national dental advisory committee
TRANSCRIPT
w w w . s c o t l a n d . g o v . u k
National DentalAdvisory Committee
July 2001
Clinical Governance inDental Primary Care
Working together for a healthy, caring Scotland
ISBN 0 7559 0182 7
NATIONAL DENTAL ADVISORY COMMITTEE
CLINICAL GOVERNANCE IN DENTAL PRIMARYCARE
July 2001
CONTENTS
1 INTRODUCTION AND BACKGROUND
2 WHAT IS CLINICAL GOVERNANCE?
3 ACTIVITIES WITHIN CLINICAL GOVERNANCE
4 CLINICAL GOVERNANCE AND THE INDIVIDUAL PRACTITIONER
5 CLINICAL GOVERNANCE AND PRIMARY CARE TRUSTS
6 ROLE OF OTHER NATIONAL ORGANISATIONS
7 CONCLUSION
APPENDICES
I MEMBERSHIP OF THE WORKING GROUP
II EXAMPLES OF GOOD PRACTICE
III PROFESSIONALS COMPLEMENTARY TO DENTISTRYPRINCIPLES OF GOOD PRACTICE
IV PERFORMANCE REVIEW SCHEME FOR THE DENTAL PROFESSIONPROPOSALS BY THE GENERAL DENTAL COUNCIL
CLINICAL GOVERNANCE IN PRIMARY CARE AN OVERVIEW
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1 INTRODUCTION AND BACKGROUND
1.1 The concept of clinical governance was introduced in the White Paper‘Designed to Care’1 where it was stated that the statutory duties of Trustswould be amended to make explicit their responsibility for quality of care.
1.2 The intention of the White Paper was that clinical governance would build on(not replace) existing patterns of self-regulation. The principles of clinicalgovernance extend these procedures more widely and systematically intothe local clinical community.
1.3 The Health Act 19992 confirmed the requirement that each Health Board,Special Health Board and NHS Trust would have a duty to put and keep inplace, “arrangements for the purpose of monitoring and improving thequality of health care which it provides to individuals”. This includes GeneralDental Practitioners whose contract is held at Primary Care Trust/IslandHealth Board level. This requirement has been re-affirmed in Our NationalHealth A plan for action, a plan for change3.
1.4 This paper aims to relate the principles of clinical governance to primarycare dentistry. It summarises current developments in professional self-regulation and describes some of the mechanisms for ensuring clinicalquality in dental primary care. Whilst it is intended mainly for a non-dentalreadership, especially Trust Directors, it is also relevant for a wideraudience of all primary care dentists. The term PCT is used in the report toinclude Primary Care Trusts and Island Health Boards.
1.5 Dental primary care comprises the following categories:
GENERAL DENTAL SERVICE
General Dental Practitioners
1.6 Approximately 2,000 dentists in Scotland practise within the General DentalService (GDS) as independent contractors. They work in a mixture ofpractices, ranging from a single dentist to large multiple practices.
1.7 One of the important distinctions between general dental practice andgeneral medical practice is that general dental practitioners (GDPs)generally own their own premises and employ their own staff. No externalfinancial support is available for staff costs. GDPs are accountable to thePCT with whom they contract for the care provided under their GDS Terms ofService.
1.8 There are no restrictions on the locations where dental practices can beestablished from a PCT perspective. In a bid to improve access to NHSdentistry in areas of high oral health need, the Scottish Executive recentlysought applications for capital grants to help establish new GDS facilities indeprived communities.
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1.9 Apart from this initiative, GDPs receive no separate financial support foritems such as practice administration and management, the upgrading ofpremises or staff training. GDPs run their practices almost entirely from feesearned from providing treatments to patients; these fees are calculated toinclude an element to meet practice expenses. Some GDPs also seepatients under private contract and the principle of a mixed economypractice where both NHS and private treatments are offered is common.
Salaried Practitioners
1.10 There are in the region of 40 salaried practitioners in Scotland who alsoprovide general dental services – but who are salaried rather thanremunerated through a fee per item system. Salaried practitioners work inhealth centres or community clinics and though traditionally employed by aHealth Board, most now hold contracts with a PCT.
