agree nor disagree with the proposal outlined. Other formats utilised included: questions asking respondents to select their preferred option from a predetermined list; ranking items in order of importance; and a free text question allowing respondents to address any other concerns. For each question, regardless of format, respondents were able to provide free text comments to discuss their response and views on the proposals. The inclusion of free text comments for each question resulted in the need for a qualitative analysis of the responses to complement the statistics provided by the closed questions.

The statistics were automatically compiled by the consultation platform reflecting the options respondents selected. A framework was developed to carry out the qualitative analysis of the comments to ensure that all the responses were treated consistently. The comments discussed in the following sections are based on the most common themes that respondents choose to discuss in response to each question. However, a number of respondents did not use the questionnaire, instead submitting written papers based around the themes in the consultation document. As a result these returns were analysed as part of the final free text response.

Please note that the qualitative analysis is based solely on the comments provided, the number of which varied widely per question, and therefore the views expressed are not necessarily representative of the wider population.

Overview of Responses

The consultation platform received a total of 427 responses. Of these 347 were from individual respondents and 80 from organisations. Individual respondents were asked to select whether they were responding as a member of the public or one of a variety of dental professionals. The breakdown of respondents by category is as follows:

Responding as	Number of Respondents
Organisation	80 (19%)
Individual	347 (81%)
Member of the public	45 (11%)
Dentist	34 (8%)
Dentist - Practice Owner	95 (22%)
Dentist - Associate	67 (16%)
Dentist - Assistant	4 (1%)
Dentist - Hospital Dental Service	9 (2%)
Dentist - Public Dental Service	36 (8%)
Dental Care Professional	32 (7%)
Other	24 (6%)
Declined to specify	1 (0.2%)

Note: Percentages may not total 100 due to rounding.

Part A: Improving Oral Health

Question 1: Which of the following would you regard as the most important? (Please rank 1-3, in order of importance)

Of the 427 consultation responses, 403 respondents answered this question
(94% response rate) and of those, 148 provided comments.

Option	1st choice	2nd choice	3rd choice	Total
Access to NHS dental services	147 (34%)	62 (15%)	59 (14%)	268 (63%)
Cost of NHS dental services	27 (6%)	49 (11%)	64 (15%)	140 (33%)
Services closer to your home address	2 (1%)	17 (4%)	18 (4%)	37 (9%)
Child dental services	32 (7%)	52 (12%)	43 (10%)	127 (30%)
Ageing population/domiciliary dental care	17 (4%)	47 (11%)	56 (13%)	120 (28%)
Oral health inequalities	53 (12%)	64 (15%)	73 (17%)	190 (45%)
Quality of NHS dental care	110 (26%)	101 (24%)	66 (15%)	277 (65%)
Other	15 (4%)	7 (2%)	16 (4%)	38 (9%)
Not answered	24 (6%)	24 (6%)	24 (6%)	24 (6%)

Note: Percentages do not total 100 as more than one option could be selected.

Summary of Responses

Of the respondents who selected 'other', a variety of issues were raised as the most important, including: remuneration and general funding for dental services; a focus on preventive dentistry; ensuring access to appropriate services for patients with additional support needs; and providing a range of treatments and services for all patients.

Of the comments provided, a substantial number of respondents expressed the view that all the options listed were equally important, with a small number also noting that they are all inter-linked, making them very difficult to rank. A few respondents noted that ranking them may not be appropriate. For these reasons some respondents chose only to rank one or two options, or not to rank any of them.

A large number of respondents commented that NHS dentistry needs to focus on prevention going forward, suggesting that this will help to address oral health inequalities, particularly in relation to children in order to build good dental habits early. Public health measures, such as sugar tax, water fluoridation, and education campaigns, were also suggested by a number of respondents as being beneficial for improving oral health.

A number of respondents also commented on the current level of remuneration, suggesting that fees are too low to be able to provide a high quality service to patients and maintain practice viability.

A Preventive-Based Approach to Oral Health Care

At present the balance of dental provision rests with restorative procedures. However, we have observed in recent years improvements in the oral health of the population, particularly children whose oral health has benefited as a consequence of the interventions of the Childsmile programme.

The consultation document introduced a number of models of how NHS dental services might be delivered in the future, including a preventive care pathway, initially for children and younger people with good, stable oral health, that would grow up with the patient. The emphasis would be on the maintenance of oral health preventing disease before it occurs in the mouth. The consultation document also offered the prospect of an Oral Health Risk Assessment ( OHRA), initially at 18 years of age, but eventually at regular intervals. This would ensure that patients receive oral health advice based on their lifestyles.

Question 2(a): NHS dental services should increasingly focus on prevention. Agree or Disagree?

Of the 427 consultation responses, 406 respondents answered this question
(95% response rate) and of those, 193 provided comments.

Option	Number of respondents
Agree	353 (83%)
Disagree	14 (3%)
Neither agree nor disagree	39 (9%)
Not answered	21 (5%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

As well as indicating support, a substantial number of respondents who agreed, chose to highlight important issues such as the link between oral and general health. Some respondents discussed wider public health measures such as water fluoridation and sugar tax.

A large number of respondents who agreed, also used this opportunity to acknowledge the success of the Childsmile programme, and how this might be extended to other age groups. Other respondents emphasised the increasing need for more periodontal treatment.

