Scotland's oral health plan consultation: analysis of responses

2 Roadshow Events With Stakeholders

Approach

As part of the consultation exercise, the Scottish Government hosted 12 roadshow events across Scotland, from the beginning of October to the middle of November 2016. The purpose of these events was to give dental health care professionals the opportunity to engage directly with the consultation exercise.

A total of 564 people attended the events, including dentists, DCPs, and staff from NHS Boards. The format of the events were identical and allowed attendees the opportunity to listen to a presentation from the Chief Dental Officer ( CDO), and a short video message from the Cabinet Secretary for Health and Sport, Shona Robison MSP. Attendees were then able to participate in a number of break-out sessions, under the following headings:

• Prevention and Risk
• Payments and Charges
• Organisation and Management
• Quality Improvement and Scrutiny.

These sessions were facilitated by a range of people, including Dental Practice Advisers ( DPAs), Consultants in Dental Public Health and officers from PSD. For each session note-takers were present to record the discussions. Each event concluded with a round-up plenary session and an opportunity to address questions to the CDO.

The following is a summary of the discussions at the break-out sessions under the themed headings. However, it must be remembered that these views are not necessarily representative of the wider population.

Theme 1 - Prevention and Risk

For this particular session, participants were asked to discuss a range of proposals under the broad headings of a new preventive care pathway and oral health risk assessment.

Participants were asked to discuss and comment on several statements, including:

"It is our aspiration to introduce a preventive care pathway with more emphasis on maintaining or improving the level of oral health"

"Initially this new preventive care pathway will be introduced for children in good, stable oral health"

"As children with stable oral health transfer into the adult service (i.e. from the age of 18) they will remain on the preventive care pathway"

"Over time it is expected that adult patients with stable oral health would move from item of treatment to a preventive treatment pathway"

There was general enthusiasm for a preventive regime but concern that this might be limited to certain groups whereas prevention is important for all. It was recognised that this was a particular challenge for people from deprived areas but can be a general issue too.

There was support for the Childsmile programme, a feeling that it could be extended to older children and the model replicated for the older population. There was some concern that a preventive scheme might be difficult to monitor but that over treatment may be encouraged if the current system remained in place as dental health improved. There was support for maintaining a capitation approach to payment for prevention, although its limitations were recognised, specifically monitoring. Some thought that at a teenage stage contact can be lost with the patient.

Participants frequently mentioned payments both to dentists and the challenge of how to charge patients. The issue of the appropriateness of the SDR in relation to the treatment of periodontal disease was highlighted.

The importance of remembering general health messages e.g. on diet and smoking was noted as was training dentists to have the skills to impart the information. It was thought that DCPs might be better equipped to do this rather than dentists.
It was also mentioned that some of these activities may be more appropriate for
a DCP.

The preventive pathway should be available to all, although targeting high risk groups was important and should generally include fluoride varnish, fissure-sealants, oral health advice, and dietary advice. There was some support for the system growing up with the patient as an evolutionary approach but there was some concern that working with two systems might be difficult. If two systems were in place some thought that the opportunity for a patient to move between them would be beneficial. There was a feeling that complex treatments should only be provided if the patient's oral hygiene justified it.

There was discussion of partnership working in communities, sugar tax, greater control of advertising and water fluoridation.

Oral Health Risk Assessment

The second part of these sessions looked at the Scottish Government's proposals to introduce an OHRA. These proposals were described as follows:

"Our intention would be to introduce an Oral Health Risk Assessment ( OHRA)
for all patients at 18 years of age as part of oral health care planning"

"An OHRA involves a full dental examination and includes a discussion between the dentist and patient about the associated risk factors such as smoking, alcohol intake and medication"

There was considerable support for an OHRA but suggestions as to the age at which it should be introduced varied from twelve to sixteen years of age, although some agreed that eighteen years of age was appropriate. It was suggested that a written report of the OHRA should be given to the patient in plain English, perhaps using a scoring system.

