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Dental specialty system is flawed


  Posted by: The Probe      7th February 2019

Barry Cockroft, former Chief Dental Officer, on embracing tier 2 competencies.

The current dental specialty system is not working and perhaps tier 2 competencies are the way forward.

For years the structure of post graduate dental training has quite closely mirrored that of medicine, with one very significant difference that disadvantages the majority of dentists and many patients in this country. In medicine, general practice is a specialty with all the educational benefits, career opportunities and potential earnings enhancements that brings. In dentistry it is the general practitioners who carry out the vast majority of the care, but they are largely excluded from a structured development programme beyond foundation training,

Unlike medicine, many of the procedures carried out by specialists are within the scope of practice of many skilled and competent general dental practitioners. The vast majority of specialists work either in dental hospitals and schools or in the private sector, with the exception of orthodontists.

Where true specialist services are required, these should be provided in centres of excellence with agreed referral protocols, where treatment that is not necessarily specialist can be provided in a more convenient environment for the patient, and where specialists are willing to support and develop other clinicians without worrying about their own specialty first.

In financial terms, the secondary care sector provides around 4 per cent of the NHS service and accounts for around 20 per cent of the budget. Of course, a proportion of this work is not appropriate for provision in primary care, and some is also required to be provided in the dental schools to facilitate undergraduate

and post graduate education – but much of it is eminently suitable for provision in the primary care sector. There are, perhaps, vested interests at play which have successfully blocked this transfer of care for many years, but the concept of introducing competencies for tier 2 services gives a massive opportunity for the majority of the profession to develop a clinical career pathway, introduce more diversity into their clinical practice, and at the same time, provide a better service for patients, reduce waiting times and save the NHS valuable resources.

As the overall oral health of the population improves and disease patterns change, the profession needs to adapt or it will cease to have a viable function and purpose in the long term.

If the NHS is going to feel confident to move services into primary care then commissioners need to be confident that those providing the care are demonstrably competent and this gives educational providers a significant opportunity. The commissioners would also need to have the confidence and support to move away from the UDA system when commissioning these services but it has been done in some areas and best practice needs to be shared.

There are many excellent clinicians and academics within both the Faculty of Dental Surgery and the Faculty of General Dental Practice who are well capable of leading this work.

The British Dental Association set out their stall against the concept when I debated it at my last conference of LDCs before retiring but my ongoing contact with undergraduates at Birmingham and elsewhere suggests that the young are interested in the idea when it has been explained to them.

There are areas of specialty which are not suitable for delivery in general dental practice, dental public health is a relatively new specialty (to somebody of my age!) but is critical to improving population health in the coming years, just as public health in the wider sense needs greater investment.

There are small dental specialties, such as oral medicine and oral pathology which would appear to be unsustainable at the scale needed unless they become part of the associated medical specialties, but are vital.

I think the restorative monospecialties are very idiosyncratic, periodontal disease is largely treated by the patient themselves and indeed without the right patient co operation the treatment is doomed to failure. I always remember going to the first graduation dinner at UCLAN and discussing this with the inspirational Lawrence Mair; Lawrence asked the graduates to stand and asked them “who treats periodontal disease?” as one they replied “patients treat periodontal disease”.

There are many skilled clinicians working in ‘specialist restorative practices’, often referred to as ‘practice limited to…’ to avoid issues with the GDC, who provide first rate care without the clinicians being on the specialist list and most of the procedures are introduced in the modern undergraduate curriculum.

Generalisation is always dangerous and there are rare but significant conditions which require truly specialist care.

Ultimately, education, research and innovation are what drive improvements in healthcare so there will always be a need for some specialists, particularly in the academic environment but a system which excludes the majority of the profession from developing their clinical skills is not sustainable.

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