Scotland’s chief Dental officer discusses the ambitious plan for the future of the country’s oral health and the challenges of meeting the needs of an ageing population
Following the publication of the new Oral Health Improvement Plan (OHIP) in January, the press headlines have highlighted some of the more ambitious aims of the new policy, such as dentists going out into the community to offer services, the reduction in regular check-ups and the end of scale and polish.
This has raised some alarm in the dental community but Margie Taylor, Scotland’s Chief Dental Officer, says this is just scaremongering. Scottish Dental magazine spoke to Margie who boldly stated the new plan is going to “change dentistry for the next generation” but she wants to make it clear the new plan is based on “evolution and not revolution” She insists the OHIP is a starting point for conversations with the profession who will have a say on how it develops.
Margie explained: “We want to do this properly and we want to do it by taking full cognisance of the views of the profession – so we are all ears.”
Dentists are very good about thinking in detail - and we want to hear what they are concerned about as we are setting up working groups to address the actions in the plan. This is how we are going to change dentistry for the next generation.
So what does OHIP mean for the future of Scottish dentistry? Margie believes that it means a great deal for the future of people’s oral health in Scotland, as well as the future of dentistry. She explained: “We are very fortunate in knowing what causes disease and also knowing what prevents it, so it seems rational and realistic to implement what we know works – and this plan helps to do exactly that.
“Dental practitioners have been working very hard over the years to improve oral health, but what we need to do is to make sure the system allows them to work on that further.
“We also have to tackle the problem of our ageing population. We have never had so many older people who are frail but have their own teeth. It’s uncharted territory but we need to have the capacity to provide dentists to go into people’s homes or care homes and be experienced enough to deal with somebody who is suffering from dementia, who may be suffering from toothache but unable to describe it.
“It’s a completely different challenge when you are trying to do that type of treatment without the usual equipment in your surgery and in different surroundings.
“But we have to be realistic about our expectations. One of the things in this plan is to accept and recognise that people who have not done domiciliary care for a long time may not feel comfortable about doing it now. The Public Dental Service (PDS) are clearly the ones who have got the most expertise but with the increase in the ageing population they are not going to be able to treat everyone – and there is no reason why they should really, as GDPs are experienced enough to contribute to that service.”
Under Part 4 of the plan – Meeting the needs of an Ageing Population –
Action 11 calls for the Scottish Government to introduce arrangements to enable “accredited” GDPs to provide care in care homes. There is great interest
in how this accreditation scheme will be set up, but Margie said it is still early days and the establishment of the scheme will require further consultation with dentists.
She said: “Our intention is to discuss the accreditation details with the profession. The people that have got the expertise at the moment are the PDS and it could well be that they would be in a position to help train GDPs, but we are still to discuss that with both those groups.
“As I’ve said, we are going for evolution and not revolution, because one of the very important issues that we have to recognise is the financial sustainability of general dental practices. Shona Robison, the Cabinet Secretary for Health and Sport, has reinforced that message and she also wants to make sure that practitioners have the confidence that
we recognise their financial sustainability is an important issue.”
As regards the numbers of GDPs that would be required to be “accredited” to serve people in care homes, this is still under discussion.
When asked about financial incentives to ‘persuade’ GDPs to provide domiciliary visits, Margie believes there is a genuine will to help but dentists may need support with the right equipment for home visits.
She said: “I don’t think I will convince every dentist to do home visits but we will be discussing with them what the incentives need to be – and one of the issues is having the right equipment to go into a home or care home.”
Financial sustainability is high
on a lot of dentists’ concerns when it comes to a wholesale change in the system of remuneration, such as the SDR and grants, and particularly, with “perceived” declining attendances, measures in the new plan to extend the period between check-ups to two years, and, potentially, drop scale and polish procedures.
While there has been concern about the declining numbers attending dentists, Margie argues that registration numbers are just as important as attendance rates, which are currently around 70 per cent of the population.
She said: “The vast majority of the dentists I know are in the business of dentistry to improve the oral health of their patients, so I’m sure they consider that as a priority. But, equally, they have to maintain the sustainability of the practice and we, of course, want them to do that as well.
“If you’ve got registration going up, and participation as defined as the people who have been to the practice in the last two years, the people who are newly registered will not have had a chance to be there in the last two years – so participation is always going to look like its coming down if the registration is going up at a particular rate.
“The important thing is that people are accessing the dentist when they want to and need to. In order to address that there needs to be plenty of dentists – and we have got that right now.
“Clearly, we want people to go back regularly to see their dentist but there is a limit to how much the government can encourage people to do that – to an extent we are relying on the practitioners to encourage their own patients back to the practice. And the figures show that the actual number attending is higher than it used to be.”
When it comes to the SDR and grants, Margie admits that the current system is too complicated and needs to be simplified, but wants to allay dentists’ fears if they think everything is going to change on 1 July.
“At the moment there are more than 400 things you can do to someone’s mouth! This is extraordinary and it seems a few too many to manage.
