07 SUMMARY
The group discussed in detail why and how the services could best meet the needs of the population, taking into account the access problems in some parts of the country for primary and secondary dental care. It was recognised that in some areas this has led to increased demands on the service and some unnecessary referrals to secondary care.
7.1CDS Remit
The remit of the CDS has changed over the last 20 years as it has responded to the need to provide a complementary service to the independent contractor GDS. The ' Action Plan for improving oral health and modernising NHS dental services in Scotland' document has recognised the need to concentrate on prevention in dentistry, whilst also maintaining a treatment service.
The CDS has adapted to meet the demands of patients with special needs, primarily those with complex clinical conditions and/or challenging behaviour. Consequently there has been a reduction in numbers of routine child patients treated by the CDS, the extent of which varies from area to area. There has been a rise in the number of adult patients treated, with a concentration on the client groups who have special needs. The dental public health role has been maintained and, with the recent introduction of the National Dental Inspection Programme, this has strengthened.
7.2 Provision of Salaried GDS
The provision of GDS is often driven, in the main, by market forces and will, therefore, encourage dentists to provide services in areas with dense population levels. Consequently when there is a shortage of dentists, remote areas, with low population density, are likely to be adversely affected.
The availability of NHSGDS has decreased over time and in an attempt to meet demand there has been an increase in the numbers of salaried general dental practitioners, particularly in rural areas. In some areas the demand for such services has given rise to long waiting times.
There are no targets for levels of manpower in relation to need for care so provision across Scotland is ad hoc.
7.3 Special Needs Patients
The definition of 'special needs' is inconsistent across the country. There appears to be a continuum of clinical need across a very broad spectrum. At one end of the continuum there are patients with profound problems whose need for advanced clinical skills is obvious. At the other extreme however there are patients whose needs are routine but are classified by clinicians, or classify themselves, as 'special needs' in order to access care from the CDS. This is a significant issue where access to routine GDS is restricted but in normal circumstances the patients would have been able to be seen by general dental practitioners. The threshold therefore for special needs services is influenced by the accessibility of GDS locally.
It is recognised that people with special needs are less likely than routine patients to be able to make their demands heard and therefore their ability to access the care they require may be compromised. This is a particular problem in areas where other routine/more able/more demanding patients are competing for a limited service.
7.4 Targeted Versus Comprehensive Children's Dental Service
A comprehensive children's service was defined as one which was dedicated to this client group and separate from other dental services. Targeted children's service was defined as that which would be complementary to the other services which children could attend. It was considered that there were pros and cons in both models, but in the former the issues of lack of continuity of care, lack of numbers of dentists willing to restrict their practice to children, the disincentive to the "family" approach to dental attendance, and organising this service within the school environment would be considered major barriers.
7.5 Joint/Split/ CDS/ GDS Posts
In some areas the duties of the CDS practitioners and those of the salaried GDS practitioner have been merged. Under this system dentists either operate under two separate contracts or one combined contract. The result in both cases is that each practitioner has the flexibility to operate under either the CDS or the GDS system.
7.6 Information Management Systems
There are two sources of relevant activity data; the form used by the CDS ( SMR 13) which is usually completed at the end of treatment for each patient and the equivalent in the GDS, which is the GP17. In addition the 'joint' CDS/ GDS clinicians and clinicians occupying 'split' CDS/ GDS posts may use both. As a result it is difficult to measure accurately the activity levels in each service, the collection of data is unnecessarily complex, its validity is compromised and any comparisons across the services are impossible.
7.7 Monitoring of Clinical Standards
The system for the monitoring of clinical standards for each of the salaried services is different. Whilst the salaried GDS is subject to the monitoring system applied to independent contractors the CDS has no national standard provision.
7.8 Out-of-Hours Services
Out-of-hours dental provision is different in each of the services. Whilst there is a contractual obligation placed on Salaried GDPs to provide emergency cover for their registered patients there is no equivalent obligation on CDS staff. This has led to locally negotiated agreements that have, in the main, been voluntary in nature. Consequently there is a lack of uniformity across the services.
7.9 Patient Charges
There are different rules for patient charges, depending on whether the treatment was carried out by the CDS or the salaried GDS.
7.10 Career Structures
Career structures exist in the CDS with financial recognition being given for additional skills and responsibility. In the salaried GDS there is no clear means of career advancement and in neither is there a recognised training pathway.
7.11 The Wider Dental Team
For the purposes of this report the wider dental team includes PCDs (Professionals Complementary to Dentistry), Oral Health Educators and dental administrative and clerical staff. The planned increased role for the wider dental team is a welcome development and could contribute towards increasing dental workforce and to the movement of emphasis towards preventive dentistry.
There is a lack of uniformity across Scotland in relation to pay grading for staff and currently there are limited career structures and opportunities for staff development.