For Generation Childsmile

… the design of a new system of preventative care for adult NHS patients is under way

01 April, 2020 / indepth
Will Peakin

Dental tools surrounding a model of a tooth

The design of a new model of oral health care in Scotland, which would transform the treatment of adult NHS patients and herald a fundamental change in the way that dentists are remunerated, has begun.

It would see the introduction of a preventative system of care, replacing the ‘drill and fill’ approach that has dominated primary dental care for more than 60 years, and the phasing in of an oral health assessment (OHA) for adults receiving NHS treatment.

The assessment would include a full clinical examination – complemented by a discussion with the patient about their general health and lifestyle choices, including alcohol, smoking and diet, and how these factors impact their oral health.

I am often told that the current system is outdated, not fit-for-purpose, and unpopular with both the profession and the public”

Tom Ferris, CDO

The patient would subsequently receive a personalised care plan in relation to gum disease and tooth decay, and oral cancer, according to the degree of risk they presented. The assessment would be repeated after a set period of time, depending on what was appropriate for the patient, but would be reviewed between assessments.

Two ‘design groups’ have been established: the first to develop the OHA, as well as the prevention and periodontal care pathway; and the second to determine the ‘NHS dental treatment offer’ that dentists would select from. Meanwhile, some initial work has started within the Scottish Government to explore financial models.

“I am often told that the current system is outdated, not fit-for-purpose, and unpopular with both the profession and the public,” said Tom Ferris, Scotland’s Chief Dental Officer. “It is a system based in the foundation of the
NHS in 1948 and which has evolved over time, with bits added on.

“The huge post-war rise in sugar consumption, and the advent of high-speed air-powered drills in the late 1950s, meant that treatment has essentially been founded on a ‘drill and fill’ approach. But, in the past decade, the science and modes of treatment have advanced significantly.

“Although there are still challenges to be met in some segments of the population, there is a generation of young people approaching adulthood – so-called Generation Childsmile – whose oral health is much improved compared with their predecessors. They do not need the same volume of restorative interventions, they need a preventative approach, and a system needs to be put in place that meets those patients’ needs.”

Membership of the OHA design group includes Professor Jan Clarkson, Co-Director of the Dental Health Services Research Unit at Dundee University, David Conway, Professor of Dental Public Health at Glasgow University, and David McColl, Chair of the British Dental Association’s Scottish Dental Practice Committee.

The second design group, which is looking at the ‘NHS treatment offer’, includes practitioners with a wide-ranging knowledge of the current Statement of Dental Remuneration, in order to inform its redesign. Work on the new financial model is being carried out by a group in the Dentistry Division of the Scottish Government’s Population Health Directorate.

The outcome of the design groups’ work will have a fundamental impact on the future of dentistry, with a reformed primary care sector also likely to have an impact on secondary care and the Public Dental Service. “We are taking our time to ensure that this is designed properly, in collaboration with the profession,” said Ferris. “It has a preventative focus and will be patient-centered.

“We’re in the design phase now. Group one has done some good work on the oral health assessment and the care pathways. Group two has begun looking at what could be the menu of treatment options available on the NHS – and we are encouraging them to be bold in their thinking.

“We’ll then bring the groups together to create a model that we can then take to the wider profession for consultation and also begin a consultation with the public. In terms of financing this new model of care, there is some internal work going on and we will aim to make sure it is easily understood and administered.”

“But,” Ferris added, “we don’t want to muddy the waters at the moment with the issue of funding; we want to get the model right first – for the patient and the profession.”

The proposal, contained in the Scottish Government’s Oral Health Improvement Plan (OHIP), has caused concerns within the profession, however. “The focus of the OHIP is a shift towards disease prevention. This is to be underpinned by a patient-centred assessment, based on most current guidance. At this stage, we have no clear understanding of the administrative burden this may pose, and the time split between clinical care and IT,” said a spokesperson for the Greater Glasgow and Clyde Local Dental Committee.

“The OHIP sets out many ambitious changes to Scottish dentistry with no mention of how these are to be funded and resourced. With increasing pressures on dentists and a decreasing dental budget, there are concerns amongst GDPs about the implications this will have on the viability of NHS dentistry in the long run. At the moment a lot of NHS practices survive by offering supplementary private treatments and there are worries that an unfair OHIP may hinder practitioners offering such treatment. The proposals to carry out general patient health checks in a dental setting have been met with apprehension as most feel this is beyond the remit of a GDP. Again, additional funding and training would be necessary for this to be implemented successfully.

“There is also concern that not enough GDPs are involved in the working groups and this is essential when the Government is designing a new oral health risk assessment and treatment pathways. There should be a wider representation of clinical staff, including associates and young dentists, so that the design and implementation is reflective of the changing profession. It is imperative that dentists must be involved in discussions on this proposal to ensure that the sustainability of NHS dentistry is taken into account.

“There is some recognition of the benefits of an oral health assessment, but major concerns about whether sufficient additional funding would be available to reflect the time taken to carry out an assessment. As well as being consulted on the key components of what will make up the assessment, it should be subject to a meaningful pilot and evaluation of patient outcome before full implementation. An oral health assessment needs to be bureaucratically light, fully integrated with our IT, remunerated appropriately and centred on both the patient and the whole dental team. Unfortunately, this is currently not evident in the vague propositions outlined in the OHIP.

“The profession is welcoming to simplifying the Statement of Dental Renumeration; a radical overhaul of the complex narrative is long overdue. However, the streamlining of item of services and moving to a more Units of Dental Activity (UDA)-based system is generally frowned upon. Reducing the frequency of dental examinations for low risk groups to 24-month recalls has raised concerns amongst GDPs as oral health can change very rapidly. Oral cancer screening is also a vital aspect of routine examinations and therefore shorter recall intervals would be preferred. Most dentists are also in favour of providing regular scale and polishes as it helps maintain favourable oral hygiene. A decrease in this provision could lead to an acceptance of a poorer standard of care by patients.

“At a time when practice overheads are constantly rising and the general morale is low, restructuring practice payments and allowances is worrying. The OHIP sets out many aspirational action points but is lacking the essential details required to alleviate the many concerns of the profession. The objectives of this plan may be positive, but without extra funding it is unlikely to come to fruition.”

A new model of NHS adult oral health care

1.The Oral Health Assessment

Based on an oral health assessment and periodontal evaluation by the dentist and information provided by the patient on their health, including lifestyle factors, such as diet and consumption of alcohol and tobacco.

2. The Care Pathway

From a discussion between the dentist and the patient, a care plan would be agreed that would include a prevention and periodontal pathway, agreement on appointment frequency, self-care steps to be taken by the patient, and options for the dentist to invoke based on an agreed ‘NHS treatment offer’.

Phase 1

1. Establishment and meetings of design groups: to develop the Oral Health Assessment (OHA) and care pathway; and an ‘NHS treatment offer’ that dentists would select from.

Initial work has also begun within the Scottish Government looking at financial models.

2. Wider engagement with the profession