A practical resource to help in the support of non-uk, eea qualified dental practitioners practising in the uk january 2011 Updated April 2012 Contents



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Key Points to Consider When Inducting or Supporting a Dentist Qualified in Poland



Dentists who qualified in Poland:


  • Prior to 1989, oral health care was almost exclusively provided with a state (public) system;

  • Since 1989 an independent, private system for the delivery of oral care has developed very rapidly;

  • May have limited experience of a publicly funded health service, if they qualified after 1992;

  • May have little experience of working in a multi practitioner environment;

  • Have limited experience of UK clinical governance requirements (e.g. clinical audit);

  • Will probably have undertaken foundation training in Poland;

  • May have experience of working with a dental hygienist;

  • Will have no experience of working with a dental therapist, an orthodontic therapist, or a clinical dental

technician in Poland;

  • May have no knowledge of formal training for dental nurses or dental technicians;

  • May have little experience of working within the wider team of dental care professionals;

  • May not be vaccinated against hepatitis B;

  • May not appreciate that amalgam separators are mandatory in the UK;

  • May require training in dental radiography, if they qualified prior to 2008.




Country : Portugal


Population: 10,561,614 (2011)


Number of registered dentist, stomatologists and odontologists: 8,026 (2010)

Number of dentist: 6,972 (2010)

Number of Stomatologists: 680(2009)

Number of Odontologists : 374 (2010)

Number qualified overseas: 695 (2009)

Number of dentists registered in the UK in 2007: 216 in 2008:272 in 2009:338 in 2010: 407 in 2011: 447

Background

Dental care is delivered by dentists, stomatologists and odontologists, (see glossary for definitions) (5). In 2007, 10.5 per cent of all dentists registered in Portugal, qualified outside Portugal and 72 per cent of these overseas dentists were Brazilians (21). In general, Portuguese dentists are younger than those in most other European Member States, with a mean age of 36.9 years. 55 per cent of dentists in Portugal are female. Most dentists work in single-handed practice but occasionally multiple practices are established, with a dentist, a stomatologist or even an odontologist.


Dental care is excluded from the Public Health System and as a result most oral healthcare is provided in private practices. Although a few hospitals and Health Centres from the National Health Service employ stomatologists and some dentists. Due to the over-production of dentists, and increasing numbers of new graduates, there is a high risk of under or unemployment for the profession (21). This may lead to more Portuguese dentists seeking employment outside Portugal. In 2008, the Portuguese Dental Association (Ordem dos Médicos Dentistas (OMD)) reported that there was a significant cross border movement by Portuguese dentists (5). The publicly funded health care system is complex and financed by taxes. Dentists may contract with one or more private or public insurance schemes. Each scheme has its own list of eligible treatments and scale of fees and most include emergency care. However, few provide cover for crowns, bridges and dentures (5). Since 2008, the Government has tried to give more emphasis to prevention and treatment for deprived groups so that some of the most vulnerable citizens, especially children, pregnant women and seniors on low income, have better access to oral healthcare (22). There are no formal controls on the quality and quantity of care provided in private practice, other than those described in the ethical code, as defined by the OMD. There is no mandatory requirement for dentists to take part in continuing professional education.
Since 2005, the undergraduate dental course has been five years in length. Previously, it was six years. After graduation, dentists must be registered by the OMD, which apart from being the representative body for dentists is also the body in charge of the regulation and supervision of their performance (15).
There is no compulsory formal training for dental nurses. It is mandatory for dentists to work with a dental nurse. There are relatively few dental hygienists (380 in 2009) and they are not allowed to work independently and without supervision. (5)
In summary, dentistry in Portugal is largely provided under private contracts. There is little publicly funded dentistry. Dentists are required to work with dental nurses. There are a few dental hygienists.


Glossary of Terms

Stomatologist

Medical practitioners with additional dental training of three years after obtaining the medical degree. They can work in hospitals, in private practice and work in other countries of the EEA under “acquired rights” legislation.

Odontologist

A professional category introduced by the Portuguese government many years ago to meet the problem of illegal dental practice of some people working in dentistry before 1974 (dictatorial regime). They perform as dentists but haven’t received any academic training. The Commission deemed that the profession of "odontologista" would therefore seem to be alternative to and to compete with that of dentist. All odontologists are now over 55 years of age.




