A spirit of quiet effectiveness
The payment regulator’s focus is on partnership and working with dentists to improve the system
The payment regulator’s focus is on partnership and working with dentists to improve the system
For those of us who are sports fans, the notion of the best referees being those you notice least is a familiar one. Whether you follow football or rugby, cricket or tennis, the officials who do their job competently and with the minimum of fuss are generally considered the best in the game.
That same spirit of quiet effectiveness and a desire to remain far from the spotlight runs deep within the Practitioner Services Division of NHS National Services Scotland.
Yet this is an organisation with deep responsibility for, and influence within, the dental profession in Scotland.
In purely practical terms, that involves ensuring prompt payments totalling more than £300m each year for services provided by more than 3,000 dentists across the country.
But those bare figures tell only one small part of the story. PSD is also transforming the future of dental service delivery.
Its e-dental initiatives include electronic claims, payment schedule reports and most recently electronic prior approval with full support for digital photographs, radiographs and models.
These advances are ensuring that the profession, and the millions of patients it serves, benefit from the transformative power of technology. Its innovative approach seeks to reduce treatment plan times for patients and slash red tape for dental professionals.
But it is the role PSD plays as the regulator of payments, and as one of the guardians of professional standards in Scotland, that has seen it thrust unwittingly into the spotlight in recent months.
There is a growing realisation within the organisation that its work, particularly its focus on partnership and working with dentists to shape and improve the system, is little understood, far less appreciated.
Martin Morrison, Associate Director, Practitioner Services Division, said: “We are here to promote and ensure good clinical practice.
“Our systems, processes and staff are motivated to identify good and bad practice and to either take corrective action where required or to communicate this to others who have that responsibility.
“Patients are our priority and our objective is to support the provision of safe, effective and person-centred care.
“Our view has always been that getting on with the job we are tasked by the Scottish Government to do – and doing it well – is good enough
“But when our organisation, and the reputations of our colleagues, is unfairly damaged, then we are simply not going to accept that.”
A major frustration for Mr Morrison is the misunderstanding over the recovery of fees paid to dentists.
The misconception that he and his colleagues work to so-called ‘recovery targets’ is especially grating. Not least because, to continue the sporting analogy, the referee is only applying the rules that all teams have agreed to abide by.
What is more, every ‘team’ has played a major role in shaping those rules thanks to PSD’s partnership and engagement with dentists and their representative bodies, such as the British Dental Association.
“Claims of minimum overpayment recovery targets are a nonsense,” Mr Morrison added. “Everyone involved in the system, which dentists and their professional bodies have played a major part in creating, accepts that overpayments can occur.
“The figure for overpayments recovered represents less than 0.02% of payments made. The fact the figure is so low is actually testament to the success of the system.
“It reflects how well the overall system of financial controls is operated and understood by our staff and dentists.
“The Regulations approved by the Scottish Parliament and the Payment Verification Protocol published by the Scottish Government accept that overpayments can occur
“They also make it clear that when they do, they should be recovered to the public purse. Our job is to recover that money on behalf of the taxpayers of Scotland and our elected government.
“No one would be happier than us if the actual recovery figure was zero, since that would mean all claims complied with the rules.
“That is not achievable so some figure needs to be assessed so that we can report actual recoveries and if they fall within expected levels.”
If minimum recovery targets are a myth, then the importance placed upon sampling as a mean of investigation is accurate but misunderstood.
“The suggestion that sampling is an unfair or indeed unlawful way to identify and overpayment and then recover it to the public purse is wrong,” he added.
“Indeed, Lord Arthurson’s report in February 2018 says that much where he advises: ‘In my view a methodology of sampling could well be characterisable as rational and in accordance with a proper construction and application of regulation 25.’”
Similar misconceptions surround PSD’s ability to recover overpayments made more than five years ago and to deduct those payments from ongoing payments to the dentist.
As Mr Morrison explained: “We only ever act on legal advice and we have opinions from two senior QCs that the five-year limit does not apply to payments made under the GDS Regulations.”
Alan Whittet, PSD’s Senior Dental Adviser, and a registered dentist with extensive practice in the GDS and as NHS Board dental practice adviser, commented: “When it comes to prior approval, decisions are always made on clinical grounds alone.
“Since the prior approval service is led by our own dentists, they are bound to make decisions in accordance with the GDC standards.
“We never turn down prior approval requests on the basis of cost. Only a dental adviser can decide not approve treatment and case is reviewed by another dental adviser before a final decision is made.
