National Dental Advisory Committee

Transcription

1 National Dental Advisory Committee Clinical Governance in Dental Primary Care July 2001 Working together for a healthy, caring Scotland

2 NATIONAL DENTAL ADVISORY COMMITTEE CLINICAL GOVERNANCE IN DENTAL PRIMARY CARE July 2001

3 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 II III IV MEMBERSHIP OF THE WORKING GROUP EXAMPLES OF GOOD PRACTICE PROFESSIONALS COMPLEMENTARY TO DENTISTRY PRINCIPLES OF GOOD PRACTICE PERFORMANCE REVIEW SCHEME FOR THE DENTAL PROFESSION PROPOSALS BY THE GENERAL DENTAL COUNCIL CLINICAL GOVERNANCE IN PRIMARY CARE AN OVERVIEW

4 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 Trusts would 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 clinical governance extend these procedures more widely and systematically into the local clinical community. 1.3 The Health Act confirmed the requirement that each Health Board, Special Health Board and NHS Trust would have a duty to put and keep in place, arrangements for the purpose of monitoring and improving the quality of health care which it provides to individuals. This includes General Dental Practitioners whose contract is held at Primary Care Trust/Island Health Board level. This requirement has been re-affirmed in Our National Health A plan for action, a plan for change This paper aims to relate the principles of clinical governance to primary care dentistry. It summarises current developments in professional selfregulation and describes some of the mechanisms for ensuring clinical quality in dental primary care. Whilst it is intended mainly for a non-dental readership, especially Trust Directors, it is also relevant for a wider audience of all primary care dentists. The term PCT is used in the report to include 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 Dental Service (GDS) as independent contractors. They work in a mixture of practices, ranging from a single dentist to large multiple practices. 1.7 One of the important distinctions between general dental practice and general medical practice is that general dental practitioners (GDPs) generally own their own premises and employ their own staff. No external financial support is available for staff costs. GDPs are accountable to the PCT with whom they contract for the care provided under their GDS Terms of Service. 1.8 There are no restrictions on the locations where dental practices can be established from a PCT perspective. In a bid to improve access to NHS dentistry in areas of high oral health need, the Scottish Executive recently sought applications for capital grants to help establish new GDS facilities in deprived communities. 1

5 1.9 Apart from this initiative, GDPs receive no separate financial support for items such as practice administration and management, the upgrading of premises or staff training. GDPs run their practices almost entirely from fees earned from providing treatments to patients; these fees are calculated to include an element to meet practice expenses. Some GDPs also see patients under private contract and the principle of a mixed economy practice 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 also provide general dental services but who are salaried rather than remunerated through a fee per item system. Salaried practitioners work in health centres or community clinics and though traditionally employed by a Health Board, most now hold contracts with a PCT Although salaried practitioners work under the same conditions as general dental practitioners, they are usually managerially and professionally accountable 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 general dental services. Like salaried practitioners they are not remunerated on a fee per item system for the GDS element of their work but are salaried and receive a small supplement in recognition of their extended duties. They are clinically accountable to a lead clinician within the PCT even for their GDS work. Emergency Dental Services 1.13 Where an Emergency Dental Service has been established within a Health Board area, treatment is usually provided under GDS contract. Participating dentists must be on a local dental list and are remunerated on a sessional basis. COMMUNITY DENTAL SERVICE 1.14 Over 270 dentists work in the CDS in Scotland. The CDS is a salaried dental service, which usually forms part of a PCT. Clinical Community Dental Officers (CCDOs) provide a service which is complementary to the GDS which incorporates screening, epidemiology, oral health promotion and the provision of dental treatment to a range of priority groups. Other secondary care functions may also be offered by the CDS including orthodontics and oral surgery. Clinical accountability lies entirely within the PCT The emergence of PCTs has, for the first time, brought the CDS and the GDS together within a single Trust umbrella. The requirement for clinical governance means that Trusts are therefore accountable for clinical performance in both the CDS and the GDS. 2

