An Action Plan for Improving Oral Health and Modernising Nhs Dental Services in Scotland

NHS GRAMPIAN DENTAL PLAN 2008 - 2012

A PLAN FOR IMPROVING ORAL HEALTH AND MODERNISING NHS DENTAL SERVICES IN GRAMPIAN

July 2008 INTRODUCTION 3 Key principles to underpin the way ahead: 4 Stakeholder Consultation 4 TARGETS FOR ORAL HEALTH IMPROVEMENT IN GRAMPIAN 6 Dental Health of Adults (over 16 years) 6 Dental Health of Primary 1 Children - 5year olds 6 Dental Health of Primary 7 Children-11 year olds 7 TARGETS FOR NHS DENTAL REGISTRATION IN NHS GRAMPIAN 10 Child NHS registrations 11 Adult NHS Registrations 11 TARGETS FOR THE DENTAL WORKFORCE IN NHS GRAMPIAN 13 Total NHS Dentists in Grampian and Scotland 1996 - 2007 13 Independent Dentists Grampian and Scotland and by CHP 14 NHS GRAMPIAN DENTAL PLAN 2008-2012 17 Consultations and National Plans 17 DEVELOPING PATIENT PATHWAYS OF CARE 18 Way Forward - A Clinical Network for Oral Health 19 Main Services/ Pathways for Delivery of Dental Care 20 ORAL HEALTH IMPROVEMENT 24 Children 24 Adults 24 Services to Improve Dental and Oral Health 24 Effective Programmes of Care 25 General and Crosscutting Initiatives 27 Adults and Older People 29 ENHANCED DENTAL SERVICES 31 Enhanced services through local contracting 31 IMPROVING AND MODERNISING DENTAL PREMISES 32 Dental Premises 32 IMPROVING INFORMATION AND COMMUNICATION 34 PATIENT CHARGING POLICY 35 QUALITY STANDARDS AND CLINICAL EFFECTIVENESS 36 EDUCATION AND TRAINING TO DEVELOP AND ENHANCE THE WORKFORCE 38 Workforce Numbers 38 Dental Education and training plan 39 Additional issues that could impact on workforce development 40 MONITORING AND EVALUATION 42 RESOURCING THE DENTAL PLAN 43 Financial Consequences of Programme 1 - Capital 1 44 Summary Revenue Financial Consequences 46 APPENDICES 47 Appendix 1 – Summary Report of Public Feedback

NHS Grampian Dental Plan July 2008 2 16/07/08 INTRODUCTION

Through this plan NHS Grampian aims to:

 Help and support people to sustain and improve their oral and dental health with clear priority given to disadvantaged individuals and disadvantaged communities.  Ensure high quality, local NHS dental services are accessible to all who need such care, delivered through clear patient-focused standards.

The core themes of this plan are to:

 Improve oral health through preventive anticipatory care and health promotion  Provide high quality patient-focused care with the patient identified as a partner and a clear understanding of the patient’s contribution to self care  Provide communities with accessible services focused on high quality, effective treatments provided through clearly defined standards  Provide, where there is long term and/or high intensity care required, support for both the patient and the carer  Embed sustainable services in local communities through investment in dental services, dental premises and leading edge technology.

The public should receive clear information on how to achieve and maintain good oral health, what services they can reasonably expect and what responsibilities they have in return.

Learning the essential skills to secure and maintain good oral health in childhood lays the foundations for a healthy mouth for life.

High quality dental services, utilising the skills of the whole dental team are a key part of this process, supporting individuals in maintaining their oral health (self care) and providing additional care and advice when needed.

Professionals who provide dental services need to feel that a career in NHS dentistry meets their aspirations and provides job satisfaction, professional development and a fair reward. If we are to improve oral health and health services, we must both attract and retain the dental workforce which NHS Grampian needs.

Meeting NHS Grampian objectives can best be achieved by taking steps to improve both oral health and health services. This will require a genuine partnership between a well-informed public, patients, public organisations and committed professionals.

NHS Grampian Dental Plan July 2008 3 16/07/08 Key principles to underpin the way ahead  Oral health as an integral part of overall health improvement  Oral health improvement supported by health policies on healthy eating, reducing addictions such as smoking and through consistent information to the public from all health professionals  Services for children, young people, elderly and disadvantaged groups focused on prevention and aim to meet the oral health needs of those in the most disadvantaged circumstances.  Patient-focused standards ensuring high quality services with more transparent information for patients  A strengthened salaried dental service targeted at those in most need.  Increasing support for practices demonstrating commitment to the NHS through the provision of NHS services.  Development of local contracts for enhanced services in general dental services  Support and encouragement for recruitment and retention of all dental team members  A workforce trained to deliver services in a way which is effective and complements and supports a preventive approach to care  Services delivered locally through integrated care pathways supported by multi- disciplinary staff, and primary and secondary care service providers  Oral health improvement supported by free dental services for those in most need and free dental examinations for all population groups  A local education and training plan to deliver an increase in the number of dental professionals and an increase in dental professionals with enhanced skills.

Stakeholder consultation in the development of the NHS Grampian Dental Plan 2008-2012

Public and professional stakeholder groups were consulted on the draft Dental Plan. Their views and comments have been incorporated into this amended plan and are summarised in Appendix 1.

Staff and professional groups consultation Consultation with these stakeholders took place between June 2007 and June 2008. Last summer members of our Oral Health and Dental Services team held evening meetings across Grampian, attracting over 70 dental professionals who were invited to comment on the future of Oral/Dental Health Services in Grampian. A further series of professional meetings were held with the staff groups based in each Community Health Partnership (total 120 staff).

Feedback Consistent themes from staff were  Supportive of direction although targets were extremely challenging  Welcomed training and education for all members of the team  Need to prioritise disadvantaged individuals and communities

Public engagement and consultation NHS Grampian Dental Plan July 2008 4 16/07/08 Consultation with public and community groups took place during April to June 2008. A user-friendly version of the consultation paper summarising the key targets and actions as set out in the full plan was produced along with a response form.

Feedback from the public consultation

50 people attended the Community Forum meeting on 27th May 2008 and their views and questions were captured in a meeting report. By the close of the consultation over 40 written responses had been received. All responses were collated and analysed according to themes which emerged. A detailed report of the public feedback was produced.

Key points which emerged

Through the public consultation, it is clear that the targets and recommendations as set out in the plan are broadly welcomed and supported by the public, but there were many views expressing some scepticism about the deliverability and affordability of the plan.

People are confused by the current range of dental services available and do not understand the difference between an NHS dentist, salaried dentists and private providers. A campaign to raise understanding of dental service provision using methods like website pages, brochures, posters, newspaper articles, etc has been suggested.

There is a consensus on the need for a consistently applied fair and transparent system of patient charging.

There is strong support emerging for the actions around oral health improvement as the way to tackle dental disease in the longer term. Prevention is seen as the key with strong support for the actions around health improvement and self-care and improving oral health of children through early interventions and education.

Recommendation 1

NHS Grampian should develop a communication and involvement plan to support the implementation of the Dental Plan and enable ongoing engagement and involvement of the public and stakeholder groups in modernising dental services and improving oral health.

NHS Grampian Dental Plan July 2008 5 16/07/08 TARGETS for ORAL HEALTH IMPROVEMENT in GRAMPIAN

Dental Health of Adults (over 16 years)

Target 1 Adults By 2010 - less than 10% of adults (over 16 years) with no teeth

Dental health has improved steadily for Scottish adults although there is little information available on the dental health of adults in Grampian with only one survey published in 1993. Projected trends identified in UK and Scottish dental health data, would suggest that by 2010 less than 10% of Grampian /Scottish adults would have no teeth.

Adult Dental Health in Grampian and Scotland (Data -Adult Dental Health UK Surveys 1972-1998) (Data -Scottish Adult Dental Health Survey 1993)

45 40 35 30 25 Scotland 20 Grampian 15 Target 10 5 0 1972 1978 1988 1993 1998 2008 2010

Recommendation 2

NHS Grampian should commission a Community Health Partnership based adult oral health survey in 2008 as part of the baseline assessment for the Dental Plan.

