Quality Assurance and Improvement
The consultation provided an opportunity to look at how we assure that patients receive the best quality care under the NHS. Currently service delivery, scrutiny and quality assurance for NHS dentistry can be disjointed. This chapter looks at each of these functions and how they may be enhanced.
Professional Leadership and Strategic Oversight at Board Level
NHS Boards have an important function in providing assurance to the public that the care they receive as a NHS patient is safe, person-centred and effective. These functions include:
- considering applications to join the dental list to provide or assist with the provision of GDS;
- undertaking dental practice inspections to ensure a high quality service;
- ensuring dentists and bodies corporate comply with their NHS terms of service;
- working with PSD on payment verification to ensure treatment claims and payments are appropriate; and,
- referring dentists and DBCs for NHS Discipline or Tribunal procedures where appropriate.
We believe that NHS Boards would benefit from a single professional source of advice and accountability. This would be in the same vein as the directors of medicine, nursing and pharmacy. There are a range of models of professional dental leadership across Boards with Consultants in Dental Public Health ( CDPH), Chief Administrative Dental Officers ( CADO), clinical leads for the PDS and Dental Practice Advisers ( DPA) each having an overview of particular elements of oral health activity.
It is our view that a professional Director of Dentistry within each NHS board would ensure a more co-ordinated approach to local assurance and a strategic approach to primary and secondary care service planning and oral health improvement across each of the Board functions. The NHS Board would be expected to designate an existing senior dental member of staff to be the Director of Dentistry.
This person would provide a point of contact for national policy delivery in association with other organisations such as NHS National Services Scotland ( NSS), Healthcare Improvement Scotland ( HIS) and NHS Education for Scotland ( NES) to ensure that national policy is being delivered at a local level.
Action 20: The Scottish Government will work with NHS Boards to introduce a Director of Dentistry in each Board area.
Applicants Listing to Deliver NHS General Dental Services
In general the listing arrangement is a suitable mechanism for ensuring that GDPs meet certain standards to provide GDS. However the consultation exercise has identified a number of weaknesses with the current process.
NHS Boards have concerns that their role is sometimes too passive, and that they do not have sufficient powers to refuse applications, only to defer in certain circumstances. While it is important that these processes are designed to ensure the NHS Board is able to establish the competency of the applicant and for the applicant to be confident the process is fair and reasonable, we feel that the balance of the process currently favours the applicant.
In future we will bring forward amendment regulations to provide NHS Boards with the powers to refuse applications where they are not satisfied that the applicant would be able to provide a safe and competent service. We will work with the service on the precise grounds for refusal of an application.
We also looked at ways that information on listing could be shared between NHS Boards to avoid duplication of effort. In the first instance, as part of the initial consultation exercise we considered moving to a national listing arrangement but concluded it was important that local arrangements continued particularly as NHS Boards are best suited to react to difficulties in access to dental services for the public.
While the national approach was viewed as impractical and could jeopardise local assurance, there was support for a single database that could be shared between NHS Boards. This would reduce the administrative workload of listing and make it easier for GDPs to list in new areas.
We also take the view that NHS Boards do not have sufficient intelligence on who is providing GDS in their areas. This is mainly to do with bodies corporate, in particular those bodies corporate that are not listed. In many circumstances it is important for the NHS Board to be able to contact the owner of the practice. The present listing arrangements for bodies corporate do not allow this to happen.
Action 21: The Scottish Government will:
- introduce regulations to provide NHS Boards with more powers to refuse potential applicants;
- introduce arrangements for a single database of information for NHS Boards; and,
- explore options in order to gather relevant information on bodies corporate.
Safe Delivery of NHS General Dental Services
NHS Boards have obligations to ensure safe provision of GDS in their areas. In 2015 NHS Boards were provided with additional powers to make an unannounced inspection of a practice where there were concerns about patient safety. However, there remain certain critical circumstances where the NHS Board requires additional powers to ensure the practice is unable to provide GDS until the NHS Board is satisfied the circumstances that led to the cessation have been put right. For example, at present a Board cannot stop the provision of GDS in a practice with insufficient decontamination provision.