1.11 Although salaried practitioners work under the same conditions as generaldental practitioners, they are usually managerially and professionallyaccountable to the employing PCT.
Joint Posts
1.12 A number of dentists who work within the Community Dental Service (CDS)hold joint post appointments; whereby they also provide some generaldental services. Like salaried practitioners they are not remunerated on afee per item system for the GDS element of their work but are salaried andreceive a small supplement in recognition of their extended duties. They areclinically accountable to a lead clinician within the PCT – even for their GDSwork.
Emergency Dental Services
1.13 Where an Emergency Dental Service has been established within a HealthBoard area, treatment is usually provided under GDS contract. Participatingdentists must be on a local dental list and are remunerated on a sessionalbasis.
COMMUNITY DENTAL SERVICE
1.14 Over 270 dentists work in the CDS in Scotland. The CDS is a salaried dentalservice, which usually forms part of a PCT. Clinical Community DentalOfficers (CCDOs) provide a service which is complementary to the GDSwhich incorporates screening, epidemiology, oral health promotion and theprovision of dental treatment to a range of priority groups. Other secondarycare functions may also be offered by the CDS including orthodontics andoral surgery. Clinical accountability lies entirely within the PCT.
1.15 The emergence of PCTs has, for the first time, brought the CDS and theGDS together within a single Trust umbrella. The requirement for clinicalgovernance means that Trusts are therefore accountable for clinicalperformance in both the CDS and the GDS.
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1.16 PCTs will need to be able to view the dental primary care function as awhole and to apply similar standards across all services and both branchesof the dental service. Directors of Community Dental Services and DentalPractice Advisers are key to this process and should be encouraged to workclosely together. The Area Dental Committee and its Sub-Committees arealso a helpful source of advice and should be consulted by PCT.
1.17 Community Dental Services can also be offered in premises outwith theremit of the PCT eg, acute hospitals. The Trusts involved must ensure jointclinical accountability for such services.
PROFESSIONALS COMPLEMENTARY TO DENTISTRY
1.18 A number of Professionals Complementary to Dentistry (PCDs) support thework of the dentist. There are probably in excess of 5,000 PCDs in Scotland.At present there is considerable variation in arrangements for training,registration and the continuing professional development of PCDs. Theseanomalies are addressed in section 5.3 of the report.
1.19 PCDs work to the prescription of a dentist to whom they are accountable.For instance, dental hygienists and dental therapists may practise dentistryonly under the direction of a registered dentist and to the extent permitted bythe Dental Auxiliaries Regulations 1986. Additional support is provided bydental nurses and reception staff.
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2 WHAT IS CLINICAL GOVERNANCE?
2.1 Clinical governance has been defined as corporate accountability for clinicalperformance. It is intended to enable the public to be provided withassurances about standards of clinical care.
2.2 Clinical governance should be seen as a positive concept that supports thecontinuous improvement of quality in clinical dental practice. This isimportant since dental practice, especially the general dental service,already has well developed systems in place to monitor the quality oftreatment.
2.3 If clinical governance were simply seen as an extension to existing qualitymonitoring systems or as a tool to identify poor practice it would lose manyof its potential benefits. Clinical governance imposes certain requirementson Trusts and Health Boards as well as individual clinicians and should beseen as part of an overall strategy to improve clinical quality.
2.4 Some examples of good practice are outlined in Appendix II.
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3 ACTIVITIES WITHIN CLINICAL GOVERNANCE
3.1 The following activities are important elements of clinical governance indentistry:
Process
• all dental staff to be appropriately trained and knowledgeable to enablethem to have the skills and competencies to deliver the care needed;
• a clinical and service environment which supports the delivery of highquality dental care;
• quality accreditation and quality improvement processes covering allaspects of dental service delivery;
• techniques such as risk management to anticipate and minimisepotential problems in the clinical dental environment;
• evidence based dental practice in day-to-day use within a supportiveinfrastructure.
Validation
• clinical audit and significant event analysis to monitor and improveexisting dental practice;
• systems to monitor standards of care in general dental practice (role ofScottish Dental Practice Division of the Common Services Agency);
• patient satisfaction surveys.