Dental Health of Primary 1 Children – 5 year olds

Target 2 Primary 1 By 2010 - 60% children with no obvious dental decay

Progress of dental health of children in Grampian has been relatively static since 1988. Preschool children in Grampian and Scotland have some of the worst oral

NHS Grampian Dental Plan July 2008 6 16/07/08 health recorded in Europe. In the latest 2006 survey of Primary 1 (5 year old) children starting school, 55.5% of children in Grampian (Scotland 54%) recorded no signs of dental decay. In Grampian there has been little change from 1988 when the recorded level was 53.2%. Scotland in contrast has recorded a consistent trend in oral health improvement over the last 10 years. The graph below also illustrates the potential benefits of the introduction of the recommended oral health improvement programmes outlined later in this plan. Clinical effectiveness reviews confirm that supervised nursery and school toothbrushing programmes and fluoride varnish applications (Childsmile) can lead to significant improvements in dental health.

Percentage of pupils in Primary 1 with no obvious dental decay 1988-2006

(Data from National Dental Inspection Programme –NDIP 1988-2006)

50 Grampian Actual 40 Dental Plan 30 Trajectory 20 Target 10 0 1988 1996 2000 2006 2008 2010 2012

Dental Health of Primary 7 Children-11 year olds

Target 3 Primary 7 By 2010 - 60% children with no obvious dental decay

Primary 7 children in Grampian were 10th in a list ranked by dental disease of Scottish health boards. Grampian was below the Scottish average and grouped with health boards in the West of Scotland. These latter health boards record amongst the worst level of dental decay in Europe. Whilst some of this disease can be linked to deprivation a considerable proportion may be linked to low motivation, self care and related to poor services.

NHS Grampian Dental Plan July 2008 7 16/07/08 Primary 7 Children with no dental disease

Moray 36% Local NDIP Aberdeen/shire 44% Survey Aberdeen City 44% 2006

Grampian local 42%

Greater Glasgow 47% National NDIP Grampian 49.60% 2005

Scotland 52.90%

Dumfries and Gallow ay 66.70%

Orkney 76.30% percentage with no obvious disease

Data - Selected statistics from the 2005 and 2006 National and Local NDIP

Recommendation 3

NHS Grampian should set new targets for dental health improvement for 2015 and 2020 for the above age groups.

National Dental Inspection Programme - targeting services

The National Dental Inspection Programme (NDIP) collects data for national statistics but also identifies local disease levels. Health Boards use the data to identify areas of high dental need and can use the data to identify areas for preventive services for children. The following are examples of the targeting process which will define those areas where programmes should be delivered as a first priority due to high need.

CHP Towns /areas with high dental need Moray Buckie, South and East Elgin, Dufftown and rural areas to the south of Moray Aberdeenshire Banff, Macduff, Fraserburgh, Peterhead, rural areas around Huntly and Oldmeldrum and small coastal villages below Stonehaven Aberdeen City Mastrick, Northfield, Torry, Tillydrone, Middlefield

NHS Grampian Dental Plan July 2008 8 16/07/08 Oral Cancer

Oral cancer trends are not identified by individual health boards in Scotland. Analysis and review of oral cancer incidence and 5 year survival needs to be identified for Grampian with appropriate targets set for both incidence and survival.

Recommendation 4

NHS Grampian with Information and Statistics Division (ISD Scotland) should identify the incidence of oral cancer and the 5 year survival rate by Health Board. Once identified Grampian should set targets for improvement of both incidence and survival.

Recommendation 5 NHS Grampian should adopt the Oral Health Targets above (Targets 1 to 3) as Health Board targets for monitoring performance of the Dental Plan.

NHS Grampian Dental Plan July 2008 9 16/07/08 TARGETS for NHS DENTAL REGISTRATION in GRAMPIAN

NHS dental registrations in Grampian 1998-2007

In Grampian only 29.5% of adults are registered with the NHS for dental care (Scotland 49%). Patients in Moray have one of the lowest registration levels in Scotland with only 15% of adults registered.

Child registration levels are equally poor, with only 57% children registered with the NHS in Grampian, well below the Scottish level - 66% of children in Scotland. Moray again records a low level with only 51% of children registered with the NHS.

Additional numbers of children and adults access primary care dental services through the Community Dental Service estimated at over 12,000 per year. There are no recorded statistics for the number of children and adults who access care under private arrangements.

Dental NHS Registrations in NHS Grampian 1998-2006

250,000 0-2y 200,000 3-5y 150,000 6-12y 13-17y 100,000 All Children 50,000 18-64y 0 65+ All adults

Data ISD Scotland 1998-2006

The above statistics show a concerning fall in NHS registrations over the last 8 years (1998-2006). Children 73,248 down to 64,715 (- 8533) Adults 208,765 down to 136,513 (-72,252)

In 2007 the 10 year trend of decrease in registrations stopped and following a low point in September 2007 registration levels have started to rise over the last two consecutive quarters.

NHS Grampian Dental Plan July 2008 10 16/07/08 Child NHS registrations Registrations act as an indicator of NHS dental care. Presently NHS Grampian has one of the lowest mainland health board registration levels and compares poorly with health boards such as Glasgow (Glasgow 73% children registered). Anecdotal evidence suggests that for children there is little private dental care. The Scottish Government has set targets for registration levels of 80% for 3-5 year olds (HEAT Target).

In order to predict and set targets, the scenario below is presented which would meet the targets set out in the Scottish Dental Action Plan. Presently child registrations in Grampian stand at 57%, with Moray the lowest level at 51%. The scenario below would suggest that in order to achieve the present Scottish average rate of registration for children (present Scottish average 67%) NHS Grampian would have to increase registrations by over 11,000 but to achieve the 2010 Scottish Dental Action Plan Targets NHS Grampian would have to register an additional 25,000 children.

Predicted target setting scenarios for Grampian children 0-2 3-5 6-12 13-17 Children Grampian number 4,080 9,436 27,791 21,185 62,492 Grampian % 24.6 59.0 65.8 63.3 57.7% Scottish action plan target by 2010 55% 85% 90% Target % 55.0% 85.0% 90.0% 80.0% 80.8% Number 9121 13,594 38007 26,773 87,500 Increase 5041 4152 10,216 5588 25,000 Data ISD Scotland 2007

Target 4 Child Registrations By 2010 - 80 % of 3-5 year olds registered (HEAT Target)

Adult NHS registrations NHS registrations act as an indicator of NHS care for adults. Feedback from consultation would suggest that there is limited private dental care for some adult groups such as the elderly (75+). In order to predict and set targets the scenario below is presented which would meet the targets set out in the Scottish Dental Action Plan.

Predicted target setting scenarios for adults 2006-2007 Adults adults 18-24 25-34 35-44 45-54 55-64 65-74 75+ total Grampian number 17,349 18,791 27,211 24,819 19,214 11,000 5,810 124,194 Grampian % 36.9 29.2 32.7 32.2 29.1 24.2 15.0 29.5 Scotland Targets 60 40 Target % 60 60 50 50 50 60 40 53 Number 28,199 38,603 41,608 38,506 33,025 27,772 15,459 223,128 Increase 10,850 19,812 14,397 13,687 13,811 16,686 9,649 99,000 Data ISD Scotland 2007

NHS Grampian Dental Plan July 2008 11 16/07/08 NHS Registration Targets

In order to meet the necessary registration targets set in the Scottish Dental Action Plan for children by 2010 and to achieve a level of NHS registration for adults similar to that achieved in Grampian in 1998, the following registration increases are presented as targets.

Target 5 Child Registrations By 2010 - an additional 25,000 child registrations which include an estimated 3800 registrations for children aged 3-5 years (HEAT )

Target 6 Adult NHS Registrations By 2012 - an additional 99,000 adult registrations

In total this would require a total of 124,000 additional NHS dental registrations in NHS Grampian by 2012. In order to achieve this number of new registrations an estimated 70 dentists are needed (average 1750 registrations per dentist) as a minimum over and above the present number in Grampian. The new dentists recruited would need to spend the majority of their time offering NHS dental services to achieve these registration numbers.

Recommendation 6

NHS Grampian should adopt the NHS Registration Targets above (Targets 4 to 6) as Health Board targets for monitoring performance of the Dental Plan.

NHS Grampian Dental Plan July 2008 12 16/07/08 TARGETS for DENTAL WORKFORCE in GRAMPIAN

Total NHS Dentists in Grampian and Scotland 1996 - 2007 Data from Information and Statistics Division (ISD), Scotland, indicate that, at September 2007, there were a total of 270 dentists working in Grampian. This statistic identified the number of dentists (headcount) and includes salaried and non-salaried principals, assistants, vocational trainees and hospital and community dentists. The equivalent figure for Scotland was 2919. There were 192 independent general dental practitioners in Grampian (2261 in Scotland). The table below illustrates the increase in dentist numbers over the last 10 years.