There was also the suggestion that there needs to be an assessment for people at the other end of the age spectrum and at other important stages in life when there are significant changes. There was a variety of opinions as to the frequency for carrying out the OHRA, from every two years to targeting certain age groups although some thought an annual OHRA would be appropriate. It was suggested that DCPs could be involved in the OHRA.

It was thought that the frequency of attendance could be assessed as part of this process and there was a recognition that there was not a universal need for six monthly check-ups except in children or where a specific need is identified. However, there was concern that leaving a patient for two years without a
check-up might be too long.

Theme 2 - Payments and Charges

For this particular session, participants were asked to discuss a range of proposals under the broad headings of a simpler system of payments and charges, and the proposals in the consultation document around enhanced services.

Participants were asked to discuss and comment on the following statement:

"The current system of remuneration for independent GDPs is complex, difficult to administer and manage, while equally difficult for patients and GDPs to understand"

On balance, most participants agreed with the general sentiments that the current system of remuneration, as defined by Determination I of the SDR, was complex and difficult to administer. Many participants observed that as practising dentists they typically used only around 25 per cent of the available codes and that simplification would help to reduce the administration of treatment.

There was some concern of the extent to which the range of treatments available on the NHS could constrain or reduce the discretion available to the dentist. It was generally recognised that a system that allowed absolute discretion may be subject to misuse, but that a sensible balance had to be found between discretion and financial governance. There was some questioning of particular restrictions, for example, why NHS and private treatment could not be provided on the same tooth.

Another theme that emerged from these sessions was the extent to which the SDR hadn't kept pace with new technological treatments in dentistry and the latest oral health care evidence. Some of the discussions pointed to the need to have a process where the SDR is updated on a timely basis, to reflect the latest clinical guidelines such as those produced by the Scottish Dental Clinical Effectiveness Programme ( SDCEP).

In an increasingly challenging financial environment discussions focused on what should (and should not) be included in any future changes to the SDR. For example, some participants questioned whether in future the NHS should concentrate on periodontal treatment, and less so on largely cosmetic procedures such as veneers. Similarly the nature of the payments system, with items of treatment, doesn't encourage the dentist to provide the necessary level of preventive advice.

That aside there was some support for the existing system, that while it clearly has a number of deficiencies, changes need to be evolutionary, progressive and proportionate. There was a general recognition that the current system of item of service payment needed to be reformed, but not replaced with a completely new system of payment that could potentially destabilise NHS dental practices and compromise the needs of the patient.

Focus on Prevention

The following statement was discussed amongst participants:

"Our vision for a new preventive dental culture requires a system of payments to dentists which reflects its positive nature and aligns payments to the needs of the patient"

Most participants recognised the need to align any future payments system to a more preventive focus and that the current system of remuneration was unsustainable in light of improvements in oral health. There was a general acknowledgement that fewer restorations are being placed, and there was a growing requirement for a preventive-based system of payment.

That aside, there were a number of challenges that would need to be addressed. There was a general concern that patients may not be responsive to preventive advice and treatment, and any payments system that is too closely aligned to the health of the patient could unfairly penalise the dentist. Any future payments system would need to carefully balance incentivising prevention with mitigation for dentists that might be unfairly penalised for the poor oral health behaviour of their patients.

The view was that the current SDR does not favour preventive treatment, and certainly not for adult patients. It is also important to recognise preventive treatment takes time, and any future fee structure needs to adequately reflect the amount of time that is taken with the patient. The general view was that there needed to be much more emphasis on periodontal treatment in any future payments system for NHS dentistry.

There was also some concern expressed about the perception and behaviour of patients. As described above dentists were generally concerned about the extent to which they may be financially penalised for the poor oral health outcomes of their patients, when this could be the consequence of patient behaviour, and not failed preventive treatment on the part of the dentist. There were also some misgivings amongst dentists about the low value patients place on preventive care, and that at present we have a system that has reinforced the perception that patients attend a dentist to have a problem remedied. In summary, any future system of preventive care needs to ensure that patients are properly educated on the true value of a preventive approach to their future oral health.

