Review Of Primary Care Salaried Dental Services In Scotland

Review of Primary Care Salaried Dental Services in Scotland


Scottish Executive, Edinburgh 2006

© Crown copyright 2006ISBN: 0-7559-5224-3

Scottish ExecutiveSt Andrew’s HouseEdinburghEH1 3DG

Produced for the Scottish Executive by Astron B48383 12-06

Published by the Scottish Executive, December, 2006

Further copies are available fromBlackwell’s Bookshop53 South BridgeEdinburghEH1 1YS

The text pages of this document are printed on recycled paper and are 100% recyclable

Membership of Group

Margie Taylor (Chair)Consultant in Dental Public Heath, NHS Lanarkshire

Dawn AdamsDirector of Community Dental Service, NHS Fife

Hannah AnwarInformation Analyst, ISD, Edinburgh

Margo BiggsLocal Health Council, NHS Forth Valley

Tom Bryce, LHCC General Manager, NHS Lanarkshire

Jan Clarkson, Senior Lecturer, DHSRU, Dundee

Mike CollinsChief Administrative Dental Officer, NHS Shetland

Kieran FallonGeneral Dental Practitioner, Glasgow

Irene HanevyCommunity Dental Service, NHS Fife

Rosemary Hutchison, Salaried General Dental Practitioner, NHS Grampian

Robert NaysmithDirector of Community Dental Service, NHS Lothian

Robert NicolSenior Dental Officer, Community Dental Service,NHS Highland

Gina O’MailleyCommunity Dental Officer, NHS Greater Glasgow

Jennifer RodgersSpecialist Registrar in Dental Public Health,NHS Lanarkshire

Colin TilleyHealth Economist, Dental Health ServicesResearch Unit, Dundee

Patrick SweeneyConsultant in Dental Public Health,NHS Argyll and Clyde

Ewen WhiteSalaried General Dental Practitioner,NHS Argyll and Clyde

Foreword v

1 Remit 1

2 Methodology 2

3 Oral Health of the Population of Scotland 4

3.1 Children’s Oral Health 5

3.1.1 Epidemiology 5

3.1.2 Treatment of Decayed Teeth 6

3.2 Adult Oral Health 7

3.2.1 Epidemiology 7

4 Current Salaried Services 10

4.1 Community Dental Services (CDS): 11

4.1.1 Remit 11

4.1.2 Client groups 11

4.1.3 Distribution 11

4.1.4 Activity 12

4.1.4.1 Clinical Activity 12

4.1.4.2 Inspections andScreening 13

4.1.5 Monitoring Clinical Standards 13

4.1.6 Out-of-Hours Services 13

4.1.7 Patient Charges 13

4.1.8 Career Structure 13

4.1.9 The Wider Dental Team 14

4.2 Salaried GDS: 14

4.2.1 Remit 14

4.2.2 Client Groups 14

4.2.3 Distribution 14

4.2.4 Activity 14

4.2.5 Monitoring Clinical Standards 16

4.2.6 Out of Hours 16

4.2.7 Patient Charges 16

4.2.8 Career Structure 16


4.3 Joint and “Combined” (or Split)GDS/CDS Posts 16

4.3.1 Joint Posts 16

4.3.2 Combined (or Split) Posts 17

CONTENTS


ii/iii

5 General Dental Services (GDS): 18

5.1 Remit 19

5.2 Client Groups 19

5.2.1 Children 19

5.2.2 Adults 19

5.3 Additional Allowances 19

5.4 Distribution 20

5.5 Activity 20

6 Workforce Issues 22

7 Summary 24

7.1 CDS Remit 25

7.2 Provision of Salaried GDS 25

7.3 Special Needs Patients 25

7.4 Targeted Versus ComprehensiveChildren’s Dental Service 25

7.5 Joint/Split/CDS/GDS Posts 26

7.6 Information Management Systems 26

7.7 Monitoring of Clinical Standards 26

7.8 Out-of-Hours Services 26

7.9 Patient Charges 26

7.10 Career Structures 26

7.11 The Wider Dental Team 26

8 Recommendations 28

8.1 New Scottish Public Dental Service 29

8.2 Special Needs Patients 29

8.3 Children’s Service 29

8.4 Provision of GDS 29

8.5 Information Management Systems 29

8.6 Healthcare Governance 29

8.7 Out-of-Hours Services 29

8.8 Patient Charges 29

8.9 The Wider Dental Team 29

8.10 Career Structures 30

8.10.1 Dental Practitioners 30


8.11 Training Role 30

9 Appendices 32

9.1 Appendix 1Strengths and Weaknesses 32

9.2 Appendix 2Special Care Dentistry 34

9.3 Appendix 3Career Pathway 36

9.4 Appendix 9.4.1Children – GDS Registrations;by Age Group 39

Appendix 9.4.2Adults – GDS registrations;by Age Group 40

Appendix 9.4.3Adults Registered by Age Group;by Health Board Area 41

Appendix 9.4.4Children Registered by Age Group;by Health Board Area 42

10 References 44


iv/v

The Community Dental Services and the Salaried General Dental Services have both contributed considerablyto the care of people of Scotland over many years. There was widespread support for both services duringour consultation on modernising dental services and improving oral health in Scotland, especially as a meansof delivering a comprehensive service to remote and rural areas where independent dental practice did notseem to be a sustainable model of care. Many managers and professionals from island and other remotecommunities consider that these salaried services enable them to design a comprehensive public dentalservice for their area matching need and demand.

These services are both directly managed by NHS Boards and enable Boards to use these staff to themaximum benefit of the community, especially where services are not available through NHS independentcontractors.

This report now sets a clear way forward for the development of the salaried dental services in Scotland witha merging of the two services into one managed dental primary care service for Scotland.

I would like to pay tribute to all those who contributed, to the members of the Working Group and in particularto Marjory Taylor who Chaired the Group and steered the process throughout.

Ray WatkinsChief Dental OfficerNHSScotland

FOREWORD

REMIT

01

The remit of the group was to review the role, remitand structure of primary care salaried dentalservices and identify an effective and efficientservice for the new millennium in Scotland.


01

METHODOLOGY

02


02/03

2.1 An initial meeting was held with the ClinicalDirectors of the CDS in Scotland to:

> discuss the remit of the group;

> gather views on the process ofundertaking the review;

> agree the representation of the ClinicalDirectors on the group;

> gather initial thoughts on the importantfactors to be considered in the review.

2.2 The group was formed involving members ofthe following disciplines:

> Community Dental Service (CDS)

> Salaried General Dental Service (GDS)

> Independent Contractor General DentalService (GDS)

> Professionals Complementary toDentistry (PCDs)

> Local Health Care Co-operatives (LHCC)

> Local Health Council

> Academia

> Health Economics

> Dental Public Health

> Information Services Division of NationalServices Scotland (ISD)

An effort was made to ensure that there wasadequate geographical spread ofrepresentation across Scotland in order toensure that a wide cross section of opinionwas canvassed and that the remote and ruraldimension was addressed appropriately.

2.3 The chair of the group agreed with the thensecretary of the BDA in Scotland the processof its involvement. It was agreed that followinginitial discussions of the working group andwhen there were draft recommendations toconsider, the views of the communityaccredited representatives (CARs) would besought. In addition, a SWOT analysis wascarried out with the CARS.

2.4 The chair of the working group was invited bythe senior clinicians group of the CDS as partof their routine meetings to discuss theproject with them. This session took the formof a SWOT analysis and helped inform theongoing work of the group. The views of thegroup were sought again when therecommendations were being formed.