Dentists 1996 1998 2000 2002 2003 2004 2005 2006 2007 (Head count ) Scotland 2323 2411 2465 2550 2583 2617 2669 2842 2919 All dentists NHS G 208 211 207 208 215 227 232 261 270 All dentists NHS G 172 174 168 165 170 177 177 193 192 Independ ent dentists (GDP) Data ISD Scotland 1996-2007

It is estimated that independent general dental practitioners deliver over 90% of the primary care services. The number of independent practitioners is closely correlated to registration levels. However these practitioners also deliver a considerable amount of private care but there is no exact estimate of their total private activity or the number of patients in private care by each independent dental practitioner.

A health survey/questionnaire is recommended in Recommendation 2 based on each Community Health Partnership to establish a clearer estimate of dental care service provision in the general population in Grampian.

Year 1996 1999 2002 2006 Target Target 2010 2012 Grampian 208 219 208 261 300 350 Grampian 39.7 49.9 57 67 Rate:100,000 Scotland 2323 2462 2550 2842 3050 3417 Scotland 45.8 56.1 60.25 67.5 Rate: 100,000 Best in Scotland Tayside 76.6: 100,000 Data ISD Scotland 1996-2006

The tables show that the trend of increased dentist numbers over the last 10 years in Grampian is similar to Scotland. However the number of dentists to population

NHS Grampian Dental Plan July 2008 13 16/07/08 ratio in Grampian has always been significantly below the Scottish dentist to population ratio. The targets below are based on the need to recruit an additional 90 dentists to Grampian between September 2006 and September 2012. It would be expected that whilst initial recruitment will be slow it would rise by 2009 to a target whereby NHS Grampian should aim to recruit an additional 20 new dentists annually.

In 2006 (ISD) statistics illustrate the low level of dentists in Grampian when compared with Scotland and Tayside

Grampian - 49.9 dentists per 100,000 population Scotland - 56.1 dentists per 100,000 population Tayside - 76.6 dentists per 100,000.population

Data ISD Scotland 2006

Target 7 Total number of dentists By 2010 - to increase the total number of dentists working in Grampian to 300 (Base - 270 Sept 2007)

Target 8 Total number of dentists By 2012 - to increase the total number of dentists working in Grampian to 350 (Base - 270 Sept 2007)

Independent Dentists in Grampian and Scotland and by Community Health Partnership (CHP) When comparing only independent general dental practitioner numbers by CHP, NHS Grampian records the two lowest levels of dentist to population ratios in Scotland (Information Statistics Division 2006).

The following ratios are calculated:- Moray 1 dentist: 3144 pop. Aberdeenshire 1 dentist: 3095 pop. Scotland and Aberdeen City 1 dentist: 2021 pop. Dundee City 1 dentist: 1360 pop. Scottish Target 1 dentist: 1750 pop.

Data ISD Scotland 1996-2006

To achieve the Scottish Dental Action Plan Target for primary care dentists of - 1 dentist: 1750 population, NHS Grampian would need to recruit 77 primary care practitioners between September 2007 and September 2012

Target 9 Number of primary care dentists By 2012 - to increase the number of primary care general dental practitioners (salaried and independent) working in Grampian to 300 (Base - 223 Sept 2007)

NHS Grampian Dental Plan July 2008 14 16/07/08 The majority of above dentists recruited to Grampian should be independent practitioners who spend the majority of their time offering NHS dental services

NHS Grampian Dental Plan July 2008 15 16/07/08 Dental Care Professionals

Presently NHS Grampian has no information on the location or qualifications of Dental Care Professionals working in Grampian i.e. Dental Nurses, Dental Therapists, Dental Hygienists, Dental Technicians.

Dental Nurses in particular play an essential role in dental service provision .It is estimated that there are presently well over 300 working in Grampian. The lack of accurate information is of considerable concern when planning the changes to dental services outlined in this plan.

To develop improved workforce planning arrangements, it is considered that a data base of all dental professionals working in Grampian should be established. This database once established would inform and monitor a Dental Workforce Development and Training Plan.

Once information on all team members is available and to ensure development of the whole dental team NHS Grampian should set targets for training and recruitment of all members of the dental team including dentists, dental therapists, dental hygienists, dental nurses, dental technicians, dental practice managers and dental receptionists.

Recommendation 7

NHS Grampian should adopt the Workforce Targets above (Targets 7 to 9) as Health Board targets for monitoring performance of the Dental Plan.

NHS Grampian should establish a Dental Workforce Database which includes all dental professionals working in Grampian.

NHS Grampian should establish Workforce Targets for all dental team members by 2010

NHS Grampian Dental Plan July 2008 16 16/07/08 NHS GRAMPIAN DENTAL PLAN 2008-2012

This paper sets out a plan to improve oral health and dental services in Grampian, with a particular focus on improving the oral health of our children. It presents our proposals for modernising NHS dental services in Grampian over the next four years but with implications for oral health and dental services well into the next decade. Service delivery and structure have already started to change with considerable recruitment to the salaried general dental services. However there is no single solution and it is only by the combination of actions highlighted in this plan that NHS Grampian will be able to deliver the improvements in dental services and oral health.

Consultations National and Local Plans

These following NHS plans have informed and shaped this plan.

“NHS Grampian Strategic Plans” NHS Grampian have over the last 10 years brought forward numerous plans to improve dental services including 2002/2003- “Dental Healthfit”.

"Towards Better Oral Health in Children", published in September 2002, set out the facts about the oral health of children in Scotland and outlined a range of possible measures to encourage health improvement. It also sought views on how to enhance preventive treatments, the promotion and practice of healthy eating and ways of using fluoride, including the issue of water fluoridation.

"Modernising NHS Dental Services in Scotland", launched in November 2003, was prepared to support and take forward proposals for changes to the system for rewarding primary care dentistry in order to promote prevention, improve access to services and improve recruitment and retention.

“Building a Health Service. Fit for the Future” - 2005

“An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland” - 2005

“Better Health, Better Care” - 2007.

To plan dental services these reports highlight the following core priorities

 Patient- sensitive local services  Information and support for patients to access care  Services based on prevention delivered through an integrated care pathway  Effective and efficient modern services delivered in modern premises and fully integrated with other NHS care  Challenging targets for delivery of high quality NHS dental services  Services monitored through appropriate patient-led standards

NHS Grampian Dental Plan July 2008 17 16/07/08 DEVELOPING PATIENT PATHWAYS OF CARE

Present structure and function of dental services

Services are delivered in a range of settings, with input from a wide range of potential dental team members: dentists, hygienists and therapists, dental nurses, receptionist/managers and dental technicians. Each has a key role to play in the delivery of patient care and there is agreement that maximising the potential of the dental team is of critical importance in tackling both oral health improvement and dental service improvements in Scotland.

General Dental Practitioners (GDP) are independent contractors who, while working under existing NHS arrangements, treat children and adults under a hybrid capitation (children) and continuing care (adults) and a fee for each item of service structure. Whilst some practitioners undertake only NHS work, most GDPs undertake a mix of private and NHS treatment with some restricting their service to private care only.

Salaried Dental Services (SDS) consisting of the Community Dental Service (CDS) and Salaried General Dental Services (SGDS) have a vital role to play in meeting the need of disadvantaged groups and those with special needs. NHS Boards commission salaried services to meet local priorities, including the need to complement GDP provision. Presently NHS Grampian employs over 50 dentists within these services .The services merge into a single public dental service in 2009. Presently these services treat in excess 30,000 patients per year, providing essential services for special care groups and standard care where independent dental services fail to offer such NHS dental care. Community Dental Service (CDS)These services undertake routine care of children but also special needs groups such as the elderly in care and adults with disabilities .Core services include health improvement programmes and monitoring for dental disease, notably through the National Dental Inspection Programme for children in Primary School, (Primary 1 and Primary 7 inspections). Information obtained at these inspections identifies schools and individuals at highest risk of dental disease. Salaried General Dental Services provide the normal range of NHS general dental services under the same regulations as independent contractors. Patients (unless exempt) receiving treatment under GDS (GDS or SGDS contribute up to 80% of the fees with and upper limit set as the maximum cost per course of treatment. Currently, within the GDS, there are over 400 different items of service and an equivalent number of patient charges for adults. Independent dentists earn the majority of their payments through a fee per item of treatment on completion of a course of treatment. Smaller monthly payments complement these payments for patients registered for NHS care - capitation payments for children and continuing care payments for adults. Recent additional payments in the form of a practice allowance and a rent allowance have been developed in Scotland only. However an estimated 70+% of dentist's NHS earnings are still earned through the item of service payment system.