Education/Discipline
• training and continuing professional development of all staff;
• systems which recognise and act upon poor performance.
3.2 Some of these activities are already well established in dentistry. There aregaps, however, and Trusts should work with primary care dentalprofessionals locally to identify areas of further work. For example, manyTrusts will have experience of risk analysis and audit in the clinical settingand may be able to extend this to any local dental practices that have limitedexperience of risk management. Area Dental Committees and their Sub-Committees should be fully involved at all stages.
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4 CLINICAL GOVERNANCE AND THE INDIVIDUAL PRACTITIONER
SKILLS AND COMPETENCIES
4.1 All dentists wishing to practice in the United Kingdom require to beregistered with the General Dental Council. It is the responsibility of thedentist to register before beginning to practise and to renew registrationannually. A dentist who does not register is practising illegally. PCTsshould ensure that the registration status of all dental practitioners in theirarea is confirmed annually.
4.2 The General Dental Council issues ethical guidance to all dentists on theDentists Register. New ethical guidance which was published in November1997 and revised regularly. It sets out to be positive and to focus on bestpractice. The document entitled “Maintaining Standards”4 covers the fullrange of ethical issues that define good practice and is in loose-leaf formatto allow for regular updating.
4.3 “Maintaining Standards” sets out the General Dental Council’s view that alldentists have a duty to undertake continuing professional developmentwhilst in practice. The same requirement is also set out in the terms ofservice for dentists working in the GDS, which states that “a dentist shall inthe provision of general dental services take reasonable steps to developprofessional knowledge and skills through activities undertaken with a viewto maintaining an up-to-date knowledge of dental science and practice.”
4.4 In seeking to ensure that all registered dentists keep up to date, the GeneralDental Council has developed mandatory re-certification based onparticipation in postgraduate education. This scheme entitled "LifelongLearning" was launched in April 2000 and means that all registered dentistsshould undertake 250 hours of postgraduate education over a 5 year period. A proportion of this should be capable of being verified by a recognisededucational body and dentists should record their participation.
4.5 There will be a 5-year re-certification cycle and dentists may be asked toprovide proof of their compliance with the GDC requirements. All dentistswho fulfil the General Dental Council’s requirements will meet one of thekey demands of clinical governance.
IMPROVING QUALITY
4.6 The promotion of evidence based clinical practice and clinical audit bothplay a part in improving quality.
4.7 The notion of evidence based practice is not new but there has been aresurgence of interest in evidence based medicine and dentistry over recentyears. Clinical governance re-emphasises the importance of this processand the need for mechanisms to support dentists in continuously improvingtheir clinical practice.
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4.8 A number of national initiatives are taking place. The Scottish IntercollegiateGuidelines Network (SIGN) has developed its first dental guidelines; theDental Health Services Research Unit (DHSRU), funded by the ChiefScientist Office, has a programme on “Effective Dental Practice”; the BritishDental Journal now publishes a supplement “Evidence Based Dentistry”5
and the internet provides many websites of relevance to evidence baseddentistry. The Faculty of General Dental Practitioners6 has an importantcontribution to make in the setting and publishing of standards.
4.9 However, it may be that some of the most effective work, in terms of actuallychanging clinical practice, will take place at a local level. Several HealthBoard areas now have “dental clinical effectiveness groups”. Localmechanisms for implementing guidelines in primary care dental practice,including links with the Dental Practice Adviser, will be of key importance inpromoting clinical effectiveness.
4.10 Clinical audit in primary care dentistry has been slow to develop. Whilstprojects in the Community Dental Service have come under the auspices ofTrust audit arrangements, progress of audit in the GDS has been morecomplex. Between 1995 and 1998 a CRAG funded project was successfullyrun by Scottish Council for Postgraduate Medical and Dental Education(SCPMDE). The project aimed to promote and develop audit within theGDS, using 6 National Dental Audit Facilitators.
4.11 A substantial number of projects have been completed by GDPs and acentral database has been developed. Audit projects are now a mandatorypart of dental vocational training (VT) in the GDS. The SCPMDE auditinitiative7 concluded that dental practitioners are willing to engage in clinicalaudit if provided with the right tools and the correct kind of help andencouragement.