While there was consensus amongst respondents that there should be an increasing emphasis on prevention, some comments from those who agreed highlighted the importance of adequately resourcing any substantial policy shift.

There was a feeling across respondents that dentists should be adequately remunerated for carrying out preventive work. A small number of those who neither agreed nor disagreed were of the view that preventive approaches were already happening.

Question 2(b): The Scottish Government should introduce a preventive care pathway. Agree or Disagree?

Of the 427 consultation responses, 408 respondents answered this question
(96% response rate) and of those, 190 provided comments.

Option	Number of respondents
Agree	280 (66%)
Disagree	45 (11%)
Neither agree nor disagree	83 (19%)
Not answered	19 (4%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Whilst there was a high level of support for this proposal, a number of those who agreed queried whether it would be possible to run two systems concurrently, and the precise mechanism for a patient moving between the two systems. A number of those who agreed also expressed concerns regarding how a preventive pathway would be funded, and how dentists would be remunerated.

Amongst those respondents who disagreed with the proposal, there was concern that too much emphasis was being placed on the dentist or dental treatment, and there needs to be more recognition that the patient has a significant responsibility for their own oral health. A small number of those who disagreed also raised questions about how a dentist would be rewarded for maintaining and improving oral health, particularly in deprived areas.

Question 2(c): Which group(s) of patients should a preventive care pathway be applied to in the first instance? (Please indicate a preferred option)

Of the 427 consultation responses, 403 respondents answered this question (94% response rate) and of those, 160 provided comments.

Option	Number of respondents
Only for children	35 (8%)
Start with children and extend to adults gradually	129 (30%)
Children and some adults	61 (14%)
From all dental patients from the start	151 (35%)
Other	27 (6%)
Not answered	24 (6%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

For those respondents who favoured the introduction of a preventive care pathway for all patients, there was concern that adults may be excluded from a preventive approach if the focus remained primarily on children. Those who favoured the children-first approach were concerned that more radical change could destabilise existing systems of care and that any change needs to be carefully managed through an evolutionary approach.

Although these two groups of respondents disagreed on how quickly a preventive care pathway could be introduced for adults, there does appear to be a consensus that the pathway should be introduced for children.

Question 3(a): In the future it would be beneficial to introduce an Oral Health Risk Assessment. Agree or Disagree?

Of the 427 consultation responses, 407 respondents answered this question (95% response rate) and of those, 205 provided comments.

Option	Number of respondents
Agree	297 (67%)
Disagree	44 (10%)
Neither agree nor disagree	66 (15%)
Not answered	20 (5%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

A number of respondents from across the spectrum commented that OHRAs are already being carried out as part of NHS dental care. There was some uncertainty amongst respondents about the exact meaning of an OHRA and the challenge will be for the Scottish Government to articulate its proposals as part of the forthcoming Oral Health Improvement Plan.

A large number of respondents who agreed expressed concerns around the time it might take to carry out this assessment, what it should include, how it might be implemented, and how it can evolve in the future taking cognisance of the latest evidence in dental care and treatment. Respondents who agreed were also of the view that dentists should be adequately remunerated for carrying out an OHRA. Some of those who agreed also provided suggestions about what should be included within the OHRA. This included an emphasis on smoking, diet and alcohol intake.

Question 3(b): If the Scottish Government introduced OHRAs, at what age should patients first receive an OHRA? (Please indicate a preferred option)

Of the 427 consultation responses, 382 respondents answered this question (89% response rate) and of those, 215 provided comments.

Option	Number of respondents
18 years of age	166 (39%)
21 years of age	16 (4%)
25 years of age	13 (3%)
Other	187 (44%)
Not answered	45 (11%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Amongst the respondents who selected 'other' and from '18 years of age' a large number of the comments suggested that the Scottish Government should consider introducing OHRAs at an earlier age. There was a sense that an OHRA would be more cost effective for younger patients, and if the decision of the Scottish Government is to introduce these assessments, then it should consider introducing them at an earlier point than 18 years of age.

Question 3(c): How often do you think OHRAs should be repeated? (Please indicate a preferred option)

Of the 427 consultation responses, 383 respondents answered this question (90% response rate) and of those, 236 provided comments.

Option	Number of respondents
Every 5 years	146 (34%)
Every 10 years	12 (3%)
Other	225 (53%)
Not answered	44 (10%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Amongst those who chose 'other', a large number of respondents were of the view that the interval between assessments should be determined by the oral health of the patient rather than a set time. A number of respondents who selected 'other' also suggested it should be more frequent than five years.

Enhanced Services

The consultation document introduced the concept of enhanced services in the following areas:

• domiciliary care (complex cases);
• oral surgery (complex extractions);
• restorative services (complex treatment);
• treatment under intravenous sedation; and,
• orthodontics.

At present many of these services are largely provided by the Hospital and Public Dental Services. These proposals envisage that in the future some of these services could be provided by dentists with enhanced skills operating out of a general dental practice setting.

Question 4(a): Complex treatments should be delivered more frequently by a local dental practice. Agree or Disagree?

Of the 427 consultation responses, 403 respondents answered this question (94% response rate) and of those, 259 provided comments.