2.5 Following an initial meeting of the group itwas agreed that there was sufficient expertisewithin the group from the CDS. Due to thediverse nature of the salaried GDS howeverand the fact that the service was relativelynew and changing very quickly, it was agreedthat there had to be an increased effort toengage with this sector. All the salaried GDSdentists were invited through their ClinicalDirectors to attend meetings withrepresentatives of the working group.Consequently two meetings were held inEdinburgh and one in Inverness. Thesemeetings took the form of a SWOT analysisand were facilitated by the chair of the group.

2.6 A summary of the results of the SWOTanalysis exercises were combined andconsidered by the group. (Appendix 9.1)

2.7 Baseline data was collected on the oral healthof the population, staffing and activity levels.In addition, the relevant Scottish ExecutiveCirculars informed the discussions.

2.8 The group met on 14 occasions.

2.9 Conclusions and recommendations werecirculated widely for comment prior to thecompletion of the document.

2.10 As a result of the consultation, the commentsreceived were considered and the documentamended accordingly.

2.11 During the process, at the request of theChief Dental Officer, a subgroup wasappointed to look at the options fordeveloping a targeted, or a comprehensive,children’s service.

ORAL HEALTH OF THE POPULATION OF SCOTLAND

03


04/05

This chapter gives a brief overview of theepidemiology of dental disease in the populationhighlighting the oral health of the population ofScotland.

3.1 Children’s Oral Health

3.1.1 Epidemiology

Dental decay is one of the major causes of illhealth in the community and is the maincause of hospital admission for generalanaesthesia among the 0-14 year old agegroup in Scotland. It is associated withconsiderable pain, discomfort and loss offunction. Its treatment represents a major costto the NHS in Scotland.(1)

The distribution of dental decay in the childpopulation is linked to socio-economic statusand the distribution of dental decay in societyis skewed, with a small proportion of childrenexperiencing the majority of the disease.(2)

As has been demonstrated in past surveys,children living in the most disadvantagedareas have 3 times the number of diseasedteeth compared to those in more affluentcommunities; additionally, only 20% remainfree of dental decay by 5 years of agecompared with over 60% of those from themost affluent areas.(3)

The national target detailed in An action planfor improving oral health and modernisingNHS dental services in Scotland(4) states that“60% of 5 year old children will have no signsof dental disease by 2010”. The results of theScottish 2003 NDIP(2) survey confirm that45% of 5 year olds had no obvious decay butthere is considerable progress required for allNHS Boards to achieve this national target by2010, despite a general improvement indental health between 1994 and 2004.(Figure 1)

In the Scottish Health Boards’ DentalEpidemiology Programme (SHBDEP) surveyof 14 year old children carried out in 1998/9,it was shown that more than two-thirds of 14year olds (68%) were found to have alreadyexperienced decay in their permanent teeth,(5)

while in a previous survey carried out in1996/7, 58% of 12 year olds had experienceddecay.(6) Although both of these figures wereimprovements over previous years, they stillshow that marked progress will be needed toreach the target of 60% of Primary 7 childrenwith no signs of dental disease in theirpermanent teeth.

As with diet, the oral hygiene practices anddental attendance patterns of children areclosely associated with those of their parentsand carers. Mothers who are irregularattenders are less likely to take their childrento the dentist at an early age and childrenwho attend a dentist regularly have betterdental health than those who attendirregularly or not at all. Children from moredisadvantaged areas are less likely to havetheir teeth brushed from the time teeth eruptand are less likely to have their toothbrushingsupervised.(7)

The main cause of dental decay is a diet highin sugars, especially frequent consumption ofsweets, confectionery and high-sugar fizzydrinks. Next to diet, good dental hygiene is amajor factor in preventing the onset of dentaldecay in children. Twice daily tooth brushingwith a fluoride toothpaste is proven to reducesignificantly dental decay. The application offissure sealants to the biting surfaces ofpermanent molar teeth soon after they comethrough is an effective means of reducingdental decay in young people.(8)

3.1.2 Treatment of Decayed Teeth

Trends in the level of restorative care receivedby children in the UK since epidemiologicalsurveys began are well documented.(2,5,6,9)

The capitation system of remuneratinggeneral dental practitioner, which existedbetween 1990 and 1996, combined withother changes in primary care dental services,appear to have failed in addressing therestorative needs of children of all ages.

In 1996, item of service payments were re-introduced within the GDSs for certainaspects of treatment, including fillings andextractions, and were linked to a modifiedcapitation system. Further incentives toregister young children in deprived areas wereintroduced in 1998.

The Care Index is used to describe the levelof restorative care a child receives. The NDIPresults for 2003(2) show that only 9% of decayhad been treated and Figures 2 and 3 showthe small percentage of filled teeth comparedto the decayed and missing components in 5and 14 year olds in Scotland. The vastmajority of dental decay in the teeth of 5 yearold children therefore remains untreated, withthe majority of the remainder being treated byextraction. The reasons behind this arecomplex and not fully understood but cannotonly be attributed to the dental remunerationsystem or access to services and registrationrates. Given the highly skewed prevalence ofdental decay described above and the factthat the most disadvantaged children havethe majority of the disease, it is likely thatthose most in need of dental treatment arethe least likely to be registered or becomeregular attendees.

3.5

3

2.5

2

1.5

1

0.5

087-88 89-90 91-92 93-94 95-96 97-98 99-00

FIGURE 2: d3mft of 5 year olds in Scotland by year

d3mft of 5 year olds in Scotland by year

Year

Source: SHBDEP

Decayed FilledMissing

60

50

40

30

20

10

0

FIGURE 1: Percentage of 5 year olds with no obviousdecay in Scotland by year

93-94 95-96 97-98 99-00 01-02 02-03 2004

Percentage of 5 year olds with no obvious decay in Scotland byyear

Year

Source: SHBDEP and NDIP

Full data not available for year 2000/01

90-91

94-95

98-99

0 0.5 1 1.5 2 2.5 3 3.5 4

FIGURE 3: d3mft of 14 year olds in Scotland by year

d3mft of 14 year olds in Scotland by year

Year

Source: SHBDEP 90/01, 94/95, 98/99

D3 FM


06/07

3.2 Adult Oral Health

3.2.1 Epidemiology

Oral health in older adults in Scotland ispoorer than in other parts of the UK.(10)

However, despite 18% of Scottish adultshaving no natural teeth, there have beensteady improvements in adult oral healthsince 1968.(11) The number of Scottish adultsretaining 21 teeth or more (the numberconsidered necessary to provide a functionaldentition) has risen substantially. Deprivationand the low priority sometimes afforded tooral health by individuals, carers and family,contribute to poor oral health.(10) For olderadults who retain some natural teeth, rootcaries and advanced periodontal disease aremore common than in younger adults.

Increased life expectancy in Scotland hasfocussed interest in healthcare provision forolder people. There is an expectation thatappropriate healthcare, including oralhealthcare services, should be an essentialpart of healthy ageing and should contributepositively to the enjoyment of older age.However, there is currently considerablevariation in the pattern of older people toaccessing and utilising health services,particularly with respect to functionally frailolder adults, who may experience difficultywhen seeking to meet oral health needs.

