Modernising NHS Dental Services in Scotland: Analysis of Responses
CHAPTER 8: DISCUSSION
The consultation responses were wide ranging and varied. The represented the views of a broad range of stakeholder sectors including the public, thus enabling both sector specific and more generalisable comments to be presented. The consultation document stimulated a wide range of arguments and recommendations, generated not only by its Chapter 6 on possible changes to the system (see Annex 1) but also its preceding chapters which set out the rationale for the suggestions for change. As such, responses tended to deviate from the response structure suggested in the consultation document and were therefore more challenging to collate and analyse. Such responses required a robust analytical framework based on the structure of Chapter 6 but with additional fields inserted as appropriate in order to capture any extra topics highlighted by respondents.
An overarching view was that the consultation was necessary in view of what were seen as the current and increasing difficulties in the delivery and funding of NHS dentistry. The exercise was seen as an opportunity to work out Scottish solutions to these issues in parallel with those being developed south of the border. There was a confidence that Scotland could formulate its own way forward, independently from England, but learning lessons from the English pilots and other such initiatives.
A mood of pride in the delivery of NHS dentistry emerged from many of the responses from dental practitioners with some reporting that their increasing delivery of private dentistry resulted from necessity rather than willingness. A few described their entire career based on delivering NHS dentistry but reported that this had, of late, become increasingly challenging. For some, there was obviously a tension between their perception of delivering a public service whilst also having to run a business which had to be profitable enough to pay themselves and others.
Individual chapters contain summaries of comments on each of the topics raised in the consultation. Other overarching impressions and themes to emerge from the responses are documented below.
Compared with other consultations, this exercise could be said to be characterised by diversity rather than consensus of views. Different views were expressed even from within respondent sectors. A good example was the issue of future funding of NHS dental services where arguments for and against a variety of different options were presented, with no one particular way forward emerging. Another example was the issue of patient charging, which attracted much debate on the pros and cons of free and charged treatment and many respondents opting for a mix of approaches as the most appropriate course of action.
Such a variety of views suggests that these issues are not at all clear-cut and there may well be many different ways of going about delivery and funding, all of which are likely to favour some but perhaps disadvantage others.
Another reason for the diversity of views may be that there appeared to be such a wide diversity of contexts within which the system is required to fit. These ranged from geographical areas, to contexts relating to different patient types and needs. A recurring theme was that one size of system would not fit all contexts and local flexibility would be necessary, albeit nesting within a standardised, national framework for NHS dentistry.
The theme of standardisation emerged in several guises. Calls were made for any system of charging for dental care to be consistent nationwide across GDS, CDS and hospital settings with a standard approach to charging across primary care in general. There were requests for consistency in quality assurance targets and standards, with a few respondents also requesting standardisation of complaints and disciplinary proceedings. The perceived current inequality of access to NHS dentistry was considered by many to be unacceptable and innovative ideas for incentives, rights and responsibilities of practitioner and patient were put forward in an attempt to standardise provision across Scotland. Many respondents referred to parallels in general medical practice and called for compatibility of salaries, funding, practice and other operational issues across different primary care services.
Many consultees made a plea for better integration of dentistry within the body of primary care. The perceived isolation of dental practice from the mainstream health care provision was seen by some as the root of many of the current problems. For some, better integration would involve shared premises, a shared patient base, shared training and greater opportunities to promote oral health prevention through a joined-up health care approach. Other benefits were seen as improved pay and conditions for practitioners with more scope of professional interaction and higher overall professional standards.
A sea-change in favour of facilitating an emphasis on prevention emerged as a key priority. Consultees described their views that current funding and delivery systems were stacked against the promotion of prevention. Some argued that the systems as they stood did not appear to reflect any central seriousness about prevention. Responses clearly displayed willingness amongst practitioners, PCDs and wider health care staff to tackle prevention, if supported by appropriate systems which incentivised this approach and did not leave them disadvantaged. In this respect, the need was seen for funding of NHS dentistry to be much more closely aligned with strategic oral health priorities.
It was interesting to note that the preventative aspect of NHS dentistry was one which, by its nature, may provide opportunities for joint working between professionals in different arms of primary health care, with more emphasis on prevention likely to be a catalyst in the better integration of these services in future.
Another issue raised by respondents and attracting many imaginative ideas was that of perceived dental workforce shortages. This was linked to difficulties encountered in the retention of trained staff. A host of suggestions was made relating to training and retaining staff by respondents from several sectors. Suggestions tended to be pragmatic and represented both carrot and stick approaches. For many, simply providing more training places was not enough. These needed to be supported by a closer alignment of training with the reality of practice, perhaps through greater use of outreach placements during training. New graduates were seen by some to need a greater guarantee of income in their early years, perhaps by supporting them with a time-limited salary in return for a specified NHS commitment. Dentistry as a career was viewed as in need of an image make-over to attract aspirations even from school children in considering their future careers.
Overall, the responses to the consultation were wide-ranging, based on personal and professional experience and provided a depth of comment of much value to inform decisions on the future of NHS dentistry in Scotland.