Summary of relevant points

1. Regulatory Mechanisms

  • The principal regulatory body in Portugal is the Portuguese Dental Association (Ordem dos Médicos Dentistas (OMD)). It regulates and supervises the performance of dentists; additionally it is the support organisation that provides relevant information on topics such as international and national legislation (23).

  • There is no specific body to register odontologists, although they do need to register with the Ministry of Health. Stomatologists are members of a college of the Portuguese Medical Association and odontologists have their own association. There is also a disciplinary body which regulates the practice of odontologists. Odontologists are not permitted to work in countries other than Portugal.

  • Vaccination against hepatitis B is not compulsory for the dental workforce, but it is encouraged.

  • Professional liability insurance is not compulsory for dentists, however, it is provided by private general insurance companies.

  • The law assumes that the primary dental qualification allows dentists to work with ionising radiation and take radiographs. There is no mandatory continuing professional education requirement specific to dental radiography.

  • Dentists may form companies which must have a clinical director, who must be a dentist.

  • There is a regulation that recommends the use of the amalgam separators, but this is not legally mandatory.

2. Education and Training

  • There are seven dental schools; three are state run, four are private.

  • Since 2005 undergraduate dental education takes five years, previously it was for six years.

  • The number of registered dentists has risen from 4,203 in 2005 to 7,180 in 2009 (6,972 active dentists in 2010).

  • There is no mandatory post-qualification foundation training

  • There are two recognised specialties in Portugal: orthodontics and oral surgery, each with a training period of three years, post registration.

3. Support Systems

  • The OMD is the national association. It provides relevant information such as international and national legislation. Stomatologists are members of a college of the Portuguese Medical Association and odontologists have their own association.

4. The Dental Team

  • Dental care is delivered by dentists, stomatologists, odontologists and dental hygienists.

  • In 2009, the number of registered dental hygienists was 380. They have to work under the supervision of a dentist and they are not permitted to give local anaesthetic.

  • Training for dental technicians is at dental schools and Health Institutes and lasts three years. Legally, they can only prepare prostheses and not treat patients directly.

  • There is no compulsory formal training for dental nurses but dentists must work with a dental nurse.

  • The majority of “practicing” dental nurses and dental technicians has no specific training and have learned from the dentists they work for or from others.

5. Dental care delivery

  • Dental care is virtually excluded from the Public Health System, for this reason oral healthcare is provided in private practices although a few hospitals and Health Centres from the National Health Service employ dentists. Only Stomatologists are allowed to work in the approximately 80 Public hospitals in Portugal, and there are very few posts for them.

  • There is a National Programme for Oral Health Promotion (PNPSO). Since 2008, a part of the public budget has been allocated to specific target groups in the population: it covers children and teenagers from 3 – 16 years, pregnant women, and elderly people with lower incomes.

  • Dentists may contract with one or more private sick fund schemes. Each scheme has its own list of eligible treatments and scale of fees and most include emergency care.

  • Most dentists work in single-chair practices but occasionally dental practices are established, with a dentist, a stomatologist or even an odontologist (the premises may be shops, special buildings, or converted houses).

6. Quality assurance mechanisms

  • There are no formal controls on the quality and quantity of care provided in private practice, other than those described in the ethical code as defined by the OMD.

  • Complaints from patients are dealt with in two different ways. If the issue involved is solely one of contract then it is considered by a legal assessor. If the quality of care is challenged then the patient is examined by the Clinical Director in a sick fund and/or by an independent dentist, followed by the ethical council of the OMD. All the procedures are very slow and could take from two to three years.

  • The Ethical Council of the OMD has the power to reprimand, suspend for up to five years or remove from the register.



Key Points to Consider When Inducting or Supporting a Dentist Qualified in Portugal



Dentists qualified in Portugal:


  • Have limited experience of a publicly funded health service;

  • Have limited experience of UK monitoring procedures for clinical practice or UK requirements for clinical governance;

  • May have little experience of working in a multi practitioner environment;

  • Will not have undertaken foundation training in Portugal;

  • Are unlikely to have experience of working with a dental hygienist;

  • Will have no experience of working with a dental therapist, an orthodontic therapist, or a clinical dental technician in Portugal;

  • May have no knowledge of formal training for dental nurses or dental technicians;

  • May have little experience of working within the wider team of dental care professionals;

  • May not appreciate that professional indemnity is compulsory in the UK;

  • May not appreciate that amalgam separators are mandatory in the UK;

  • May not appreciate that continuing professional education is a requirement for ongoing dental registration in the UK;

  • May have experienced difficulty finding employment as a dentist in Portugal.