NHS Grampian Dental Plan July 2008 18 16/07/08 The Hospital Dental Service (HDS) delivers secondary care services. Presently there are nine consultants who with their support staff offer a wide range of specialist services. These are described as Maxillo-Facial, Restorative and Orthodontic Services. These consultant led services deal with some of the most challenging head and neck cases including oral cancer, facial trauma, oral and facial deformities and malocclusions as well as complex dental treatments.

North of Scotland Shetland and Orkney have a close relationship with NHS Grampian with hospital specialist services supplied through regular consultant clinics on both islands. A more formal managed clinical network for dental services across the North of Scotland Health Boards is in development.

Way Forward – a Clinical Network for Oral Health

The current structure for service delivery within Grampian is fragmented and is not conducive to a cohesive high quality service provision for the population of Grampian. Care pathways are complex and indistinct with poor definition for patients. To address this issue it is proposed that a Clinical Network for Oral Health in Grampian is developed over the coming months and is complemented with a programme of redesign of the present dental services and their management. Service redesign should incorporate changes associated with the developing structure and management of the 3 Community Health Partnerships.

Network Framework Oral and Dental Health Clinical Network Lead Group

Core Governance Health Workforce Education/ Themes Improvement Development Training

Integrated Urgent Access, Urgent care, Out of Hours Care, Pathway Emergency Dental Care

Patient Care Pathways

Oral Health Improvement Independent Teaching General Dental Services Practitioners Special Care General Dental(independentIntermediate Secondary and Special Services Specialist Care Services Needs (Salaried) Care

It is recognised that the above diagram only gives an overview of the service structure. In addition dental representatives from Shetland and Orkney will be invited to participate in network meetings.

NHS Grampian Dental Plan July 2008 19 16/07/08 Main Services/ Pathways for Delivery of Dental Care

Care Pathway - Preventive Care (Links with all primary dental care services)

Teams Oral Health Improvement teams based at each CHP

Target groups General Public Children and adults with high need Special needs and special care groups Function Liaise and co-ordinate oral health promotion with local authorities and CHP health professionals for health improvement Co-ordinate preventive health improvement within General and Salaried Dental Services Manage the nursery and school tooth brushing programmes which now extends to an estimated 10,000 children in NHS Grampian Introduce a clinical health improvement programme from birth – Childsmile Introduce the Childsmile clinical prevention programme to all children in care Introduce a health improvement programme to all elderly in care – Adultsmile Introduce a health improvement programme to all special needs children and adults

Outcome Oral health improvement programmes and targets

Care Pathway - Routine Dental Care (NHS Registration)

Teams General Dental Services (independent and salaried) practices

Target groups All population who request NHS routine primary care dental services with registration Most Primary Care Dental services should be available in all main centres of population in Grampian.

Independent General Dental Practitioners Routine care and registration as the main focus of dental care for the majority of the people in NHS Grampian

Salaried Dental Practice Routine care and registration. CHP based services which focus on routine dental care for those areas where there is no independent dental service offering NHS dental care access. Salaried services will develop a “public health” orientated dental service offering community based services

NHS Grampian Dental Plan July 2008 20 16/07/08 Outcome NHS registration targets and local service delivery. Routine Care Guarantee -12 weeks for children under 12 years

Care Pathway - Urgent Dental Care, Access and Emergency Dental Care

Teams Salaried Dental Services, Out of Hours Care primarily through Grampian Dental Emergency Service, NHS 24, General Dental Practitioners

Target groups Those in need of urgent or emergency care Those who wish access to a limited dental service without registration.

Functions Offer emergency and urgent out of hours care in liaison with a daytime unplanned care “access” service not leading to registration

Outcome Emergency and urgent care targets

Care Pathway - Intermediate primary care specialist services

Teams Salaried specialist and special interest teams Independent dental practitioners with a special interest

Target groups Children and adults with high need Special needs and special care groups Intermediate primary care specialist services for Oral Surgery and Oral Medicine Children and Orthodontics Restorative Adult Special Needs

Functions Organise and deliver local dental services within a clinical network with consultants, primary care specialists and dentists with special interest

Outcome Support delivery of National Access targets.

Support delivery of Teaching, Training and Education

NHS Grampian Dental Plan July 2008 21 16/07/08 Care Pathway - Secondary Care Services

Teams Consultant Secondary Care Dental service teams 3 Consultant led teams with 9 consultants

Target groups Secondary care referrals

Functions Specialist care and treatment Treatment planning for care in primary care

Outcome Support delivery of National Access targets for Better Care without Delay Care

Care Pathway - Teaching Services and Academic Secondary Care Service

Teams Aberdeen University through Aberdeen Dental School Consultant led teams with 6 teaching consultants NHS Education Scotland

Target groups Students and professionals

Patient groups Indirectly through the teams above

Functions Education, training, teaching and professional development

Outcome Education and training targets

Total Care Pathway

Care pathways will overlap between service units to deliver appropriate care services. It is essential that NHS Grampian clearly publicises with both professionals and patients the care systems and care pathways to ensure easy timely access for patients. The Information and Communication Plan will include Grampian Dental Help Line, NHS 24 and receptionist staff in all dental services.

Crosscutting services

Children’s Dental Services and the School Dental Service The Scottish Government has indicated that Scotland may require a school dental service. However 51%-57% of children are under the care of NHS family practitioners and it may be confusing to parents and children if the present school based dental service attempted to

NHS Grampian Dental Plan July 2008 22 16/07/08 offer full care to all children and remove them from the care setting where they are presently under care.

NHS Grampian should consider how the services outlined above could form an integrated Child Care Network with children offered care in a family setting where that is available but with a comprehensive care service offered to all preschool and school children for whom NHS dental care service is not available.

The School Dental Service should integrate into the above service through a community consultant-led child dental service offering the following services.  Annual inspection of all children starting and leaving primary school  Annual inspection of children starting nursery  Identification through the above 3 inspections of all children not under routine dental care  Integrated preventive service with Childsmile offered to all targeted children within all targeted schools  Referral of children with no dental disease or minimal dental disease in the previous 3 years to a general dental/salaried practice for family-based care  Identification of children not under dental care through collaborative integrated working across children’s services  Increased interaction with the school nurse service  Potential development of a school dental nurse system in designated areas linked to Childsmile There was no clear model suggested during the consultation and it is suggested that the development of a children’s dental service/school dental service should be a topic for further review.

Recommendation 8

NHS Grampian should develop dental service teams based on the pathways identified above. Priority should be given to the following service during 2008/2009 Childsmile – preventive and anticipatory care Emergency and urgent access Undergraduate teaching services Intermediate specialist care services

Recommendation 9

NHS Grampian should develop an Integrated Child Care Dental Service which incorporates Childsmile and a new School Dental Service

NHS Grampian Dental Plan July 2008 23 16/07/08 ORAL HEALTH IMPROVEMENT

Children

Successive national oral health surveys have revealed very high levels of dental decay in young children in Grampian, with children from the most disadvantaged communities commonly demonstrating the highest levels of decay. The problem often starts at a very early age.

If we are to tackle the problem, we need to ensure that children from all communities in Grampian access care regimes/pathways of care which emphasise the importance of good dental health, healthy eating habits and self/parental care from early childhood. This requires a partnership between a range of dental and health professionals, children, parents of children, carers and local organisations such as schools and preschool organisations.

Adults

Dental health has improved for many Scottish adults over the last 30 years. An estimated 100,000 more adults in Grampian, now have some natural teeth compared to 1972. The improvements that have been achieved in oral health are the result of more positive attitudes and behaviours of the general public, disease prevention programmes and improved dental services.

Despite these improvements, oral disease is still a problem for many Grampian adults and access to dental services is increasingly problematic with access being most challenging in the more rural areas of North Grampian.

The most recent 1998 Adult Dental Health Survey revealed that:

 41% of Scottish adults reported some dental pain in the past 12 months  56% of Scottish adults over 65 years had no natural teeth remaining

Services to improve dental and oral health

Improvements in oral health, particularly for children, cannot be achieved solely by those providing dental services. They require a multi-faceted approach, involving other sectors within the NHS and other statutory agencies, such as education authorities, and by tackling the broader determinants of poor oral health such as diet and smoking. Oral health improvement also needs commitment from the population - communities, individuals, patients and parents.

However, high quality, accessible dental services available to those who wish to use them are a key component for sustained improvement. Services should offer an opportunity for regular assessment of oral health needs (free examination), preventive care for those identified at highest “risk”, regular care and advice, and appropriate treatment to maintain and sustain oral health.