Adults over 60 years of age, who currentlymake up a fifth of the UK population, willconstitute one-third by 2030; in Scotland,those aged 65 and over will increase by justover 50%, with those over 80 years of agerepresenting the section of the populationwith the greatest increase in numbers.(12)

The impact of factors such as systemicdisease, poor nutritional status and drugassociated changes in the oral tissues,together with the potential impact of disability,all have an important influence on the abilityof older people to maintain good oralhealth.(13)

Conversely, poor oral health may impactsignificantly upon general health by impairingthe ability of individuals to maintain anadequate diet, resulting in reduced overallwell-being for affected individuals.(14)

Recent work by Steele et al,(15) whichexamined UK adult dental health survey data,indicated that the number of adults retainingnatural teeth is likely to grow substantially.There are clear inequalities in the dentalhealth of adults, with a smaller proportion ofthose from more deprived areas (DEPCAT 5,6, 7) (16) retaining their own teeth.

Many factors are implicated in the reductionof edentulousness. There have been changingattitudes towards oral health and dentistryamong the general population, and thesehave been influenced to some degree byadvances in restorative dentistry andchanging treatment patterns of dentalpractitioners.(17, 10) The increased use offluoride, including fluoride toothpaste, hasalso had an impact.

The Action Plan(4) has set a target that by2010, 95% of 45 to 54 year olds shouldretain some natural teeth. In 1998, 87% ofthis age group had some natural teeth andamong the age cohort (35 to 44 year olds)who will be 45-54 in 2010, 96% had retainedsome natural teeth.(10) Progress is, therefore,being made towards the national target. Theproportion of adults with 21 or more naturalteeth (the number consistent with a functionaldentition) has risen from 64% in 1972 to 78%in 1998.

Adults living in disadvantaged areas havefewer natural teeth, more actively decayedteeth and fewer restored teeth. In Scotland41% of adults with some natural teeth reporthaving had pain in the previous 12 months.Furthermore, 30% percent of dentate adultsin Scotland report feeling self-conscious ortense because of their teeth, mouth ordenture in the previous 12 months and just

over 20% find that their oral condition causesthem embarrassment and makes it difficult torelax.(10)

Predictions of future total teeth loss havebeen made, and assuming no increase in theincidence of total tooth loss, the proportion ofadults with no natural teeth can be expectedto continue to fall, and to reduce to singlefigure percentages in all age groups up to theage of 74 by 2008.

In older people, studies have shown thatuntreated caries was most commonly foundon the crowns of the teeth (25%), although asubstantial number (18%) also had rootcaries.(10) One longitudinal study of caries inolder adults has found that over three years,caries developed on an average of 2.4 coronalsurfaces and 1.1 root surfaces per person peryear. For older adults who are functionally frailand unable to manage oral hygiene measuresindependently, the rates are much higher.Recent UK data indicate that, in adults overthe age of 65, an average of 10.6 teeth werevulnerable to root surface caries and a thirdhad existing root caries lesions.(18)

The second most prevalent oral diseaseinvolves the gums. Periodontal (gum)conditions in the form of pocketing are seenin over half the adult population. Theprevalence of pocketing, loss of attachmentand calculus increases with age with 85%over the age of 65 affected.(10)

Over 500 new cases of oral cancer arediagnosed each year in Scotland and thereare about 230 deaths. The incidence inScotland is approximately 13 per 100,000while the incidence in England and Wales isabout 7 per 100,000. Within Scotland therewas a rise of over 40% in the incidence oforal cancer between 1985 and 1996. Whileapproximately 85% of new cases occur inthose aged 50 and over, a trend of increasingprevalence has been most apparent in theyounger age groups.(19)

In addition to ageing, there are other well-recognised risk factors for oral cancer,the most significant of which are tobacco andalcohol use. One large case-control studyshowed(20) that the risk of oropharyngealcancer increased more than 35 times inindividuals who consumed two or more packsof cigarettes and more than four alcoholicdrinks per day.

There is evidence linking oral cancer to theuse of smokeless tobacco products, the useof which is common among South Asianpopulations of the UK. Moreover, there isextensive misinformation and lack ofawareness about the risk factors and earlysigns of oral cancer in this population.(21)

As with other oral and dental diseases, theoccurrence of oral cancer is associated withdeprivation and deaths from such cancers arethree times greater in those from deprivedareas, compared with those from affluentareas. Early diagnosis is essential, astreatment of early lesions requires a lessradical approach and has better survival rates.


08/09

CURRENT SALARIED SERVICES

04

This chapter describes the current primary caresalaried dental services, explaining the remit,function, distribution and activity of the CDS andthe primary care Salaried GDS.

4.1 Community Dental Service (CDS)

4.1.1 Remit

The CDS is a directly managed service inwhich staff are remunerated by salary. Its roleand remit were defined in 1989(22) andupdated in 1997.(23)

These circulars identify a Public Healthfunction to include screening, healthpromotion and preventive public healthprogrammes for children and adults withspecial needs. The service undertakes annualinspections of children’s oral health as part ofthe National Dental Inspection Programme.

The second function is the treatmentobjective of the service, providing acomplementary service to the GDS byidentifying special needs groups. Morerecently there has been an increasedcommitment to act as a safety net treatmentservice for those patients who do not obtaintreatment from the GDS.

4.1.2 Client groups

As indicated above, the CDS provides a fullrange of treatment services, for those withspecial needs (community care groups) andan enhanced ‘safety-net’ role for thosepatients of any age who cannot or will notobtain treatment from the GDS.

In most NHS Board areas, the CDS providesa service to older people, especially those inresidential or nursing care, or who haveimpaired mobility. This service complementsthe care provided by the GDS. The definitionof “special needs” is not easily defined andcurrently encompasses both people whosespecial needs refer to their social or emotional

needs but have routine dental problems, andalso to people whose systemic conditionsrender dental treatment more demanding andtime consuming.

During the review process, the groupattempted to define ‘special needs’; thedefinition however seems to be inconsistentacross the country, but the definition from thejoint Advisory Committee for Special CareDentistry documents “Training in Special CareDentistry” (2003) and “A Case of Need forSpecial Care Dentistry” (2003) is cited forguidance. (Appendix 9.2)

The treatment of special needs groups isoften more complex and time consuming thanthe routine provision of treatment due to, forexample, complex medical histories of theclient group, or behavioural aspects arisingfrom their condition.

As more adults retain some natural teeth intolater years, complexity of treatment increasesaccordingly. Furthermore, as patientexpectations of treatment rise, there is agrowing need for appropriately equipped andaccessible dedicated dental care facilities forthe treatment of older adults with complextreatment needs. Such facilities could be usedby both general and community dentalpractitioners where local agreement is reached.

4.1.3 Distribution

Between 1980 and 2004 the number of WholeTime Equivalent Community Dental Officers inScotland reduced from 278 to 192(24). Incontrast, the number of Senior Dental Officers,who have greater experience and skills in thecomplex management issues associated withCommunity Care, has risen from 6.5 WTE to37.2 WTE in the same period. Although thisreflects the general trend, the group felt thatthe WTE figure of the Community Dental staffmay not be absolutely accurate.


10/11

4.1.4 Activity

4.1.4.1 Clinical Activity

Activity in the CDS is monitored bycompletion of SMR 13 forms, which is apatient based system recording the clinicalactivity and courses of treatment carriedout in the service. The forms are processedand summarised by Information ServicesDivision (ISD), and distributed quarterly.

Overall activity within CDSs in Scotland isdetailed in Appendix 3. While the overallnumber of courses of treatment appears tohave reduced over the years, it should benoted that the proportion of adults (withmore complex treatment needs) hasincreased during this time.

CDS activity under the special needscategories for Scotland is detailed Figure 4.