Country : Romania


Population: 21,413,800 (2011)


Number of registered dentists: 16,456 (2010)

Number of active dentists: 15,395 (2010)

Qualified overseas : 485 (2010)

Number of dentists registered in the UK in 2007: 155 in 2008: 255 in 2009: 344 in 2010: 460 in 2011: 554

Background

In Romania the number of dentists is increasing rapidly, in November 2009 there were 13 dental schools and the number of dentists graduating per year was 1,500. If this level of graduation is maintained, there will potentially be many under or unemployed dentists in Romania (5). In September 2009, 2,000 students of which 35 per cent were not EU citizens entered Romanian dental schools. Almost 90 per cent of dentists work in private practice and 60 per cent of dentists are owners of their dental practices. Private fees are set and negotiated by dentists. A full-time dentist working either in the National Statutory Health Insurance Scheme (NSHIH) or privately would have about 2,500 patients on his/her list.
The statutory health insurance system was established in 1998. General and oral health care depends on the compulsory membership of each insured citizen in the Social Health Insurance System. The National Social Health Insurance Houses (NSHIH) at national level and County Social Health Insurance Houses (CSHIH) at county and capital level administer the system. The whole population is insured and pays monthly a fixed amount of their salaries to the CSHIH, situated in the county where they live. The system of social health insurance provides a legally prescribed standard package of general and oral healthcare. It includes 100 per cent of the preventive care for children and adolescents, dental treatments of children and adolescents (up to 18 years), preventive consultation; pain relief and emergency surgical treatments. In theory the statutory health insurance scheme covers dentistry. However, in practice as each dentist receives a maximum of 200 Euros per month from the CSHIH, most dental care is provided under private arrangements. In rural areas only 15 per cent of the population access dental treatment; in urban areas, 85 per cent of the population has access. Continuing education is compulsory for all dentists. There are relatively few dental auxiliaries in Romania. At present, with the large numbers of dentists graduating each year, there is little enthusiasm to train or employ dental hygienists.


Summary of relevant points

1. Regulatory Mechanisms

  • The practice of the profession is organised by the Medical Chamber for Medicine and Dentistry with mandatory membership. It is regulatory, advisory, scientific and a trade union.

  • The Romanian Collegiums of Dental Physicians (RCDP) registers all dentists and dental specialists. Since 2004, it has been a legally based, non-governmental organisation and serves the whole country at national level.

  • Dentists work under the ethical code for general physicians, which cover relationships and behaviour between physicians, dentists, contracts with patients, consent, and confidentiality, continuing education and advertising. It is administered by the regional body of the RCDP in each of the 40 counties and in Bucharest.

  • The main functions of the National Social Health Insurance Houses (NSHIH) at national level and County Social Health Insurance Houses (CSHIH) are to pay the providers of medical and dental services and to control the quantity and quality of the services.

  • The quality of dentistry in the public dental service is assured by each County Health Board, who monitor aspects such as infection control.

  • All dental team members must be vaccinated against hepatitis B and this has to be monitored by the County Health Board. However, it is known that a number of dentists refuse to be vaccinated against hepatitis B.

  • Indemnity insurance is compulsory for all dentists. Dentists are free to choose the level of indemnity insurance cover starting from a minimum level established by NSHIH.

  • Since 1998, dental practices can be limited companies and no more than one third of members can be non-dentists (5).

  • Training in radiation protection is given during undergraduate studies and the dentist is the only competent person in the dental practice to undertake radiography. There is no ongoing continuing education requirement for this.

  • There is compulsory verifiable collection and incineration of bio-hazard contaminated medical and dental waste. Amalgam separators are not required by law.

  • The CSHIH controls the number of new dental practices able to work within the National Health System. However, the local RCDP councils often allow dentists to establish their own general dental practices. There are no rules regarding the type of a dental practice in terms of type of building. There is no state assistance for establishing a new practice, so some dentists take out commercial loans from a bank. When starting new practice, private dentists have to inform the local health authorities, and to obtain all the necessary permissions.

2. Education and Training

  • Until 2003, dental schools were known as Faculties of Stomatology, as a part of a University of Medicine and Pharmacy. Now they are called Faculties of Dental Medicine.

  • In 2011, the number of dental schools was 13 and the student intake was 2,000 (35 per cent of whom are neither Romanian nor EU nationals); and the number of graduates was 1,500. Three of the dental schools are privately funded.