4.12 As a consequence of funding made available by the Scottish ExecutiveHealth Department a network of dental audit facilitators has beenestablished in conjunction with a post of National Dental Audit Facilitator.Appropriate infrastructure and multi-professional links at a local level shouldsupport this and each Trust should consider how these could be developed.
4.13 Practitioners also should be encouraged to maximise the educational valueof complaints in the primary care setting. The effective management ofcomplaints can benefit services through feedback into the quality cycle.
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5 CLINICAL GOVERNANCE AND PRIMARY CARE TRUSTS
SKILLS AND COMPETENCIES – DENTAL PRACTITIONERS
5.1 The role of the General Dental Council has already been summarised insection 4.1–4.5 onwards, as have the current arrangements governing theregistration of dentists. For those dentists who wish to practice as aPrincipal within the GDS, a year of vocational training (VT) is mandatoryunless exemption is given by virtue of equivalent experience outwith thegeneral dental service. It is, however, still possible to practise as anassistant within the GDS without having undertaken VT. Dentists who havequalified in countries in the European Union are also exempt from VT. Thisis a matter for considerable concern. It is considered that PCTs should bemade aware of the latter anomaly and ensure that entry to a list is monitoredand if necessary supported with education to avoid difficulties whenclinicians have trained outwith Scotland.
5.2 The Scottish Council for Postgraduate Medical and Dental Educationadministers the above arrangements. General Professional Training aimsto provide young graduates with 2 years of structured postgraduate trainingin a mix of primary and secondary care and is being piloted and developedthroughout Scotland. This a welcome measure of increasing quality.
SKILLS AND COMPETENCIES – PROFESSIONALS COMPLEMENTARY TODENTISTRY
5.3 A number of professional groups support the work of the dentist includingdental nurses, hygienists, therapists, receptionists, practice managers anda range of dental technicians.
5.4 A key requirement for all these groups is that they are appropriately trainedfor the tasks they undertake. Teamwork is of critical importance in dentalpractice and part of the induction and ongoing training of dental staff shouldalways be on a team basis.
5.5 Prior to 1999 there were concerns that a number of these groups were notrequired to register and were not subject to any formal professionalregulation. In May 1999 the General Dental Council agreed a range offundamental changes to the role of PCDs including the introduction ofstatutory registration for all members of the dental team. Thus, dentalnurses and dental technicians, (including oral and maxillofacial prosthetistsand technologists and clinical dental technicians) could after legislativechange join dental hygienists and dental therapists who are alreadyenrolled with the GDC.
5.6 Registration will mean that all PCDs should be able to work in every sectorof dentistry and it should be axiomatic that education, training, qualificationand lifelong learning for PCDs is a fundamental part of these changes.
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5.7 In the short term it is recommended that PCTs should consider how toencourage good practice in the employment, training and development ofPCDs within primary care dentistry. Some examples are given inAppendix III.
QUALITY ACCREDITATION/QUALITY IMPROVEMENT
5.8 A recent report8 by the National Dental Advisory Committee (NDAC) on therole of Dental Practice Advisers (DPAs) makes a number ofrecommendations relating to quality accreditation and quality improvementin general dental practice.
PRACTICE INSPECTIONS
5.9 At present there is no national system for inspecting GDS practicesalthough there has been a nationally agreed checklist. The process ofinspection has also been rather ad hoc, with some Health Boardsconducting annual inspections and others only inspecting on an occasionalbasis.
5.10 The NDAC report recommends that all new GDS practices are inspectedprior to opening and that existing practices are inspected at least once every3 years. Practices where problems have been identified should beinspected more frequently and arrangements should be in place for ad hocrequests for inspections to be made by the PCT. The Scottish Executive arecurrently reviewing this process.
5.11 The report recommends that practice inspections should include localGDPs (nominated through the Area Dental Committee) who receive trainingand are calibrated to ensure consistency across Health Board areas.
5.12 There are already rigorous standards in place for practices that provide VTand it is recommended that all dental practices in Scotland should worktowards these standards. It is also recommended that the same standardsshould be applied to Community Dental Clinics. This would help ensureconsistency throughout dental primary care. In addition, work is beinginitiated in collaboration with the Clinical Standards Board for Scotland todevelop Standards for clinical dentistry.