NHS Grampian Dental Plan July 2008 24 16/07/08 Effective programmes of care

National and local health plans have helped to inform the way forward towards improving oral health in Scotland. These programmes are most effective on the most vulnerable in society.

Action point –

Dietary change Foods and drinks high in sugar are the main cause of dental decay - a small can of sugared carbonated drinks contains 7/8 teaspoons of sugar.

 Improving the diet of people in Grampian has a central role in improving oral health. Good dietary habits should be established from the early years with home, school and community all playing a major part.  Opportunities exist for better promotion of healthy eating in the community with all health professionals supporting consistent information and integrated services.  A wider range of measures could be implemented in schools to reduce the availability of unhealthy food and improve healthy options.  The public requires improved education on healthy eating with clear, consistent and achievable messages.

Action point –

Improved self care Tooth brushing from early years with fluoride toothpaste has shown to be highly effective in reducing dental decay in children. For children, effectiveness is related to concentration of toothpaste and assurance of the process through supervision.

 Effective oral hygiene practice should be established at a young age, supervised by parents and carers.  Nurseries and primary schools should enable and facilitate good oral hygiene practice.  Children unable to maintain their oral health through simple self care should be supported through support for carers.

Action point -

Targeted preventive services for those in most need

Dental services can identify children at highest risk of dental disease and through anticipatory care offer effective preventive non-invasive treatments which are effective in substantially reducing dental disease in disadvantaged individuals and groups.

 Dental services should be based on a preventive philosophy, supported by a suitably modernised service.

NHS Grampian Dental Plan July 2008 25 16/07/08  Dental services for children should be targeted at those in most need, through targeted use of dental services.

Action point -

Integrated comprehensive services

Services for children should be integrated across all health professional groups and across all sectors of child care to deliver a unified consistent service.

Principles of care

 Children and families should be offered varying levels of support dependent on need.  Support, treatment, preventive advice and care should be offered within a quality assured system.

Summary:

There is a clear need for a robust and overarching strategy for children's oral health improvement. To achieve sustainable oral health in our children requires co-operation and partnership across communities throughout Grampian.

 Schools and local organisations are seen as essential partners to combat oral disease.  Schools and communities have a major role in developing good dietary and oral health habits.  Health and dental services need to be more pro-active in improving oral health, including undertaking a more community-orientated approach and adopting a modern and friendly image.  All services should ensure integrated consistent advice with particular action by midwives, health visitors, and health promotion teams.  Action to reduce the availability of sugary products in schools and nurseries and to promote healthier eating through the Health Promoting School concept will make a significant contribution to oral health improvement.  Dental practices should be supported and funded to develop as Childsmile practices.

NHS Grampian Dental Plan July 2008 26 16/07/08 General and crosscutting initiatives

The benefits of a multi-disciplinary approach to oral health are well-recognised. Benefits include improvements to both general health and well-being and to oral health. In order to tackle the causes of dental disease, it is essential that all those with responsibility for the care of children are clear on their responsibilities.

Health services and local authorities and individuals all have a key role to play.

Community Health Partnerships must build on the present progress and ensure that key agencies work together to ensure an integrated approach to improving oral health and securing the type of integrated care essential to improving the oral health of children.

NHS Grampian will:

 Establish an integrated comprehensive care system for children in most need  Enable and train, (with NHS Education Scotland) dental care professionals to deliver preventive care services for children  Ensure that oral health is seen as an integral part of health improvement actions in particular for children and young people  integrate professionals and related care programmes such as Scottish Framework for Nursing in Schools, Health Promoting Schools Programme etc  Empower professionals across all public services to contribute positively to oral health improvement through education and training  Give the responsibility to Community Health Partnerships to achieve a more co-ordinated approach across community-based services, to assess needs and respond through multi-professional and multi-agency action  Establish early contact with appropriate health professionals during pregnancy and in the first year of life to offer advice on weaning and oral hygiene practices and to establish the necessary skills, such as tooth brushing, essential to good dental health throughout life.

Within dental services, NHS Grampian will:

 Set up Childsmile Dental Teams at each CHP to be responsive to the needs of children  Childsmile teams will take a preventive care approach and delivered mainly by dental nurses and dental therapists/hygienists  Ensure that all dental services are child friendly  fund and support NHS dental practices to offer -Childsmile services in all communities in Grampian, initially targeting this development in the 20-30 practices delivering services to children with the greatest need  Implement through these teams, schemes to promote registration and associated preventive activity from birth  Integrated Care Pathway for all children which includes a comprehensive school preventive service with Childsmile teams offering through mobile services a nursery and school based preventive service for all children with high risk of disease who do not or cannot attend local dental services

NHS Grampian Dental Plan July 2008 27 16/07/08  Introduce a local Intermediate Specialist Children’s Service within each CHP through the salaried dental services offering a local service for those with extensive disease, dental trauma, special needs and urgent care  Within the above service offer local orthodontic treatment within a clinical care network led by the Hospital Dental Service for those children and young people who are assessed under the Index of Orthodontic Treatment Need (IOTN) as having defined clinical need

The following targets will be used as operational targets for each Community Health Partnership (CHP)

Infants and Preschool Children (under 5 years) By 2010  All infants and preschool children identified as high risk or with dental disease in their preschool years will have an offer of access to local dental care as infants or on starting nursery school and together with their parents and carers will have access to dental advice  The number of children aged 0-2 years under dental care/supervision will increase to 55% (2007 24.6%)  The number of children aged 3-5 years under dental care/supervision will rise to 80% (2007 59%)  Pre-school children in areas where dental disease is highest will be offered dietary advice, preventive dental advice packs, support and access to the Childsmile programme in a practice, nursery or school through community based organisations and dental services  All nursery schools will offer supervised fluoride tooth brushing schemes and support healthy eating and drinking (water) policies  Children with the highest risk of dental disease should be offered access to enhanced preventive services through Childsmile  All infants aged 6 months to 1 year will receive a toothbrush, toothpaste and health information.  Older preschool children and children in nurseries in communities with high need will receive health promoting dental packs  Dental programmes will link with and support present community- based programmes providing dietary advice, water fountains and fresh fruit

School Children (6-12 years) By 2010  All children starting school will receive preventive information packs  All primary school children will receive a risk assessment and be offered oral health advice on starting and finishing primary school (National Dental Inspection Programme )  30% of primary schools in communities with the highest need (estimated 90 schools) will be offered supervised tooth brushing in P1 and P2  All small schools with less than 50 pupils will be offered total school tooth brushing programmes

NHS Grampian Dental Plan July 2008 28 16/07/08  All schools will demonstrate their support for healthy eating and drinking (water) policies through the Health Promoting Schools Programme  Children in primary schools who do not access routine care or preventive care through the general dental services will be offered care through the salaried dental services  Children in primary schools with high need as identified through the National Dental Inspection Programme will , if they do not access an intensive preventive service through their general dental practitioner be offered intensive preventive care through Childsmile

12+ years - Secondary School By 2012  All secondary schools will have an Oral Health Promotion Programme which links to holistic health promotional programmes for teenagers  Extend care to older children aged 12-15 years who are unable to receive care through a general dental practitioner where possible delivering care in the local community through the salaried dental service

As children become teenagers, with growing independence and freedom of choice, we must ensure that we enable them to make the healthy, informed choices which will safeguard oral health. This is a key stage where participation in sport has a valuable contribution to make to general health and well-being. It is important that young people are given appropriate advice at this time on preventing dental trauma and protecting teeth from injury.

Most importantly, we must ensure that health and education partners work together with young people to raise awareness of good oral health and that they are fully informed of the impact of smoking and alcohol on oral health, particularly in relation to oral cancer.

Adults and Older People

In addition to delivering comprehensive services for adults with special needs and high need, NHS Grampian needs to deliver preventive services to targeted groups of adults not only in the community but also within institutions such as prisons or care homes.

The following targets will be used as operational targets for each Community Health Partnership (CHP)

Adults By 2012  Develop and deliver oral health care preventive support programmes for adults in most need - Adultsmile o Prisoners o Homeless o Elderly in care o Elderly in home care o Adults with special needs

NHS Grampian Dental Plan July 2008 29 16/07/08  Promote oral health through Healthy Working Lives  Have in place appropriate oral health care and support programmes for all elderly care homes and the elderly in home care  Registration levels for 65-74 year olds should increase to 60% (2007 24%)  Registration levels for people aged 75 years and over should increase to 40% (2007 15%)  Older people with special needs will have individual care programmes and be part of a preventive support programme  Prisoners and the homeless have access to dental services

Recommendation 10

NHS Grampian should adopt a guarantee of 12 weeks for routine care of children under 12 years of age and seek to set a similar target for all children under 16 years of age.