The pattern of provision of domiciliarycare for community care groups haschanged over the last decade. In l991/92there were approximately 3,000domiciliary cases treated in the CDS andin the year 2003, there were 9,700 cases.This has implications for staff and patientsin terms of time commitment, health andsafety issues, quality of treatmentoutcomes and what aspects of dentalcare can appropriately be provided on adomiciliary basis.

In summary, the activity in the CDS haschanged markedly over the last couple ofdecades with a reduction in staffing levels, aconcomitant reduction in patient numbers,and within that an increase in the proportionof adults being seen and a greateremphasis on clients with special needs.

9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

0

MentalHealth

FIGURE 4: Activity in the CDS under special needs categories for Scotland

Treatment Type

Source: PHIS needs assessment report on ‘Community Care and Oral Health April 2002’

2003

PhysicalDisability

Geriatric MedicallyCompromised

1990

LearningDisability

Psycho-geriatric

Anxiety /Phobia


12/13

The provision of domiciliary care forcommunity care groups has implicationsfor staff and patients in terms of timecommitment, health and safety issues,quality of treatment outcomes and whataspects of dental care can appropriatelybe provided on a domiciliary basis.

4.1.4.2 Inspections and Screening

CDSs in Scotland have established goodworking relationships with local authoritiesand undertake NDIP inspections in primaryschools in Scotland.

Inspections are undertaken as a means ofmaking an initial assessment of oral healthneeds and identifying individuals requiringfurther treatment. NDIP provides basicdental inspections for Primary 1 andPrimary 7 children annually, informingparents of their child’s dental status.Detailed inspections are carried out everyyear in Primary 1 and Primary 7 inalternate years, enabling NHS Boards todirect services and oral health promotioninitiatives to areas with the greatest need.

Within Scotland, oral health inspections arealso carried out for people cared for inresidential settings, with limited screeningbeing undertaken in smaller units such asgroup homes, and day and resourcecentres. Some children attending specialschools or special units within mainstreamschools also receive dental inspectionsfrom the CDS.

4.1.5 Monitoring Clinical Standards

Currently there are no nationally agreedprotocols for monitoring clinical standards inthe CDS. All dentists are required to undergocontinuing professional development and thisis monitored by the GDC.

4.1.6 Out-of Hours Services

Staff of the CDS do not have a contractualobligation to provide a service for theirpatients out of working hours. There ishowever a ‘professional obligation for dentiststo make adequate provision for their patients’and many CDS staff are involved in an out ofhours rota for an agreed fee.(25)

4.1.7 Patient Charges

Children attending the CDS and GDS are notcharged for their treatment, adults who wouldnormally be eligible to pay under the GDSRegulations are subject to charges on alimited basis i.e. dentures, bridges.

4.1.8 Career Structure

The CDS does not have a formal careerstructure but there are many frameworks inplace addressing the career pathway fordentists. Many Community Dental Services inScotland are involved in the VT/GPTschemes, crosslinked to the Hospital andGDSs. Dentists who are employed by theservice are encouraged, but not obliged, towork towards a second degree in PublicHealth or Community Medicine, or a secondqualification, for example, MFDS/MSND.Dentists with a second degree, and anappropriate amount of clinical experience arethen entitled to apply for a senior post.

There is also the possibility of developing,within the CDS, a special interest in oneparticular branch of dentistry which cancomplement their general dental skills.

4.1.9 The Wider Dental Team

In addition to dentists, the CDS employs awide team of dental nurses, hygienists,therapists, oral health promoters, oral healtheducators and administration staff. This teamcontributes to the overall care of the patientand the wider community, as well as theprofessional development of one another.Since the only Dental Therapy School in theUK closed several years ago, the number oftherapists has dwindled. Recently, however,their scope for carrying out a wide range ofprocedures has increased. With theincreasing awareness of the PCDs’ role incontributing to improving oral health, thereshould be the opportunity not only to makebetter use of their skills, but to ensure that thedentists employed in the service are able tomaximise their own potential.

4.2 Salaried General Dental Service (Salaried GDS)

4.2.1 Remit

The remit of the Salaried GDS is the same asthat of overall GDS, except that SalariedGDPs are remunerated on a salaried basis,rather than item of service and are managedas part of the Salaried Dental Services. Theremit of the General Dental Service isdescribed in 5.1

Salaried GDPs are usually recruited to areaswhere access to NHS GDS is limited, oftendue to retiring practitioners being unable tosell their practices or where dentists havemoved into the private sector.

Whilst difficulties in selling dental practiceshas historically been mainly a rural issue, it isnow becoming a problem in more populatedareas. The consequential gap in the capacityof GDS services necessitates theappointment of salaried practitioners in sometowns and cities.

4.2.2 Client Groups

Salaried GDPs are permitted to treat allcategories of patients, as do independentNHS general dental practitioners as detailedin section 5.1.

4.2.3 Distribution

Recent figures indicate that there are currently 81Salaried GDP posts established in Scotland. Dueto recruitment difficulties not all these posts arefilled. There is no recognised appropriate level ofdentist to population ratio across Scotland solevels of salaried practitioners will depend on localcircumstances, influenced by demand and need.

4.2.4 Activity

Table 1 shows the activity of salaried dentistsfor year ending March 2004. The table whichshows a wide variation of registered patientsper practitioner provides a head count, butnot the whole time equivalent figure. The tablealso shows a wide variation in numbers ofregistered patients per dentist and thisreflects the differing practices across thecountry. The group felt that it was influencedby the following issues:

> dentists may be taking patients onreferral from colleagues and are notregistering them;

> the GP17 forms may not be routinelycompleted;

> in areas where demand is high, andsupply is low, patients may be beingseen on a casual basis and thereforeare not being registered;

> if demand is too high there is littleincentive to re-register patients.


14/15

The activity data collected for the SalariedGDSs is lower in some cases than the activityin the GDS. Suggestions as to why this mightbe were put forward by the group:

> patients typically seen by this serviceare made up of a higher proportion ofchildren than would normally be seen;

> patients requiring more time consumingtreatment plans (anxious and specialneeds patients);

> some practitioners have long distancesto travel before being able to start work;

> practitioners carry out manytreatments for which there is no item ofservice to claim on the GP17 form, forexample, review appointments andpreventive treatments, so there is anelement of under-counting whenanalysing their activity.

Number of registrations3

Forms processed Number ofdentists1,2

Children Adults

Scotland 62,165 81 13,704 35,783

Argyll & Clyde 9,079 8 1,666 3,959

Ayrshire & Arran 6,190 7 1,287 3,281

Borders 2,834 4 739 1,907

Dumfries & Galloway 2,173 3 616 1,425

Fife 0 1 36 1,258

Forth Valley 950 1 369 448

Grampian 7,813 9 439 4,503

Greater Glasgow 0 0 10 35

Highland 13,308 18 3,320 8,726

Lanarkshire 275 1 0 5

Lothian 7,329 9 1,206 3,620

Orkney 4,095 7 880 2,324

Shetland 6,997 9 3,123 2,965

Tayside 0 0 6 19

Western Isles 1,122 4 7 1,308

TABLE 1Activity of salaried dentists, year ending March 2004

1 Excludes dentists who hold both salaried and non-salaried list numbers in the GDS; this is to avoid counting them twice, as they are already countedas non-salaried dentists.

2 The number of salaried dentists active at 31 March 2004.3 The number of registrations at 31 March 2004.

Source: Scottish Dental Practice Board Annual Report 2003/04

4.2.5 Monitoring Clinical Standards

All dentists are required to undergo continuingprofessional training and this is monitored bythe GDC. Clinical standards are monitored bythe Practitioners Services – Dental (PSD) inrelation to Salaried GDS.

