Full text of DOI:10.1038/sj.bdj.4800409a

PRACTICE
personal dental services
Personal Dental Services —
a practitioner’s point of view
1
2
N. Barker, and H. Dixon,
Health Authority.
NHS dentistry has seen many changes recently. The latest has
been the introduction of Personal Dental Services. This article
describes the experiences of two general dental practitioners in
their practice who entered as a first wave pilot. The article
explains the steps involved in generating a proposal and
preparing a practice to run as a pilot. The authors have
highlighted areas of particular concern for others to consider
before embarking on a similar journey.
The expression of interest was accepted
and the practice was asked to develop a
full business case for which a budget was
allocated.
Business case
Identifying need
The initial requirement was to identify the
need in the local population. The practice
decided to limit its pilot to the children of
he concept of Personal Dental Services improve the oral health of the community. Greenstead where need was greatest. The
(PDS) is to develop a service aimed at Personal Dental Services appeared to be the Health and Social Services Institute at Essex
T
meeting specific local need by a contract natural vehicle to implement this change.
University helped to develop a questionnaire
that the practice then used to gather data
from specific age groups of schoolchildren in
set up between a health authority (the pur-
chaser) and another body, usually general Expression of interest
dental practitioners (the providers and/or The surgery has always been aware of a high chosen schools across the Greenstead estate.
performers). incidence of decay in its child patients. It This process took the two dentists and the
The example involves a small, three originally attempted to rectify this by oral health educator 3 clinical days to assimi-
surgery general dental practice presently approaching several local schools with a view late the data and one weekend to enter the
operating in North Essex Health Authority. to providing oral hygiene advice. An oral information into a computer. The University
The service is provided by partners Dr health educator was employed to meet this then analysed and reported on this data
Nick Barker and Dr Hayden Dixon who need. However, after only a few months it which revealed a great need for oral health
have run it since 1994.
The Bromley Road Dental Surgery is 2 ing at such a rate that it demanded more and
became apparent that this service was grow- awareness among its subjects.
At the same time, children from these same
miles north east of Colchester town centre. more time and money while generating no age groups (5, 12 and 14-year-olds) were
The Greenstead housing estate has some income for the practice. A difficult decision being examined at the practice to assess their
15,000 residents, including 4,000 children. had to be made to terminate the service. DMF scores according to the criteria set
The surgery is situated at its northern bound- In September 1997, the partners met the down by British Association for the Study of
ary. It caters for a high proportion of families Consultant in Dental Public Health for Community Dentistry (BASCD). The mean
from lower socio-economic backgrounds. North Essex Health Authority. Having con- dmf scores for the average age group (aged 12
1
The nearest dental practice lies 1 mile to the sidered the idea of providing some form of years) were 1.29, compared with 0.48 for the
2
west and has been established for a long time. oral health service under the auspices of North Essex region. Of these children,
There are a large number of dental practices in PDS, the group decided to submit an expres- 48.9% had dmf scores of greater than 0 (ie
Colchester accepting National Health Service sion of interest to the regional office of the had experienced some decay), compared
patients, an unusual situation in the present
climate.
with only 25.8% for the whole of North
Essex. The data collected on this occasion
was sent to the local Community Dental Ser-
vice to be analysed and reported upon. This,
coincidentally, was the start of a good work-
ing relationship that allowed these two par-
ties to interact and aim their individual
services toward specific and separate targets.
Because of time restraints the children had
to be seen during surgery opening hours by
the providers. This necessitated training the
staff in BASCD scoring which was stimulat-
ing for the staff. Seeing these extra patients
was, however, a burden on the practice.
The ‘Health for Greenstead’ initiative, a
local multi-disciplined political group dedi-
cated to improving conditions in the local-
ity, were keen to incorporate a dental
component to their agenda. Communica-
tion channels were opened between this
group, North Essex Health Authority and
the practice to develop ideas on how to
In brief
ꢀ A personal experience of a first
wave Personal Dental Service pilot.
ꢀ The integration of a dental therapist
into a general dental practice.
ꢀ The use of an oral health educator to
promote better oral health in the
local community.
ꢀ Targeting preventive treatments to
children most at risk.
ꢀ Using Personal Dental Services to
provide a more comprehensive
service to our patients and to
develop the practice.