Recommendation 11

NHS Grampian should adopt the above health improvement programme targets for monitoring performance of the Dental Plan

NHS Grampian Dental Plan July 2008 30 16/07/08 ENHANCED DENTAL SERVICES

Enhanced services through local contracting

NHS Grampian should develop a package of measures to modernise NHS dental services so that they can be readily accessed by those who need them. The national contract is inflexible to local needs and in order to develop locally responsive services NHS Grampian should consider how to develop local enhanced contracts based on the needs of local communities.

Clinical services considered suitable for such contracts would include: Preventive care services Access, Out of Hours and urgent care Specialist services

NHS Grampian is responsible for planning and securing the provision of NHS dental services to meet local needs. Community Health Partnerships (CHP) will play a key role in promoting a more co-ordinated approach to community based services and supporting clinical networks.

It has been acknowledged that the current dental remuneration system has become outdated and does not adequately support the development of the quality assured services essential to improving oral health.

Therefore, to complement the national contract system, NHS Grampian should develop a local system of contracting, with enhanced contracts for designated services. A local contract framework should initially be developed Grampian-wide prior to moving to local service contracts as part of the responsibility of CHPs.

The Scottish Government will continue to improve national remuneration. Local contractual arrangements through NHS Grampian should develop as complementary forms of remuneration funded by NHS Grampian core allocation to complement the present system i.e. locally commissioned enhanced services. Conditions of these enhanced services should be reviewed as the Scottish Government announces any change to the statement of dental remuneration.

Services considered in this plan for local (enhanced) contracts  Child care programme for those with high need (Childsmile sessions)  Out of hours and urgent appointment system  Specialist care  Quality standards related premises and services

Governance arrangements for these payments will safeguard NHS Grampian where dentists do not fulfil the conditions of the local contract to the defined quality standards.

Recommendation 12

NHS Grampian should support the development of enhanced service contracts for dental practitioners. NHS Grampian Dental Plan July 2008 31 16/07/08 IMPROVING and MODERNISING DENTAL PREMISES

Dental premises Dental premises in NHS Grampian fall in to the following categories: Primary care premises 65+ Estimated Independent dental practices. Normally capital funded (or leased) by dentists themselves 15+ Salaried and Community practices built and funded by NHS Grampian. These are located in health premises. 11 These practices are located in schools owned by local authorities. 5 Mobile dental caravans

Secondary care premises Hospital dental service departments in Aberdeen Royal Infirmary and Dr Gray’s, Elgin.

New premises and premises modernisation programme

Many of the premises developed for dental services were not designed for the purpose but are modified from previous use such as shops or homes. Recent regulations have been introduced on Health and Safety, Disability access and discrimination. Premises are regularly inspected against set standards. However recent review of standards for decontamination and disability access would suggest that the majority of the premises are not fit for purpose and require significant investment to achieve national standards. Scottish Government recognised this need in 2000 and again in 2005 through allocation of substantial resources to NHS Grampian to progress this process with new developments throughout Grampian. NHS Grampian has recently started investment plans through financial support for both NHS Grampian developments and by supporting independent practices. Planning to date has been opportunistic with developments identified where space and need and finance coincided.

Estimates would suggest that from 50% to 80% of the dental premises will not be fit for purpose by 2010. A premises survey/assessment has now started. This will result in a programme to identify and prioritise developments and to plan improvements which may take over 10 years. Throughout this process priority will be given to those practices with the highest levels of NHS commitment.

NHS Grampian Dental Plan July 2008 32 16/07/08 A substantial programme of premises improvements and development is essential to provide facilities to meet professional standards and patient needs. This should include addressing health and safety, infection control and disability issues. NHS Grampian should invest resources to complement resources from the Scottish Government. These combined resources should allow the following developments.

 Develop at least 100 new primary care dental surgery/chair spaces for an expanded service over the next 4 years  Modernise and/or expand suitable practices  Develop child and patient-friendly practices  Support practices to maintain and deliver “safe” services  Identify through a locality planning system the number of primary care facilities from which NHS dental services are available  Facilitate amalgamation, relocation to new premises or replacing unsuitable premises  Ensure incentives to open up new facilities or take over existing practices in areas of high need/demand  Consider a range of options to facilitate these processes including third party developments.

The above should guide the premises plan.

Recommendation 13

NHS Grampian should undertake a survey of all premises used for dental care and develop and resource a plan to modernise and improve premises offering NHS dental services.

NHS Grampian Dental Plan July 2008 33 16/07/08 IMPROVING INFORMATION and COMMUNICATION

Use of information technology and health information to support health is somewhat limited in primary care dental services. It is essential that dentistry adopts an information ethos that supports health improvement and patient-sensitive standards of communication. Extending use of information and communication services is a vital component in improved clinical care and health.

NHS Grampian in partnership with other Special Health Boards particularly NHS Education Scotland and NHS 24 should support  Support the introduction of a comprehensive programme of support for information technology to link all dental services to the NHS net  Provide support to practices for training for approved clinical systems  Develop an information network to give accurate and timely advice to patients Patients need access to information on improving and sustaining oral health together with information on accessing dental services when they need them, particularly when urgent care is required. NHS Grampian will build on the expertise of NHS 24 and NHS Grampian in delivering emergency dental care and will seek to support the development of a new integrated dental access, urgent and emergency service.

This service will:

 Provide better information to patients about oral health, service availability, and about rights and responsibilities  Ensure a "help-line" for local people to help them access services  Provide with NHS Education Scotland support for the training and development of staff, including practice managers and receptionists. Joint training will facilitate an information network which delivers accurate timely information to patients and the general public.

Targets By 2010 Everyone in Grampian will be able to access advice and support on dental health and dental services through NHS 24 By 2010 All patients will be able to access urgent care within 24 hours By 2010 All patients with a dental emergency will be linked with the emergency dental service (professional advice) within 1 hour

Recommendation 14

NHS Grampian in partnership with NHS 24 should ensure that the general public has easy access to information on oral health. Initial priority should be given to developing and promoting information concerning the urgent and unplanned care dental network.

NHS Grampian Dental Plan July 2008 34 16/07/08 PATIENT CHARGING POLICY

The majority of adult patients pay for dental services, whilst children are excluded from most charges, but can be charged for some services – for example a gum shield. Traditionally patients who visited hospitals or the Community Dental Services did not pay for their dental care. The regulatory framework for service charges will change as the Salaried Dental Services merge with the Community Dental Services. The intermediate specialist care service will be required to charge patients who are referred from the Hospital Consultant Service for care.

NHS Grampian needs to set out a clear charging policy for dental staff and patients. This policy should include clear patient information and ensure appropriate standards of financial governance. Patients and the general public must be appropriately advised on NHS dental service charges normally through both verbal and written communication.

NHS Grampian will require to set up a system whereby:

 defined patient groups clear charging policy for defined treatments e.g. child gum shield  clear policy where a service is offered free of charge e.g. dental care for terminally ill patients  clear charging policy where no NHS patient charge exists e.g. for a dental implant

Recommendation 15 NHS Grampian should support the development of a dental charging policy for all NHS Grampian Dental Services. Policy will need to be consistent with other Health Boards across Scotland.

NHS Grampian Dental Plan July 2008 35 16/07/08 QUALITY STANDARDS, CLINICAL GOVERNANCE and CLINICAL EFFECTIVENESS

Dental Standards

NHS QIS (Quality Improvements Scotland) and the Care Commission have identified comprehensive patient-based standards for dental services in primary care. Whilst elements of these standards are being achieved there is at present no overarching structure to implement or monitor these standards.

Patients have the right to expect high quality services delivered by a range of well- trained health professionals in premises suitable for the delivery of that care. NHS Grampian should support professionals in delivering the highest standards of oral health care. NHS Grampian should base their system on the primary care dental standards developed jointly by NHS QIS and the Care Commission.

In addition to the support for dental infrastructure and premises outlined earlier in this plan the following should be integrated into a comprehensive quality assurance system:

 Service quality through continuing professional development and audit  Practice visits/inspections for all dental practices within a 3 year cycle  Develop an “accreditation" scheme for NHS dental practices and provide financial support to practices linked to inspection and accreditation  Monitor clinical care through the Regional Dental Officer system  Monitor clinical care through local contracting framework  Encourage and support each practice to develop practice development plan.  Support the development of more advanced skills for all dental professionals so that practitioners with special interests can provide community based “specialist” services  Risk Assessment, critical incident analysis and risk management  Regular patient feedback on care received.

