Answer the question

02 July, 2010 / business

Q. Huge sums have been spent on capital investment in practices to meet decontamination requirements.

Can this be sustained in light of the country’s current financial situation?

The decontamination issue is enormous and when I meet practitioners, that’s what they bring up. Over the last few years we have been giving out capital money to help practitioners. It was over £80 million given to the boards and £58m has been allocated to provision of dental services and training – decontamination makes up part of this.

With regards to the costs, we are still working on quantifying what these need to be. We know that once you have bought the equipment, you have to maintain it and this can be quite a high cost.

We are now looking at how often the equipment has to be maintained, because if the equipment and the sophistication of the equipment is developed over time, then the question has to be asked: do we have to test it as often as we previously thought? Until we have bottomed that out we can’t estimate how much the revenue costs are going to be for the practices.

We are in the middle of doing that at the moment.

Q. What are the main decontamination issues that dentists are raising with you and how are you responding to them?

I’m pretty impressed that so many dentists have just got on with it and put local decontamination units (LDUs) in their practices. It has taken a considerable effort for hundreds of practices and they’ve done it. It’s an enormous inconvenience to a lot of practitioners but dentists are practical individuals and if you tell them what is required they simply go off and do it. I think Scottish dentists can be very proud of what they have achieved.

There are some dentists who are having more difficulties than others, some are going to have to move premises for example, but we have given them an extension of the timescale to help them do that and we have asked the boards to liaise with them.

For instance, if the board is building a new health centre then they can offer a local practice a place so that they can move their practice in there. In years gone by, that really didn’t happen very much. But there are one or two locations where practitioners have been invited into the health centres.

There are also dental access initiatives available for people wanting to move and it would be nice to think that decontamination has helped a few practices and given them the opportunity to move into better accommodation as well as giving them a bit of a challenge and trying to move with all the new guidelines.

Q. There has been some criticism recently of the advice on cross-contamination given in the document HTM 01-05.  What’s your position on this?

HTM 01-05 is the English document. In Scotland, we are doing it slightly differently so I don’t know if the accusations would still be the same. However, this is a difficult issue because it is the precautionary principle that we are going by. We are taking this precaution in case there is a time bomb waiting and it is very difficult to prove there is a time bomb waiting.  However, we don’t want, in a couple of decades, to look back and wish we had done something differently.

If this had been an easy problem to solve, somebody would have solved it by now and there wouldn’t be this controversy.

We have got specialists advising us and you have to recognise that there are a lot of experts in the field and we can’t just ignore those experts. What we have to do is try and apply that in as practical and realistic a way as we possibly can.

I think the discussion has got bogged down with vCJD, but there are bugs like hepatitis B and C that we really need to clean off the instruments as well. So most patients would expect the instruments in their mouths to be as clean as possible and that’s really what we are trying to achieve.

Q. Dentists are being told that it is a GDC requirement for instruments to be sterilised but they don’t need to be sterile for use in the mouth?

That’s another issue because the mouth is not a sterile place. One of the discussions we have is around when the instruments are taken out of the autoclave, do you need to wrap them, even supposing you are taking them across the corridor into another room, do you need to wrap them before you put them in a cupboard and leave them there for a while? It doesn’t sound as if it would cost very much but in actual fact it would cost an enormous amount of money if you were wrapping every single instrument between patients. We have asked the Health Technology Assessment Board here to tell us what they think the risk is with that so that we can go back to the practitioners and either say you don’t have to wrap them or it would be best to. But I think it would be worth us taking our time and just seeing what the risk is or not.

Q. Are there any plans to change the Scottish NHS remuneration system to reflect systems in England and Wales?

The straight answer is no. We don’t have any plans to impose the English system on the practitioners in Scotland. We are always looking at any system in other countries that might be worth considering. But we haven’t looked at England and thought, that’s better than what we’ve got.

There is always going to be room for improvement and, at the moment, we are considering how we should deal with the Statement of Dental Remuneration because the dentists have about 450 different treatments they can carry out on a patient. That’s a lot to manage when you are administrating a practice.

So what we would like to do is simplify it for the patients. But we know that if we change the system completely, it could cause confusion out there. What we are trying to do is work with the profession on this.

Q. The difference in pay of the salaried service dentists in Scotland and the rest of the UK is widening. How do you think this will affect recruitment and retention?

I don’t know whether the gap is widening. I think there is a gap at the moment between one and the other. This is a bit of a difficult question for me to answer just now because we are in the middle of negotiations with the salaried service and if I started discussing it then it would compromise those discussions.