6 1.16 PCTs will need to be able to view the dental primary care function as a whole and to apply similar standards across all services and both branches of the dental service. Directors of Community Dental Services and Dental Practice Advisers are key to this process and should be encouraged to work closely together. The Area Dental Committee and its Sub-Committees are also a helpful source of advice and should be consulted by PCT Community Dental Services can also be offered in premises outwith the remit of the PCT eg, acute hospitals. The Trusts involved must ensure joint clinical accountability for such services. PROFESSIONALS COMPLEMENTARY TO DENTISTRY 1.18 A number of Professionals Complementary to Dentistry (PCDs) support the work 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. These anomalies are addressed in section 5.3 of the report PCDs work to the prescription of a dentist to whom they are accountable. For instance, dental hygienists and dental therapists may practise dentistry only under the direction of a registered dentist and to the extent permitted by the Dental Auxiliaries Regulations Additional support is provided by dental nurses and reception staff. 3

7 2 WHAT IS CLINICAL GOVERNANCE? 2.1 Clinical governance has been defined as corporate accountability for clinical performance. It is intended to enable the public to be provided with assurances about standards of clinical care. 2.2 Clinical governance should be seen as a positive concept that supports the continuous improvement of quality in clinical dental practice. This is important since dental practice, especially the general dental service, already has well developed systems in place to monitor the quality of treatment. 2.3 If clinical governance were simply seen as an extension to existing quality monitoring systems or as a tool to identify poor practice it would lose many of its potential benefits. Clinical governance imposes certain requirements on Trusts and Health Boards as well as individual clinicians and should be seen as part of an overall strategy to improve clinical quality. 2.4 Some examples of good practice are outlined in Appendix II. 4

8 3 ACTIVITIES WITHIN CLINICAL GOVERNANCE 3.1 The following activities are important elements of clinical governance in dentistry: Process all dental staff to be appropriately trained and knowledgeable to enable them to have the skills and competencies to deliver the care needed; a clinical and service environment which supports the delivery of high quality dental care; quality accreditation and quality improvement processes covering all aspects of dental service delivery; techniques such as risk management to anticipate and minimise potential problems in the clinical dental environment; evidence based dental practice in day-to-day use within a supportive infrastructure. Validation clinical audit and significant event analysis to monitor and improve existing dental practice; systems to monitor standards of care in general dental practice (role of Scottish 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 are gaps, however, and Trusts should work with primary care dental professionals locally to identify areas of further work. For example, many Trusts will have experience of risk analysis and audit in the clinical setting and may be able to extend this to any local dental practices that have limited experience of risk management. Area Dental Committees and their Sub- Committees should be fully involved at all stages. 5

9 4 CLINICAL GOVERNANCE AND THE INDIVIDUAL PRACTITIONER SKILLS AND COMPETENCIES 4.1 All dentists wishing to practice in the United Kingdom require to be registered with the General Dental Council. It is the responsibility of the dentist to register before beginning to practise and to renew registration annually. A dentist who does not register is practising illegally. PCTs should ensure that the registration status of all dental practitioners in their area is confirmed annually. 4.2 The General Dental Council issues ethical guidance to all dentists on the Dentists Register. New ethical guidance which was published in November 1997 and revised regularly. It sets out to be positive and to focus on best practice. The document entitled Maintaining Standards 4 covers the full range of ethical issues that define good practice and is in loose-leaf format to allow for regular updating. 4.3 Maintaining Standards sets out the General Dental Council s view that all dentists have a duty to undertake continuing professional development whilst in practice. The same requirement is also set out in the terms of service for dentists working in the GDS, which states that a dentist shall in the provision of general dental services take reasonable steps to develop professional knowledge and skills through activities undertaken with a view to 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 General Dental Council has developed mandatory re-certification based on participation in postgraduate education. This scheme entitled "Lifelong Learning" was launched in April 2000 and means that all registered dentists should undertake 250 hours of postgraduate education over a 5 year period. A proportion of this should be capable of being verified by a recognised educational body and dentists should record their participation. 4.5 There will be a 5-year re-certification cycle and dentists may be asked to provide proof of their compliance with the GDC requirements. All dentists who fulfil the General Dental Council s requirements will meet one of the key demands of clinical governance. IMPROVING QUALITY 4.6 The promotion of evidence based clinical practice and clinical audit both play a part in improving quality. 4.7 The notion of evidence based practice is not new but there has been a resurgence of interest in evidence based medicine and dentistry over recent years. Clinical governance re-emphasises the importance of this process and the need for mechanisms to support dentists in continuously improving their clinical practice. 6