“There’s a lot of discussion to be had with the profession and one of the reasons we have not had wholesale change of the SDR is because of the impact it might have had on practices.
“We said in the consultation that grants are confusing but it’s not our intention to reduce the quantum. Our intention is to make it easier to apply for them and make it more straightforward – similarly with the SDR.
“We want to make changes at a pace that not only brings about a health improvement but also maintains the financial viability of the practices – this is at the forefront of our minds.”
Margie said that one of the common misconceptions about the SDR is that every single item is based on the cost of providing the procedure, plus a profit margin for the dentist. She explained: “The SDR is based on what the average practitioner covers during an average amount of treatment and to give them a reasonable living at the end of the day. There are some elements that do not cost anything to provide in terms of sundries, for instance oral health advice, but there are other things that are more expensive and the SDR is designed to balance these out.
“But if you go down the route of describing absolutely everything and what the profit is in relation to that item then you will get great disparities. What we aim to do is to give practitioners a reasonable living but it’s not based on absolute profit margins for every single item.”
While oral health advice does not consume sundries it does take up a valuable part of dentist’s or hygienist’s time and some practitioners have asked whether they will be recompensed for this as prevention is the main theme of the new plan.
Margie said: “If you are tackling periodontal disease you are expected to give the patient oral hygiene advice but if we are moving the whole system towards prevention – and we are saying that that is very important – what we need to do is work out with the profession how we achieve that.
“One of reasons why the allowances came in was to try to get the practitioners off the capitation treadmill – it’s a fine balance and we will be speaking to them about what that balance should be.”
In the section, ‘Focus on Prevention’, the document states that people with good oral hygiene could be left for up to two years between appointments – a cause of concern regarding the detection of oral cancers from some dentists.
Margie said: “I can understand that thought, and, although the guideline from NICE said up to two years, I think it’s a big leap to say to people who have been coming in every six months for the last decade to say to them that we want you to come every two years.
“But quite a lot of people go annually at the moment, so that should not be too
much of an issue, especially if they have a history of good oral hygiene and have not have had any problems. The high-risk ones, for instance older, smoking, drinking males, you would probably want to see them more regularly.”
One of the more controversial elements of the new plan is its downgrading of scale and polishing as an effective measure against the prevention of gum disease… and a valuable income stream for dentists.
She said: “I think there has been a bit of scaremongering going on about this because if you read the document it’s pretty conservative about scale and polish, but people have interpreted the evidence and have concluded that we are getting rid of them.
“What the evidence has shown for your patient who is a regular attender, and is looking after their mouth is that the simple scale and polish is not of any more benefit than actually giving oral hygiene advice. But, of course, there are a lot of people that can’t or won’t look after their mouths or have not attended the dentist for a long time – so it is too big a leap to say we don’t need scale and polish any more.”
During the discussion, Margie reiterates her “evolution not revolution” mantra and the need for further consultation with the profession. She said: “We consulted widely before the plan was developed, both with the practitioners and the public, and as I’ve discussed here there is more consultation to do with GDPs.
“Dentists are very good about thinking in detail – and we want to hear what they are concerned about as we are setting up the working groups to address the 41 different actions identified in the plan.
“This is how we are going to change dentistry for the next generation in order to improve oral health and reduce inequalities.”
Margie Taylor – recollections over 10 years
Margie Taylor took up post as Chief Dental Officer (CDO) for Scotland in May 2007 and looking back over 10 years at the helm of the profession she regards her tenure as an “enormous privilege”.
She explained: “My role is to improve the health of the population so to have that as one of my main aims is just perfect as far as I’m concerned.”
She said that the biggest change over her tenure has been the improvement in oral health: “When I started nearly 40 years ago, I spent a lot of time taking teeth out of children and I realised that there must be a better way of dealing with this. Prevention seemed to me to be the obvious way forward so when I hear from practitioners and others that dental health is improving – and we see this in the statistics – that’s the biggest change for me.
“I’m not saying that because I want to take credit for it because the CDO does not achieve anything unless there are a whole lot of other people contributing to the cause.”
She’s also impressed with the commitment and resilience of the dental community to meet challenges, such as the introduction of decontamination facilities.
She said: “I’m enormously proud of the profession and how they reacted to this under extremely difficult circumstances. This was an enormous change for them but the profession responded incredibly well.”
While access to dentists has improved over the past decade, Margie is concerned about the affect Brexit will have on dental provision, particularly in more rural and isolated areas.
She said: “When I came into post there was an access problem – we did not really have enough dentists at the time, so we’ve taken the steps to fix that. But now I think Brexit will cause issues as nearly half the dentists in some of the rural areas of Scotland are from the EU. So, with Scotland not becoming as attractive to dentists compared to their home EU countries, this is going to mean our workforce planning is not going to be as straightforward.
“But while being Chief Dental Officer is not always plain sailing, even on a bad day you just remember it is just a privilege to be in the job.”