Option	Number of respondents
Agree	222 (52%)
Disagree	73 (17%)
Neither agree nor disagree	108 (25%)
Not answered	24 (5%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Respondents who agreed with this proposal also chose this opportunity to express a number of reservations, including the need for appropriate training, equipment, adequate funding, and the potential role of Health and Social Care Partnerships ( HSCPs) in strategic planning and commissioning of these services. A number of respondents who agreed were of the view that a move to complex treatments being provided in local practices would improve patient access to NHS dental care.

For respondents who disagreed there was concern expressed regarding funding arrangements and the training and experience required to carry out certain complex treatments. Some respondents who disagreed were also of the view that certain complex treatments should be carried out within secondary care due to the resources and equipment available within hospital settings.

Those who selected 'neither agree nor disagree' were also concerned about funding arrangements, and training and experience. These respondents also requested more detailed information about the proposal.

Question 4(b): Which treatments should be delivered in this way? (Please tick all that apply)

Of the 427 consultation responses, 387 respondents answered this question (91% response rate) and of those, 146 provided comments.

Option	Number of respondents
Domiciliary care (care in your own home, or care home)	210 (49%)
Certain oral surgery procedures, such as complex tooth extractions	259 (61%)
More advanced dental restorations such as complex root canal treatment	234 (55%)
Treatment under sedation	229 (52%)
Orthodontic treatment	222 (52%)
Other	62 (15%)
Not answered	69 (16%)

Note: Percentages do not total 100 as more than one option could be selected.

Summary of Responses

Respondents were able to select more than one option for their response, which many of them chose to do.

The issues raised within the comments included the training requirements for carrying out certain complex treatments, views that the current fees are not appropriate for the complexity of these treatments, and concerns about the wider financial implications of carrying out these treatments in a general dental practice setting.

Some respondents chose to discuss the role of specialists, particularly in relation to orthodontics. These respondents stated that orthodontic treatment should only be provided by specialists. Other respondents noted that there will always be a need for some treatments to be carried out in a hospital setting by specialists.

Although the difference between the most and least favoured option is around 10 percentage points, domiciliary care came out bottom of the list of choices presented to respondents. This is possibly explained in the comments that a number of dentists made about the particular challenges of domiciliary care, including the time and equipment required to carry out a domiciliary visit.

Some respondents discussed the role of the Public Dental Service ( PDS) in providing complex treatments, with many commenting on the experience and expertise within the PDS, particularly in relation to treating complex patients. Respondents also commented that should local practices provide more complex treatments this would reduce the strain on the PDS.

Patient Charges

At present children and young people under 18 years of age are entitled to free NHS dental treatment, while all adults receive free NHS examinations. An adult patient is required to pay 80 per cent of the cost of their NHS dental treatment up to a maximum of £384 per course of treatment unless they are in one of the groups entitled to free NHS dental treatment or qualify for help towards the cost under the NHS Low Income Scheme.

The consultation document acknowledged that NHS dental charges can be complicated for the patient, and because they are linked to the amount of care and treatment received, vary substantially. In view of these difficulties, the consultation exercise offered the prospect of a simpler system of charges, particularly for adult patients who may in the future qualify for a preventive care pathway.

Question 5: The existing system of NHS dental charges needs to be simplified. Agree or Disagree?

Of the 427 consultation responses, 406 respondents answered this question (95% response rate) and of those, 230 provided comments.

Option	Number of respondents
Agree	244 (57%)
Disagree	91 (21%)
Neither agree nor disagree	71 (17%)
Not answered	21 (5%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Amongst those wishing to see a simpler system of charges, a substantial number of respondents recognised that the Statement of Dental Remuneration ( SDR) would benefit from a degree of simplification, both in terms of the number of items, and the complex provisos related to each item.

A large number of respondents who agreed, and those who disagreed, felt that the current remuneration level is too low and that it should reflect the cost of materials, equipment and laboratory costs. There was a sense that the system of payment restricts the clinical freedom of the dentist, and more opportunity should be available in the future for dentists to provide patients with treatments that are appropriate for them. Additionally, a few PDS dentists commented that the current set of items of treatment do not adequately reflect the complexity of the work they routinely carry out.

For those who disagreed with the need to simplify charges a number believe that the current system works, with a few arguing that the complexity reflects the natural complexity of dental treatment. It was suggested that simplification can lead to a whole range of unintended consequences, including inequitable outcomes for patients.

A large number of respondents who disagreed and those who neither agreed nor disagreed were concerned this might mean a move to a system similar to that adopted in England, where dentists receive payments for 'units of dental activity'. There was concern that change, particularly something that duplicated the arrangements in England, could lead to a deterioration in the oral health of patients.

Of those who neither agreed nor disagreed a number of respondents acknowledged the complexity of the current system with some suggesting that it needs to reflect the complexity of modern dental treatment. A small number of respondents felt that it is not the charges that need simplified but the SDR itself, with unused codes being removed and items updated.

Part B: Arrangements for General Dental Services

The consultation document afforded the opportunity for discussion around the future administrative arrangements governing General Dental Services ( GDS). At present NHS Boards are responsible for a range of administrative functions including holding the dental lists of contractors and assistants, practice inspections, NHS Discipline and Tribunal cases and General Dental Council ( GDC) referrals.