10 4.8 A number of national initiatives are taking place. The Scottish Intercollegiate Guidelines Network (SIGN) has developed its first dental guidelines; the Dental Health Services Research Unit (DHSRU), funded by the Chief Scientist Office, has a programme on Effective Dental Practice ; the British Dental Journal now publishes a supplement Evidence Based Dentistry 5 and the internet provides many websites of relevance to evidence based dentistry. The Faculty of General Dental Practitioners 6 has an important contribution 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 actually changing clinical practice, will take place at a local level. Several Health Board areas now have dental clinical effectiveness groups. Local mechanisms for implementing guidelines in primary care dental practice, including links with the Dental Practice Adviser, will be of key importance in promoting clinical effectiveness Clinical audit in primary care dentistry has been slow to develop. Whilst projects in the Community Dental Service have come under the auspices of Trust audit arrangements, progress of audit in the GDS has been more complex. Between 1995 and 1998 a CRAG funded project was successfully run by Scottish Council for Postgraduate Medical and Dental Education (SCPMDE). The project aimed to promote and develop audit within the GDS, using 6 National Dental Audit Facilitators A substantial number of projects have been completed by GDPs and a central database has been developed. Audit projects are now a mandatory part of dental vocational training (VT) in the GDS. The SCPMDE audit initiative 7 concluded that dental practitioners are willing to engage in clinical audit if provided with the right tools and the correct kind of help and encouragement As a consequence of funding made available by the Scottish Executive Health Department a network of dental audit facilitators has been established in conjunction with a post of National Dental Audit Facilitator. Appropriate infrastructure and multi-professional links at a local level should support this and each Trust should consider how these could be developed Practitioners also should be encouraged to maximise the educational value of complaints in the primary care setting. The effective management of complaints can benefit services through feedback into the quality cycle. 7

11 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 in section onwards, as have the current arrangements governing the registration of dentists. For those dentists who wish to practice as a Principal within the GDS, a year of vocational training (VT) is mandatory unless exemption is given by virtue of equivalent experience outwith the general dental service. It is, however, still possible to practise as an assistant within the GDS without having undertaken VT. Dentists who have qualified in countries in the European Union are also exempt from VT. This is a matter for considerable concern. It is considered that PCTs should be made aware of the latter anomaly and ensure that entry to a list is monitored and if necessary supported with education to avoid difficulties when clinicians have trained outwith Scotland. 5.2 The Scottish Council for Postgraduate Medical and Dental Education administers the above arrangements. General Professional Training aims to provide young graduates with 2 years of structured postgraduate training in a mix of primary and secondary care and is being piloted and developed throughout Scotland. This a welcome measure of increasing quality. SKILLS AND COMPETENCIES PROFESSIONALS COMPLEMENTARY TO DENTISTRY 5.3 A number of professional groups support the work of the dentist including dental nurses, hygienists, therapists, receptionists, practice managers and a range of dental technicians. 5.4 A key requirement for all these groups is that they are appropriately trained for the tasks they undertake. Teamwork is of critical importance in dental practice and part of the induction and ongoing training of dental staff should always be on a team basis. 5.5 Prior to 1999 there were concerns that a number of these groups were not required to register and were not subject to any formal professional regulation. In May 1999 the General Dental Council agreed a range of fundamental changes to the role of PCDs including the introduction of statutory registration for all members of the dental team. Thus, dental nurses and dental technicians, (including oral and maxillofacial prosthetists and technologists and clinical dental technicians) could after legislative change join dental hygienists and dental therapists who are already enrolled with the GDC. 5.6 Registration will mean that all PCDs should be able to work in every sector of dentistry and it should be axiomatic that education, training, qualification and lifelong learning for PCDs is a fundamental part of these changes. 8

