Healthfit Is the Title of a Programme Comprising an Ongoing Service of Events Designed

Introduction

“HealthFit” is the title of a programme comprising an ongoing service of events designed to create a strategic framework for health services in Grampian, to serve as a basis for detailed service planning work.

This report is a summary of the Dental HealthFit event held in Peterhead on 5 and 6 June 2003 which brought together over 100 people, clinicians, managers and public representatives – all ‘experts’ in their own right. Drawing on their experience and judgement, participants worked together to find the ‘best fit’ for Grampian’s dental services balancing their different interests and taking into account the various forces, drivers and constraints on change which affect them and the system in which they operate.

Dental services in Grampian are currently facing considerable pressures, with access to primary and secondary dental care severely limited for a significant proportion of the local population. There is recognition of the difficulties in recruitment and retention of all grades of staff to Grampian, together with severe accommodation problems facing hospital and community services which prevents further development. The delivery of continuing postgraduate education is also recognised as a negative driver in attracting potential staff to the region. These are some of the important drivers which were explored at the Dental HealthFit event.

HealthFit creates an open, inclusive and transparent atmosphere in which service planning can take place and allows the people actually providing and using the service to develop a shared vision of the future. Some strong messages and original learning emerged about how services might need to be organised in the future and the changes at local, regional and national level required to deliver them. The vision which has emerged represents an achievable and powerful framework for the more detailed planning of dental health services in Grampian. The Dental HealthFit event and this report is a starting point and a foundation on which this more detailed ongoing work can be built.

Thanks are due to the Reference Group, established to plan and design the event (see appendix) and to the event sponsors, The Dental Directory, Wrigleys and NHS Grampian. Finally, thanks to the participants themselves who openly shared their experiences and creatively explored solutions to improve dental health services in Grampian in the face of the current pressures on the system.

Martin Donachie

Chairman

Area Dental Committee

DENTAL HEALTHFIT

Purpose and Process

The Purpose of HealthFit

It is clear to the new NHS Board in Grampian that if the local health system is going to respond to all the pressures for change, as well as meet the expectations of ministers, staff and the public, then there has to be fundamental, whole-system change across the entirety of the health service in Grampian. Funding for services is under pressure, access to care across Grampian is inequitable and press and public concern about the ‘state’ of the health service is growing. Propping up the status quo is no longer an option.

The NHS Grampian Board is attempting to create a vision for the future – a well understood and widely accepted view of how services should develop across the region – which will guide current decision making and provide the basis for a set of robust and integrated service improvement plans.

What is required is an open, inclusive and transparent way of using the opportunities created by a Unified Board that will create the right climate for change, overcoming any natural resistance among service users, politicians and professionals about reshaping services and establish a clear and shared vision of the future.

This is the objective of the HealthFit programme.

The Process

With the help of a local Reference Group, made up of managers and clinicians from across the patch, OPM (the Office for Public Management) designed an event based on a large-scale open negotiation process that would enable over 100 local people from the health service and its public sector partners, along with opinion formers in local communities, to produce a shared view of what a modern health and social care system would be like in Grampian and what outcomes should be expected.

This event took place in January 2002 and a report setting out the process and outcomes of this work is available separately.

Dental HealthFit

Representatives from the Dental Service proposed to build on the successful experience of this model to respond to the current pressures on dental services in Grampian and to develop a shared view of what modern dental services should be like. A Reference Group was made up of clinicians and managers from across the service who designed and organised an event to:

• be clear about the forces and drivers for change operating in the national and local health and social care economy and dental health services in particular;

• understand what ministers and policy makers are expecting as a result of Our National Health: A Plan for Action: A Plan for Change, the impending White Paper and what this means for Grampian;

• produce a shared view of what modern dental health services would be like in Grampian, in the context of a health and social care system and what outcomes should be expected; and
• create a climate in which this change – the modernisation of dental services in Grampian – can be welcomed, understood and pursued enthusiastically.

As a first stage in this process and in preparation for the event, the current forces, drivers and constraints on dental services which any new initiatives or ways of working would have to accommodate, were identified. An analysis of the local and national forces and drivers was prepared by local clinicians and is available as a companion to this report.

At the event itself, groups of clinicians, managers and members of the public, using IT based geographical information systems were firstly asked to identify the pressures and constraints on their services. These ‘teams’ were then asked to consider the changes and developments which would need to be made to cope with these pressures and deliver the best services to patients and their families in the future.