  • To enter dental school a student needs to be a high school graduate and pass an entry examination.

  • Since 2003 dental training lasts five years.

  • To obtain the right to work as a dentist, a dental graduate has to undertake a written test with 200 questions, a practical test and to defend his or her diploma project.

  • There is no need for foundation training prior to entering independent practice.

  • Specialist training is undertaken in the Dental Faculties and the Boards of the Faculties monitor and are responsible for the quality assurance of the training.

  • There were three recognised specialties in Romania: orthodontics: three years training; oral-maxillofacial surgery: five years training; dento-alveolar surgery: three years training. A further three: endodontics, periodontology and prosthodontics were recognised in October 2009.

  • Any dentist can undertake specialist training, but the Ministry of Health limits the number of specialist training places. The trainees are paid during their course by a fixed salary supported by the Ministry of Health. In this period they cannot work in private dental practice.

  • In the past, dentists followed a stomatological training in which they completed a primary medical degree followed by a period of clinical dental training leading to qualification as stomatologists (dental physicians). A number of older Romanian dentists still have this title.

3. Support Systems

  • The Romanian Dental Association of Private Practitioners (RDAPP) used to represent and the dental profession. However, there is also another association – the National Union of Associations of Dentists (NUAD) which now represents some dentists.

  • Specialists have their own professional associations.

4. The Dental Team

  • Dental technicians are trained in dental technician colleges, within the dental schools. Their training lasts for three years, with a final examination leading to a diploma. Since 2007 dental technicians have to register with the Order of Romanian Dental Technicians.

  • Dental technicians normally work in separate dental laboratories and invoice dentists (or directly to the patient) for completed prosthetic work.

  • There is some illegal practice by non qualified dental technicians, but the number of cases is decreasing every year.

  • Dental nurses train in secondary medical schools, for three years of study leading to a final examination and diploma. They must register with the Order of Romanian Medical Assistants.

  • The duties of dental nurses are: assisting dentists, maintaining records, sterilisation, infection control, and office work. There are limited numbers of dental nurses in Romania.

  • There are about 100 dental hygienists in Romania. Schools for dental hygienists have opened and closed over the last 20 years. At present, with the large numbers of dentists graduating each year, there is little enthusiasm to train or employ dental hygienists.

  • The RCDP have provided data which shows that there are eight denturists in Romania, but there is no further information about these.

5. Dental care delivery

  • Romania has a statutory health insurance system which was established in 1998 and there is compulsory membership of each insured citizen in the Social Health Insurance System.

  • Patients pay dentists who work in the private sector directly and completely. Every dentist chooses whether to work only with CSHIH or in independent practice or both. There are two systems of payment, one is item of treatment fees, for NSHIH dentists and for private dentists the patient has to pay all fees themselves.

  • Since the end of 2002, dental treatment fees have not been amended, as the NSHIH stated that the contract is not mandatory but optional for dentists. The NSHIH pays dentists who accept the terms offered to them. Some work is paid for completely, whilst other work is paid at only 40-60 per cent of the cost.

  • The social health insurance provides cover for all prevention and treatments for children and young people, until they are 18 years old. For adults, the NSHIH initially covers 10 per cent of the costs of the list of dental treatments. Patients directly pay the difference of 90 per cent.

  • Almost 95 per cent of dentists work in private dental practice and 60 per cent of dentists are owners of their dental practice. Private health insurance companies are not yet functioning in Romania although private dental insurance companies are legally recognized. .

  • Dentists working in hospitals are part of maxillo-facial surgery teams. All of them are employed by the hospitals, which are owned and run by regional government. They can also work part-time in private practices. In each “county” capital there are clinics for emergency dental treatment, where the dentists are paid for by the state.

  • Academic dentists are normally salaried employees of the Faculty of Stomatology (Dental Schools). Most also work in private practice. The titles of university teachers are Professor, Associate Professor, both of which involves a further degree (publication activities, a record of original researches and a PhD is also required) and Lecturer.

  • In 2009 in rural areas, there were 1,597 dental practices and about 15 per cent of the population accessed dental treatment. In the same year, in urban areas there were 10,086 dental practices. Some specific groups in rural areas, (children, farmers, retired persons) are having trouble accessing dental care. However, in cities with dental schools, there are many dentists and the dentist : population ratio is often 1:400.

6. Quality assurance mechanisms

  • Continuing education is compulsory for all dentists. It is provided by universities and by specialist dental societies. The RCDP records the hours completed by dentists who are required to complete 200 hours in five-year cycles.