The particular proposal in the consultation was that some or all of these functions could be carried out by a national body.

Question 6: A range of 'shared services', currently provided by NHS Boards, should be provided by a national body. Agree or Disagree?

Of the 427 consultation responses, 379 respondents answered this question
(89% response rate) and of those, 152 provided comments.

Option	Number of respondents
Agree	127 (30%)
Disagree	92 (22%)
Neither agree nor disagree	160 (37%)
Not answered	48 (11%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Amongst a number of those respondents who agreed, and those who neither agreed nor disagreed, there was a sense that a national body could allow for greater consistency in the application of rules, and more standardisation in the services provided across NHS Board areas than happens at present. A variety of potential services were suggested by a number of respondents who agreed and neither agreed nor disagreed, including: listing; vaccination checking; pre-employment checks, such as Protecting Vulnerable Groups ( PVG); and NHS Discipline and Tribunals.

A few of the respondents who disagreed believed that there would be no advantage to the proposal. Whilst others suggested that dentistry could learn from the administration of medical services, both in terms of the methods used to share information and in having a more standardised approach to listing.

The importance of local knowledge and concerns about its loss were emphasised across all respondents. A number of those who agreed with the proposal highlighted that a national body would need to take cognisance of local knowledge whereas amongst those who disagreed, a large number of respondents felt that NHS Boards know their areas and are in a better position to meet local needs.

Question 7: Which duties could be taken on by this national body? (Please tick all that apply)

Of the 427 consultation responses, 298 respondents answered this question (70% response rate).

Option	Number of respondents
Hosting dental lists	68 (16%)
Practice inspections	56 (13%)
NHS Discipline and Tribunals	43 (10%)
GDC referrals	37 (9%)
Other	94 (22%)
Not answered	129 (30%)

Note: Percentages may not total 100 due to rounding.

Of the 298 responses to this question 105 respondents provided comments. Most of the respondents who commented were selecting additional duties, as due to technical difficulties with the consultation platform only one option could be selected. To take these comments into consideration a manual recalculation of the support for each option, based on original choice selected and additional choices reflected in comments, has been carried out. The breakdown of this recalculation is as follows:

Option	Number of respondents
Hosting dental lists	111 (26%)
Practice inspections	95 (22%)
NHS Discipline and Tribunals	81 (19%)
GDC referrals	83 (19%)
Other	56 (13%)
Not answered	129 (30%)

Note: Percentages do not total 100 as more than one option could be selected.

Summary of Responses

A substantial number of respondents stated that they wanted to select all of the duties listed. Of the respondents who selected 'other', a large number suggested that there should not be a national body, whilst a small number commented that they needed more information about the proposal before options could be chosen. A small number of respondents were unsure or felt they did not know enough about the duties to make a decision. A variety of other services which could be provided by a national body were suggested by a few respondents, including: listing; NHS Discipline and Tribunals; and GDC referrals.

Contractual Arrangements for Practice Owners

The consultation document identified a number of specific areas for consideration, including whether there should be a formal written contract between the NHS Board and practice owners. At present rather than a written contract, NHS Boards make 'arrangements' with dentists or Dental Bodies Corporate ( DBsC) to provide
a service. A contract was thought to offer transparency of obligations and requirements on both sets of contractual parties.

Question 8: A formal contract should be introduced between NHS Boards and the practice owner(s). Agree or Disagree?

Of the 427 consultation responses, 379 respondents answered this question (89% response rate) and of those, 169 provided comments.

Option	Number of respondents
Agree	172 (40%)
Disagree	91 (21%)
Neither agree nor disagree	116 (27%)
Not answered	48 (11%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

The need for more information was a dominant theme across all respondents but particularly amongst those who neither agreed nor disagreed with the proposal.

A number of those respondents who agreed with the proposal tended to see a contract as an opportunity to clarify the role of the NHS Board and practice owner; help to clarify liability and accountability; and identify who owns a practice and has responsibility for its day-to-day running. A few respondents felt that individual clinicians should still retain a degree of responsibility. Some general concerns about DBsC and how a contract would work in relation to DBsC were raised by a small number of respondents.

The potential for the proposal to lead to 'control of entry' was viewed positively by a small number of respondents who agreed and those who neither agreed nor disagreed. This would allow NHS Boards to better manage supply of practices and service delivery.

Amongst a number of those who disagreed with the prospect of a contract, there was a sense that this might become something similar to the arrangements in England with tendering for NHS dental services. A small number of those who disagreed expressed concern about the precise balance of professional responsibility between the individual dentist and practice owner, fearing the implications this could have on the employment status of associates. A small number of respondents felt that the arrangements at present effectively amount to a contract between the NHS Board and provider and this system should be continued.

Patient Registration

Patients currently register with an individual dentist. However, there are some circumstances where registration with a dentist may be problematic, for example, in the event that the dentist leaves the practice. Registration with the practice affords a number of advantages. This would ensure that in the event a dentist leaves the practice, patients would continue to be registered with the practice. At present a patient may have to register with another dentist in the practice or with another practice in these circumstances.

Question 9: Patients should be registered with the dental practice. Agree or Disagree?

Of the 427 consultation responses, 380 respondents answered this question (89% response rate) and of those, 164 provided comments.