12 5.7 In the short term it is recommended that PCTs should consider how to encourage good practice in the employment, training and development of PCDs within primary care dentistry. Some examples are given in Appendix III. QUALITY ACCREDITATION/QUALITY IMPROVEMENT 5.8 A recent report 8 by the National Dental Advisory Committee (NDAC) on the role of Dental Practice Advisers (DPAs) makes a number of recommendations relating to quality accreditation and quality improvement in general dental practice. PRACTICE INSPECTIONS 5.9 At present there is no national system for inspecting GDS practices although there has been a nationally agreed checklist. The process of inspection has also been rather ad hoc, with some Health Boards conducting annual inspections and others only inspecting on an occasional basis The NDAC report recommends that all new GDS practices are inspected prior to opening and that existing practices are inspected at least once every 3 years. Practices where problems have been identified should be inspected more frequently and arrangements should be in place for ad hoc requests for inspections to be made by the PCT. The Scottish Executive are currently reviewing this process The report recommends that practice inspections should include local GDPs (nominated through the Area Dental Committee) who receive training and are calibrated to ensure consistency across Health Board areas There are already rigorous standards in place for practices that provide VT and it is recommended that all dental practices in Scotland should work towards these standards. It is also recommended that the same standards should be applied to Community Dental Clinics. This would help ensure consistency throughout dental primary care. In addition, work is being initiated in collaboration with the Clinical Standards Board for Scotland to develop Standards for clinical dentistry. DENTAL PRACTICE ADVISERS 5.13 The NDAC report recommends that the role of DPAs should facilitate support and development of the dental practice, general dental practitioners, the improvement of standards and liaison with the CDS DPAs should, for instance, carry out pre-inspection visits to practices in order to help identify shortfalls, to enable practitioners to develop appropriate risk management strategies and to act as an information source eg, on aspects of health and safety legislation. 9

13 5.15 DPAs are also important partners in the process of improving quality in primary care dentistry, including the implementation of guidelines; clinical audit; training needs assessment and the promotion of continuing professional development for practitioners. PERFORMANCE MONITORING 5.16 Unlike other health-related disciplines, dentistry has been relatively well monitored over the years. This is mainly due to the form of remuneration for GDS dentists whereby they claim item of service fees for the treatment provided. This lends itself to closer regular scrutiny than other areas of the service Two of the roles that the Scottish Dental Practice Division (SDPD) carries out on behalf of its Board already relate to standards of care and clinical governance. These are, to ensure that: treatment provided is clinically necessary; treatment provided has been carried out satisfactorily Clinical scrutiny of cases is carried out in SDPD by a team of 4 Dental Advisers, who examine the case information submitted by dentists and three Dental Reference Officers to whom patients may be referred for a clinical examination There is currently no equivalent system for monitoring clinical quality within the 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 be submitted to SDPD for prior approval before treatment is initiated. If SDPD is concerned about the appropriateness of the planned treatment the dentist may be so advised, whether or not the patient is referred to the Dental Reference Service This procedure is intended to encourage the dentist to reflect on the proposed treatment and safeguard patients from receiving inappropriate care. SDPD is in an almost unique position within the NHS in its ability to give prospective clinical approval for a range of primary care treatments. AUTHORISATION OF PAYMENT AND MONITORING OF STANDARDS OF CARE 5.22 On completion of treatment, when claims are submitted for payment, information on the items claimed for payment is analysed by SDPD. A number of cases are referred to the Dental Reference Service for clinical examination to determine if the treatment provided has been carried out to an adequate standard. These referrals are random although further 10