What I can say is that the proposal to bring the community dental service and the salaried general dental services together is under discussion with the profession at the moment.

Q. Can you see where the BDA and many of the critics of continuous registration are coming from?

I think it was quite well summed up in your magazine when there was a variety of opinion. One practitioner said that for the dentist who wants to reduce their NHS commitment then this wouldn’t work for them. But for the dentist who wants to hold on to his NHS patients then it will.

So I’m getting feedback from both sides of the story. Once it’s been in for a while we can establish what the real impact has been. The GDPs are still able, if they want, to deregister these patients. So they don’t have to keep them on their books. But if they do choose to keep them on their books then they will get a list before the payment is reduced to 20 per cent (after three years). They will get a list from practitioners services saying these patients will come off your list. They can opt at that stage to ignore it, to remind the patients that they need to come back or to deregister them.

So I think what we have to do is just monitor this and see how it progresses.

Q. Do you think that initiatives like Childsmile will make a difference to improving Scotland’s poor oral health record?

There are various aspects to Childsmile. Childsmile Core, which has been nursery tooth brushing, has already been around for a while and we are seeing the oral heal
th improve. Childsmile Nursery and Childsmile Schools and the application of fluoride varnish is being rolled out but isn’t everywhere yet. And the Childsmile Practice, crucially, involves the GDPs.

It is probably the biggest programme like this anywhere and the practitioners realise that it is quite new and there are development issues that we are dealing with as we go.

The emphasis is on helping the people who need the help most, which are the people in the most deprived areas.

The ongoing challenge is going to be to continue to improve oral health but we also have the issue of the increase in the number of elderly people. As people get more frail then their manual dexterity can be compromised and they have more difficulty maintaining oral hygiene. So, there is an issue out there for the future as people get older and maybe the condition of their mouth deteriorates. Because in the past many old people had no teeth at all, but now they are maintaining their teeth, which, of course makes people look younger for longer, but it means that the dental care they need is a bit more involved.

So I think that’s going to be a big challenge for the future as well.

Q. Should patients have direct access to hygienists and other DCPs without referral from a dentist?

It is helpful to have one person directing patients towards the hygienist or the therapist. If you had people self-directing directly to hygienists and therapists it would mean that the treatment would be ‘bitty’. The dentist wouldn’t be getting the opportunity to see the overall picture.

There are things that hygienists can do, things that a therapist can do but it is the dentist who can do the lot. Now, they may choose, quite rightly, to refer to hygienists because they are doing it all the time. But I think there is a real benefit in someone taking an overview of treatment so the patient is referred to the right people at the right time.

Q. Could hygienists, therapists or nurses see patients for regular check-ups and if any work or further opinion is needed then refer up to the dentist?

The difficulty is that the practice of dentistry is ingrained within a legal framework. If you are expecting a hygienist to be a diagnostician, that puts them in a very difficult position. They could look at a soft tissue lesion and think that looks like oral cancer. But they are not qualified to actually diagnose that it is, in fact, oral cancer. So, if you set the hygienist up in that gatekeeper role then I think you might be putting your patients at risk.

Q. Should everybody that treats patients have a list number?

Well, I am discussing at the moment with the Practitioners Services Division (PSD) whether everybody needs a list number or not. My understanding is that the list number is really an administrative tool and whether giving everybody a list number is the best way to use it as an administrative tool or not I don’t know. So we are in the middle of talking to PSD about that.

Q. Will CDTs be able to apply for NHS list numbers?

We would welcome clinical dental technicians working for the NHS. There are two options at the moment, either they work in general dental practice with a dentist or they work for the salaried service. But they don’t want to do that. They would rather have their own arrangement and in order to get that other arrangement, my understanding is that it would need primary legislation.

Obviously what we want to do is develop the CDTs and make best use of their skills. One of the places that would be very useful to have them is in the salaried service where they have got responsibility for care homes with lots of elderly people who have no teeth of their own. I can see them making a major contribution there.

And certainly locally, in NHS Lothian for instance, the person that runs the service there would be delighted to employ them in that way.

Q. Funding for Dental Care Professionals (DCP) CPD – how will you envisage this could happen (in terms of releasing a nurse from practice to attend and the subsequent loss of income related to bringing in an agency nurse)?

I was in the company of several dentists at an event recently and I asked them about the issues relating to CPD for DCPs. They said that there are not that many big issues. They said that there is a choice of things that you can do, you can have in-practice CPD that everybody is involved with, such as resuscitation. Somebody also said that they organise events for the practice so that everybody is doing that at the one time, they take a day out and do that. Another dentist said that they were doing online CPD for their DCPs.