1
2
General dental practitioner, General dental
practitioner, Bromley Rd Dental Surgery, 13A
Bromley Rd, Colchester, Essex CO4 3JE
Correspondence to: H. Dixon
REFEREED PAPER
Identifying services
In identifying the services required, the
Received 20.05.99; accepted 13.08.99
© British Dental Journal 2000; 188: 125–128
BRITISH DENTAL JOURNAL VOLUME 188. NO.3 FEBRUARY 12 2000
125

PRACTICE
personal dental services
partners developed a care package aimed at General Dental Services and must show by the Dental Practice Board was allocated in
providing treatment to those patients who ‘value for money’. After several meetings relation to payments made in the equivalent
needed it most, streamlining the service and with the finance department of the Health period the previous year, taking into account
making it more cost-effective and efficient. Authority, many costs were acknowledged any increase in fees. The fund provided by
The package divided patients clearly into but not without much justification. This the Health Authority was to meet those extra
three groups using a combination of DMF became tiring at the end of a day’s surgery, costs involved in running the pilot. These
score, plaque score and cooperation score. often adding 5–6 hours to a working week monies were then added together and held
The DMF scoring followed the guidelines over a period of 2 months. The breakdown by the Dental Practice Board to be released
set by BASCD, the plaque score used was of cost headings is shown in Table 1.
along existing patterns by requesting pay-
that described by Silness and Loe in 1963 The set up costs were clearly identifiable ment through transmission of claims. The
and the cooperation score was generated by by reasoning what would be required to prime difficulty was allocating capitation
the practice in consultation with the local commission a surgery for the therapist and payments according to the levels of treat-
Community Dental Service.
purchase the materials that the oral health ment need. At best this was by estimation of
Discussions with the Health Authority educator would need to work in the sur- ratios of patient numbers in the three levels
and the Community Dental Service high- rounding community. The growth of the that would be further modified once a
lighted two services that would enhance pilot would entail a need for greater funding clearer picture arrived. This calculation was
what the practice could provide.
as the number of child patients grew with the important in order that the full and correct
An oral health educator was needed to increased exposure in the community. The amount of money was accessed over the
operate both in the surgery and the sur- expected growth was calculated by a specific course of the pilot.
rounding community. The educator’s work increase in the present rate of growth.
in the surgery environment would be to
The next step was to go back to the begin- Monitoring
provide dietary advice and oral hygiene ning and identify the existing cost of running Monitoring was to take place at two levels.
instruction to the child patients of the prac- the practice by generating an income and Birmingham University carried out central
tice on a one-to-one basis. In the commu- expense report. By breaking expenses down monitoring for the benefit of the Depart-
nity, they would visit the local schools, into categories, areas were found where new ment of Health. The practice and Health
cub/scout groups and several other organi- or greater costs would be incurred and this Authority agreed that local monitoring
sations as well as liaising with healthcare was then extrapolated to calculate annual should be conducted by the reference
workers such as midwives and school expenses involved solely in running the department of the Dental Practice Board
nurses. A job description was then clearly pilot.
set out and included in the business case
along existing guidelines but with a higher
proportion of patients being examined.
Monthly meetings were arranged for the
documentation.
Identifying remuneration
A dental therapist was also to be The monies required to meet the costs would steering group (comprising Health
employed at the practice to provide those similarly come from two areas. First, the cap- Authority staff and the partners) to review
treatments most needed. Particular empha- ital costs for setting up the pilot would come and evaluate activity levels and remunera-
sis went on preventive treatments such as from an application to access the money tion, and find solutions to any problems
fluoride applications, fissure sealing and an available in the Investing In Dentistry fund. encountered.
enhanced dietary advice and oral hygiene Second, running costs were to be met by a
instruction programme.