DENTAL PRACTICE ADVISERS
5.13 The NDAC report recommends that the role of DPAs should facilitatesupport and development of the dental practice, general dental practitioners,the improvement of standards and liaison with the CDS.
5.14 DPAs should, for instance, carry out pre-inspection visits to practices inorder to help identify shortfalls, to enable practitioners to developappropriate risk management strategies and to act as an informationsource eg, on aspects of health and safety legislation.
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5.15 DPAs are also important partners in the process of improving quality inprimary care dentistry, including the implementation of guidelines; clinicalaudit; training needs assessment and the promotion of continuingprofessional development for practitioners.
PERFORMANCE MONITORING
5.16 Unlike other health-related disciplines, dentistry has been relatively wellmonitored over the years. This is mainly due to the form of remuneration forGDS dentists whereby they claim ‘item of service’ fees for the treatmentprovided. This lends itself to closer regular scrutiny than other areas of theservice.
5.17 Two of the roles that the Scottish Dental Practice Division (SDPD) carriesout on behalf of its Board already relate to standards of care and clinicalgovernance. These are, to ensure that:
• treatment provided is clinically necessary;
• treatment provided has been carried out satisfactorily.
5.18 Clinical scrutiny of cases is carried out in SDPD by a team of 4 DentalAdvisers, who examine the case information submitted by dentists andthree Dental Reference Officers to whom patients may be referred for aclinical examination.
5.19 There is currently no equivalent system for monitoring clinical quality withinthe CDS, and such a system should be established.
PRIOR APPROVAL AND TREATMENT PLANNING
5.20 High cost cases and cases involving specific items of treatment have to besubmitted to SDPD for prior approval before treatment is initiated. If SDPDis concerned about the appropriateness of the planned treatment the dentistmay be so advised, whether or not the patient is referred to the DentalReference Service.
5.21 This procedure is intended to encourage the dentist to reflect on theproposed treatment and safeguard patients from receiving inappropriatecare. SDPD is in an almost unique position within the NHS in its ability togive prospective clinical approval for a range of primary care treatments.
AUTHORISATION OF PAYMENT AND MONITORING OF STANDARDS OFCARE
5.22 On completion of treatment, when claims are submitted for payment,information on the items claimed for payment is analysed by SDPD. Anumber of cases are referred to the Dental Reference Service for clinicalexamination to determine if the treatment provided has been carried out toan adequate standard. These referrals are random although further
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completed cases may be referred where there is a specific concern over thestandards of treatment being provided.
5.23 As well as monitoring the quality of treatment carried out, statisticalinformation on prescribing patterns is gathered and fed back to dentists inthe form of practitioner profiles. These profiles can help practitionersdetermine how they compare with their colleagues at both local and nationallevel.
5.24 Dentists with an aberrant prescribing pattern can be identified as statisticaloutliers for one or several items of treatment. If they are unable to justify thisexcessive treatment prescribing a process of Prior Approval by Targetingcan be implemented, whereby the dentist is required to submit all cases ofthis nature to SDPD for approval prior to the commencement of treatment.This is intended to safeguard patients and cause the dentist to reconsiderhis/her treatment decisions. Often this results in a dramatic change inprescribing patterns.
EDUCATIVE ROLE OF THE SDPD
5.25 SDPD has access to information on all NHS treatments carried out inScotland. As well as providing global information to organisations such asthe Scottish Executive, Dental Health Services Research Unit, HealthBoards, Trusts and SCPMDE it is also able to provide more specificfeedback to dentist groups, vocational GDPs and students through regularmeetings, seminars and lectures.
5.26 Individual dentists about whom SDPD have a concern may also be invited toan informal discussion with Dental Advisers. The aim of these meetings isto: encourage dentists to address these concerns; encourage closecollaboration between the DPA, DA and SCPMDE.