4.2.6 Out of Hours

Under their NHS terms of service, SalariedGDPs are obliged as part of their contract tomake arrangements to ensure that their NHSregistered patients have access to emergencytreatment. This service can be provided byindividual dentists, or by groups of practices.

4.2.7 Patient Charges

Patients attending the primary care SalariedGDS are subject to the same charges for theirtreatment as those treated under the GDSgenerally. Salaried dentists are required tocollect patient charges in accordance with theregulations and to remit all charges collectedto the health board. Salaried dentists arerequired to use the standard NHS claim formsfor the treatment of patients and submit theseto the PSD. The PSD processes the claimsfor care and treatment provided but becausesalaried dentists receive a set salary, they arenot entitled to receive the scheduled fees.

4.2.8 Career Structure

There is no formal career structure within thesalaried GDS, although there are optionsopen to dentists for higher training andpromoted posts are available.


The dentists who work in the GDS or thesalaried dental services work as part of awider dental team made up of dental nurses,dental hygienists, therapists andadministration staff. Currently therapists arebeing trained in Scotland and in the futurethey will be able to contribute to the work ofthe team by providing an extensive range ofclinical procedures.

4.3 Joint and “Combined” (or Split) GDS/CDSPosts

These terms have evolved to describepractitioners whose remit is neither wholly inthe CDS, nor in the GDS. Special terms andconditions have been developed to allowpractitioners to respond to local need. Theyhave, however, evolved in two ways andthese are explained here.

4.3.1 Joint Posts

These posts arose from the occasionalnecessity of community dental officers toprovide GDSs in areas that could not accessdental services routinely. The spirit of the postremained essentially within the CDS and therevenue consequences of the salaried portionremained with the cash-limited budgets ofhealth boards. The salary scale is the sameas that for CDS, plus an additionalresponsibility allowance, the latter comes fromthe non-cash-limited GDS budget.

A major anomaly arises in the responsibilityallowance associated with joint posts, whichis paid in order to reflect the GDS element ofthe job. However, this is not reflected in othersalaried posts.


16/17

4.3.2 Combined (or Split) Posts

Combined or split posts were created inorder to address more serious problems ofaccess to primary dental care services inareas where the population levels made itmore realistic for a single practitioner to takeon the roles of both a salaried dental officer(GDS) and that of a community dental officer,albeit with a relatively small element of CDSactivity. However, in this case, the emphasisis heavily weighted towards GDS. The CDSelement in many cases is present to ensurethat school inspection programmes can stillbe implemented within the current legalframework. The budgetary split is dependenton the individual Board need. Dental officerswork within the GDS regulations in a familysetting, but also implement the school dentalinspection programme in their area, thusperforming a public health role within a GDSframework.

GENERAL DENTAL SERVICES (GDS)

05


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This chapter briefly describes the currentindependent contractor GDS in order to provide acontext for the report.

5.1 Remit

The General Dental Practitioner service is themain primary care dental service and themajority of General Dental Practitioners areindependent contractors. As such they canchoose whether or not to treat people underthe National Health Service. In addition, thereis no restriction on where a dentist maypractise and this is often dictated by marketforces. Due to these factors, it is thereforedifficult to plan GDSs to reflect the needs ofthe community.

The monitoring and authorisation ofpayments is carried out for the service byPSD on behalf of the Scottish Dental PracticeBoard (SDPB). Practitioners may also treatpeople on an ‘occasional’ basis, usually foremergency problems.

Individual General Dental Practitionercontracts are held by the NHS Boards.

5.2 Client Groups

5.2.1 Children

NHS GDPs treat children and young peoplebelow 18 years of age under a hybridcapitation agreement. In September 1996 theoriginal capitation contract was replaced witha modified contract in which the capitationpayment is supplemented by item-of-servicefees for certain treatment procedures. Thisagreement allows for the provision of a fullrange of free dental care includingexamination, curative and preventivetreatments as well as some more complexrestorative and orthodontic procedures.

GDPs currently are paid a basic capitationpayment for patients under 18 years of age tosecure and maintain oral health for eachpatient. However, in order to encourageregistration of children, they receive anenhancement of the capitation fee, whichincreases as the deprivation category of thedental practice increases, when the patient isaged 0-2 years old. Where the patient is aged3-5 years old, the dentist receives anenhancement of the capitation fee if the postcode of the practice falls into DeprivationCategories 6 and 7(16). For children aged 6and 7 years old, they receive similarenhancements, also according to the postcode of the practice. Dentists receivingthe enhanced capitation fee are required toassess the patients’ caries risk, render thechild dentally fit and seal the first permanentmolar teeth as soon as possible aftereruption.

5.2.2 Adults

General dental practitioners are remuneratedby a combination of a capitation system,known as Continuing Care, and a fee for itemof service. Routinely, adults have to meet80% of the cost of NHS treatment up to amaximum charge. If patients fall into one ofseveral exemption categories, e.g. expectantor nursing mother, receiving family credit orincome support, or incapacity benefit they areentitled to free NHS care.

5.3 Additional Allowances

In recent years, additional allowances havebeen introduced, for instance, to help pay forpractice improvements, to act as incentives toattract practitioners to remote and rural areas,and to encourage newly qualified practitionersto stay in Scotland.

5.4 Distribution

The provision of GDS varies acrossScotland and has changed over the lastdecade. Although there have been increasesin the dentist to population ratio in Lothian,Lanarkshire and Glasgow, in the WesternIsles, Shetland, Orkney, Highland, Dumfriesand Galloway and Borders, there has beena reduction.

Figure 5 shows the distribution of dentists byNHS Board in Scotland and highlights thevariation in concentration of dentists from theremote and rural areas, such as Orkney andShetland where there is a very lowconcentration, to Glasgow and Lothian,where there is a much higher number ofdentists per head of population.

5.5 Activity

The activity in the GDS is recorded by apatient based form, known as the GP17 form.This is the same form as used by the SalariedGDP service and is similar to the system inthe CDS. However, as well as monitoring theclinical activity, the GP17 is also used by thePSD facilitating payment for the dentist.

The overall number of dental examinationsundertaken in Scotland by general dentalpractitioners is shown in Table 3 and hasremained relatively stable in the past 4 years.The number of examinations has increasedsince the early 1990s with 1.96 millionexaminations undertaken in 1991/92 and over2 million in recent years.

600,000

500,000

400,000

300,000

200,000

100,000

0

Root CanalTreatments

FIGURE 6: Activity by item of service 1991/92 and 2001/02

Treatment Type

Source: SHBDEP

2001/02

Shetland

Tayside

Western Isles

0 10 20 30 40 50 60

FIGURE 5: Dentist population ratio by NHS Board 1991/02 and 2003/04

dentists/100,000 population

Source: SDPB Annual Report 1991/02, 2003/04

2003/04 1991/92

Orkney

Lothian

Lanarkshire

Highland

Glasgow

Grampian

Forth Valley

Fife

Dumfries and Galloway

Borders

Ayrshire and Arran

Argyll and Clyde

Veneers Extractions Sedations

1991/92


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TABLE 3Number of examinations in Scotland; year ending March 2004 (non-salaried GDS only)

Source: Scottish Dental Practice Board Annual Report 2003/04

2000 2001 2002 2003 2004

No. of examinations (000s) 2,214 2,189 2,185 2,213 2,168

The overall proportion of the Scottishpopulation registered with a general dentalpractitioner is detailed in Appendix 9.4 (pages39,42) and the trends in child and adultregistrations are described in more detail insubsequent sections of this report. As can beseen registrations peak among the 6-12 and35-44 year old age groups.