14 completed cases may be referred where there is a specific concern over the standards of treatment being provided As well as monitoring the quality of treatment carried out, statistical information on prescribing patterns is gathered and fed back to dentists in the form of practitioner profiles. These profiles can help practitioners determine how they compare with their colleagues at both local and national level Dentists with an aberrant prescribing pattern can be identified as statistical outliers for one or several items of treatment. If they are unable to justify this excessive treatment prescribing a process of Prior Approval by Targeting can be implemented, whereby the dentist is required to submit all cases of this nature to SDPD for approval prior to the commencement of treatment. This is intended to safeguard patients and cause the dentist to reconsider his/her treatment decisions. Often this results in a dramatic change in prescribing patterns. EDUCATIVE ROLE OF THE SDPD 5.25 SDPD has access to information on all NHS treatments carried out in Scotland. As well as providing global information to organisations such as the Scottish Executive, Dental Health Services Research Unit, Health Boards, Trusts and SCPMDE it is also able to provide more specific feedback to dentist groups, vocational GDPs and students through regular meetings, seminars and lectures Individual dentists about whom SDPD have a concern may also be invited to an informal discussion with Dental Advisers. The aim of these meetings is to: encourage dentists to address these concerns; encourage close collaboration between the DPA, DA and SCPMDE. WHISTLEBLOWING AND DISCIPLINARY ACTION 5.27 The GDC document Maintaining Standards makes it clear that dentists cannot ignore situations which might put patients at risk through unethical practice and, where concerned, they should discuss this with a senior colleague or an appropriate professional body. As a consequence of this SDPD now receives significantly more information from dentists on unsatisfactory work or working practices of colleagues. The accuracy of this is always investigated thoroughly and, where necessary, counselling or investigative procedures implemented. The defence societies have an important role here in working with their members to raise awareness of key issues and to address problems at an early stage Any situation that SDPD judges to require possible disciplinary action is currently referred to the PCT with whom the practitioner is in contract. A decision to take local disciplinary action can only be made by the Trust. In practice this is often delegated to a Reference Committee who must decide if action should be taken. This may take one of four routes, referral to: 11

15 a discipline committee (which is convened by a second Health Board area); an NHS Tribunal; the GDC; or the police/procurator fiscal There have been concerns expressed in the past over a lack of consistency between Health Boards in their approach to handling cases referred for possible disciplinary action by the SDPD. Current proposals to centralise the GDS disciplinary process are welcome and should help to bring consistency and fairness Now that further changes have taken place within primary care it is therefore essential that there is absolute clarity at a local level on the respective roles of the SDPD, Health Boards and PCT. There must also be clarity on lead responsibility, timescales for action and accountability at each stage in the process. POOR PERFORMANCE 5.31 It is important to stress that most issues do not result in disciplinary or criminal action, referral to the Professional Conduct Committee of the GDC or to the police/procurator fiscal. More often the problem is likely to be one of poor performance which is not severe enough to merit referral The GDC published proposals for a Performance Review Scheme for the dental profession (see flow diagram in Appendix IV) which is directed at the dentist whose performance is seriously deficient and whose standard of professional conduct might not currently result in an appearance before either its Professional Conduct or Health Committee. The scheme has been the subject of wide consultation and was supported by the profession and the GDC in May In May 2000 the GDC approved the establishment of a comprehensive UK-wide system for dealing with poor clinical performance in dentistry and its introduction is now dependent upon the necessary legislative changes At a local level it is important that there are mechanisms available to deal with poor performance or low standards of practice. The role of PCTs and other professionals such as Dental Practice Advisers is critical in this regard. The NDAC report on the role of DPAs highlights this issue in more detail Information on poor performance may come from a variety of sources including practice inspection reports; Independent Review Panel reports; patient complaints; information from colleagues and information from SDPD to Trusts. 12

16 5.35 The DPA is often the best person to meet with the practitioner, to offer support and advice and to agree a course of action designed to remedy the situation. It is also important that the Medical Director is fully involved at all stages to ensure that the PCT is able to discharge its clinical governance responsibilities. 13