combination of payments from the Dental Exit arrangements
Practice Board and money added by the Finally, conditions were clearly set out to
local Health Authority. The money provided allow an exit by any party from the contract
Identifying costs
A great deal of time and effort was spent on
identifying and then agreeing the costs of
running the pilot between the Health
Authority and the surgery. Two areas of
expense were noted: first, the capital costs
involved in both setting up the surgery and
growth of the pilot, second ongoing costs to
run the pilot. The Health Authority, with a
view to any double accounting, examined
these ongoing costs very stringently. The
costs had to be related to services being pro-
vided that were above and beyond those
incurred by a surgery operating under the
Table 1
Wages
Ongoing costs
Therapist
Travel
Oral Health Educator
Dental Surgery Assistant
Oral Health Educator
Receptionist
Sundries
Clinical waste collection
Utilities
Pilot Manager
Dentist’s time in meetings
Computer maintenance
Equipment maintenance
Stationary
Materials
Therapist
Oral Health Educator
Pilot Manager
Postage
Inflation
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PRACTICE
personal dental services
provided certain parameters were met.
There was no margin for error in the costing
of the pilot, the providers thought long and
hard when considering the financial impli-
cations that would cause their exit.
Table 2
Role of the pilot manager
1. Weekly meetings with dentists to assess:
• Levels of registration
• Productivity of staff
• Weekly audit of PDS budget; income vs expense
The consultation process
An integral part of developing a Personal
Dental Services bid is the process of consul-
tation with the dental profession. This is
important on both a local and national level.
Locally, letters were written to the Local
Dental Committee, dental practitioners,
Community Health Council and the Com-
munity Dental Service.
On a wider scale, discussions were held
with the British Dental Association, the NHS
Executive and the Dental Practice Board.
Representatives from the BDA visited the
practice, providing advice and support and
reassurance that no serious omissions had
been made from the ‘business case’.
The NHS Executive met locally with the
partners and Health Authority representa-
tives at an early stage. They highlighted
areas that needed clarification and offered
advice on improvements that could be
made. What appeared to be a daunting list
of eminent personnel, actually proved to be
an enjoyable and enlightening meeting.
Part of the DPB annual conference
focussed on new developments within the
NHS, namely Personal Dental Services,
and as a consequence the partners were
invited to participate, outlining the expe-
2. Prepare information and meet with Health Authority representatives along
with dentists on monthly basis.
3. Weekly meeting with therapist and oral health educator to review and assess
past, present and future activities.
4. Weekly contact with local consultation contacts to identify need/activities for oral
health educator.
5. Monitor travelling expenses of oral health educator.
6. Calculate wages for oral health educator.
7. Liaise with:
• Essex University and BASCD contacts re re-monitoring of data.
• DPB re information reports
• BDA re PDS activities of practice.
• Other PDS pilots
• Media contacts, both professional and social to gain attention for pilot study
and heighten practice’s public profile.
8. Prepare presentations at post-graduate meetings.
9. Produce PDS newsletter
10. Attend Health for Greenstead meetings.
11. Attend Continuing Development and Education courses.
12. Run complaints service for PDS.
Intense and lengthy pricing meetings vices from the Department of Health
riences to date and putting the case of the were a weekly occurrence as the local Health appeared to be happy with the facts and fig-
general dental practitioner. This experi- Authority commissioners, accountants and ures to date.
ence was both daunting and challenging partners went over the initial plans in detail.
but a great opportunity to mix with the
Physical preparations
‘great and the good’ of the dental world. NHS executive meeting
Commissioning the third surgery began.
The presentation was successful, fun and The NHS executive was understandably This involved time-consuming meetings
educational. keen to keep a close watch on the develop- with various representatives, each with their
The business case was then sent to the ment of the pilot. Consequently, the part- own ideas of how to put together the basic
Department of Health for their considera- ners and Health Authority staff were invited necessities. Not surprisingly the quotes var-
tion.
to Richmond House to answer questions on ied tremendously.
financial and other matters and to express
The computer software proved to be a
Preparing to run the pilot
confidence, or otherwise, in the practicality greater problem than had been expected.
Confirmation that the bid had been success- of the project.
The problems were due to confusion as to
ful was received by the end of May 1998. This experience was not as intimidating who should pay for the specific changes to
The positions of oral health educator and as had been anticipated. It was useful to the software. Central government funding
therapist needed to be filled as well as many meet the decision-makers face-to-face and was initially going to be provided but this
other adjustments to the normal running of exchange views. The Chief Dental Officer was never put in writing. This caused
the surgery.
and Section Head for Personal Dental Ser- concern for the Health Authority who
BRITISH DENTAL JOURNAL, VOLUME 188, NO. 3, FEBRUARY 12 2000
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PRACTICE
personal dental services
would not be able to afford the additional the proposed pilot must obviously provide ideas are developed. Personal Dental Service
expenditure. This situation has yet to be benefits over the existing system.
fully resolved. The benefits to the providers were the
is but the latest of these developments.