Option	Number of respondents
Agree	254 (59%)
Disagree	78 (18%)
Neither agree nor disagree	48 (11%)
Not answered	47 (11%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Amongst a number of respondents who supported this proposal, there was a sense that this might enhance continuity of care, particularly when a dentist leaves the practice. Whilst a small number felt that the arrangement already exists, or for all intents and purposes, this is what happens in their experience. Concerns were raised about the impact of lifetime registration, with a small number suggesting that patients should have to attend regularly over a specified period of time to remain registered.

A large number of respondents who disagreed felt that patients should continue to be registered with an individual dentist, as they are the person responsible for the care of the patient. Concerns about what effect this change would have on the patient-dentist relationship and the impact of these proposals on the precise balance of payments that went to the practice and the individual practitioners working in the practice were raised by a number of respondents.

Concern about remuneration and the balance of payments and the view that this arrangement already exists was reiterated by a small number of those respondents who neither agreed nor disagreed with the proposal. Questions were raised over responsibility, with a few respondents believing that practices are already obligated to provide continuing care in the case of a dentist leaving and others suggesting the proposal could ensure accountability and be reassuring for patients.

Question 10: Patients should have a responsible dentist. Agree or disagree?

Of the 427 consultation responses, 383 respondents answered this question (90% response rate) and of those, 134 provided comments.

Option	Number of respondents
Agree	302 (71%)
Disagree	33 (8%)
Neither agree nor disagree	48 (11%)
Not answered	44 (10%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

A substantial number of comments, from respondents across all three groups, reflected the link between responsibility and registration, with a large number suggesting that the person with whom the patient is registered is their 'responsible dentist'. The view that having a 'responsible dentist' is something that already happens within the current system was also highlighted by a large cross section of respondents.

Amongst those who supported the proposal a substantial number of respondents emphasised its importance for continuity of care, and building a strong dentist-patient relationship, with many patients preferring to see the same dentist at
every visit.

Of those who disagreed a few respondents noted that having a 'responsible dentist' is not necessary as this is not an arrangement that exists with GPs where patients are registered with the practice. The need for more information was highlighted by a few respondents who neither agreed nor disagreed with the proposal.

Earnings and Expenses Information

This section links to recent exercises by the Scottish Government to obtain earnings and expenses information of dentists in Scotland. Under the auspices of the Doctors' and Dentists' Review Body ( DDRB) the Scottish Government conducted two separate earnings and expenses exercises for the 2016 and 2017 DDRB reports. In view of the difficulties of obtaining this information, the consultation document was a useful vehicle to explore the possibility of making the supply of earnings and expenses a terms of service requirement.

Question 11: The provision of earnings and expenses information should be a terms of service requirement. Agree or Disagree?

Of the 427 consultation responses, 370 respondents answered this question (87% response rate) and of those, 136 provided comments.

Option	Number of respondents
Agree	118 (28%)
Disagree	143 (33%)
Neither agree nor disagree	109 (26%)
Not answered	57 (13%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Amongst respondents who agreed, a small number stressed that it was important to have transparency around earnings paid through public money to avoid suspicion and demonstrate the position clearly to DDRB. A small number of respondents noted that care would be needed when interpreting financial data, as practices operate using a variety of different business models and arrangements, with a few also noting that there would need to be appropriate measures in place to ensure confidentiality.

A substantial number of respondents who disagreed with the proposal felt strongly that they should not be required to share commercially sensitive earnings and expenses information as, in their view, dental practices are private, independent companies. A small number also noted that the proposal feels unnecessarily invasive. A number of respondents took the view that this information is already available from a variety of sources, including HMRC and the payments schedules held by Practitioner Services Division ( PSD).

Amongst those who neither agreed nor disagreed a small number of respondents reiterated the view that this information is already available from a variety of sources. In discussing the need for transparency, a few respondents noted that it would be fair to have greater transparency around NHS earnings and expenses whilst others highlighted the view that the system used to gather the information needs to be transparent. A number of respondents also highlighted the need for more information, with some raising concerns about the purpose of the proposal and others noting that they did not understand the question.

Future Provision

The consultation document includes a number of proposals around responsibility for patients, including the prospect that DBsC would be required to list, and that GDC-registered practice owner(s) or director(s) would be required to provide a minimum number of hours of NHS clinical care per week in each practice. The intention behind these proposals is to ensure greater clarity of responsibility for patient care, and a stronger connection between practice ownership and the actual provision of clinical care to the local community being served by the practice.

Question 12: GDC-registered practice owners or GDC-registered directors of a dental practice should be required to provide a minimum number of hours of NHS clinical care per week in each practice location. Agree or Disagree?

Of the 427 consultation responses, 379 respondents answered this question
(89% response rate) and of those, 181 provided comments.

Option	Number of respondents
Agree	170 (40%)
Disagree	150 (35%)
Neither agree nor disagree	59 (14%)
Not answered	48 (11%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Amongst those that agreed with this proposal, a small number felt that it would help address concerns relating to DBsC, be beneficial in improving patient care,
and ensure that the owner was more in touch with the actual day-to-day running of the practice.

A large number of those that disagreed were concerned that the proposal was impractical and was unfair on practice owners, particularly those with multiple practices. A number of respondents were concerned that such a proposal was designed to address problems with DBsC but if enacted many would be unable to meet the requirement.