WHISTLEBLOWING AND DISCIPLINARY ACTION
5.27 The GDC document ‘Maintaining Standards’ makes it clear that dentistscannot ignore situations which might put patients at risk through unethicalpractice and, where concerned, they should discuss this with a seniorcolleague or an appropriate professional body. As a consequence of thisSDPD now receives significantly more information from dentists onunsatisfactory work or working practices of colleagues. The accuracy of thisis always investigated thoroughly and, where necessary, counselling orinvestigative procedures implemented. The defence societies have animportant role here in working with their members to raise awareness of keyissues and to address problems at an early stage.
5.28 Any situation that SDPD judges to require possible disciplinary action iscurrently referred to the PCT with whom the practitioner is in contract. Adecision to take local disciplinary action can only be made by the Trust. Inpractice this is often delegated to a Reference Committee who must decideif action should be taken. This may take one of four routes, referral to:
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• a discipline committee (which is convened by a second Health Boardarea);
• an NHS Tribunal;
• the GDC; or
• the police/procurator fiscal.
5.29 There have been concerns expressed in the past over a lack of consistencybetween Health Boards in their approach to handling cases referred forpossible disciplinary action by the SDPD. Current proposals to centralisethe GDS disciplinary process are welcome and should help to bringconsistency and fairness.
5.30 Now that further changes have taken place within primary care it is thereforeessential that there is absolute clarity at a local level on the respective rolesof the SDPD, Health Boards and PCT. There must also be clarity on leadresponsibility, timescales for action and accountability at each stage in theprocess.
POOR PERFORMANCE
5.31 It is important to stress that most issues do not result in disciplinary orcriminal action, referral to the Professional Conduct Committee of the GDCor to the police/procurator fiscal. More often the problem is likely to be one ofpoor performance which is not severe enough to merit referral.
5.32 The GDC published proposals for a Performance Review Scheme for thedental profession (see flow diagram in Appendix IV) which is directed at thedentist whose performance is seriously deficient and whose standard ofprofessional conduct might not currently result in an appearance beforeeither its Professional Conduct or Health Committee. The scheme hasbeen the subject of wide consultation and was supported by the professionand the GDC in May 1999. In May 2000 the GDC approved theestablishment of a comprehensive UK-wide system for dealing with poorclinical performance in dentistry and its introduction is now dependent uponthe necessary legislative changes.
5.33 At a local level it is important that there are mechanisms available to dealwith poor performance or low standards of practice. The role of PCTs andother professionals such as Dental Practice Advisers is critical in thisregard. The NDAC report on the role of DPAs highlights this issue in moredetail.
5.34 Information on poor performance may come from a variety of sourcesincluding practice inspection reports; Independent Review Panel reports;patient complaints; information from colleagues and information from SDPDto Trusts.
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5.35 The DPA is often the best person to meet with the practitioner, to offersupport and advice and to agree a course of action designed to remedy thesituation. It is also important that the Medical Director is fully involved at allstages to ensure that the PCT is able to discharge its clinical governanceresponsibilities.
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6 ROLE OF OTHER NATIONAL ORGANISATIONS
SCOTTISH COUNCIL FOR POSTGRADUATE MEDICAL AND DENTALEDUCATION
6.1 SCPMDE was established as a Special Health Board in 1993 withresponsibility for managing and funding postgraduate medical and dentaleducation and training in Scotland. Its purpose is to ensure that doctors anddentists have the appropriate skills and motivation to meet the changinghealth needs of the people of Scotland.
6.2 SCPMDE, through its Dental Committee oversees the provision of educationand training of vocational trainees and issues completion of trainingcertificates on the basis of evidence of prescribed or equivalent experience.The salaries of vocational GDPs and the training grades in the HospitalDental Service are funded by Council. SCPMDE also provides the resourcesfor the continuing education programme for GDPs and CCDOs in Scotland.
DENTAL HEALTH SERVICES RESEARCH UNIT
6.3 The Dental Health Services Research Unit (DHSRU) is funded by the ChiefScientist and is located in the University of Dundee. Its remit is to studypatterns of delivery of dental care in Scotland; to identify the factors ofimportance in achieving dental health; to determine attitudes to dental careand to measure the relative effectiveness of different dental procedures andmaterials.
6.4 DHSRU has 3 major programme areas of which one, Effective DentalPractice, is of particular relevance to clinical governance. The programmeaddresses the question of how evidence based practice can beimplemented efficiently in dental primary care.