The authors felt it prudent to be a part of
Lengthy discussions spanning 2 months employment of auxiliary staff to help in the this process and contribute in a small way to
were spent by the partners liaising between treatment of difficult child patients. This the future of our profession. Developing a
the DPB and the software suppliers to would further free up the provider’s time Personal Dental Services bid was never
ensure that all the criteria were met for the to undertake more advanced restorative about financial gain. At this stage the
effective running of the scheme and trans- work. There was also a sense of satisfaction authors have found that the careful scrutiny
mission of data. This was more time-con- and achievement in advancing their pro- of the finances by the Health Authority has
suming than had been anticipated, as the fessional careers.
adjustments to the computer software and The benefits to the practice were to financial gain nor a loss. The benefits to the
their interpretation by the DPB had to be increase the number of registered patients practice have been an increase in the profile
synchronized. and raise the practice’s profile in the local of the practice in the local community
meant that the practice has made neither a
Since converting all the registered chil- community because of increased exposure through media coverage and publicity. A
dren to Personal Dental Services meant a through word of mouth and media cover- clearer understanding was gained regarding
change in the way treatment was to be pro- age. Staff also became more integrated in the running of the NHS, which has indi-
vided, the practice needed to close for staff practice life as a consequence of greater rectly led to more efficient management of
retraining. The complexities of software teamwork.
adjustments were explained as well as how The benefits to the patients were a level of
the practice.
Certainly political, and all responsible
to cope with the extra number of patients, service which was specifically targeted at opinion, leans to prevention of disease
appointment scheduling and so forth. New their individual needs with a greater empha- rather than simply dealing with the results
staff were brought on board and working sis on prevention of dental disease. The ther- of neglect and abuse. The purpose of this
hours and responsibilities were shuffled, apist could spend more time with the patient pilot is to indicate that prevention and
hopefully to the satisfaction of all con- than the dentist would be able to do under education of a target group is not only
cerned. This obviously affected the staff the financial constraints in the NHS.
who were used to a set routine. Thankfully The benefits to the Health Authority significant long-term cost savings for the
the staff were cooperative and appreciated were that the practice will meet clear local public purse.
immediately cost effective but will have
that the benefits to the practice would out- needs. Further, they could be seen to be
So, was it all worthwhile? Yes. But the
weigh the inconveniences. Specific times acting proactively. The pilot may also major hitch was the unclear roles of each
were made available to the oral health edu- prove to be a more cost-efficient service party in developing this bid. If the authors
cator and pilot manager to allow them to for the NHS.
had it all to do again then a written contract
perform their duties with minimal inter- However, it has been a long and arduous defining tasks and remuneration would be a
ruption to the smooth running of the prac- process and brings the practice to an uncer- great benefit.
tice. These positions were filled by tain and pioneering financial position.
The authors would like to thank Dr Mark Shackell,
promoting existing staff members who had
expressed an interest in furthering their Conclusion
careers.
Because of increased amounts of data has not been an altogether straightforward
required by the DPB and Health Authority, procedure. It has taken many hours of dis-
new roles have evolved that have been cussion and hard work. It has, nevertheless,
Consultant in Dental Public Health for North Essex
Health Authority, Dr Andrew Clayton, Dr George
Brown of North East Essex Community Dental
Services and Julie Powell for their assistance in
co-ordinating and correlating statistics, together with
advice and encouragement.
Developing a Personal Dental Services bid
assigned to the pilot manager (Table 2).
been extremely worthwhile and rewarding,
and, retrospectively, a good investment of
time and energy.
1
2
Data collected and analysed by North East
Essex Dental service using Survey Plus.
BASCD co-ordinated NHS Dental
Epidemiology Programme Caries Prevalence
Surveys 1995/6.
Benefits
To justify the amount of time spent in
preparing and actioning the business case, static entity. Rather, it is evolving as new
National Health Service dentistry is not a
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