So it’s not been around for very long and we may hear from practitioners that they have other views but at the moment I’m not getting a whole lot of feedback that there is a major issue with that.

Q. What would you say your biggest challenges have been in your time as CDO?

Probably decontamination, I think the minute I came into this office decontamination emails flooded in and letters flooded the desk. So that, without doubt, has been the biggest challenge as far as taking up time is concerned. The ongoing challenge of course is the fact that we need to try and improve oral health and that’s beginning to happen and it is very nice to see that it’s happening amongst the most deprived groups.

There aren’t many health interventions that you can see the progress as quickly as you can see in relation to improving dental health. And there aren’t that many interventions that you can see the progress amongst the most deprived groups. But, we are beginning to see that.

Q. What would you say you have achieved in your time as CDO?

The CDO relies on so many other people to achieve anything so for the CDO just to take something and say that’s my achievement, I think that would be inappropriate. So anything that we do achieve, we achieve with the help of a whole lot of other people ranging from GDPs, the salaried service, hospital consultants, the academics etc.

For instance, the Aberdeen Dental School was built very quickly and the students were in just over a year after the announcement was made. And that was an enormous achievement by Dundee and Aberdeen Universities, NHS Education for Scotland, the Scottish Funding Council and NHS Grampian.

They all worked really well together in a way that I thought was a very impressive achievement but it wasn’t my achievement, it was a joint effort by a whole team of people.

One of the things that I have found very helpful is meeting the GDPs. On a regular basis I go out a see a group of maybe eight or 10 different GDPs and we meet up for a chat. That has been very helpful in me being able to understand what the hardworking, committed practitioner out there is thinking and feeling.

You can imagine that in this job you meet the people that are running the GDC or the BDA and all these bodies. But you don’t always interact with the practitioner who is just getting on with his day-to-day work. That has been, I think quite valuable and I hope that they feel the same.

Hector Brodie, GDP, Tillicoultry

On decontamination: I was pleased to see the CDO praising the profession for the resourcefulness shown in adapting practices for LDUs. How reassuring that was. But to try to gain the higher ground by stating that it resulted from government initiatives is clearly wrong. It is because practitioners are caring people who have a vested interest in their patients and their practices.

When the state offers to buy our practices and employ us as clinical and administrative directors, then and only then, can it claim the higher ground. Until then the state will remain a servant to the community, which is why we pay our taxes.

On remuneration: It looks to me as if a change is on the way. Having been in practice for nearly 40 years, never has the
administration of a large treatment bank been easier, as it is all on the computer. To me this is a red herring. It is not the number of treatments, it is the type.

A review of the NHS fee structure should start with a review of treatment needs and patient expectations. The mind set has changed not a bit since 1948, even the narrative style is the same.

Perhaps a core service for all is the way forward, with the funding for more complex work targeting those who can least afford to pay.

A Consultant in general dental health

On cross-contamination: The Scottish system is not markedly different. The basic principles are very similar.

The main problem they are talking about is vCJD and the risk of that is so remote, I think it is something like one in five million. It is a very, very small risk.

Even the specialists can’t agree and different microbiologists can’t agree. I know one professor who says that instruments need to be sterile but not sterile at the point of use, whereas another says that they need to be sterile and sterile at the point of use. So we have two experts who can’t agree.

My main concern is that a lot of these recommendations and guidance documents have been issued with very little evidence behind the thinking.

Claire Walsh, GDP, Glasgow

On CDTs: This is a’ watch and wait’ area; the numbers of registered CDTs are small in Scotland, and the profession as a whole is still evolving in the UK. For the GDP with a difficult case, or if the dentist prefers not to provide dentures, referral to a CDT with an NHS list number (or equivalent) would ensure the patient could have treatment provided under NHS arrangements, if this was desired/required.

This in turn might reduce the number of patients who seek treatment from so-called denturists, who are carrying on the business of dentistry illegally. Watch this space…

On CPD: Many practices provide core CPD training in-house., This is entirely appropriate. However, there are many courses available through NHS Education Scotland (NES) in other areas of interest; these courses can be difficult for DCPs to access if cover is not available within the practice, as the dentist would need to take time off, or hire an agency nurse.

Anecdotally, nurses working in general practice have had problems attending these courses in the past. Now that CPD is compulsory for nurses, this is a potential area of difficulty, particularly in smaller practices with fewer staff.

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