6.5 The programme is designed to exploit a number of opportunities including:
• the development of a newly founded SCPMDE co-funded Dental PracticeBased Research Network;
• existing links with HSRU and the Cochrane Group on EffectiveProfessional Practice;
• new work on dental evidence based guidelines with SIGN and theFaculty of General Dental Practitioners (UK);
• a successful competitive application to an NHS R&D programme tomount a randomised controlled trial of implementation of clinicalguidelines in dentistry.
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CLINICAL STANDARDS BOARD FOR SCOTLAND
6.6 The Clinical Standards Board for Scotland was established in April 1999 asa Special Health Board. The work of the Board will concentrate initially onhealth priority areas. The issue of clinical standards in dental primary carewill in the long term be part of its programme of work.
6.7 The Faculty of Dental Surgery of the Royal College of Surgeons of Englandpublished a Self Assessment Manual and Standards in 1991 which was asignificant step in the drive to develop suitable standards for general dentalpractice. The Faculty of General Dental Practitioners is continuing thisprocess and has produced a series of guidance documents on specifictopics.
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CONCLUSION
7.1 Clinical governance is a dynamic process within NHSScotland with a rangeof organisations contributing to its ongoing development. Within primarycare dental services the Clinical Standards Board for Scotland, ScottishCouncil for Postgraduate Medical and Dental Education, British DentalAssociation, Primary Care Trusts, General Dental Council and the Faculty ofGeneral Dental Practitioners will all have an important role as this reporthighlights.
7.2 Contributions from all organisations should be co-ordinated through onebody to maximise the benefit of each and avoid duplication of effort in orderto achieve a coherent and robust system for Scotland.
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REFERENCES:
1. Designed to Care: Renewing the NHS in Scotland. The Stationery Office. 19982. Health Act 19993. Our National Health. A plan for action; a plan for change. Tactica Solutions.20004. Maintaining Standards: Guidance to Dentists on Professional and PersonalConduct. General Dental Council. November 1997, last revised May 2000.5. Evidence Based Dentistry Vol 1 (published as a supplement to the British DentalJournal)6. Faculty of General Dental Practitioners http://www.rcseng.ac.uk/public/tgdp.htm7. Rennie JS, Development of Audit for General Dental Practitioners in ScotlandSCPMDE May 19988. Dental Practice Advisers in Scotland. National Dental Advisory Committee.July 2001
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APPENDIX 1
MEMBERSHIP OF THE WORKING GROUP
Chairman:
Mr G Ball Consultant in Dental Public Health, Borders Fife and LothianHealth Boards
Members:
Mr D Arthur Dental AdviserDental Practice Division
Mr R Broadfoot General Dental PractitionerGlasgow
Dr F Elliot Medical DirectorFife Primary Care NHS Trust
Mr J Herrick Community Dental Services ManagerLomond and Argyll Primary Care NHS Trust
Dr J Rennie Dental DirectorScottish Council for Postgraduate Medical and Dental
Education
Mr T Timmons Dental Practice AdviserLothian Health
Mr F Toner General Dental PractitionerCupar
Secretariat:
Ms M Miller Health Planning & QualityScottish Executive
Mrs K Scott Fife Health Board
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APPENDIX II
EXAMPLES OF GOOD PRACTICE
Health Boards and Trusts should consider the priorities outlined in the main reportin the light of local circumstances. However, much good practice already existsand some examples are included below. This list should not be regarded asexhaustive.
AUDIT
“In Autumn 1994 CRAG awarded SCPMDE £250,000 over 3 years to develop auditfor General Dental Practitioners in Scotland. The principal aim of the project wasto establish a small national resource which would promote and develop auditwithin the GDS in Scotland”1. Six audit facilitators were appointed andremunerated on two sessions per week. A number of projects were completed byGDPs details of which are currently held on a database managed by SCPMDE.
Since the project ended some Health Boards have appointed their own dentalaudit facilitators (including Greater Glasgow, Argyll and Clyde, Ayrshire and Arran,Lothian and Fife).
In some Health Boards substantial extra funds have been made available tosupport dental audit and, in these areas, the participation rates of local GDPs havebeen high. Community Dental staff and Hospital Dental staff should also beincluded to ensure that audit projects are as broad based as possible.