Patient Charges

Participants were asked to consider the current system of NHS dental charges and the impact on patients:

"At present the charging system (for patients) is extremely complex…We propose that adults in good oral health should pay a simplified system of charges"

Participants had varied views on the level of dental charges, and to some extent these views reflected their particular patient base. A number of dentists were concerned that NHS dental charges were too low, and typically patients were generally surprised at how little they had to pay. Amongst this group of dentists there was a feeling that the patient contribution, for patients who are not exempt from NHS dental charges, was too low and undervalued NHS dental care.

However, some dentists whose patient base consisted mainly of patients from deprived and less well-off areas took the opposite view and were sensitive to the financial constraints of their patients. Their concern was that an increase in NHS dental charges could affect the attendance of patients and could potentially be detrimental to oral health.

For some dentists there was a concern that the system of charges was compounding inequalities, with comparatively well-off patients paying too little, while for patients on lower incomes, the cost of NHS dental care was still a concern. Some participants were keen for the Scottish Government to explore a system of sliding-scale NHS dental charges that were linked to a patient's ability to pay.

Check-Ups

There was more consensus amongst participants about the value of free NHS check-ups. This was seen as critical in ensuring that patients attend the dentist on a regular basis, particularly patients who may be put off at the prospect of how much they may have to pay.

Allowances (Paid to NHS Dental Practices and Dentists)

Participants were asked to express their views on the following proposal:

"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 GDPs, that reward the level of NHS commitment and quality of service provided"

In general dentists were concerned about the precise detail contained in these proposals, and were keen to emphasise the importance of allowances in ensuring the continued financial viability of NHS dentistry. Some participants were concerned that a consolidation of existing allowances could financially destabilise practices and that it was difficult to ensure against adverse outcomes given the diversity of circumstances between practices and dentists.

Whilst consolidation to some degree might be sensible, some participants thought consolidating from the current set to only two allowances might be overly ambitious. For example, it was felt that there would always be a role for specific allowances such as the remote and rural allowance, vocational training, and maternity allowance. There was also strong support for the General Dental Practice Allowance (GDPA) and rent reimbursement scheme, as these provided dental practices with a regular reliable and substantial source of income.

The mix of principal-owners and associates meant that the discussions sometimes focused on how radical change in the balance of practice and dentist allowances could impact on the relationship between principal and associate.

There was some scepticism about any new allowance that was linked to quality.
A number of participants thought that quality should be something that is automatically provided and not something that is directly linked to any future allowance. There was also some concern about the appropriate measures of quality and how these could be included in future allowance payments.

Enhanced Services

The second part of these sessions looked at the Scottish Government's proposals around expanding the role of dentists in providing domiciliary care to patients and other more complex clinical procedures. These proposals were described as follows:

"Introduce an enhanced service model for the provision of domiciliary care in a care home setting, and for highly dependent people in their own homes"

"Undertake in partnership with NHS Boards and Health and Social Care Partnerships ( HSCPs) the development work to pilot enhanced services within GDS in oral surgery, restorative services, intravenous sedation and orthodontic care"

Generally dentists gave a qualified welcome to these proposals. A key issue was the need for adequate remuneration; if these enhanced services were to successfully shift the balance of care from hospital or the Public Dental Service
to independent dentists, then it is important that the funding properly incentivises dentists. There was some concern that the existing fee structure would not be
an adequate incentive with a number of participants indicating oral surgery as a case in point.

With regard to domiciliary care, many participants thought that this might not be the best fit for an enhanced service model. Dentists tended to see domiciliary care as a mainstream service and it was important to ensure that as many dentists, and members of the dental team, continued to see their patients as possible. It was important for the patient to maintain continuity of care and in many circumstances that meant retaining their own dentist.

A number of other considerations were raised, including whether there was the prospect that enhanced services would be available in some NHS Board areas, but not necessarily across all of Scotland. There was a danger, depending on the priorities between NHS Boards, that patient choice could be affected. There was a real concern about the role of HSCPs in any future determination on enhanced services provision.