A number of respondents who neither agreed nor disagreed reiterated the view that the proposal was impractical, with a small number acknowledging that whilst there are issues with DBsC this proposal may not be the best way to deal with them. In discussing the impact on patient care a small number of respondents debated whether the proposal would be beneficial, ensuring owners were involved, or detrimental, as dentists would have limited time at each location.

Question 13: Bodies corporate must list with the NHS Board for the provision of GDS. Agree or Disagree?

Of the 427 consultation responses, 378 respondents answered this question
(89% response rate) and of those, 78 provided comments.-

Option	Number of respondents
Agree	280 (66%)
Disagree	15 (4%)
Neither agree nor disagree	83 (19%)
Not answered	49 (11%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Of those who supported this proposal a number of comments reflected concerns with governance under the DBsC model and the lack of transparency in many cases with ownership. A small number of respondents viewed this proposal as an opportunity to standardise the listing, management and governance of DBsC and ensure accountability alongside other practices who subscribe to an independent contractor model.

Of those who neither agreed nor disagreed with the proposal a small number of respondents felt that they did not fully understand the question, highlighting the need for more information about the purpose of the proposal. A few respondents noted that some of the other proposals in the document would provide clarity over practice ownership, whilst others felt that rules should be applied equally to DBsC and individual owners. Concerns regarding the DBsC model were also reiterated by a few respondents.

Allowances

The General Dental Practice Allowance (GDPA) is paid for practice expenses (i.e. to help address increasing requirements in relation to the provision of high quality premises, health and safety, staffing support and information collection and provision). All practices which provide GDS are entitled to receive 6 per cent of accumulative gross earnings paid through GDPA, while practices that are deemed NHS committed are entitled to an additional 6 per cent (12 per cent in total) ¹. A practice that is NHS committed is also entitled to reimbursement of rent, abated by the proportion of NHS to total earnings.

For a non-specialist practice to be NHS committed, it must ensure that:

• all dentists provide GDS to all categories of patients;
• there is an average of at least 500 patients per dentist accepted for care and treatment, of which at least 100 per dentist must be fee paying adults; and,
• the dentists in the practice have average gross earnings of £50,000 or above per dentist during the last 12 month period.

A range of individual allowances are payable to dentists including commitment and seniority payments, payments for vocational trainers, maternity, paternity and adoptive leave, remote areas, recruitment and retention, and Continuing Professional Development ( CPD) and clinical audit.

It is the Scottish Government's view that we need to work towards a reduced number of allowances, including a new practice allowance and a new allowance payable to dentists, that reward the level of NHS commitment and quality of service provided.

Question 14: There should be a reduced set of allowances, including a new practice allowance and GDP allowance, that reward the level of NHS commitment and quality of service provided. Agree or Disagree?

Of the 427 consultation responses, 374 respondents answered this question
(88% response rate) and of those, 186 provided comments.

Option	Number of respondents
Agree	157 (37%)
Disagree	93 (22%)
Neither agree nor disagree	124 (29%)
Not answered	53 (12%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

The need for more information was highlighted by a substantial number of respondents, particularly those who neither agreed nor disagreed with the proposal. A large number of those respondents who agreed with the proposal reflected on what elements allowances should reward, with some support for linking any future allowance to NHS commitment and quality. Other suggestions included: length of service, learning through CPD, postgraduate qualifications, and Dental Reference Officer ( DRO) scores. A number of respondents were concerned that these proposals might result in a reduction in the amount of money that in future would be provided through allowances, emphasising that the system should be simplified rather than a reduction in funding to ensure the stability of practices.

For those respondents who disagreed with the basic proposal, a large number strongly highlighted the fact that many practices rely on allowances to maintain their financial viability. A number of respondents queried what measures or criteria would be used to determine quality and how this would be defined. There was some discussion by a small number of respondents of the view that item of service fees are too low.

Concerns were reiterated by a number of respondents who neither agreed nor disagreed that many practices rely on allowances to maintain their financial viability and that the proposal signalled a reduction in the overall value of funding, which it was stressed would have a negative impact on practices. A number of respondents also discussed what elements allowances should reward, favouring commitment and quality, potentially in combination.

Question 15: There should be a new qualification criteria to determine which practices are NHS committed. Agree or Disagree?

Of the 427 consultation responses, 371 respondents answered this question
(87% response rate) and of those, 151 provided comments.

Option	Number of respondents
Agree	193 (45%)
Disagree	63 (15%)
Neither agree nor disagree	115 (27%)
Not answered	56 (13%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Amongst those who agreed with the proposal, a number of respondents speculated about potential suitable criteria for the determination of NHS commitment. A number of suggestions were made, including the number of patient registrations; the level or range of monitored treatment activity; and a minimum level of patients per surgery. There was a feeling practices that only offered NHS treatment to children or exempt adults should not qualify as NHS committed.

A small number of those who agreed also expressed the view that the current criteria of NHS commitment is unfair, the qualification threshold is set too low, and is easily manipulated by practices with business models that include a small amount of NHS exposure. It was also suggested by a small number of respondents that commitment criteria should be reviewed as part of a wider review of the whole remuneration system.