  • A mixed commission of the CSHIH and the RCDP investigates complaints from patients. However they can only judge the quality of work in the NSHIH system.

  • In the private system, the quality of dental work can be judged only by the RCDP. From the quality point of view, the CSHIH has the right to control regularly the activities of dentists who have a contract with them.

  • A complaint by a patient is first screened by the Local Board of RCDP and is then forwarded to a commission of the RCDP that deals with complaints. Those that are judged to be reasonable are sent to a commission of dental experts, with more than 10 years’ experience, nominated from RCDP membership. If the complaint is confirmed, the consequences for the dentist are proportional to the gravity of the facts (medical problems and complaints, financial problems and complaints, or both). The RCDP can impose “gradual sanctions”, which can lead to the suspension of the dentist. A complaint may be referred to the judicial system.

  • The final sanctions are validated by the RCDP county level; judicial decisions are very rare.

  • The dentist can appeal to the RCDP Commission at national level and after to the regular court in those instances. If the official commission of the RCDP establishes that the dentist is guilty he must repeat the treatment, paying for all the costs.





Key Points to Consider When Inducting or Supporting a Dentist Qualified in Romania



Dentists qualified in Romania:


  • Unless they qualified before 1990, have limited experience of a publicly funded health service;

  • May have little experience of working in a multi practitioner environment;

  • Have limited experience of UK monitoring procedures (e.g. NHS dental services) or UK requirements for clinical governance (e.g. clinical audit);

  • Will not have undertaken foundation training in Romania, if they have qualified since 1990;

  • May have little experience of working with dental nurses;

  • Are highly unlikely to have experience of working with a dental hygienist;

  • Will have no experience of working with a dental therapist, an orthodontic therapist, or a clinical dental technician in Romania;

  • May have little experience of working within a wider team of dental care professionals;

  • May not appreciate that amalgam separators are mandatory in the UK;

  • May not appreciate the severity of the disciplinary sanctions possible in the UK;

  • May not have knowledge of working with private health insurance companies;

  • May have experienced difficulties in obtaining employment as a dentist in Romania.





Country : Slovakia


Population: 5,435,273 (2011)

Number of registered dentists: 3,248 (2011)

Number of active dentists: 3,248 (2011)

Qualified overseas : 0 (2007)

Number of dentists registered in the UK in 2007: 39 in 2008: 46 in 2009: 46 in 2010: 45 in 2011: 43

Background

In 2011, the Slovak Chamber of Dentists register included 3,248 dentists of whom 1973 (62 per cent) were women and 1275 (38 per cent) were men. Of these, 2495 dentists (76 per cent) worked in their own private practice and 579 (24 per cent) worked as employees either in these private practices or in state institutions. Over 80 per cent of active dentists work in private practice.


The distribution of dentists is not balanced, there are too many dentists in big cities and there is a shortage of dentists in some rural areas (24).
Dentists working in private practice work as independent entrepreneurs and are free to decide where and how they will work (5).
There are relatively few dental hygienists. However the use of dental nurses is widespread (5). Every dentist must work with a nurse by law.
There are two public dental schools in the Slovak Republic. Training for dentists lasts for six years after which dental graduates are free to obtain a licence and are allowed to work independently. There are three dental specialties recognised in Slovakia: orthodontics, paediatric dentistry and oral maxillo-facial surgery. Continuing Professional Education is mandatory and is evaluated every five years (24).



Summary of relevant points

1. Regulatory Mechanisms

  • The Slovak Chamber (Association) of dentists acts as a regulatory and support body for dentists. It creates an environment and conditions for a high-quality provision of dental services for patients following international standards.

  • There are three steps towards establishing general practice: first registration with the Slovak Chamber of dentists, then a licence for the practice of dentistry issued by the Chamber and finally permission to open a dental practice is issued by the municipality office.

  • It is compulsory for dentists to have indemnity insurance. Every dentist has to be insured against civil liability for the practice of his/her profession. The Chamber has a collective contract of insurance covering members.

  • If there are claims from a patient and a public establishment is involved, the establishment is liable. Nevertheless, if a dentist’s fault is proven, the establishment may claim return of the incurred costs.

  • The Public Health Authority of the Slovak Republic is the body responsible to give permission for the running and the operation of ionising radiation equipment. The dentist must undergo a training course in dental radiography and pass an examination every five years.

  • Amalgam separators are legally required.