Other issues identified were the level of training required in order to provide these services, whether they were genuinely cost effective compared with a specialist in a hospital setting, and the possibility that it may create a two-tiered system of care with some practices offering these services and others not.

There was also some reservations that these proposals amounted to the English-based system of commissioning services, and that any replication of this system would not be well received with dentists in Scotland. There were concerns that dental practices may invest in providing an enhanced service only to lose the contract at a later date. There was a concern that if the system of enhanced service provision wasn't designed properly, then this could financially destabilise practices.

In summary, most dentists were content to work within an enhanced services framework, and that it made sense to explore ways to shift the balance of provision in certain areas where more complex procedures could be safely delivered in a general dental practice setting.

Theme 3 - Organisation and Management

For this particular session, participants were asked to discuss a range of proposals under the broad headings of contractual arrangements and locality planning.

Participants were asked to discuss and comment on the following statement:

"The Scottish Government believes that the present arrangements (for the governance of GDS) need to be modernised to more fully reflect a contract between NHS Board and the practice, while retaining arrangements with each individual GDP"

Generally speaking there was an element of scepticism amongst attendees at these events with the prospect of a formal contract between the NHS Board and the dental practice. Ostensibly to ensure that the NHS Board has sufficient oversight of the delivery of dental services in their area, there was a general concern amongst dentists that the level of control would be disproportionate. Most of the discussions demonstrated that dentists value their independent status and regarded these proposals as a potential long term threat to this status.

Participants expressed a number of particular misgivings about this proposal, including how responsibility for patient care would be discharged. For example, would the practice owner have ultimate responsibility for patient care, and how could they discharge that responsibility when the care and treatment is provided by another dentist within the practice. There was some concern that the status of associates could be adversely affected by this proposal, and whether in the future it could change the model of service delivery, in favour of salaried dentists.

On balance, there was recognition that there may be a problem with governance and visibility of practice ownership, particularly with the growth of bodies corporate, but that it was important that any solution was proportionate. There was a general feeling amongst participants that all dentists should not necessarily have to bear significant changes if the problem was confined to a minority of providers.

Closely linked to this proposal was the following statement:

"At present patients are registered with individual dentists or Dental Bodies Corporate. The Scottish Government would like to explore further the benefits of a patient being registered with a practice, while having a responsible GDP within the practice"

Similar to the first proposal in this particular set of discussions, the response to this proposal was broadly negative. Dentists were concerned there would be no identifiable individual to ensure responsibility for and continuity of patient care. Dentists felt that the existing system of capitation and continuing care payments was working reasonably well and any move towards a system where patients registered with the practice could jeopardise the present arrangements.

There was a general view that the existing system allows the dentist to build a relationship with the patient. However, where the patient is registered with the practice this may adversely affect the dentist-patient relationship. Participants were concerned about the adverse consequences of these proposals, and while the present system is not perfect, it is important that in any future changes, the value from the existing arrangements is not lost.

Concerns were also expressed about the financial consequences of these arrangements for associates. As referred to above, because each dentist, principal-owner and associate has their own list of patients, they receive capitation and continuing care payments. Associates who participated in these sessions were concerned that registration with the practice would mean the loss of these direct payments and would place more emphasis on the principal-associate agreement.

The final proposal in this section was as follows:

"There needs to be a much stronger link between practice ownership and the delivery of day to day patient care... The Scottish Government believes this is the correct opportunity to consult on a requirement for GDC-registered practice owners or directors to provide a minimum number of hours of NHS clinical care per week in each practice"

The perception amongst participants was that this proposal was a reaction to particular problems attached to the body corporate model, where the practice owner becomes quite detached from the actual clinical care provided to the local community. While this proposal had some support amongst principals who owned a single practice, those who owned multiple practices spoke out strongly against it. Their concern was that they were being unfairly penalised for a situation that had arisen with the body corporate model, and that if these proposals were to be introduced, they could be seriously detrimental to the viability of their business.

