Apart from the obvious bonfire of the items of treatment codes from 700 to 45 and the associated narrative, there have also been changes to the General Dental Services regulations. Two of the more interesting changes are around mixing NHS and private treatment on a single tooth, and how a contractor (any dentist or dental body corporate listed on sub-part A of the first part of a health board's dental list) must "manage" a patient's oral health.
We have summarised these changes, which come into effect from 1 November, and there is also a letter from the Chief Dental Officer of Scotland (CDO), detailing the amendment Regulations.
Mixing treatment on one tooth
The first change permits the mixing of NHS and private treatment on a single tooth. This brings the National Health Service (General Dental Services) (Scotland) Regulations 2010 in line with those of England and Wales, which until 2006 had the same wording.
The deletion of the clause containing the phrase "single tooth" rendered mixing legal in England by default. In Scotland this was a change that the Scottish Dental Practice Committee (SDPC) had lobbied for. The CDO has outlined what benefits he sees in this change "I hope you will experience the benefit of the removal of this provision which will provide greater clinical freedom for you to provide NHS treatment and removes unnecessary restrictions on patient choice".
While mixing on the same tooth is allowed, the other regulations in Scotland remain the same. Specifically, a dentist should not advise falsely that the care and treatment which is necessary in the patient's case is unavailable or seek to mislead the patient about the quality of care and treatment available under NHS dental services.
The differences between alternative treatments is still a tightrope walked by any dentist discussing the choices with their patients, since the GDC imposes restrictions on these communications as well.
Standard 1.7.2 advises that you must make clear to your patients which treatment you can provide on the NHS, and which can only be provided on a private basis.
Meanwhile, Standard 1.7.4 says you must not pressurise patients into having private treatment if it is available to them on the NHS.
For example, a patient can be provided with an NHS root canal treatment along with a private crown or private white filling if the patient wants a tooth-coloured restoration specifically for aesthetic reasons only[2]. The Determination states that tooth-coloured crowns should not be placed on teeth distal to the second premolar. It is important that the patient provides consent for this mixing and that the choices are provided in a fair and balanced conversation to explain the features, advantages, benefits and risks of the options.
Managing oral health
The second wording change that prompts the question why, is the change being made from contractors having to "secure and maintain" patient oral health, to "managing" patient oral health.
The regulations define "oral health" in the GDS (Scotland) Regulations 2010, as meaning "such a standard of health of the teeth, their supporting structures and other tissues of the mouth, and of dental efficiency, as it is reasonable in the case of any patient, having regard to the need to safeguard the patient's general health".
The previous wording of "secure and maintain" is founded on the requirement of the dentist to complete a course of treatment with that goal in mind.
It could be argued that the course of treatment would not be complete until the dentist secured and maintained the patient's oral health, using all the means at their disposal to do so, from prevention to extensive interventions of treatment.
The reality is of course that there is no finite point clinically where it can be said that the patient's oral health is secured.
The emphasis in "managing" the patient's care, implies a different relationship with a patient where dentists take a more modern and progressive approach to supporting the patient achieving oral health. The impetus and responsibility for behaviour change shifts from the dentist to the patient who will be helped to manage their care and take personal responsibility, rather than the onus being entirely on the treating dentist. For their part, the dentist can adopt an evidence based preventive focused approach to support the patient to achieve the best oral health they wish and can achieve.
This was the bedrock of contract reform and the pilots set up by the late Jimmy Steele in England and explained in detail in his seminal paper[3]. The concept of Care Pathways was explained with a patient taken on a journey to health, supported by the dental team and strong clinical guidelines through a specific pathway. The concept also outlined that access to advanced complex care (crown, bridges and molar endodontics) would be contingent on the patient looking after their own oral health and the treatment being feasible and beneficial to the patient. There is of course a different payment system in Scotland, but this is an approach which may gain traction.
This fits very well with the concept of "managing" a patient's care rather than securing it. This allows the dental team to phase treatments[4][5] with the goal of managing potentially high-needs patients with longstanding chronic oral health issues over a period of time to achieve the defined oral health goal of "dental efficiency".
These are new and unique opportunities for dentists in Scotland to deliver care for patients with a different way of working, with the patient encouraged to take responsibility for their own oral healthcare with the support of the dental team.
[1 - subheading] Sinek. S Start with why - how great leaders inspire everyone to take action Penguin 2011
[2] Statement of Dental Remuneration No161 Amended 21 September 2023
[3] NHS Dental services in England - an independent review led by Professor Jimmy Steele June 2009 NHS England
[4] Understanding NHS dentistry-preparing for the future. D'Cruz L, Rattan R, Watson M Dental Publishing 2010 Chapter 7 p74-77
[5] Avoidance of doubt: provision of phased treatments 8 July 2021 NHS England Reference PAR615