The teams presented their proposals to the wider group of participants to ensure that they were credible and deliverable and were not incompatible with the development of a whole-system approach.

There was a high degree of consistency and agreement in the various models and proposals suggested. They were also realistic and took account of the economic and political realities as well as the impact of geographical and workforce factors as well as public and professional expectations.

Forces, Drivers And Constraints On Dental Health Services In Grampian: A Summary

Background

It is recognised that young children in Scotland have one of the highest levels of dental decay in Western Europe. Although in the last survey of five-year-old children (1999/2000), Grampian was placed third out of 15 Scottish Health Boards, we still lie in the bottom third of all Health Authorities/Boards in the UK.

The Government’s White Paper “Towards a Healthier Scotland” (1999) identifies dental health as a key health topic on which actions need to be taken. It is pointed out that decay is strongly linked to deprivation. The poorest 10% of children have 50% of decay. The White Paper set a target that 60% of five-year-olds should have no experience of dental decay by the year 2010. At the moment the percentage is 44%.

Grampian has pockets of urban deprivation but the deprivation index is less reliable in sparsely populated rural areas as in parts of Grampian. This rural dimension is also compounded by varying patterns in the ratio of General Dental Practitioners per head of the population for example, which range from 1:2900 in Aberdeen City, 1:4400 in Moray to 1:5000 in Aberdeenshire against a Scottish average of 1:2700.

Pressures on the Clinical Workforce

The dental workforce consists of General Dental Practitioners (GDPs) and Community Dental Officers (CDOs) working in primary care, with hospital-based consultants providing specialist treatment in Orthodontics, Oral and Maxillofacial Surgery and Restorative Dentistry. Dental Nurses, Hygienists and Therapists are playing an increasingly vital role in the delivery of dental health services.

Shortage of clinical staff across all areas of the service is threatening the viability of some services in certain locations. The consultant per population ratios, for all the hospital based specialist services in Grampian, are well below national recommendations.

Factors relating to geography, quality, training, support, remuneration and unsustainable workload all influence the recruitment and retention of clinical staff.

The Scottish Executive is developing a number of initiatives to improve pay, education and working conditions and the White Paper “Partnership for Care” in particular, includes a commitment to introduce new levels of remuneration of dental professionals in primary care.

Changes in Clinical Practice

Change and development in clinical practice and technology is having an impact on the scope, setting, cost and delivery of services generating increasing demand for specialist skills whilst at the same time facilitating increased accessibility and pressure for decentralisation. Ensuring that premises and equipment remain fit for purpose is a particular challenge for dental services. Limitations on the development of suitable surgeries restrict access to dental services and the capacity for vocational training, outreach and general professional training schemes as well as recruitment.

Focus on Quality and Clinical Effectiveness

Patients and the public expect the NHS to provide safe, high quality care and treatment. The Scottish Executive has set up a new body – NHS Quality Improvement Scotland (QIS) – which combines the functions previously undertaken by the Clinical Standards Board and the Scottish Hospitals Advisory Service. QIS will ensure rigorous and independent monitoring and inspection with robust arrangements to investigate and tackle serious failure. Difficulties in supporting single-handed practices, limited access to training and development opportunities and high workloads all have implications for the quality and clinical governance of dental services.

New Forms of Governance and Accountability

“Our National Health: A Plan for Action, A Plan for Change” (2000) introduced a new model of governance replacing the separate Health Board and Trust structures with a single unified NHS Board focusing on health improvement across a single health system. This commitment to inter-disciplinary, integrated working across a unified health system has been further underlined in the most recent White Paper “Partnership for Care” (2003) which abolishes NHS Trusts from April 2004. Each NHS Board is responsible for developing a single Local Health Plan with local Joint Health Improvement Plans to be produced by local authority/LHCC areas.

Information for Health

“Our National Health” (2000) and “Partnership for Change” (2003) both stress the importance of improving public access to health information as well as providing improved clinical information systems. NHS24, a new telephone helpline for patients, has already been introduced in Grampian and will widen patient access to services. Out-of-hours dental services have also been introduced in Aberdeen with a high level of demand for the service. “Partnership for Health” (2003) outlines the commitment to develop electronic patient record systems including an electronic Integrated Children’s Services Record in partnership with local authorities as part of a Ministerially chaired E Health Programme Board. Insufficient investment and inconsistent application of IM&T is a significant challenge for dental services.

Dental Education and Training

Over the last ten years, Grampian has seen an increasing volume of postgraduate education and training activities available to Dentists and the uptake for postgraduate courses is high. The difficulties in Grampian do not stem from the volume and quality of postgraduate training but from the availability of suitable accommodation, workforce issues and the economics of providing high quality patient care in the NHS.