Practice owners also expressed the view that clinical care could deteriorate as a consequence of this proposal. They envisaged a situation where they have to spend one day per week in each of their practices, and felt this could jeopardise the safety and effectiveness of the care they provide. For some participants who were directors, the feeling was the proposal would make it impossible for them to continue with their present business model.

Finally, practice owners were concerned about the potential impact on those who chose to reduce their commitment during the later period of their career. It is possible that this proposal could jeopardise any attempt by practice owners to retain ownership but reduce their level of clinical commitment.

In summary the general feeling amongst participants was that this proposal had the potential to be wide ranging in impact, with the potential for adverse consequences throughout the whole dental community. If the Scottish Government and NHS Boards were concerned about the body corporate model, then it was important to identify solutions that addressed this rather than impacting on the independent contractor model.

Locality Planning

The second part of these sessions looked at the Scottish Government's proposals around locality planning, with a greater role for Health and Social Care Partnerships, and having a Director of Dentistry in each NHS Board area:

"In the medium to longer term we envisage an increasing role for HSCPs in locality planning for NHS dental services in their respective areas"

There was a general recognition that market forces were perhaps not the best mechanism for dealing with local service planning. Depending on the location of these roadshow events, dentists sometimes spoke out strongly about concerns of over-supply, particularly in the central belt areas of Scotland. At present NHS Boards have no powers to restrict where practices set up and in many cases this is leading to the displacement of patients as practices set up close to one another. At the same time some degree of strategic planning might encourage more practices to set up in deprived areas.

Some participants reflected on their experience of the Scottish Dental Access Initiative ( SDAI) Scheme. While this scheme had improved access significantly in many areas of Scotland, it was increasingly challenging for existing SDAI practices to meet their grant conditions of additional patient registrations when other practices decide to locate within their catchment area.

A number of participants, while accepting that over supply in certain areas was a very real danger, thought that greater strategic control would ultimately impact on their independent contractor status. As independent contractors they have to accept the risk of the potential for over supply and that is the price of independent contractor status. There were also misgivings expressed about the role of HSCPs, that dentistry is not a priority for these relatively new organisations, whether it will just add another layer of bureaucracy to the planning process, and is there sufficient knowledge and intelligence to plan dental services in their locality.

Director of Dentistry

Participants were asked to consider the following proposal:

"We envisage a Director of Dentistry in each NHS Board who will have strategic oversight of all aspects of NHS dental services and oral health improvement in their area"

In general this was seen as a reasonable way forward by participants. For example, some participants commented that having a Director of Dentistry might help to ensure some degree of joint stewardship of both GDS and PDS. Others commented that while the role was excellent in theory, it might be difficult to recruit suitably qualified people with experience of the independent contractor model, PDS, and other NHS Board dental services. There was also a feeling that the role should not displace other roles within the NHS Board such as the Clinical Director.

Theme 4 - Quality and Scrutiny

For this particular session, participants were asked to discuss a range of proposals under the broad headings of monitoring a future preventive pathway; use of quality indicators; and the proposals in the consultation document around direct access to dental care professionals.

Participants were asked to discuss and comment on the following statement:

"The Scottish Government envisages a new Clinical Monitoring Service that
will monitor the new preventive care pathway for those patients with good
oral health"

Given that the consultation document did not contain a detailed preventive care pathway and views were being sought on the principles, the discussion was quite wide ranging. There was a clear understanding that a preventive pathway would require monitoring, although it would not be straightforward and was very
patient dependent.

Participants agreed that prevention was important, however, there was only
so much the dental team could achieve, as changing patient oral health
behaviours was equally as important. It was recognised that the dental team
would benefit from education on strategies to help patients make the requisite behavioural changes.

The DRS of PSD currently delivers scrutiny of clinical care and could be a vehicle to monitor any preventive pathway. However, it was variously described as critical, adversarial and destructive. Therefore, the DRS should be restructured and redefined. Overwhelmingly, participants commented that the DROs should visit dental practices to undertake clinical scrutiny. This should be a supportive visit and the role should be one of clinical improvement and not criticism. Several commented that the DRO visit could coincide with the practice inspection visit.