Trends show that, overall registrations inScotland among adults have increased onlyslightly from 47% in 1991/92(26) to 49% in2003(1). Registration levels fall dramatically inolder age groups with only 28% of adults over75 years of age being registered in Scotlandand is shown in Appendix 9.4.1.

Trends in the proportion of children registeredwith a general dental practitioner in Scotlandis shown Appendix 9.4.2.

Since the early 1990s the proportion ofchildren registered has risen from a Scottishaverage of 54% in 1991/92 to 66% in 2004,although in recent years this figure hasplateaued. It is encouraging to note that theproportion of very young children enteringgeneral dental care (0-2 year olds) hasincreased from 15% in 1996 to 35% in 2004,but again these figures have plateaued inrecent years.

Child dental registrations continue to peak inthe 6-9 and 10-14 year old age groups.

Figure 6 shows the pattern of activity by itemof service in GDS over the 10 year period until2001/02. Proportionately, the biggest changehas been in the provision of crowns, whichhas reduced, but there has also been a

reduction in the numbers of tooth extractions.Other items of service have changed less.

General dental practitioners can also providehome (domiciliary) care to patients confined totheir place of residence because of theirphysical or mental condition. The majority ofthese visits are for older adults either living athome or in care establishments.

The vast majority of domiciliary dental carecurrently involves dental check ups and theprovision, repair or alteration of dentures andextractions. These aspects of dentaltreatment require less dental equipment to betransported to the individual’s home, incomparison to restorative treatment, of whichrelatively little is provided on a domiciliarybasis.

The number of domiciliary courses oftreatment and visits in NHS GDSs in Scotlandrose during the 1990s but has nowsignificantly reduced to 511 visits in year2003/04 compared to 24,000 visits in2001/02.

WORKFORCE ISSUES

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The ability to deliver oral healthcare services to anincreasingly dentate population depends on theexistence of an appropriately trained dentalworkforce. Pressures on the dental workforce havea direct bearing on the increasing demand on oralhealth services for older people. Workforcemodelling, carried out by Scottish Council forPostgraduate Medical and Dental Education(SCPMDE, now known as NHS Education forScotland), identified that the current rate of increaseof 1.9% each year since 1995 was not sustainableand would lead to a significant shortfall in the future,unless action was taken.

Key factors influencing supply include the following:

> Increased early retirement

> Increased part-time working

> Increased proportion of women in the dentalworkforce

> Increase in non-NHS working

There has been a recent increase in “private”activity in the GDS, and while it is considered asignificant proportion at 15% of the activity, it is stilllimited. A gap still exists between the supply anddemand of NHS dentistry.

Despite several recent initiatives to address retentionof the dental workforce in Scotland, there arerecognised problems in the future supply of dentistsat a time when there are very significant pressures toincrease demand for dental treatment, including carefor older people. The recent assessment of thedental workforce in Scotland(27), Workforce Planningfor Dentistry in Scotland. NES/ISD, has found thatthe key factors increasing the utilisation of dentalservices are: increasing proportion of older people inthe population, together with increasing toothretention in this group. An increasing demand fordental services is compounded by an increasingrestriction on provision of NHS dentistry in someparts of Scotland.

A recent development, that may partially help toalleviate the loss to the dental workforce, is thedecision to extend the duties of ProfessionalsComplementary to Dentistry (PCDs) and expand thenumber being trained in Scotland.

SUMMARY

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The group discussed in detail why and how theservices could best meet the needs of thepopulation, taking into account the accessproblems in some parts of the country for primaryand secondary dental care. It was recognised thatin some areas this has led to increased demandson the service and some unnecessary referrals tosecondary care.

7.1 CDS Remit

The remit of the CDS has changed over thelast 20 years as it has responded to the needto provide a complementary service to theindependent contractor GDS. The ‘ActionPlan for improving oral health andmodernising NHS dental services in Scotland’document has recognised the need toconcentrate on prevention in dentistry, whilstalso maintaining a treatment service.

The CDS has adapted to meet the demandsof patients with special needs, primarily thosewith complex clinical conditions and/orchallenging behaviour. Consequently therehas been a reduction in numbers of routinechild patients treated by the CDS, the extentof which varies from area to area. There hasbeen a rise in the number of adult patientstreated, with a concentration on the clientgroups who have special needs. The dentalpublic health role has been maintained and,with the recent introduction of the NationalDental Inspection Programme, this hasstrengthened.

7.2 Provision of Salaried GDS

The provision of GDS is often driven, in themain, by market forces and will, therefore,encourage dentists to provide services inareas with dense population levels.Consequently when there is a shortage ofdentists, remote areas, with low populationdensity, are likely to be adversely affected.

The availability of NHS GDS has decreasedover time and in an attempt to meet demandthere has been an increase in the numbers ofsalaried general dental practitioners,particularly in rural areas. In some areas thedemand for such services has given rise tolong waiting times.

There are no targets for levels of manpower inrelation to need for care so provision acrossScotland is ad hoc.

7.3 Special Needs Patients

The definition of ‘special needs’ isinconsistent across the country. Thereappears to be a continuum of clinical needacross a very broad spectrum. At one end ofthe continuum there are patients withprofound problems whose need for advancedclinical skills is obvious. At the other extremehowever there are patients whose needs areroutine but are classified by clinicians, orclassify themselves, as ‘special needs’ inorder to access care from the CDS. This is asignificant issue where access to routine GDSis restricted but in normal circumstances thepatients would have been able to be seen bygeneral dental practitioners. The thresholdtherefore for special needs services isinfluenced by the accessibility of GDS locally.

It is recognised that people with specialneeds are less likely than routine patients tobe able to make their demands heard andtherefore their ability to access the care theyrequire may be compromised. This is aparticular problem in areas where otherroutine/more able/more demanding patientsare competing for a limited service.

7.4 Targeted Versus Comprehensive Children’sDental Service

A comprehensive children’s service wasdefined as one which was dedicated to thisclient group and separate from other dentalservices. Targeted children’s service wasdefined as that which would be

complementary to the other services whichchildren could attend. It was considered thatthere were pros and cons in both models, butin the former the issues of lack of continuity ofcare, lack of numbers of dentists willing torestrict their practice to children, thedisincentive to the “family” approach to dentalattendance, and organising this service withinthe school environment would be consideredmajor barriers.

7.5 Joint/Split/CDS/GDS Posts

In some areas the duties of the CDSpractitioners and those of the salaried GDSpractitioner have been merged. Under thissystem dentists either operate under twoseparate contracts or one combined contract.The result in both cases is that eachpractitioner has the flexibility to operate undereither the CDS or the GDS system.

7.6 Information Management Systems

There are two sources of relevant activitydata; the form used by the CDS (SMR 13)which is usually completed at the end oftreatment for each patient and the equivalentin the GDS, which is the GP17. In additionthe ‘joint’ CDS/GDS clinicians and cliniciansoccupying ‘split’ CDS/GDS posts may useboth. As a result it is difficult to measureaccurately the activity levels in each service,the collection of data is unnecessarilycomplex, its validity is compromised and anycomparisons across the services areimpossible.

7.7 Monitoring of Clinical Standards

The system for the monitoring of clinicalstandards for each of the salaried services isdifferent. Whilst the salaried GDS is subject tothe monitoring system applied to independentcontractors the CDS has no national standardprovision.

