NHS pilots in primary care--an insight into the future?

UNLABELLED: This article looks at the background to the current changes in primary care dentistry being piloted in England. It looks at the structure of the different elements being piloted, such as the oral health assessment, interim care appointments and care pathways. It also examines advanced care pathways and how complex care will be provided when clinically feasible and beneficial to the patient. The authors have worked in a type 1 pilot practice since September 2010. CLINICAL RELEVANCE: The NHS contract currently being piloted in England delivers care through care pathways and clinical risk assessments with prevention as an important building block for the delivery of services. There are new measures planned for measuring quality outcomes in primary care. This has implications for how services are delivered, who delivers them and how dentists will be remunerated in the future.

Incentives and remuneration systems in dental services.

The aim of this study was to examine the effects of an incentive-based remuneration system on number of individuals under supervision and on quality of public dental services in Norway. The basis for the study was a natural experiment in which all public dental officers in one county were given the opportunity to renegotiate their contract from a fixed salary contract to a combined per capita and fixed salary contract. Comprehensive data were collected before and after the change. A main finding is that the transition to an incentive-based remuneration system led to an increase in the number of individuals under supervision without either a fall in quality or a patient selection effect.

Evaluation of the end user (dentist) experience of undertaking clinical audit in a PCT-led NHS Modernisation Agency pilot scheme.

INTRODUCTION: A new dental contract was introduced in the National Health Service (NHS) General Dental Services (GDS) in April 2006. Responsibility for clinical audit activities was devolved to Primary Care Trusts (PCTs) as part of their clinical governance remit. In July 2003, an NHS Modernisation Agency pilot scheme for clinical audit was launched by Southend PCT. AIM: The aim of this study was to evaluate this scheme. METHODS: A qualitative research method was used. It used audiotape recorded semi-structured research interviews with eight general dental practitioners (GDPs) who had taken part in the scheme. The evaluation focused on dentists' experiences of the scheme. RESULTS: Dentists appreciated the central PCT-based coordinator for the scheme and found that the streamlining of design, analysis and report writing within the audit projects enabled efficient use of time. The design by an outside agency appeared to add credibility to the scheme. Participants felt that comparability of data derived from clinical audit was enhanced by the scheme and could lead to comparison across PCT patch, regional or even national levels. The use of feedback mechanisms within the scheme was appreciated and thought to help produce maximum value from a clinical audit project. There was evidence of beneficial change occurring within practices and for patients. CONCLUSIONS: This study provided an evaluation of a particular clinical audit scheme, several aspects of which differed from the traditional GDS scheme. Organisations proposing to undertake clinical audit activities in conjunction with dentistry in the future may benefit from incorporating elements of this scheme into their project design.

Developments in oral health policy in the Nordic countries since 1990.

PURPOSE: There is a number of systems for the provision of oral health care, one of which is the Nordic model of centrally planned oral health care provision. This model has historically been firmly based on the concept of a welfare state in which there is universal entitlement to services and mutual responsibility and agreement to financing them. This study reports and analyses oral health care provision systems and developments in oral health policy in the Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) since 1990. MATERIAL AND METHODS: Descriptions of and data on the oral health care provision systems in the Nordic countries were obtained from the Chief Dental Officers of the five countries, and contemporary scientific literature was appraised using cross-case analyses to identify generalisable features. RESULTS: It was found that in many respects the system in Iceland did not follow the 'Nordic' pattern. In the other four countries, tax-financed public dental services employing salaried dentists were complemented by publicly subsidised private services. Additional, totally private services were also available to a variable extent. Recently, the availabilty of publicly subsidised oral health care has been extended to cover wider groups of the total population in Finland and Sweden and, to a smaller extent, in Denmark. Concepts from market-driven care models have been introduced. In all five countries, relative to the national populations and other parts of the world, there were high numbers of dentists, dental hygienists and technicians. Access to oral health care services was good and utilisation rates generally high. In spite of anticipated problems with increasing health care costs, more public funds have recently been invested in oral health care in three of the five countries. CONCLUSION: The essential principles of the Nordic model for the delivery of community services, including oral health care, i.e. universal availability, high quality, finance through taxation and public provision, were still adhered to in spite of attempts at privatisation during the 1990 s. It appeared that, in general, the populations of the Nordic countries still believed that there was a need for health and oral health care to be paid for from public funds.

The historical and political background to the proposals for local commissioning of primary dental care by primary care trusts.

This paper provides a background to the changes that are about to occur in the system for primary oral healthcare delivery in the NHS. This is part of a far wider reform programme involving all public sector services. The challenges that the Government faces are not unique: all countries are striving to alter their care systems to address the changing expectations of the electorate while attempting to control both the costs and inequalities. What is unique to the United Kingdom is the historical legacy of the NHS and its political importance, which should not be underestimated. An overview of the agenda for change in all parts of the health sector is presented. This is followed by a more detailed analysis of the proposals for future delivery of primary oral care in the NHS and the subsequent issues arising. A consistent theme running throughout the Government's agenda is devolution. Indeed, the detailed programme discussed in this paper applies only to England and Wales. The fact that Scotland has different plans highlights the importance of the political and cultural setting to any reform programme.