Some participants speculated that routine monitoring of prevention could be through a review of record cards and claims submitted. The challenge of monitoring preventive care is the lack of tangible measures to observe, unlike current items of service treatments. Although over the longer term there would be improved outcomes.

Use of Quality Indicators

Participants were asked to consider the use of quality indicators:

"A pilot commenced on 1 April 2015 gathering information on a range of quality indicators, both at practice and GDP level. The purpose of the pilot is to determine whether we can identify at an early stage those practices or GDPs that are experiencing difficulties, enabling the NHS Board to offer support"

Discussions were typically broader than describing potential indicators, although periodontal status and caries rates were generally regarded as important indicators. Most participants recognised the need to demonstrate that dentists deliver quality services and had an improvement focus both at individual and practice level.

It was suggested that peer review, continuing professional development, clinical audit, significant event analysis, practice inspection, DRO scrutiny and patient complaint review were good processes but not linked in any structured way to bring about real benefit. It was felt that systematic patient surveys were required, perhaps similar to travel review websites. There was some concern expressed that quality indicators may inadvertently lead to 'league tables' of dental practices which was thought to be unhelpful. Equally, multisource feedback should be introduced perhaps as part of dentist appraisal and should be based on similar processes that already exist for GPs.

Quality Improvement Activities

A number of participants suggested that all quality and improvement processes could be subsumed within a Practice Development Plan (PrDP). The PrDP would be developed using information from:

• the DRO (who would have visited the practice);
• the DPA with information on actions arising from the practice inspection and quality indicator performance;
• a CPD Tutor from NHS Education for Scotland who would have helped the dental team develop Personal Learning Plans; and,
• a dentist appraisal process.

Participants took the view that it was important to develop appropriate support networks in such a challenging environment, and therefore the DRO, DPA, CPD Tutor and Dentist Appraiser should be at the centre of any support network.

Protected Learning Time ( PLT)

"We believe that PLT could be of benefit to dental practices and teams, to assists them in undertaking quality improvement initiatives"

Generally this was welcomed as a proposal with most participants viewing this
as a positive and progressive development, providing it was supported with adequate funding, was team focused and managed by NHS Boards. The feeling
was the introduction of PLT could facilitate collective learning between practices.

The Scottish Dental Practice Board

Finally these discussions allowed the opportunity for participants to consider the future role of the SDPB. For most participants there was no clear delineation between the Board and the role of PSD; in fact a number of participants confused the two bodies, and the specific remit of the SDPB was not well understood. It was therefore difficult for participants to comment on any future role when the existing role was so poorly understood.

Direct Access to Dental Care Professionals

The second part of these sessions considered the specific workforce proposal around DCPs:

"We are currently exploring options for listing DCPs to allow patients to directly access treatment under General Dental Services from them, without the requirement to first be seen by a dentist"

Participants had very mixed views on the introduction of direct access to DCPs and the impact this would have on practices. There was no settled view with some participants seeing this as a threat and others that this proposal might present opportunities. DCPs currently work to a significant degree with children and this should continue. Many felt that there was merit in increasing the role of DCPs in providing on-going dental care and oral health prevention to older people, particularly those who are housebound or living in residential care settings.

That said, it was important if direct access was to be introduced that DCPs take full responsibility for any care they delivered and it should not fall to the dentist as team leader. Some felt direct access was primarily a cost cutting exercise by the Scottish Government.

Wider Workforce Issues

In terms of wider workforce roles, generally participants felt that there was a danger of over supply of dentists and with DCPs also increasing in number, and able to take on more of the routine dental care of patients. There needed to be a primary care dental workforce review focusing on changing roles and their long term impact and skill mix requirements for the future.

There was also felt to be a need for a more team based delivery focus with clarity over roles. For example, the first OHRA could be undertaken by a dentist, but then the patient could be seen:

• by a DCP for up to two years on a care pathway before returning to the dentist for review; and,
• by the dentist due to the complexity of the care required.