Of those respondents who disagreed with the proposal a small number expressed the view that the current system works well enough. Whilst others highlighted the view that it penalises practices for even a small amount of private treatment when they are otherwise NHS committed. Suggestions for alternative qualification criteria were made by a few respondents and included basing commitment on offering a full range of treatment; the percentage of patients registered; or having additional commitment payments for those in deprived areas.

Of those who neither agreed nor disagreed with the proposal, concerns that patients opting for private treatments could adversely affect commitment levels for practices which are largely NHS was highlighted by a few respondents. It was also noted by a few respondents that comparing NHS earnings to private is not always representative of commitment to the NHS and that practices need appropriate levels of funding to be able to provide high quality care. There was also a concern that changing the criteria would be used to make financial savings.

Finance

This particular proposal is linked to the earlier proposal to introduce a range of enhanced services within a national framework. At present the budget for GDS is held centrally by the Scottish Government and the consultation document proposed that there may be opportunities in the future to devolve some funding streams to NHS Boards and HSCPs, particularly any future funding stream connected with enhanced service delivery.

Question 16: The control of funding for NHS dental services should be gradually devolved to HSCPs. Agree or Disagree?

Of the 427 consultation responses, 375 respondents answered this question
(88% response rate) and of those, 146 provided comments.

Option	Number of respondents
Agree	42 (10%)
Disagree	178 (42%)
Neither agree nor disagree	155 (36%)
Not answered	52 (12%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Of those respondents who disagreed and neither agreed nor disagreed with the proposal, a large number expressed concern over the security of the devolved funding and whether in the future NHS Boards or HSCPs would use this funding for priorities outside dentistry. A large number of respondents were also concerned about the level of understanding and experience that HSCPs have of managing a dental service and noted there is a lack of dental representation and as such are perhaps not equipped at present to take on this responsibility. Concerns were also raised by a number of respondents about the effect this proposal could have on the availability of, and access to, NHS dental services.

Professional Leadership, Quality Improvement and Scrutiny

The consultation document offered the opportunity for respondents to comment on a range of proposals related to professional leadership, and quality improvement and scrutiny, including:

• the introduction of a Director of Dentistry in each NHS Board, with strategic oversight of all aspects of NHS dental services and oral health improvement in their area;
• the future remit of the Scottish Dental Practice Board ( SDPB);
• enhanced clinical monitoring;
• a national database of key indicators of quality; and,
• protected learning time for dentists and practice staff.

Question 17: There should be a Director of Dentistry with oversight of all aspects of dental services and oral health improvement at Board level. Agree or Disagree?

Of the 427 consultation responses, 377 respondents answered this question
(88% response rate) and of those, 154 provided comments.

Option	Number of respondents
Agree	214 (50%)
Disagree	68 (16%)
Neither agree nor disagree	95 (22%)
Not answered	50 (12%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

A substantial number of respondents who agreed with the proposal highlighted that anyone appointed to this role would need to have appropriate experience. However, there was less agreement on what type of experience would qualify someone for this role, but the most common suggestion was the person should be a dentist. A small number of respondents also highlighted this role would require funding. It was noted by a few respondents that input from dental public health specialists, such as the Consultants in Dental Public Health, was essential for the planning and commissioning of dental services.

A number of respondents who disagreed with the proposal expressed the view that this role is unnecessary, adding additional bureaucracy and managerial positions. The financial implications of introducing this role were a concern for a number of respondents, and a few were also concerned that anyone appointed to this role would lack relevant experience.

Of those who neither agreed nor disagreed a number of respondents highlighted the need for relevant experience to undertake this role and the most common suggestion was that a dentist should be appointed. The source of the funding for this role was queried by a small number of respondents. The view that this role is already fulfilled by other positions was highlighted by a small number of respondents but the need for clear leadership within dentistry was also recognised.

Question 18: The Scottish Government proposes to review the remit of the Scottish Dental Practice Board. In your view should the SDBP be:

Of the 427 consultation responses, 342 respondents answered this question
(80% response rate) and of those, 108 provided comments.

Option	Number of respondents
Tasked with a revised remit	55 (36%)
Placed with a different host organisation	8 (2%)
Abolish and its functions subsumed elsewhere	56 (13%)
Retain the existing remit	83 (19%)
Other	40 (9%)
Not answered	85 (20%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

Many of the respondents from across the spectrum chose to highlight their views of the Scottish Dental Practice Board as an organisation. A number of respondents were critical of the SDPB; however, there were also a number of comments expressing support for the organisation. A number of respondents also expressed views that they were unsure of the role of the SDPB.

From those respondents who selected 'tasked with a revised remit' there were a number who suggested the SDPB could take on the quality agenda including DRO scrutiny and practice inspections.

Enhanced Clinical Monitoring

The basis for the current system of clinical monitoring is two-fold; prior approval
of NHS dental treatment plans where the cost of the treatment exceeds the prior approval limit (currently £390) or where a specific treatment requires prior approval, and the monitoring of pre- and post-treatment through the Dental Reference Service ( DRS).

Question 19: In view of the proposal to introduce a new preventive care pathway, a new 'enhanced' Clinical Monitoring Service for patients would be required. Agree or Disagree?

Of the 427 consultation responses, 376 respondents answered this question
(88% response rate) and of those, 146 provided comments.