An increasing number of general dental practices have reached their required vocational training standard but it has not been easy to fill the Vocational Training places available.

There is currently no undergraduate dental education in Grampian although a pilot student outreach scheme for final year students from the Dundee Dental School was run in 2002. This is to be followed in September 2003 by an embryonic outreach scheme from Dundee Dental School in which final year students will spend time in Community Dental Service clinics. Proposals have been developed to extend this student outreach by developing links to a Dental Access Centre for final year students from both Glasgow and Dundee.

NHS Education for Scotland (NES) has recently assumed responsibility for the continued professional development of the professions complementary to dentistry which will lead to increased demand for postgraduate training for these staff who are vital to the development of the service.

Public Expectations and Pressure on Resources

Patient, public and political expectations of the NHS continue to rise alongside socio-economic and demographic pressures on the service. Despite the significant increase in resource for the NHS in recent times, the demands on the service are ever increasing and will require prioritisation, innovative service redesign and an increased emphasis on partnership both with other public sector agencies and the private sector. It is critical that the public are involved in making these changes at a strategic and operational level as well as their own personal health care.

Partnership Working – Community Health Partnerships

The focus on health improvement, the wider determinants of health and the integration of services is stimulating partnership working across service sectors and professions. The development of local Community Health Partnerships as set out in the White Paper “Partnership for Care” (2003) will be a major focus and catalyst for this work building on the existing foundations laid by LHCCs and local authorities. There is an opportunity for dental services to play a significant part in LHCCs and the emerging Community Health Partnerships where the strength of primary care is the ability to provide a generic and holistic approach to care. At the same time, the development of Managed Clinical Networks provided by the multi-professional teams organised around the patients pathway of care offers the opportunity to integrate dental healthcare across primary care and specialist services.

Remote and Rural Issues

There are many definitions of remoteness and rurality, but that used most often (Scottish Economic Statistics 2000) defines these locations on the basis of “local authority districts with a population density of less than one person per hectare” – equivalent to less than 100 people per square kilometre. Of the fourteen districts in Scotland that fall into this category, two are in Grampian – Aberdeenshire and Moray. Grampian is also one of the areas noted as rural in the recently published ‘Health in Scotland 2002’ (2003).

A full analysis of the local and national forces and drivers was prepared by local clinicians and is available as a companion to this report.

Building Public Confidence

During Dental HealthFit, members of the public shared powerful accounts of their experience of dental services in Grampian with the participants. Difficulties in obtaining services timeously and the co-ordination of care within dentistry and with other NHS services were particularly strong messages.

Accordingly, a small number of overarching aims for the Dental Service in Grampian were agreed at an early stage:

Dental Services in Grampian should focus on:

• Improving the oral health of the people of Grampian

• Ensuring speedy and equitable access to high quality dental services

• Building public confidence in dental services and ensuring that the needs of the patient remain central to the delivery of the service

Key Strategic Themes

During Dental HealthFit, a number of key strategic themes emerged from the Working Groups:

• Traditionally separate strands of dental services should be redesigned as part of an integrated, whole system approach to oral healthcare in Grampian.

• There should be an emphasis on multi-disciplinary working which maximises the use of clinical skills, facilitates the development of new professional roles and increases system capacity.

• Managed Clinical Networks should be developed across Grampian and the North of Scotland to maximise use of scarce skills and resources and to improve patient access.

• The public should be able to access the dental services they require, speedily, effectively and with confidence.

• A balance must be struck between the need to provide services as close to patients’ homes and communities as possible and the requirement to provide safe and sustainable specialist services.

• The needs of vulnerable patient groups must be recognised and addressed as well as people living in rural areas and areas of deprivation.

• Dental services should positively involve and engage the public in order to improve oral health, develop greater mutual understanding and to support system change.

• Dental services require to build stronger partnerships within the NHS eg with LHCCs and with the emerging Community Health Partnerships (“Partnership for Care”) and other external agencies in order to explore joint venture opportunities and make best use of resources.

• A properly integrated, long-term strategy for the planning, development and education of the workforce should be developed.

• Dental services should make appropriate use of new technologies in order to support improvements in service quality and patient access eg teledentistry, ECCI, electronic, integrated patient record.

• The Strategy for Dental Services should be a key element of NHS Grampian’s overarching strategy as part of a holistic approach to health.

A Programme for Action