  • The steps to obtain registration as a foreign dentist are as follows: recognition of the diploma by the Ministry of Education and pass a language test of knowledge of the Slovak language controlled by the Ministry. The employer is also required to prove that the language competency of the employee is sufficient.

  • Hepatitis B vaccination is compulsory.

2. Education and Training

  • To enter dental school students have to pass the state qualification for university entrance and a successful result in the dental studies entrance examination.

  • The undergraduate course lasts for six years.

  • An average of 56.5 per cent of time is allotted to medical science and 40.5 per cent to dental science.

  • From 2009 foundation training is not required and dentists are able to open their own practice immediately after graduating.

  • Slovakia has three specialties: orthodontics, paediatric dentistry, oral maxillo-facial surgery. The training for orthodontics and paediatric dentistry lasts for three years. Oral maxillo-facial surgery lasts for four years.

  • The co-ordinating role in continuing education is undertaken by the Chamber together with the educational institutions and associations of specialists. Training takes place at Dental School clinics, or at the Slovak Medical University, or in dental practice under supervision of a specialist.

3. Support Systems

The Slovak Chamber of dentists acts as a regulatory and support body for dentists. It creates an environment and conditions for a high-quality provision of dental services for patients following international standards.

4. The Dental Team

  • Training for dental hygienists is conducted at state-medical schools. After high school they study for three years at the University of Prešov, which leads to a bachelor degree. They must be registered with the Association of Dental Hygienists.

  • Dental hygienists must work only under the supervision of the dentist. The number of hygienists is low.

  • Training for dental technicians is conducted at secondary schools. The length of the course is four years. To open their own dental laboratory, a dental technician has to pass a three years’ specialised study at University. They have to register with the Slovak Chamber of Dental Technicians.

  • Dental technicians can work in independent laboratories or, rarely, be employed by a dentist or a dental practice.

  • Dental nurses are educated at secondary schools for four years, they work at the chair side as employees of dentists.

  • Dental nurses are registered with the section for nurses working in Dentistry of the Chamber of Nurses and Midwifes.

5. Dental care Delivery

  • All citizens of Slovak Republic must be compulsorily insured with one of three health insurance companies.

  • Since 2000, the government listed treatments and services that can be provided within the scheme and set co payments for other treatments not covered by the scheme (4,5).

  • About 90 per cent of private dentists have an agreement with an insurance company.

  • Dentist are paid from the health insurance according to the treatment completed and are paid fully or partly by the insurance company depending on the patient’s co-payment.

  • Health insurance companies have fixed amounts of funds allocated to oral health care and once the annual allocation is reached, they stop payments to dentists (24).

  • General dental practitioners calculate their own prices but net profit should be a maximum of 30 per cent. A dentist whose profit is more than that breaks the law on prices, which may lead to a fine or other sanctions.

  • There are public polyclinics in the Slovak Republic with a number of health professionals. They can be public or private. They also can provide private services. Dentists employed at public establishments receive a fixed salary.

  • In hospitals the treatment is limited to oral maxillofacial surgery, undertaken by specialists.

  • Dentists who work in dental schools are normally full-time salaried employees of the university. They are able to combine part-time teaching and to work in private dental practice (with the permission of the university).

  • Dentists working in private practice work as independent entrepreneurs. Prices in private practices are different, dependent on the place and region of the provider and also on the overheads of the provider. Before each treatment, an informed approval of the choice and way of treatment must be obtained from the patient.

6. Quality assurance mechanisms

  • Continuing education for dentists is compulsory and it is evaluated by the Chamber over a five year period.

  • The dentist needs to provide proof of 250 credits for each five year period.

  • Dental practitioners may be quality controlled by another dentist who is employed by an insurance company; they control the invoices that dentists send to the insurance company from a professional (clinical) point of view.

  • In most cases quality is controlled by patient’s complaints. A patient can present a complaint to a dentist, to the Municipality offices, to the Control Committee of each regional Chamber of Dentists, to the Section of state supervision and control of the Ministry of Health or directly to the court.

  • Patients who are not satisfied with provided oral care can contact the Authority with a written complain directly. A patient is entitled to lodge a complaint and demand compensation before going to court (5).

  • The sanctions against dentists who break the ethical code may lead to an admonishment. If they repeatedly fail to respect the admonishment, then the dentist will get a fine of up to SK 10,000 (300 Euros) or up to SK 50,000 (1,470 Euros) (2012).