. In order to progress the above systems, NHS Grampian should set up a Dental Quality Improvement Group/Dental Clinical Governance Group to steer, monitor and support the development of quality standards in Grampian dental services. This group should link and report through the NHS Grampian Clinical Governance structure.

NHS Grampian Dental Plan July 2008 36 16/07/08 Supporting Quality: the Dental Clinical Effectiveness Programme

NHS Grampian should develop local support mechanisms for dental professionals who are identified as exhibiting signs of concerning clinical care

It is essential that oral health services and treatments are underpinned by evidence of effectiveness. There is already in place a range of published clinical standards and guidelines in dentistry. In addition there is a Scottish Dental Guideline Group. NHS Grampian Dental Quality Improvement Group should ensure it liaises with the national group and promotes the uptake of any new guidance.

Recommendation 16

NHS Grampian should adopt the NHS QIS /Care Commission dental standards and develop a system to monitor and measure the standards.

Recommendation 17

NHS Grampian should set up a Quality Improvement /Clinical Governance Group which links with and reports through the NHS Grampian Clinical Governance structure.

NHS Grampian Dental Plan July 2008 37 16/07/08 EDUCATION and TRAINING to DEVELOP and ENHANCE THE WORKFORCE It is essential that if NHS Grampian is to achieve the aim of securing improvement in oral health and health services, we must act now to ensure that current workforce issues do not restrict our ability to deliver the comprehensive service to which we aspire.

Workforce numbers

Dentists

Although the number of dentists in Grampian has increased by 70% since 1975, and continues to rise steadily, NHS Grampian does not have enough dentists to meet our needs. Presently NHS Grampian has some of the lowest levels of dentists to population ratio in Scotland, UK and Europe.

Estimates of future workforce needs should be based on  Ratios of dentists to population in the UK with NHS Grampian recording one of the lowest UK ratios  Adjacent Health Board (Tayside) with almost double the rate of dentists/head population  Scandinavian countries with ratios of 1 dentist to 1000 population or less  Need for NHS Grampian to register an additional 124,000 patients by 2012 which would be equivalent to a dentist workforce of over 60 additional dentists  Concern that NHS Grampian has some of the poorest oral health in UK for children and adults  Concern at the poor services for the priority groups in Grampian with only 15% of the elderly (75+) registered with the NHS in Grampian

Based on the above levels NHS Grampian requires at least 77 extra primary care dentists over the period 2007-2012. A further 20 dentists are required to be involved with education and training and the new dental school, and a further number needed for an intermediate specialist service and for access. In total it is considered that based on September 2007, 20 additional dentists each year to 2012 i.e. 100 extra dentists by September 2012. The targets set in the earlier workforce section will act as indicators for this target.

Dental care professionals

The dental team relies considerably on other professionals to support the dentist. Dental care professionals in the past have not been used as effectively as they should. There are considerable treatments that dentists presently undertake that could be done by a dental therapist. A recent article suggested that over 50% of present NHS dental treatments could be done by therapists. Dental nurses could play an increasing role in preventive care (e.g. Childsmile programme) but also participate in a wide range of associated care such as triage as part of an emergency out of hours care system

NHS Grampian Dental Plan July 2008 38 16/07/08 The number of dental nurses and dental therapists in Grampian needs to expand. Training targets are outlined below.

Dental education and training plan In the process of planning future dental services in line with this plan NHS Grampian needs to identify the gaps and service developments needs. This analysis would inform the service on the educational/workforce development of present staff. This analysis would also inform the development of a comprehensive education and training plan for NHS Grampian which would be produced in liaison with NHS Education Scotland. NHS Grampian should develop an education and training plan for dental services which  trains and delivers new professionals for the North of Scotland  develops the present workforce through additional skills to deliver enhanced services

Aberdeen Dental Outreach Centre – dental students 2006 onwards The opening of this facility in 2006 increased the profile of NHS Grampian with Dundee undergraduate dental students. It allows 6 to 10 students at any one time to visit Aberdeen and helps to attract young graduates to the area.

Aberdeen Dental Education Centre The opening of this centre in 2006 considerably increased the facilities in Aberdeen for dental education with lecture theatre, seminar rooms and a clinical skills unit.

Aberdeen Dental School – dental graduates 2013 onwards Developing an undergraduate dental school in Grampian within the next 2 years is a significant challenge. It is estimated that a minimum school size should be at least 20 undergraduates a year with a total student population of 80 students. A project development group linking the Universities of Dundee and Aberdeen and led by NHS Grampian is tasked to deliver the project including the academic staff and the new dental school building by September 2009. It is intended that the school will be a graduate entry school. NHS Grampian needs to support workforce development of the local staff that may be involved in the project both professional and support.

Targets 2008 -2015 to achieve with key partners including Aberdeen and Dundee Universities and NHS Education Scotland

Dental School  Develop and deliver with key partners a new dental school in Aberdeen by 2009 which focuses on supporting dental services across the whole of the North of Scotland Dentists  From 2013 onwards deliver 20 new graduates annually from Aberdeen University  By 2009 deliver 20 1st year vocational training posts

NHS Grampian Dental Plan July 2008 39 16/07/08  By 2010 deliver 25 1st year training posts  By 2013 deliver up to 40 places ( 1st and 2and year) in a 2 year Foundation Programme  Develop and support training courses to deliver dentists with enhanced skills/dentists with special interest with a view to delivering 3 or 4 annually from 2009 onwards

Dental therapists

 Encourage dental therapist graduates to consider NHS Grampian as an area for permanent employment through offering experience in the dental outreach centres for students from Dundee University and the University of the Highlands

Dental nurses

Deliver with NHS Education:  Dental nurse training school/courses which delivers at least 40+ new dental nurses annually between 2008 and 2010  A dental nurse training centre in Elgin in addition to Aberdeen City  Courses for enhanced skills for dental nurses  Train over 30 Childsmile dental nurses by 2009/10  Train at least 5 dental nurses with enhanced skills annually thereafter

Increasing the workforce numbers, workforce development and appropriate recruitment of skilled dental staff will be one of the largest challenges for NHS Grampian over the next 5 years. There are issues which will continue to influence the need for a considerably increased workforce.  More elderly people keeping their teeth well into their old age  Continued increase in demand for more advanced restorative care such as implants  Increase in non-NHS demand  Increased early retirement of dental professionals  Increased part-time working by dental professionals  Increased dental professionals contributing to teaching and quality standards

Additional issues that could impact on workforce development

Modern services and innovative approaches such as teledentistry will allow new approaches to working practices, service delivery, and education and training. Technology will allow more flexible ways to support oral health care needs, particularly in remote communities.

Return to work and keeping in touch schemes for those wishing career breaks are an important component to recruitment for all dental professionals.

NHS Grampian Dental Plan July 2008 40 16/07/08 NHS Grampian may be unable to recruit dental professionals with advanced skills required for the new services and therefore training a number of dental professionals locally is an option which must be considered.

Recommendation 18

NHS Grampian should adopt the above workforce targets for annual recruitment and training of members of the dental team to ensure that it has a workforce to achieve the dental services identified in this plan.

NHS Grampian should aim to recruit a minimum of 60% of the professional staff into independent dental practice.

Recommendation 19

NHS Grampian should develop a recruitment strategy for dental professionals. NHS Grampian should identify a dental training budget to deliver the workforce above.

NHS Grampian Dental Plan July 2008 41 16/07/08 MONITORING and EVALUATION

It is essential that the development of the above plan including the targets and services proposed are monitored and evaluated to ensure that the outcomes are consistent with the proposal. Building on existing work, the creation of a practice governance and quality assurance process and the creation of a Dental Plan Delivery Manager (DPDM) who will provide dedicated support to the Dental Plan Delivery Team (DPDT) to ensure that the system remains focused on performance management and delivery of the key service targets. The Dental Plan Delivery Team (DPDT) will identify a core data set for regular monitoring and evaluation of the above plan. The minimum data set will include CHP data and local area data to allow monitoring of services, oral health and workforce within defined localities.

Minimum data set for locality planning  Oral health of children and adults  NHS dental services and registrations  Standards of premises from which NHS services are offered.  Quality assurance information on services provided  Dental workforce  Patient satisfaction

Traffic Light system

Initially the Dental Plan Delivery Team will monitor a performance of our key targets) contained within this Plan through the Traffic Light system, agreeing with our CHP colleagues appropriate trajectories where possible. In the medium term reporting and performance management will be delivered through CHP structures aggregating up to NHS Grampian performance, which will be reported though the Consultant in Dental Public Health.