The full report on the development of audit for general dental practitioners inScotland which describes the SCPMDE project is available.
PERSONAL LEARNING PLANS
Two projects have recently been funded by SCPMDE (one in partnership with aHealth Board) which are designed to encourage GDPs to develop a morestructured approach to assessing and meeting their learning needs. Theseprojects, using a dental facilitator are designed to enable GDPs to review theirtraining needs, to construct personal learning plans and to meet those needswithin a programme of postgraduate education.
Re-certification for the dental profession will bring a requirement on individualdentists to demonstrate that they are undertaking a certain level of postgraduateeducation. This includes verifiable education from a recognised educational bodyas well as non core learning activities.
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RESEARCH NETWORKS
Whilst the Dental Health Services Research Unit in Dundee has a particular role indeveloping a Dental Practice Based Research Network, there have been otherlocal research initiatives. For instance Tayside Research and DevelopmentNetwork (http://www.dundee.ac.uk/generalpractice/tayren.htm) is a researchnetwork which includes both general medical practitioners and general dentalpractitioners from the Tayside area. Models of good practice which are multi-professional should be encouraged.
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APPENDIX III
PROFESSIONALS COMPLEMENTARY TO DENTISTRYPRINCIPLES OF GOOD PRACTICE
The requirement is that all team members must be appropriately trained for thetasks they undertake as a key element of quality care and clinical governance.
The teamwork approach necessitates joint training of various groups ofprofessionals with similar needs.
This emphasis on teams also requires:
• Training on working in teams• Communication skills• Audit and peer review – team and self-audit
Dental Nurses
Dental nurse training has traditionally been carried out “on the job” with aneducational course to supplement this training. Good practice requires to bedefined in order that patients are safely treated in an appropriate environment.
Key elements of good practice:
• Basic induction with emphasis on health and safety and clinical riskmanagement
• Occupational health assessment• Written employment contract• Dresser (shadowing) system for new Dental Nurses• Practice Manual (developed by all members of the dental team)• Health and Safety Contract• Resuscitation training• Appraisal system• Clarity of accountability and responsibility• Team training
The importance of the witness and chaperone role of dental nurses has grown inimportance as litigation increases.
Dental Receptionists
In the past general training with no specific dental input was the only source offormal training for this group.
A dental receptionist programme (DRP) has been developed along similar lines tothe Medical Receptionist Programme (MRP).
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The first level is DRP 1 which concentrates on communication skills and dentalterminology. The second level is DRP 2 which starts to deal with confidentialityissues, complaints handling and Information Technology.
Patients will often measure the quality of their care on their experiences inarranging appointments and receiving general advice about their treatment. It istherefore essential that dental receptionists receive formal training and support.
Practice Managers
Training programmes for practice managers in general medical practice areappropriate for dental practice managers as the requirements are very similar.
Important skills are:
• Leadership• Conflict resolution• Team working• Budget management• Risk management• Recruitment and Selection• Appraisal
Hygienists
This group are registered with the General Dental Council and they have thereforecompleted an approved training programme.
Joint update courses with the dental surgeons are an example of good practicewhich could be recommended.
Team training with other members of the dental team is an essential element ofgood practice.
Dental Therapists
This group work within the Community Dental Service and the Dental TeachingSchools at the present time. There are proposals to change the regulations inorder that they can work in General Dental Practice.
Their expansion into the General Dental Services will have implications for thedental team and appropriate support and training will be required when thisoccurs.
23
Dental Technicians and Clinical Dental Technicians
Traditionally dental technicians have carried out their work on the prescription ofdental surgeons and work in independent practice. The General Dental Councilhas proposed that a new profession known as clinical dental technicians will beestablished and will be one of the Professionals Complementary to Dentistry(PCDs). This new group will require to be integrated into the dental team and as aresult there will be training and support issues for all team members.
PUBLICPROTECTION
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w w w . s c o t l a n d . g o v . u k
National DentalAdvisory Committee
July 2001
Clinical Governance inDental Primary Care
Working together for a healthy, caring Scotland
ISBN 0 7559 0182 7