17 6 ROLE OF OTHER NATIONAL ORGANISATIONS SCOTTISH COUNCIL FOR POSTGRADUATE MEDICAL AND DENTAL EDUCATION 6.1 SCPMDE was established as a Special Health Board in 1993 with responsibility for managing and funding postgraduate medical and dental education and training in Scotland. Its purpose is to ensure that doctors and dentists have the appropriate skills and motivation to meet the changing health needs of the people of Scotland. 6.2 SCPMDE, through its Dental Committee oversees the provision of education and training of vocational trainees and issues completion of training certificates on the basis of evidence of prescribed or equivalent experience. The salaries of vocational GDPs and the training grades in the Hospital Dental Service are funded by Council. SCPMDE also provides the resources for 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 Chief Scientist and is located in the University of Dundee. Its remit is to study patterns of delivery of dental care in Scotland; to identify the factors of importance in achieving dental health; to determine attitudes to dental care and to measure the relative effectiveness of different dental procedures and materials. 6.4 DHSRU has 3 major programme areas of which one, Effective Dental Practice, is of particular relevance to clinical governance. The programme addresses the question of how evidence based practice can be implemented 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 Practice Based Research Network; existing links with HSRU and the Cochrane Group on Effective Professional Practice; new work on dental evidence based guidelines with SIGN and the Faculty of General Dental Practitioners (UK); a successful competitive application to an NHS R&D programme to mount a randomised controlled trial of implementation of clinical guidelines in dentistry. 14

18 CLINICAL STANDARDS BOARD FOR SCOTLAND 6.6 The Clinical Standards Board for Scotland was established in April 1999 as a Special Health Board. The work of the Board will concentrate initially on health priority areas. The issue of clinical standards in dental primary care will 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 England published a Self Assessment Manual and Standards in 1991 which was a significant step in the drive to develop suitable standards for general dental practice. The Faculty of General Dental Practitioners is continuing this process and has produced a series of guidance documents on specific topics. 15

19 CONCLUSION 7.1 Clinical governance is a dynamic process within NHSScotland with a range of organisations contributing to its ongoing development. Within primary care dental services the Clinical Standards Board for Scotland, Scottish Council for Postgraduate Medical and Dental Education, British Dental Association, Primary Care Trusts, General Dental Council and the Faculty of General Dental Practitioners will all have an important role as this report highlights. 7.2 Contributions from all organisations should be co-ordinated through one body to maximise the benefit of each and avoid duplication of effort in order to achieve a coherent and robust system for Scotland. 16

20 REFERENCES: 1. Designed to Care: Renewing the NHS in Scotland. The Stationery Office Health Act Our National Health. A plan for action; a plan for change. Tactica Solutions Maintaining Standards: Guidance to Dentists on Professional and Personal Conduct. General Dental Council. November 1997, last revised May Evidence Based Dentistry Vol 1 (published as a supplement to the British Dental Journal) 6. Faculty of General Dental Practitioners 7. Rennie JS, Development of Audit for General Dental Practitioners in Scotland SCPMDE May Dental Practice Advisers in Scotland. National Dental Advisory Committee. July

21 APPENDIX 1 MEMBERSHIP OF THE WORKING GROUP Chairman: Mr G Ball Consultant in Dental Public Health, Borders Fife and Lothian Health Boards Members: Mr D Arthur Dental Adviser Dental Practice Division Mr R Broadfoot Dr F Elliot Mr J Herrick General Dental Practitioner Glasgow Medical Director Fife Primary Care NHS Trust Community Dental Services Manager Lomond and Argyll Primary Care NHS Trust Dr J Rennie Dental Director Scottish Council for Postgraduate Medical and Dental Education Mr T Timmons Mr F Toner Dental Practice Adviser Lothian Health General Dental Practitioner Cupar Secretariat: Ms M Miller Mrs K Scott Health Planning & Quality Scottish Executive Fife Health Board 18