Special Health Boards and links with partners Quality, health improvement, education and training, information and out of hours care are core issues highlighted in this action plan. These functions are all remits of Special Health Boards in Scotland. The plan will require NHS Grampian to develop and maintain collaboration with all of the Special Health Boards and involve close working with representatives of the service, the public, the professions and academic institutions.

Recommendation 20

NHS Grampian should agree a programme and timetable to monitor and evaluate the Dental Plan.

NHS Grampian Dental Plan July 2008 42 16/07/08 RESOURCING the Dental PLAN

A flexible approach requires to be nurtured in order to retain existing NHS practices and to encourage new NHS practices to establish the facilities necessary to support future NHS activity and the training of professionals to deliver this activity.

Programme 1 – Building Capacity – Capital Investment

Most existing dental practices in Grampian, private and NHS, use all available accommodation to support current levels of service delivery. The key risk to the deliverability of the action plan is therefore the availability of the infrastructure and a sufficient number of dental surgeries to support recruitment of the required 60-70 additional mainly independent dentists.

There are essentially two stages in the creation of additional capacity.

Stage 1 - Train more first year vocational trainees (dentists) - Grants to expand or improve premises in support of Vocational Training (£1m 08/09 and £1m 09/10)

We must provide sufficient additional training surgeries to service the numbers of first year vocational trainees we hope to attract. The intention is to place trainees with existing practices and to encourage those practices to take a fresh intake of trainees on an annual basis.

This initiative will create the infrastructure necessary to support the annual increased training requirement as the number of trainee’s increase in line with the NHS Grampian Dental Plan. Practices will be required to provide a written undertaking that vocational training will be carried out in the practice for at least four out of the next five years. Practices will also be required to increase the level of NHS dental registrations in the first two years rising to a guaranteed minimum level at the end of year two which will be maintained in each of the next three years. Vocational trainees undertake 100% NHS activity.

Stage 2 - Retain trainees in Grampian on completion of training - Grants to expand or improve premises in support of dentists in general practice including existing premises’ compliance with decontamination and Disability Discrimination Act (DDA) regulations (£9.4m over next 4 years)

Once the trainees are fully qualified it will be necessary to create further additional dental surgeries to allow the now fully qualified dentists to enter practice and remain within Grampian.

NHS Grampian Dental Plan July 2008 43 16/07/08 Financial Consequences of Programme 1 - Capital

The following table details the capital resource impact of implementing the proposed service changes in line with the recommended actions:

Phased Financial Impact - Total planned changes

Capital 2008/09 2009/10 2010/11 2011/12 Total New £000s £000s £000s £000s £000s NHS Regs

Vocational training 1000 1000 2000 19500 Decontamination 500 2500 1500 1500 6000 Existing Establish New practices 750 750 750 750 3000 105000 Upgrade community Clinics and caravans 100 100 100 100 400 Existing

Gross Impact of Program 1 Building Capacity 2350 4350 2350 2350 11400 124500

Available Funding : SGHD Decontamination allocation (estimated) -400 -400 -400 -400 -1600 NHSG Capital Identified in LDP (AIG final approval pending) -1000 -1000 -2000

Net Balance of Capital Funding required 950 2950 1950 1950 7800 124500

Capital funding of £11.4m over the four year period of the plan is required to deliver the program. Presently £2m of this investment is identified as part of the agreed NHSG LDP for 08/09 and around £0.4m per annum of national funding towards decontamination can be expected. No identified source of funding exists to meet the balance of the expenditure (£7.8m) although one potential source of funding is the Scottish Government Dental Access Initiative against which individual practices can make application for grant funding.

 This figure assumes that 20 vocational training surgeries, 60 new general dental surgeries, 120 existing general dental practice surgeries and 19 community dental surgeries to be upgraded or replaced, and an average of 3 surgeries per practice.

 Grant calculation £100k per practice and £25k per additional surgery. Vocational training grants are £100k per practice.

 There are no revenue consequence to NHS Grampian associated with Programme 1. All proposed capital grants are to improve independent practice owned premises and will not attract capital charges. Practices will service their own salary and running costs from charges for dental services provided within the premises.

NHS Grampian Dental Plan July 2008 44 16/07/08 Programme 2 - Recruitment

Recruitment efforts will continue across independent and salaried GDP services in parallel to Programme 1. It is intended to ensure that physical capacity can be utilised immediately it becomes operational. All costs associated with recruitment and retention including all salary and operating costs of practices once established will be met through the Demand-Led Non Cash Limited Allocation for General Dental Services. There is no revenue consequence to NHS Grampian of progressing Programme 2 under the current financial regime. It should be recognised however that there may be a future risk should the dental services allocation be moved to form part of NHS Grampian’s unified budget in future years.

Programme 3 – Health Improvement

The SHGD have made a substantial allocation available on a recurring basis specifically to target children and this will be applied effectively over a number of initiatives aimed at hitting the targets for dental disease in the younger age groups. The main cost pressure in this program for which there is no identified source of funding relates to the requirement to establish a dedicated resource to plan and lead the education and health improvement strategy for dentistry. Several of the key performance targets for NHS Grampian are “oral health improvement” targets and this resource is deemed essential if NHS Grampian is to deliver against these.

Programme 4 –Efficiency and Patient Pathways of Care

The SGHD have made a specific allocation available on a recurring basis to support emergency dental care. This funding will be targeted at a local enhanced service covering targeted Grampian NHS practices. The main cost pressure in this program for which there is no identified source of funding relates partly to the planned development of dentists with a specialist interest in oral surgery and, restorative surgery. Potentially this initiative will shift some activity from the acute specialist service into primary care and may create the opportunity to self-fund through resource transfer. However the main development would be to offer local community based services and reduce referrals to specialist services.

The other planned developments that require to be funded relate to the creation of a practice clinical governance and quality assurance process and the creation of a Dental Plan Delivery Manager who will provide dedicated support to the Dental Plan Delivery Team to ensure that the system remains focused on performance management and delivery of the key service targets.

A final component is a training resource to facilitate the development and maintenance of the above systems and programmes.

NHS Grampian Dental Plan July 2008 45 16/07/08 Summary revenue financial consequences –Programmes 2, 3 and 4 - Revenue The following table details the revenue resource impact of implementing the proposed service changes in line with the recommended actions: Phased Financial Impact - Total planned changes

Revenue – annual incremental costs 2008/09 2009/10 2010/11 2011/12 Recurr Activity £000s £000s £000s £000s Total £000s PROGRAM 2 – RECRUITMENT

Additional Independent GDPs 2700 2700 2700 2700 10800 as above Additional salaried GDPs 450 450 450 450 1800 As above Salaried intermediate care dentists 450 450 450 450 1800 500

Gross Impact of Programme 2 Recruitment 3600 3600 3600 3600 14400

Available Funding :

SGHD Demand led NCL General Dental Servs -3600 -3600 -3600 -3600 -14400

Net Balance of funding required for programme 2 0 0 0 0 0

PROGRAMME 3 – HEALTH IMPROVEMENT

Enhanced Practice Contracts 100 80 80 80 340 12500 Nursery/School Toothbrushing 100 70 15 15 200 14000 Childsmile Dental Nurse Teams 100 100 60 60 320 5000 Health Promotion 50 50 NOS Co-ordination 70 0 North Scotland Supervisory Role 80 80 Dental Public Health Team 175 50 50 275

Gross Impact of Programme 3 500 425 205 205 1265

Available Funding :

SGHD Childsmile allocation (predicted 2010 onwards) -700 -150 -150 -1000

Net Balance of funding required for programme 3 -200 425 55 55 265 Health Improvement

PROGRAMME 4 – EFFICIENCY AND SHIFT IN BALANCE OF CARE

Emergency Care 100 60 20 20 200 Specialist Services (Oral/Restorative surgery) 100 25 25 150 Quality Practice awards 50 25 75 Patient questionnaire 25 25 Practice Inspections 25 25 Practice audit 50 50 Action Plan Delivery Manager 23 23 46 Education and Training 25 25 25 25 100

Gross Impact of Program 4 Efficiency and Patient 148 283 145 95 671 Pathways of Care

Available Funding :

SGHD Allocation for Emergency Care 160 10 10 20 200 -12 273 135 75 471 Net Balance of funding required for programme 4

Overall Net Revenue Funding requirement -212 698 190 130 736

NHS Grampian Dental Plan July 2008 46 16/07/08 APPENDICES

Appendix 1 – Summary Report of Public Feedback

NHS Grampian Dental Plan July 2008 47 16/07/08