Linking clinical audit in general dental services to primary care trust clinical governance -- progress report of an approach used in Southend.

Clinical audit has been defined as the systematic, critical analysis of the quality of dental care, including the procedures and processes used for diagnosis, intervention and treatment, the use of resources and the resulting outcome and quality of life as assessed by both professionals and patients. The aim of clinical audit is to encourage dentists to self-examine different aspects of their practices, to implement improvements where the need is identified and to reexamine, from time to time, those areas that have been audited to ensure that a high quality of service is being maintained or further improved. Since 1st April 2001, all general dental practitioners (principals and assistants) working in the General Dental Services (GDS) have been required to participate in a rolling programme of at least 15 hours of clinical audit or peer review every three years. The first three-year cycle ended on 31st March 2004. By the end of December 2003, 96% of dentists had either under- taken or committed to undertake clinical audit/peer review activities. This initiative, in conjunction with the voluntary clinical audit and peer review schemes which preceded it, has provided opportunities for dentists and their practices to use these activities to assist in quality improvements in their practices, for the benefit of their patients. However, there are other methods for carrying out clinical audit and, in the NHS, there is a need to link it to clinical governance. This paper gives a progress report on an approach that has been piloted by Southend Primary Care Trust (PCT). It deals with the rationale for the project and outlines the methods used. It does not report results. These will follow in a subsequent paper.

Opportunities for the dental team arising out of the new arrangements for primary dental care.

Many changes are occurring in the delivery of dental care to patients as a result of the implementation of a series of Government initiatives to improve the services to patients throughout the National Health Service (NHS). Dentistry is no exception, and the whole dental team should benefit from new opportunities that have opened up as a result of these changes. This paper outlines a number of these initiatives, and describes some of the potential opportunities that may develop for each group within the dental team. Many of these changes are already in the pipeline, many depend on funding, and many depend on a change in the mindset of established organisations and institutions to think 'outside the box'. The author believes that none of the changes outlined or discussed in this paper challenge the position or status of any group; however, they do require all members of the dental team to examine the way in which they work, to look at the evidence base for these ways of working, and then perhaps look for innovative solutions to the employment, training and development of all members of the team.

Introducing dentists with special interests (DwSIs) -- past, present and future perspectives.

This paper provides the national context for the development of practitioners with special interests (PwSIs) in light of the recent introduction of the concept to dentistry. Given the shortage of specialists and consultants in some dental specialities and the fact that a number of referrals could be managed in the primary care sector, the development of an additional tier to bridge the gap between current capacity and demand for services in secondary care seems to be a practical solution. The introduction of the DwSI and the future training opportunities it affords will pave the way for the development of a cadre of accredited primary care practitioners with enhanced skills who, together with their secondary care colleagues, will help widen the choice available to patients in terms of the nature and locality of NHS dental care provided. In time, DwSIs may wish to train to become full specialists or consultants and have their accredited prior learning and experience recognised towards completion of full specialist training.

Outlook of British dentists towards their profession.

Dental practice in Britain has undergone significant changes in recent years. These changes have undoubtedly affected the outlook of dentists towards dentistry. This study was undertaken to examine the current outlook of general dental practitioners working in the General Dental Service. A representative sample of 1000 dentists was surveyed by mail. The response rate was 73.7 per cent. Most characteristic of the respondents' outlook on various aspects of their profession is the wide diversity of opinion. Neither respondent gender or practice location were associated with outlook. More preventively oriented dentists and those whose practices were most busy, however, were found to have a more positive outlook.

The development and practice of social dentistry in Germany.

The traditions of social dentistry in Germany represent early forms of dental public health development. It was promoted in dental care facilities where salaried dentists delivered services to target groups, i.e., schoolchildren and sickness fund members. They enabled larger numbers of patients to receive dental care, especially those of lower class origin who otherwise would have remained untreated because of lack of financial resources or scarcity of manpower. School dental clinics not only delivered dental treatment, but also distributed oral hygiene and nutritional information to school-aged children. Social dentistry in the prefluoride era in Germany pursued an egalitarian and social-class oriented concept of dental care delivery, aiming at compensating the detrimental effects that the private practice-based, fee-for-service financed dental care system had produced in the lower classes of the population. The impact of the Nazi regime nearly abolished the institutions of social dentistry. They never were restored in West Germany after World War II. In East Germany dental care had been organized according to traditions of social dentistry, i.e., delivering services in dental treatment centers. Since the unification of the two German states, the institutions of dental care delivery in former East Germany have been restructured to fit the private practice-based model of former West Germany, eliminating most of the social dentistry institutions in the country.

Valedictory address from Ian Benington OBE of the British Dental Association.

Professor Ian Benington OBE was installed as the President of the British Dental Association at last year's British and Irish Dental Association's Annual Conference in Belfast 2002. At this year's 2003 British Dental Association's Annual Conference in Manchester on April 24-26, 2003, he gave his valedictory address.

Presidential address from the new president of the British Dental Association.

Professor Ian McIntyre was installed as the new President of the British Dental Association at this year's 2003 National Annual Conference held in Manchester on April 24-26, 2003.