  • The ultimate sanction is to be excluded from membership of the Slovak Chamber of dentists.


Key Points to Consider When Inducting or Supporting a Dentist Qualified in Slovakia



Dentists qualified in Slovakia:


  • Since 1990, have worked mainly in private practice and have contracts with the public insurance scheme;

  • May have experience of working in a multi practitioner environment;

  • Have limited experience of UK monitoring procedures (e.g. NHS dental services) or UK requirements for clinical governance (e.g. clinical audit);

  • If they have graduated from 2009 onwards, will not have undertaken foundation training in Slovakia;

  • Are unlikely to have experience of working with a dental hygienist;

  • Will have no experience of working with a dental therapist, an orthodontic therapist, or a clinical dental technician in Slovakia;

  • May have little experience of working within the wider team of dental care professionals;

  • May have little experience working in wholly private dental practice;

  • May have a lot of experience on following guidelines, infection control measurements and administrative tasks;

  • May not appreciate that the dental training in the UK is five years and not six years as in Slovakia.



Country : Spain


Population: 47,190,493 (2011)



Number of registered dentists: 27,826 (2010)

Number of active dentists: 27,826 (2010)

Qualified overseas :5,879 (2009)

Number of dentists registered in the UK in 2007: 281 in 2008:288 in 2009:390 in 2010: 538 in 2011: 640

Background

Spain is divided into 17 autonomous regions and two autonomous cities. Each region/city has autonomy over its health policy, but with a coordinating body at a national level which specifies the coverage offered by the public health system. Whilst the universally accessible Spanish Health Service offers extensive medical care coverage, oral health care coverage for the adult population is limited to oral surgery and the prescription of pharmaceutical products by salaried dentists. Dental treatment is mainly provided in a private fee-for-service system which includes more than 90% of dental professionals. Recently, all Spanish children aged 6-15 years have been able to access free basic oral health care and treatment of their permanent teeth. How this is offered depends on the Region; about half run a capitation system (with public finance and public or private provision of services), with the other half running an older model in public clinics. Most of the autonomous regions/cites have developed dental public health programmes with preventive activities including oral health education and fluoride mouth rinsing.


Dental care is delivered mostly by dentists, although a few hospitals employ stomatologists (see glossary for definitions). Approximately 92 per cent of the profession work privately and are largely in single-chair practice. There is a small Public Dental Service (PDS) which operates in Primary Health Care Units managed by each regional healthcare institution. This only provides emergency care, which is a legal requirement. Regions have delegated powers to establish local systems for the provision of health care which may supplement the PDS through specific programmes. At present, these programmes are largely confined to prevention and paediatric dentistry (5).
Generally, healthcare provided by the government or the regions is funded by deductions from earnings, supplemented by employers for their employees. These payments are aggregated into a national social security pool from which pensions and unemployment and sickness benefit are also funded. There is an annual budget for health. However, the social security fund is often in deficit, and has to be supplemented from national taxation (5).
Some regional authorities have introduced a capitation system for children of 6 to 14 years old. Private practitioners are eligible to accept patients from these schemes. Patients attending the PDS pay nothing for their care.
There are no formal controls on the quality and quantity of care provided in private practice, other than those described in the ethical code. Like most European countries, professional liability insurance is compulsory for dentists and is provided by private general insurance companies. There is no mandatory requirement for dentists to take part in continuing professional education. An extended system of evaluation of the continuing education systems is being developed, after encouragement by the government (5).
Until 2001, it was possible to train as a stomatologist, in Spain; this involved a period of medical training, followed by further training as a dentist (5). No specialties are formally recognised. Some Spanish universities offer postgraduate courses in different specialist areas, some of which are full-time for three years and would lead to recognition as a specialist in other countries. Some Spanish dentists have also completed specialist training in other EU member states. However, they are not recognized in Spain. After graduation, dentists must be registered by the Consejo General which has a central register held in Madrid.
There is no formal training or qualification for dental nurses; they are trained by dental practitioners (5). Dental hygienists must hold a registerable qualification. They are allowed to carry out prophylaxis and oral health education, but only under the prescription of a dentist, who must be present in the building while they are working (5). They are not allowed to give local anaesthetic (25). Dental technicians may only work in commercial laboratories (5).
In summary, dentistry in Spain is largely provided under private contracts. There is little publicly funded dentistry. Dentists generally work with dental nurses. There are dental hygienists and dental technicians and the numbers of each group are growing. At present, there appears to be both un- and under-employment of new dental graduates in Spain (25).