Action 22: The Scottish Government will explore the possibilities for providing NHS Boards with more powers to prevent GDS being provided from practices where there is danger to patients.
Monitoring of Clinical Quality
The Dental Adviser ( DA) function provides pre-treatment reviews and approval for complex or high cost treatment plans, including orthodontics. The Dental Reference Officer ( DRO) service monitors the quality of NHS dental treatment by inspecting a random sample of patients. At present the service is not well attended by patients. During the consultation exercise GDPs had many views about how the service could be improved, including whether patients could be seen in the practice rather than elsewhere. With over four million courses of treatment being provided annually and the move to a more preventive based approach there is a requirement for a more effective clinical quality monitoring service.
Currently, both the DA and DRO service are hosted within Practitioner Services Division ( PSD). However it would seem appropriate to separate the payments function from clinical quality monitoring. The DA service with its payment verification function should remain within PSD and the DRO service with its clinical quality monitoring remit should transfer to be under the direction of the Director of Dentistry within NHS NSS.
Action 23: The Scottish Government will work with NHS NSS to reconfigure the DRO and DA service to ensure a more effective and responsive service in the future.
Scottish Dental Practice Board ( SDPB)
The consultation highlighted a significant degree of misunderstanding amongst respondents of the role of PSD and the SDPB. PSD makes payments to GDPs on behalf of NHS Boards but also make certain payments or estimated payments on behalf of the SDPB. We believe that the governance of this process should be entirely under the remit of NSS.
Action 24: The Scottish Government will consider how the functions of the SDPB can be subsumed within NHS NSS.
Assurance that Service Providers are Safe and Effective
The consultation highlighted the concerns that some GDPs have with the disciplinary process, in particular that some NHS Boards are using the General Dental Council ( GDC) as the only recourse for disciplinary issues. In many cases this is unnecessary, it is not satisfactory from the point of view of the GDC and can cause unnecessary distress for the GDP.
Against this backdrop the Chief Dental Officer ( CDO) has chaired a working group on ensuring that satisfactory arrangements are in place that are proportionate to the problem under consideration. As well as publishing a pathway for supporting practitioners for NHS Boards to work to, the intention of the Scottish Government is to ensure that NHS Discipline and Tribunal procedures are in place so that NHS Boards have a satisfactory recourse without unnecessary referral to the GDC.
Action 25: The Scottish Government will:
- publish a pathway to support dental practitioners locally; and,
- when necessary, ensure that NHS Boards use local disciplinary procedures and NHS Tribunals where appropriate.
Improvement Activity is Evidence-Based and Data-Driven
The consultation reported on a Scottish Government pilot, launched on 1 April 2015, to gather information on a range of quality indicators, both at practice and GDP level. The intention is to roll this out nationally by 1 January 2020.
The quality indicators would include anti-microbial prescribing patterns; Childsmile interventions; practice inspection; out of hours arrangements; DRO scores; practice complaints procedure and involvement in quality improvement.
Action 26: The Scottish Government will work towards a single database of quality improvement information for NHS Boards with appropriate access for dental teams and the public.
In June 2014, the then Cabinet Secretary for Health, Wellbeing and Sport announced that HIS would lead on developing and delivering more comprehensive assessments of the quality of care across health and social care services. The final report; ‘Building a comprehensive approach to reviewing the quality of care: Supporting the delivery of sustainable high quality services’ was published in March 2016. 
Based on the HIS report the intention is to develop a new framework in dentistry that will drive improvement at practice, NHS Board and national level. The framework should provide guidance on what ‘good’ quality care might look like, what form of evidence might be available to provide assurance of this and what support dental teams may need to deliver any improvement in quality.
The framework will assist the public to be suitably informed on what they can expect of their NHS dental service and what is expected of providers. We also intend HIS and NES to support the framework by providing the dental team with education and study development in quality improvement.
Action 27: The Scottish Government will:
- commission the development of a National Framework for Quality Assurance and Improvement across NHS dental services, using the HIS report as a starting point; and,
- work with HIS and NES on ensuring an overarching approach to quality improvement education and activity for NHS dental teams.