Option	Number of respondents
Agree	220 (52%)
Disagree	74 (17%)
Neither agree nor disagree	82 (19%)
Not answered	51 (12%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

A number of respondents who agreed discussed issues around the practicalities involved in effective monitoring, including how a preventive system would be monitored, and the need for a monitoring system that was clear and concise for practitioners and patients.

Some respondents who agreed also discussed the role of the DRS and the level of monitoring it may be able to provide. Suggestions were made that DROs carry out their monitoring role in the practice, and that the current DRS should be reviewed with a view to expanding to include a focus on prevention.

A number of respondents who agreed also questioned how a new clinical monitoring service would be funded.

For those who disagreed, there was a concern about how a new system would be funded, with a few respondents of the view that the funding required would be better used elsewhere. Some respondents were also of the view that the current system was effective.

The most common response from those who neither agreed nor disagreed was the need for more information about the preventive pathway and what the enhanced monitoring would involve.

Quality Improvement Activities and Protected Learning Time

The consultation document also reported on a Scottish Government pilot, launched on 1 April 2015, to gather information on a range of quality indicators, both at practice and dentist level. The purpose of the pilot was to determine whether it would be possible to establish indicators that might help NHS Boards identify dentists and practices that are experiencing difficulties. The emphasis was on establishing an early warning system to allow NHS Boards the opportunity to provide support before the issue would escalate to the next level.

Question 20: The Scottish Government proposes developing, and rolling out across Scotland, a national database of key indicators of quality. Agree or Disagree?

Of the 427 consultation responses, 380 respondents answered this question
(89% response rate) and of those, 145 provided comments.

Option	Number of respondents
Agree	229 (54%)
Disagree	63 (15%)
Neither agree nor disagree	88 (21%)
Not answered	47 (11%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

A number of respondents who agreed suggested that any new database of quality indicators should be linked to the Scottish Patient Safety Programme. Amongst those respondents who agreed, caution was expressed that the indicators should be robust, appropriate and relevant. Others commented on the need to ensure that this wasn't used as part of the disciplinary approach.

Some respondents who disagreed also shared the view that the system could be punitive towards dentists. For some of the respondents who disagreed there was a request for more information which was also requested by a number of those who neither agreed nor disagreed.

Question 21: The Scottish Government proposes the development of a process that will make protected learning time available for dentists and practice staff. Agree or Disagree?

Of the 427 consultation responses, 384 respondents answered this question
(90% response rate) and of those, 158 provided comments.

Option	Number of respondents
Agree	328 (77%)
Disagree	24 (6%)
Neither agree nor disagree	32 (7%)
Not answered	43 (10%)

Note: Percentages may not total 100 due to rounding.

Summary of Responses

This proposal was well received by respondents, however, there were a number of points raised by those who agreed. This included how any protected learning time would be funded and how practitioners would be compensated for loss of earnings. A number of respondents who agreed also chose to discuss the potential benefits of protected learning time for the wider dental team and the opportunity it would provide to develop whole practice teams.

For those who disagreed there was some concern that it was difficult to find the time to carry out learning and development activities. The issue of funding for protected learning time was also raised by those who disagreed and neither agreed nor disagreed.

Part C: General Comments

The final question of the consultation offered respondents the opportunity to provide any additional comments. Of the 427 consultation responses, 327 respondents chose to use this option (77% response rate). A range of comments were provided, many of which relate to the issues covered within the previous questions. The summary below provides details of the issues which were raised that were not covered within the consultation questionnaire.

Respondents discussed the consultation process with some taking the view that the outcome of the consultation has already been decided and further consultation should take place. Others were more supportive and welcomed the process.

Some respondents took the view that the consultation document did not accurately represent the role of the PDS. Some comments were made regarding the limited discussion on the role of the Hospital Dental Service ( HDS) and the Scottish Emergency Dental Service. A suggestion was also made regarding the importance of involving third sector organisations.

Piloting and gradual change was also suggested along with looking at regimes in other parts of the world.

Comments were made regarding patient charges, such as that treatment should be free at the point of need and that patients should be charged for failure to attend appointments.

Some respondents pointed out that each NHS Board can be different in terms of the population, geography and remote and rural issues, with recruitment and access to NHS dentistry being particularly difficult in remote areas.

Opportunities for career progression were discussed by some respondents. In addition to this, there were comments about what graduates are taught at dental school with suggestions being made that the curriculum should be more aligned with NHS dentistry.

A number of respondents chose to discuss lifelong registration with suggestions made that this does not show an increase in patient attendance.

Health inequalities were also addressed, with some respondents urging caution
in relation to identification for services based on the Scottish Index of Multiple Deprivation ( SIMD). The importance of considering groups such as those with special care needs, people who are homeless and older people was also noted.

The dental workforce was also raised, particularly the role of Dental Care Professionals ( DCPs), with suggestions made that DCPs can often be under-utilised. A suggestion was made that more hygiene-therapists ( HTs) should be trained. Concern was also expressed about what Brexit might mean for dentists from
EU countries.

For a small number of respondents there was concern expressed regarding dentistry as a business. This included concern regarding the costs for staffing, materials and laboratory costs. Some respondents expressed concern regarding the lack of occupational health provision available. A number of respondents were of the view that the morale in NHS dentistry was low with suggestions that this was because of regulation and paperwork.