7.8 Out-of-Hours Services

Out-of-hours dental provision is different ineach of the services. Whilst there is acontractual obligation placed on SalariedGDPs to provide emergency cover for theirregistered patients there is no equivalentobligation on CDS staff. This has led to locallynegotiated agreements that have, in the main,been voluntary in nature. Consequently thereis a lack of uniformity across the services.

7.9 Patient Charges

There are different rules for patient charges,depending on whether the treatment wascarried out by the CDS or the salaried GDS.

7.10 Career Structures

Career structures exist in the CDS withfinancial recognition being given for additionalskills and responsibility. In the salaried GDSthere is no clear means of careeradvancement and in neither is there arecognised training pathway.

7.11 The Wider Dental Team

For the purposes of this report the widerdental team includes PCDs (ProfessionalsComplementary to Dentistry), Oral HealthEducators and dental administrative andclerical staff. The planned increased role forthe wider dental team is a welcomedevelopment and could contribute towardsincreasing dental workforce and to themovement of emphasis towards preventivedentistry.

There is a lack of uniformity across Scotlandin relation to pay grading for staff andcurrently there are limited career structuresand opportunities for staff development.


26/27

RECOMMENDATIONS

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8.1 New Scottish Public Dental Service

The current CDS and Salaried GDS shouldcombine to form a new Scottish Public DentalService.

This service should:

> provide care for people with special needs

> complement the current GDS andspecialist services, especially in remoteand rural areas

> have a public health role and oral healthpromotion targeted both at populationsand individuals

> make greater use of specialists

> make greater use of professionalscomplementary to dentistry both clinicallyand for the public health role, i.e. NDIP.

8.2 Special Needs Patients

The needs of patients with ‘special needs’should be safeguarded particularly wherelocal access to GDS is limited.

The definition of ‘special needs’ should beclarified and the needs of the client groupquantified to ensure that adequate provision ismade for people with the greatest need.

8.3 Children’s Service

The service to children should be an integralpart of the public dental service,complementing the role of the GDS andtargeted to areas, or groups, of high need.

8.4 Provision of GDSs

Appropriate levels of NHS dental provision perpopulation in each CHP should be quantifiedand targets developed by NHS Boards.

8.5 Information Management Systems

The process of data collection should beuniform across the service, recordedelectronically, and should provide data onwaiting times and outcomes comparable withother services.

8.6 Healthcare Governance

Systems should be developed for monitoringclinical standards to ensure a consistentlyhigh level of care for patients as set out inthe Quality Improvement Scotland DentalStandards using dental reference officerswith appropriate experience relevant to theclient groups.

8.7 Out-of-Hours Services

Provision should be made by NHS Boards foran out-of-hours dental service involving allrelevant staff ensuring the availability of thosewith appropriate experience of the varyingclient groups to meet local needs.

8.8 Patient Charges

The new service should apply a uniformcharging system for all clients, which wouldbe the same as applied to those attendingthe GDS.

8.9 The Wider Dental Team

The skills of PCDs, Oral Health Educators,administrators and clerical staff should bedeployed in the new salaried dental service tocontribute to dental workforce levels, and tomove the emphasis towards healthimprovement.

8.10 Career Structures

8.10.1 Dental Practitioners

In order to provide the skills to maximise theamount of care available in the primary caresetting there should be a career structure thatencourages advancement and provides theopportunity to develop appropriate skills. Therecommended structure takes into accountthe need to have intermediate grades of staffbetween the pure generalist and thespecialist.

The career grade level would be similar to thecurrent community dental officer/salariedgeneral dental practitioner grade.

There should be an advanced level ofpractitioner (senior dental officer/dentists withspecial interest), who would have experiencein certain aspects of clinical practice or wouldfor instance practice in a remote settingwhere the threshold of referral to a secondarycare setting is higher than would be normallyexpected of a CDO/GDP. These posts wouldbe quality assured and would recogniseexpertise that practitioners have built upthrough years of practice or through trainingprogrammes organised possibly on asecondment basis.

There should be an Associate Specialistgrade, which would require greatercompetency in certain areas of clinicalpractice. These may relate to:

> treating client groups whose medicalcondition requires the practitioner to havegreater skills, experience or knowledgethan would be expected of a CDO/GDP;

> management;

> skills in a recognised specialty.

The specialist practitioner and the consultantgrades would require the clinician to followthe recognised training pathways already inexistence.

The training pathways for the new integratedservices should take account of the skills ofthose currently in service when attributing agrade in the future.


Career pathways should be developed for thewider dental team (PCDs, Oral HealthEducators, administrators and clerical staff).

8.11 Training Role

The training role of the new public dentalservice will be twofold. There will be theopportunity for the service to provide trainingfor practitioners who will be making a careerwithin the service, and also for practitionerswho require to enhance particular skills onlyavailable in the public dental service. To meetthese needs a formal training pathway andsuitable infrastructure will be required.


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APPENDIX 9.1

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STRENGTHS

Financial – e.g. guaranteed income, access to funding, paidleave, not profit motivated therefore less pressure financially,pension scheme.

Personal/Career – e.g. training and education accessible andsupported, personal development through CPD and specialinterest, good support network and contact with peers, jobsatisfaction.

Organisation/Management Structure – e.g. Time to lookinto issues such as prevention/quality/cross infection, clinicalfreedom, freedom to use and purchase equipment/sundries,access to skilled staff (PCDs).

Patient Services – e.g. patient-led approach, filling a gapgeographically, contributing to the community, safety net foremergencies and providing hospital based service, raisedawareness in areas of need and with health professionals,access for unregistered/poor attendees, out-of-hours access,ethical, patient needs put before business.

WEAKNESSES

Financial – e.g. less cost effective than NHS practice, notenough or no senior salaried GDPs, undercounting of salariedGDP activity, lack of equity with independent GDPs pensions,limitations of fee scale and lack of opportunity to undertakeprivate work, poor salary, no uniform system of on-callpayment.

Personal/Career – e.g. feeling undervalued, no appropriatemeasure of performance, multiple responsibility and lack ofclarity, lower professional standing, no careerprogression/structure, on-call burden and high responsibilitylevel especially in remote areas and community, overworked.

Organisation/Management Structure – e.g. lack of clarityover role/management structure, lack of flexibility, difficulty inrecruitment especially remote areas, variation of clinicalstandards, poor management, poor housekeeping, policydecisions impact on clinical freedom.

Patient Services – e.g. no long-term gain for patient, waitinglists problematic, less links to specialists, difficult toaccommodate people due to work pressures.

OPPORTUNITIES

Financial – e.g. move to single salaried dental service, linkpayments to patients seen, golden ‘hello’s’, funding for on-call,question free dentistry, delegated financial responsibility.

Personal/Career – e.g. better career progression, teamapproach encompassing CDS and salaried GDS, developmentof performance indicators, ability to treat without regulations,provide incentives to recruit more staff (flexible workingpatterns) staff appraisal, managers visit salaried GDP in placeof work, supported career development, incentive to return withnew skills, create a network for salaried GDS, representation onADC, integrate CDS and salaried GDS.

Organisation/Management Structure – e.g. develop clinicalinterests, develop oral health strategy for practice, take us outof NHS, more use of PCDs, streamline administration, promoteservice to undergraduates, integrated and improved IT, formaltraining for dental managers, better communication with publichealth and independent contractors, universal on-call system.

Patient Services – e.g. target areas of greatest need, look atservice from patients perspective, emphasise prevention andpatient responsibility, respond to patient demand for solution toimmediate problems (access), meeting needs of olderpeople/housebound, target specific unregistered groups,making better use of existing clinics.

