NHS dentistry reform; the start of a journey

The first step towards a truly modern NHS dental service

08 December, 2023 / indepth
 Will Peakin  

A major reform of the system of payment for NHS dentistry in Scotland came into effect on
1 November. Among the changes are a significant reduction in the number of ‘items of service’ – treatments, procedures and undertakings – from more than 500 to 45.

The Scottish Government describes the new system as a ‘high-trust, low bureaucracy model’ which, it says, “will empower dentists to use their clinical discretion and knowledge of best practice in delivering care. The revised suite of items should be seen, therefore, as broad outcomes of care as opposed to more granular treatment items as under the previous SDR.”

In an accompanying memo it states: “It reflects the start of a journey where, in each step, we empower dentists in how they provide NHS dental care to patients. Payment reform is also the first step towards a truly modern NHS dental service which appropriately assesses, responds to and supports the oral health needs of every patient in Scotland.

The high-trust, low bureaucracy model will empower dentists to use their clinical discretion and knowledge of best practice in delivering care

“Through the fee structure, there will be increased incentives to ensure dentists focus on prevention as well as disease, reflecting modern dentistry. Patients will benefit from treatment items being brought in line with current best practice guidance, particularly around periodontal treatment, helping maintain and improve oral health.

“The reform also provides greater visibility of NHS care to patients through the reduced range of treatment items, meaning the new system will be much easier for patients to understand.”

Another major change has been made – in the regularity that NHS patients receive routine check-ups. For patients in good oral health, with low oral health risk factors, a recall of 12 months is “sufficient to determine any changes in lifestyle, risk factors and/or development of new dental disease. For patients assessed as having higher risk, shorter intervals may be determined as appropriate and may therefore continue to be consistent with the intervals as previously prescribed.”

At the same time the Scottish Government announced a six per cent increase in the fees paid for items of service, including orthodontic items, and capitation payments. The pay award has also been applied to the vocational trainee salary, backdated to 1 April.

Reform of the payment system for NHS dentistry was welcomed by the Royal College of Surgeons of Edinburgh’s Faculty of Dental Surgery. Professor Grant McIntyre, Dean of the Faculty, which represents dentists across the UK and internationally, said: “This is the first major reform for dentistry in Scotland in decades and it is welcomed.

“At present, a lot of patients presenting for dental appointments require repair work rather than prevention, which is not only costly for patients but also damaging to their oral and sometimes overall health.

“The historical item of service funding model for dentistry in Scotland placed inadequate value on disease prevention and focused almost exclusively on treatment. Now, rather than being paid solely for the treatment of dental diseases, GDPs will be renumerated for the prevention aspect, which will hugely benefit patients.

“Patient safety and health promotion is key to easing the huge pressure NHS dentistry is facing, and helping the patients who are suffering because of that. However, with only 50 per cent of the adult population regularly attending their general dental practitioner, the Faculty would encourage the Scottish Government to work with the profession to educate the public on the need for regular examinations of the oral cavity by a dentist in order to identify the early signs of cancer in and around the mouth in addition to the other diseases that affect the oral cavity.

“The Faculty will be launching a new suite of Dental Diploma Examinations in 2024 which will provide recognition of expertise in seven key specific areas of dentistry for general dental practitioners. We would hope with further revisions to Determination 1, that the Scottish Government will recognise such additional clinical skills through further financial enhancements.”

However, the Government was challenged by Scottish Liberal Democrat leader Alex Cole-Hamilton MSP over the increase in charges to patients.  An adult patient receiving a single surface filling will now pay £12.72, instead of the current £8.80. The cost to the patient of a single tooth extraction appointment will also increase from £14.76 to £28.84.  The cost of a basic acrylic denture will increase from £70 to £117.

Mr Cole-Hamilton also revealed that more than 136,000 calls have been made to emergency dental care lines by those unable to register with an NHS dentist. Speaking during First Minister’s Questions, Mr Cole-Hamilton said: “Vast numbers of people are being forced to call emergency dental helplines because they can’t find an NHS dentist.

“An investigation I’m publishing today shows that happened almost 16,000 times last year in Fife alone. That’s hardly surprising given that there is just one Fife practice accepting new NHS patients. Across Scotland, people are desperate, some even resorting to DIY dentistry. The First Minister’s Recovery Plan promised to abolish NHS dentistry charges altogether.

“They’re not going away; next week they’re going up. Some will double. And what the Government didn’t tell you is that there are new charges for those emergency appointments and things like denture repairs. So, can I ask the First Minister, why are people paying more for less under the SNP?”

In response, Humza Yousaf said the pandemic had a “significant impact” on dentistry in Scotland. The First Minister said the Government had removed dental charges for those aged under 26. He added: “In terms of growing the NHS dental workforce in Scotland, we have 55 dentists per 100,000 of the population. That’s compared to 43 per 100,000 in England. So, we are investing in our NHS dental services.”

For the past month a public information campaign has been running in newspapers on radio and via digital advertising. The ‘Brush Up’ campaign aims to clarify NHS dental patient rights and what treatments are included under the NHS. Community engagement has included posters in pharmacies, GP surgeries, libraries and dental practices, all directing the public to further inform via scanning a QR Code or updated information on NHS Inform.

The challenge

The new SDR is the most radical change to primary care dentistry since the 1990 contract, which introduced capitation and continuing care for the first time, writes Gerard Boyle.

Since then, we have seen the addition of allowances into the mix, resulting in a package of remuneration today which is comprised of about 60 per cent item of service, almost 25 per cent capitation, and the remainder paid in allowances.

This first phase of dental reform is ambitious in its scope, introducing a completely new, simplified SDR, through which the Scottish Government hopes to deliver a system which is much lighter on bureaucracy, enabling a prescribing culture based on trust, where the clinician is freer to deliver whatever care that they deem appropriate.

However, having worked within the governance structures of NHS Boards and Practitioner Services for several years, while this lighter touch is fair for the majority of practitioners, for the small cohort of our profession who regularly appear on our radar, it carries some risk.

Our governance is focused mainly on Prior Approval at the pre-treatment stage, and on DRO examinations post-treatment. Through this, we have safeguards to ensure treatment is appropriate, in compliance with the GDS Regulations and the SDR and that it is carried out with proper skill and attention. How we now focus these resources will be a challenge for us going into 2024.

The timescale for this first phase of dental reform has been tight and the targets faced by Practitioner Services have been considerable, ensuring our personnel and our systems are ready
to receive and process Prior Approval submissions and claims for payment for 1 November.

But we have delivered on time, and within the specification the Scottish Government requested. There have been some ‘teething problems’ with all of the practice management systems suppliers, as we expected, and it is clear this new SDR will require some refinement over the next few months.

However, we are committed to working closely with the Scottish Government to help ensure the new model for NHS dentistry works for the profession and continues to deliver a high standard of care to patients.

Gerard Boyle is Senior Dental Adviser at Practitioner Services

Tags: SDR

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