“Each quarter representatives from SDPC and SOSG peer review 10 random anonymised requests from both general and orthodontic specialist practices.
Their decision is compared with ones made by dental advisers. In the last five years there has not been a single occasion in which this peer review has disagreed with the original decision we made.”
What is also clear is that, as with football referees who may choose to issue warnings or dish out yellow and red cards, PSD uses a range of options to safeguard the integrity of dentistry.
“Our approach is to show flexibility wherever appropriate,” continued Mr Morrison. Our first approach to recover overpayments is to seek agreement with the dentist.
“However, our legal advice also confirms that the Regulations give us the ability to deduct overpayments from ongoing monthly GDS payments.
“When we do that we always set the value at a level which will not cause the practice or dentist hardship, but that ensures the money is returned to the GDS budget within a reasonable timescale.”
In common with every other organisation within the wider public health landscape, PSD has activated its resilience plan and targeted its resources where they will be most needed to support Scotland’s dentists through the current COVID-19 crisis.
“It is particularly unfair,” continued Mr Morrison. “That my colleagues, who are working so hard to ensure services are protected in this difficult time, are those who have been most hurt by the recent, unjustified criticism.”
It is also clear that PSD considers its work critical in ensuring the system fairly protects and rewards the overwhelming majority of dentists who abide by the rules that they themselves have signed up to and helped create through their representative organisations.
Mr Morrison concluded: “The payments system operates on trust in an attempt to balance out the cost of administration and maximising the payments made to dentists.
“The vast majority of dentists comply with the rules and that is evidenced by the assurance that the PV programme gives – 99.98%.
“When that trust is broken by a minority, we need to take action else the system will become more bureaucratic for everyone.
“The cost of managing it will spiral. Funds will be diverted funds which would be best invested in front-line dental care away from the payments made to dentists. No one wants that to be the outcome from a small number of dentists not playing fairly.”
MYTH: PSD works to “targets”.
FACT: PSD never works to “targets” for recoveries.
MYTH: PSD get bonuses if they hit those “targets”.
FACT: Staff don’t get bonuses for hitting “targets” that don’t exist. Neither would they want or accept them. To do so would be highly unethical.
MYTH: PSD investigate dentists to catch them out.
FACT: PSD carries out the Payment Verification activities in line with nationally agreed protocols. It works in partnership with territorial NHS Boards to do so.
MYTH:PSD keeps the cash it recovers from overpayments.
FACT: Every penny that is recovered by PSD is returned to the public purse, to be available for the benefit of the people of Scotland.
MYTH: PSD recovers patient contributions for claims which are identified as overpayments.
FACT: Normally these are refunded to patients by the dental practitioner. PSD would only consider recovering these in order to subsequently refund the patient themselves.
MYTH: I will be referred to the GDC if I don’t agree to a recovery of an overpayment.
FACT: We would consider referring the dentist to the GDC if they did not recognise their error and remediate their clinical and claiming practice. GDC referrals are always done in conjunction with the relevant NHS Board.
MYTH: I’ll be sent to the GDC even if it was a honest mistake.
FACT: If the mistake solely related to incorrect claims and the payments were recovered, then that would be very unlikely. If patients were harmed, that would be a matter for the NHS Board to consider in the first instance and a GDC referral could result.
Practitioner Services Division – FAQs
What is PSD?
PSD is a division of NHS National Services Scotland, a NHS agency created by the 1978 NHS Scotland Act which created the infrastructure of the NHS as we know it today.
What does PSD do?
We provide a range of support and payment services to four primary care contractor groups: General Medical Practices, General Dental Practitioners, Community Pharmacies and Optometrists.
How many staff do you have?
We employ around 400 staff working from four locations across Scotland. We manage £2.4bn of Scottish taxpayers’ money, around 22 per cent of the NHS Scotland budget.
What do you do for dentists?
- In addition to our payment role, PSD:
- Authorises complex or expensive dental treatment in advance of treatment;
- Approves discretionary fees for treatment outwith the scope of the Statement of Dental Remuneration
- Manages the Scottish Dental Reference Service which provides a quality report on the treatment planned or provided by the patient’s dentist;
- Provides support and advice to dentists helping them deliver care whilst remaining compliant with the rules and regulations;
- Delivers training to dentists already operating within or just joining the GDS in Scotland.
What specific dental expertise is within PSD?
The dental team comprises of managers, administrative staff and registered dentists. We have 14 dental advisers/dental reference offices and around 30 other staff working in administration, prior approval, payment and payment verification, customer services and SDRS.
For more information visit the websites below: