Primary care services
- The definition of primary care
- Key legislation relating to primary care service provision
- The types of primary care NHS dental services
- The primary care dental team
- Introduction to epidemiology
This chapter seeks to introduce the role of primary dental care services (PDCS) and the key role that the primary care dental team can play in the assessment and management of evidence-based practice. When thinking about primary care, whether as a patient or as a service provider, we need to consider what the term ‘primary care’ denotes.
Since its inception in 1948 the National Health Service (NHS) has aimed to provide care which enables equitable access to provision for all. It seeks to provide a service which is acceptable to communities, providing what they want or need, is responsive to changing population needs, is cost effective and, above all, which can be held accountable. It is therefore not surprising that services based in the primary care setting, where most patients receive care, have evolved. In such a model of provision, care is provided at the ‘primary’ level, based upon the health needs of the local population. The genesis of ‘primary dental care’ supports notions that health needs can vary with demography (region to region). It accounts for influences which are placed upon populations who live and work in different environments and by different cultures, customs and traditions. Primary dental care should be based upon the needs of the local population rather than being solely disease based; it accepts that disease rates are not universal and may be more prevalent in certain communities than others. In such a model of healthcare provision, patient needs can be preventative as well as curative, as care can be based upon both health and ill health determinants.
The Oxford English Dictionary defines the word ‘primary’ as meaning ‘occurring first in time or sequence’. Primary dental care seeks to provide the point of contact for local populations through devolved funding regimes. Funding is considered against the needs of local and not regional health trends. Primary care is the first facet of care provision working alongside healthcare services in meeting the needs of the overall health economy. Primary care denotes the provision of services which are funded and resourced at a local level, based upon local community and population needs. By 1995 the NHS had officially adopted the term ‘primary care’. The framework of dental healthcare provision in the United Kingdom therefore includes primary, secondary and tertiary care services. Secondary healthcare is defined by the European Observatory on Health Systems and Policies as care provided by medical or dental specialists, usually in a hospital setting, but also some specialist services provided in the community. Tertiary care refers to medical and related services of high complexity and usually high cost. Tertiary care is generally only available at national or international referral centres.
The framework of UK primary dental care service provision
The provision of care through the NHS is an ever evolving process. This section will describe the current existence of the Strategic Health Authority and Primary Care Trusts and the proposed replacement of these bodies with the NHS Commissioning Board and the General Practitioner Commissioning Consortia (GPCC). These reforms, led by the Coalition Government elected in 2010, follow in the footsteps of work carried out prior to the installation of this Government.
In 2008, a report entitled High Quality Care for All was published (DoH, 2008). This report, led by Lord Darzi and co-produced with the NHS, examined the provision of high quality care as opposed to building capacity within the NHS. In 2009, building on the findings of this paper, an independent review into NHS dentistry, led by Professor Jimmy Steele, was published (DoH, 2009). His report, Dental Services in England, suggested that if dentistry was to be aligned with the rest of the NHS oral health, rather than dental activity, was the required outcome that all practitioners should be working towards. Furthermore, a change to the contractual arrangements within NHS dentistry would be required if a high quality, accessible service was to be delivered to the population. Since 2006, the local commissioning of dental care has been the responsibility of 10 strategic health authorities (SHA). At the current time, Strategic Health Authorities are a key link between the Department of Health and the local NHS. Each SHA oversees primary care trusts (PCTs), which commission dental services in order to meet community healthcare needs. Primary care trusts are the ‘purchasers’ (commissioners or procurers) of primary care services and contribute to the work of other health trusts (e.g. acute hospital trusts, ambulance trusts, care trusts, mental health trusts, foundation trusts, etc.) in meeting the health needs of communities.
The SHAs are tasked with working closely with the PCTs, whose remit is to act as service commissioning and workforce planning advisers. So effectively PCTs are local commissioners of medical and dental care. In this model, PCTs are responsible for assessing and meeting the dental needs of their local community, and reporting these to the SHA.
- The installation of the Coalition Government in 2010 brought with it the promise of change and reform in the NHS. Structural Reform Plans (SRPs) were introduced and an SRP was published for each department within Government that set out measureable objectives. This placed accountability for Government reforms within each of the specific departments, and spending within departments was dependant on the Spending Review carried out by HM Treasury. The priorities of SRPs, Department of Health Structural Reform Plan, October 2010 (DoH, 2010a) were centred upon a patient led NHS, relocation of resources to promote healthcare outcomes, transformation of NHS accountability and improvements in public health and social care.
Publication of the White Paper; Equity and Excellence: Liberating the NHS (DoH, 2010b), set a long-term plan for reforming the NHS. Detailed within the paper were changes to the contractual arrangements within NHS dentistry which included replacing SHAs with an NHS Commissioning Board and PCTs with the GPCC, by April 2013. The quality assurance of the GPCC would be the responsibility of the NHS Commissioning Board, as opposed to the Care Quality Commission (CQC). The CQC is an independent regulator of all health and adult social care in England. All primary care dental providers were required to have registered with the CQC by April 2011to be able to legally carry out the business of dentistry. Primary Dental Care establishments are accountable to the CQC for standards of quality and safety.
Government policies continue to iteratively shape and change oral care provision. Thus, dental services, and the staff who provide such care, will continue to be engaged in on-going cycles of review and reform that will shape the nature and provision of primary care dentistry.
The provision of NHS dental services
The general dental service contract
The UK has a well established framework of general dental services (GDS)/personal dental services (PDS). Such services are often referred to as ‘high street dental practices’ or ‘providers of family dental care’. Dental practices are independent businesses commonly owned and managed by general dental practitioners, although practices may be owned and managed by dental care professionals (DCPs), corporate bodies and limited dental companies. Practitioners are able to offer private treatment whilst also entering into a service level agreement (SLA) with the PCT for the provision of NHS services. The NHS patient activity expected, in terms of SLA delivery, is measured in units of dental activity (UDAs). Each dentist receives a block fee, in accordance with their SLA/defined UDAs, and payments to the dentist are made monthly by the PCT through the agency of the Business Services Authority. The practice owner, if unsuccessful in the delivery of the SLA/UDAs, may be required to repay elements of the funding claimed from the PCT. The patient receiving the NHS treatment contributes to the monies paid in the form of a set patient charge, depending on the work being carried out. Financial implications are commonly cited by patients along with general access problems, as barriers to their receiving dental care.
The GDS/PDS is delivered through the services of dentists, dental therapists, dental hygienists and dental nurses. GDPs can recruit staff as required, and therefore the skill mix will vary from practice to practice. Following changes to the Dentists Act (1984) in July 2002, dental therapists were legally permitted to work as members of the GDS team, in addition to their former roles in the salaried dental services (SDS). A dental practice may also provide dental care through the appointment of a Foundation Trainee (FT). Foundation Training is mandatory for the first year post qualification and a 2-year Foundation Training course is available. A FT will continue to train and work alongside an experienced general dental practitioner, or FT trainer, during his or her first year (or possibly two years) of practice. FT positions are open for application to those dental students who have qualified at a UK dental school. Salaried Therapist Vocational Trainee posts are also becoming available in certain areas of the country, commonly on a part-time basis of three days per week.
The proposals set out in the White Paper Equity and Excellence: Liberating the NHS requires the dentist to employ the appropriate skill mix required to meet the needs of their patients. This vision is reinforced in the consultation document Liberating the NHS: Developing the Healthcare Workforce ‘creating an environment where talent flourishes and where everyone is able to realize their potential’ (DoH, 2010c, p. 13). Whilst practices and the salaried services may wish to keep lists of their patients, the formal requirement of patient registration ceased to exist after April 2006, as did the requirement for registered patients to be seen ‘out of hours’ in an emergency. The responsibility for out-of-hours emergencies lies with the PCT. From April 2006, all local PCTs were allocated a budget for dentistry within their area, after which their funds became what was termed ‘cash limited’ (i.e. restricted to the agreed level). The GDP must therefore seek prior approval to set up a new dental practice, to expand an existing practice, or to amend their SLA.
Salaried dental services
The salaried services are made up of the traditional community dental service (CDS) and PDS. These services are PCT led, and structures and remits may therefore vary between trusts, dependent on local population needs. Typically, services operate via a referral service from GDS and other healthcare services (HCS). However, emergency care can be accessed directly by patients at selected centres, called dental access centres, which are part of the PDS.
The community dental service
The CDS is a complementary service to the GDS offered through PCTs to fulfil the remit of:
- Providing dental care requiring specialist skills for individuals referred from the GDS and other health professionals, or, for those who cannot otherwise access treatment. These may include people with special needs or requiring specialised services, such as anxious patients, or, assistance with people who are restricted within their homes or are hospitalised.
- Screening of school children.
- Contributing to epidemiological surveys and data, such as the publication of decayed, missing and filled deciduous teeth (dmft) rates.
- The provision of oral health promotion and education services where needs are identified by the PCT.
The CDS are often located in a medical centre or health centre and are subject to the same treatment charges as in the GDS. The staffing skill mix will vary from one CDS centre to another, but traditionally includes: dentists; surgical dentistry and paediatric dentistry, dental therapists, dental hygienists, dental nurses and oral/dental health promotion teams.
The personal dental service agreement
The PDS was first established in 1998, following the introduction of the NHS (Primary Care) Act 1997. The government aims of the PDS scheme included increasing access to NHS dental services, enabling practices to adopt a preventative approach to dental treatment and oral health and providing local solutions to local problems. PDS funding is based on the PCT contract.
Initially PDS schemes replaced some GDS and CDS contracts but later some specialised services and practices (e.g. orthodontics, oral surgery, periodontics, endodontics and sedation), transferred to the PDS scheme.
PCTs work in partnership with PDS practices to address inequalities in oral health locally, seeking to provide dental access to those who need it most. PDS practices are not limited to NHS provision, and may offer a mix of both private and NHS care to patients, as in the GDS. Management of the practice remains the responsibility of the principal dentist who holds the PCT contract. This dentist is known as the ‘provider’, and may choose to contract others to do some or all of the work within the practice, and these individuals are known as the ‘performers’. Performers may include, for example, other dentists within the practice, dental hygienists and dental therapists. The skill mix of staff is the choice of the dentist, dependent upon the needs of patients.
Dental access centres
In addition to the GDS, SDS and the personal dental services, primary care dental services are also offered through dental access centres. Dental access centres fall within the PDS to provide emergency care to patients who are not able to access a GDP. The service provided can vary from area to area depending on local needs, resources and patient demand/need. The priority is to treat those with an urgent need initially. An adult or child can seek the full range of NHS dental treatment at any access centre during weekday working hours. Dental access centres are located in areas where the patients’ oral health needs are high, and access problems are prevalent. Appointments are not always needed as emergency slots are reserved. Standard NHS patient charges apply. Patients are generally directed to access centres for care by the ‘NHS Direct’ helpline services.
Until the reforms led by the current Coalition Government are introduced the PDS will continue to be co-ordinated through PCTs, and contracts will be integrated into new arrangements. Patients in pain may present as dental emergencies outside routine working hours; the emergency dental service supports the work of the dental access centres, by providing ‘out-of-hours’ emergency care.
Emergency dental services
The aim of the emergency dental service (EDS) is to provide urgent dental treatment, out of normal surgery hours, to patients who cannot wait until the next working day. In addition to this, the EDS scheme, funded (currently) by local PCTs, operates in most regions providing emergency care to patients who are not registered with a dentist. These services are commonly linked to health centres or hospitals, providing cover for evenings, weekends and bank holidays.
The provision of ‘out-of-hours’ emergency dental treatment is currently the responsibility of the PCTs. Strategic health authorities and PCTs work together to ensure that emergency services are available, and that all PCT regions have service provision. The hours and days of availability of an EDS are likely to differ from region to region. Services may be operated:
- On a ‘walk in’ basis.
- Through an appointment system.
- Through a triage centre which then books an appointment depending on the needs of the patient.
- Via screening through an ‘on call’ rotational service.
The funding bodies of primary care dentistry and practitioners need to work together to find the most effective and efficient way of providing emergency cover in their r/>