22 APPENDIX II EXAMPLES OF GOOD PRACTICE Health Boards and Trusts should consider the priorities outlined in the main report in the light of local circumstances. However, much good practice already exists and some examples are included below. This list should not be regarded as exhaustive. AUDIT In Autumn 1994 CRAG awarded SCPMDE 250,000 over 3 years to develop audit for General Dental Practitioners in Scotland. The principal aim of the project was to establish a small national resource which would promote and develop audit within the GDS in Scotland 1. Six audit facilitators were appointed and remunerated on two sessions per week. A number of projects were completed by GDPs details of which are currently held on a database managed by SCPMDE. Since the project ended some Health Boards have appointed their own dental audit facilitators (including Greater Glasgow, Argyll and Clyde, Ayrshire and Arran, Lothian and Fife). In some Health Boards substantial extra funds have been made available to support dental audit and, in these areas, the participation rates of local GDPs have been high. Community Dental staff and Hospital Dental staff should also be included to ensure that audit projects are as broad based as possible. The full report on the development of audit for general dental practitioners in Scotland which describes the SCPMDE project is available. PERSONAL LEARNING PLANS Two projects have recently been funded by SCPMDE (one in partnership with a Health Board) which are designed to encourage GDPs to develop a more structured approach to assessing and meeting their learning needs. These projects, using a dental facilitator are designed to enable GDPs to review their training needs, to construct personal learning plans and to meet those needs within a programme of postgraduate education. Re-certification for the dental profession will bring a requirement on individual dentists to demonstrate that they are undertaking a certain level of postgraduate education. This includes verifiable education from a recognised educational body as well as non core learning activities. 19

23 RESEARCH NETWORKS Whilst the Dental Health Services Research Unit in Dundee has a particular role in developing a Dental Practice Based Research Network, there have been other local research initiatives. For instance Tayside Research and Development Network ( is a research network which includes both general medical practitioners and general dental practitioners from the Tayside area. Models of good practice which are multiprofessional should be encouraged. 20

24 APPENDIX III PROFESSIONALS COMPLEMENTARY TO DENTISTRY PRINCIPLES OF GOOD PRACTICE The requirement is that all team members must be appropriately trained for the tasks they undertake as a key element of quality care and clinical governance. The teamwork approach necessitates joint training of various groups of professionals 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 an educational course to supplement this training. Good practice requires to be defined 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 risk management 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 in importance as litigation increases. Dental Receptionists In the past general training with no specific dental input was the only source of formal training for this group. A dental receptionist programme (DRP) has been developed along similar lines to the Medical Receptionist Programme (MRP). 21

25 The first level is DRP 1 which concentrates on communication skills and dental terminology. The second level is DRP 2 which starts to deal with confidentiality issues, complaints handling and Information Technology. Patients will often measure the quality of their care on their experiences in arranging appointments and receiving general advice about their treatment. It is therefore essential that dental receptionists receive formal training and support. Practice Managers Training programmes for practice managers in general medical practice are appropriate 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 therefore completed an approved training programme. Joint update courses with the dental surgeons are an example of good practice which could be recommended. Team training with other members of the dental team is an essential element of good practice. Dental Therapists This group work within the Community Dental Service and the Dental Teaching Schools at the present time. There are proposals to change the regulations in order that they can work in General Dental Practice. Their expansion into the General Dental Services will have implications for the dental team and appropriate support and training will be required when this occurs. 22

26 Dental Technicians and Clinical Dental Technicians Traditionally dental technicians have carried out their work on the prescription of dental surgeons and work in independent practice. The General Dental Council has proposed that a new profession known as clinical dental technicians will be established 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 a result there will be training and support issues for all team members. 23

27 PUBLIC PROTECTION PATIENT FOCUS RAISING STANDARDS PROFESSIONAL ACCOUNTABILITY

28 CLINICAL GOVERNANCE IN DENTAL PRIMARY CARE CPD and re-certification Development of the practice team THE QUALITY PRACTITIONER Maintaining Standards Good Practice guidelines Local quality assurance

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