THREATS

Financial – e.g. Fee scale/grossing not a good measure, moveto a ‘cash limited budget’, people moving to earn more money(loss of personnel), resources allocated to dentistry.

Personal/Career – e.g. perception of independent GDPs(unfair competition), PCDs taking dentist jobs (future), lack ofperformance indicators, more practitioners going private(increased work pressure), stress due to workload, frustrationwill drive people to leave, core service may not be attractiveservice to practitioners, more on-call service requirement,perceived value of salaried dentistry by GDP and public.

Organisation/Management Structure – e.g. low level ofavailable workforce, lack of commitment by government toprovide comprehensive dental service, inappropriatecomparisons made with other areas/services, imposition of coreservice, demise of ordinary GDS, lack of appropriate use ofPCDs, recruitment and retention difficulties, service vulnerable topolitical policy, unattractive to new graduates and negativeinfluence on undergraduates, status quo ‘not an option’.

Patient Services – e.g. knock-on effect to time availability forspecial needs patients, continued poor diet/habits from generalpublic.

APPENDIX 9.2

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Special Care Dentistry

Special care Dentistry is concerned with providingand enabling the delivery of oral care for peoplewith an impairment or disability, where thisterminology is defined in the broadest of terms.Thus Special Care Dentistry is concerned with theimprovement of oral health of individuals andgroups in society who have a physical, sensory,intellectual, mental, medical, emotional or socialimpairment or disability or, more often acombination of a number of these factors. Itrequires an holistic approach.

From the joint Advisory Committee for Special CareDentistry documents “training in Special CareDentistry” (2003) and “A Case of Need for SpecialCare Dentistry” (2003).

APPENDIX 9.3

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Dentists with special interestsRemote and Rural

Qualification,e.g. Sc/MFGDP

Membership

Associate Specialist Special Care,Lead Clinician

VT/GPT/SHO

Career GradePractitioner

TrainingProgrammes

MFDS

SpRTraining CCST

SpecialistPractitioner FTTA

Consultant

ManagementQualification

Clinical Director

= Training elements

APPENDIX 9.4

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9.4.1 CHILDREN - GDS REGISTRATIONS; BY AGE GROUP

Source: ISD Scotland Website

While all age groups may access dental care from the GDSs (GDS). NHS dental registration has been shownto decline progressively with increasing age. In addition, access to dental services is known to be problematicin certain parts of Scotland, notably in rural and remote areas.

Registrations at 31 March 2000 2001 2002 2003 2004

Children: number registered 754,545 743,469 733,743 725,494 716,070

0-2 61,003 59,751 56,986 55,262 54,879

3-5 125,788 122,660 120,653 117,498 113,089

6-9 200,196 195,013 189,076 185,397 182,167

10-14 240,277 239,549 240,614 239,688 238,524

15-17 127,281 126,496 126,414 127,649 127,411

Children: % registered 66% 65% 65% 66% 66%

0-2 34% 34% 34% 34% 35%

3-5 67% 67% 67% 68% 66%

6-9 77% 75% 72% 75% 76%

10-14 74% 73% 74% 74% 74%

15-17 66% 67% 67% 66% 65%

9.4.2 ADULTS – GDS REGISTRATIONS; BY AGE GROUP


Registrations at 31 March 2000 2001 2002 2003 2004

Adults: number registered 1,972,310 1,969,008 1,960,605 1,959,293 1,935,634

18-24 238,545 235,130 230,455 228,271 222,325

25-34 426,800 406,644 385,933 368,146 346,805

35-44 459,284 461,512 461,971 461,636 454,726

45-54 352,630 359,879 358,401 358,714 358,377

55-64 242,149 246,387 257,660 268,918 274,343

65-74 162,324 165,968 169,700 174,686 177,667

75 and over 90,578 93,488 96,485 98,922 101,391

Adults: % registered 50% 49% 49% 49% 49%

18-24 53% 52% 51% 52% 50%

25-34 54% 53% 52% 53% 52%

35-44 60% 59% 58% 59% 58%

45-54 53% 54% 53% 52% 53%

55-64 46% 46% 48% 49% 48%

65-74 37% 38% 39% 39% 40%

75 and over 26% 27% 28% 27% 28%


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9.4.3 ADULTS REGISTERED BY AGE GROUP; BY HEALTH BOARD AREA


%registered

Totaladults

18-24 25-34 35-44 45-54 55-64 65-74 75 +

Adult registrations at 31 March 2004

Scotland 49% 1,935,634 222,325 346,805 454,726 358,377 274,343 177,667 101,391

Argyll & Clyde 50% 163,341 18,881 27,681 38,103 30,376 23,858 15,653 8,789

Ayrshire & Arran 52% 150,707 16,946 24,376 32,724 28,215 23,496 15,686 9,264

Borders 46% 38,571 3,562 5,399 8,224 7,110 6,416 4,795 3,065

Dumfries & Galloway 40% 46,858 5,014 6,795 10,057 8,411 7,866 5,386 3,329

Fife 51% 139,338 15,211 23,147 32,390 26,693 21,340 12,909 7,648

Forth Valley 50% 107,855 12,623 19,152 26,112 20,230 15,412 9,445 4,881

Grampian 40% 163,700 20,617 29,226 38,811 32,556 23,236 12,968 6,286

Greater Glasgow 53% 361,949 43,574 71,466 87,764 64,479 44,617 30,846 19,203

Highland 30% 49,427 6,224 7,208 11,093 9,410 7,706 5,043 2,743

Lanarkshire 48% 206,386 25,110 39,523 50,520 37,740 27,536 17,274 8,683

Lothian 51% 314,549 34,722 62,070 75,746 56,309 42,408 27,497 15,797

Orkney 19% 2,809 242 429 720 575 448 268 127

Shetland 45% 7,532 619 1,354 1,851 1,688 1,218 537 265

Tayside 57% 173,440 18,227 27,528 38,566 32,773 27,237 18,353 10,756

Western Isles 44% 9,172 753 1,451 2,045 1,812 1,549 1,007 555

9.4.4 CHILDREN REGISTERED BY AGE GROUP; BY HEALTH BOARD AREA


% registered Total children 0-2 3-5 6-9 10-14 15-17

Child registrations at 31 March 2004

Scotland 66% 716,070 54,879 113,089 182,167 238,524 127,411

Argyll & Clyde 64% 58,507 4,353 8,908 14,949 19,539 10,758

Ayrshire & Arran 69% 54,864 4,649 8,155 13,233 18,497 10,330

Borders 61% 13,849 1,022 2,094 3,340 4,776 2,617

Dumfries & Galloway 63% 19,638 1,193 2,906 5,069 6,704 3,766

Fife 62% 47,758 3,822 7,573 11,993 15,584 8,786

Forth Valley 68% 42,027 3,175 6,772 10,872 14,192 7,016

Grampian 60% 66,745 4,293 10,603 16,804 22,652 12,393

Greater Glasgow 71% 129,787 10,895 20,505 33,196 42,585 22,606

Highland 62% 28,058 1,825 4,318 7,227 9,514 5,174

Lanarkshire 61% 76,125 5,176 12,425 19,582 25,623 13,319

Lothian 71% 113,157 9,868 18,628 28,862 36,830 18,969

Orkney 27% 1,161 24 159 410 416 152

Shetland 59% 3,153 313 550 818 1,021 451

Tayside 74% 59,595 4,156 9,215 15,388 20,095 10,741

Western Isles 30% 1,646 115 278 424 496 333


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REFERENCES

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Review Of Primary Care Salaried Dental Services In Scotland

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