Glossary of Terms

Stomatologist

Medical practitioners with additional dental training of three years after obtaining the medical degree. They can work in hospitals, in private practice and work in other countries of the EEA under “acquired rights” legislation.




Summary of relevant points

1. Regulatory Mechanisms

  • The principal regulatory body in Spain is a single federal organisation, the Consejo General de Colegios Oficiales de odontólogos y estomatólogos de España which has a Council (Consejo General) of which the Presidents of each of the 19 regional Colegios are members.

  • Vaccinations such as hepatitis B are not compulsory for the workforce, although they are recommended.

  • Liability insurance is compulsory for dentists and is provided by private general insurance companies.

  • There are many radiation protection regulations relating to facilities, dosage and controls. To take a radiograph formal training must have been undertaken, with a license at the end of this. However, continuing training in dental radiography is not mandatory.

  • Dentists are permitted to form companies, in which to practice. Non-dentists can own or be on the board of such companies.

  • Since 1986 it has been mandatory to fit amalgam separators to all newly equipped premises or newly installed units. This requirement extends to the installation of older units in new premises. However, there may be differences in the autonomous regions towards compliance.

2. Education and Training

  • In 2008 there were 12 publicly funded dental schools and six private dental schools.

  • In all the schools the course lasts five years.

  • Currently about 2,00 students enter Spanish dental schools each year.

  • Until 2001, it was possible to train as a stomatologist; this involved a period of dental training by qualified medical practitioners, followed by further training as a dentist.

  • There is no requirement for post-qualification foundation training in Spain.

  • No specialties as defined in the 1978 EU Dental Directives are formally recognised.

3. Support Systems

  • The Consejo General de Colegios Oficiales de odontólogos y estomatólogos de España which has a Council (Consejo General) is the support organisation for dentists in Spain.

4. The Dental Team

  • Dental care is delivered by dentists, stomatologists and dental hygienists.

  • In 2007, the number of registered dental hygienists was 3,000. They have to work under the supervision of a dentist and they are not permitted to give local anaesthetic.

  • There is a qualification for Dental Technicians which is obtained after training and education at schools of Formacion Professional, over a two year period. Voluntary registers are kept by the regional associations, but there is no national mandatory requirement. However, in some regions it is compulsory and the numbers of such are growing.

  • Dental assistants work at the chair side. They have no formal training or qualification; they are trained by dental practitioners, (4). Most Spanish dentists appear to work with a chair side assistant.

5. Dental care delivery

  • There is a small Public Dental Service which operates in primary health care units.

  • Most oral healthcare is provided in private (liberal) practices. Dentists who practice outside hospitals, universities or the public dental service are referred to as private practitioners. Approximately 92 per cent of the profession work in this way and are largely in single-chair practice.

  • Regions which have delegated powers to establish local systems for the provision of health care may supplement this service through specific programmes. At present, these programmes are largely confined to prevention and paediatric dentistry.

  • Only 18 per cent of the population (2007) uses these private insurance schemes to cover their dental care costs.

  • Patients in Spain do not attend for dental care on a regular (periodical) basis, but tend to go when they have dental problems, only. There is no form of domiciliary (home) care. Less that 40 per cent of Spaniards attend a dentist each year.

6. Quality assurance mechanisms

  • An extended system of evaluation of the continuing education systems is being developed, after encouragement by the government. It becomes compulsory in 2012.

  • Complaints are investigated through a medical system. Where these are upheld a warning may be recorded on the dentists file, but they may only be prevented from practicing in the service by judicial sentence following malpractice.

  • If a patient wishes to complain about a dentist in general practice, this may be to either the Regional Colegio or Municipal Consumer Offices in the Town Halls or directly to the courts. Complaints to the former are considered by a Deontologic committee, which has only dental members.

  • These committees may arbitrate, issue a private or public warning, suspend a dentist or, in severe cases, refer to the courts for removal from the Register.





Key Points to Consider When Inducting or Supporting a Dentist Qualified in Spain



Dentists qualified in Spain:


  • Have limited experience of a publicly funded health service;

  • Have limited experience of UK monitoring procedures (e.g. NHS dental services) or UK requirements for clinical governance (e.g. clinical audit);

  • Will not have undertaken foundation training in Spain;

  • Will have no experience of working with a dental therapist, an orthodontic therapist, or a clinical dental technician in Spain;

  • May have no knowledge of formal training for dental nurses or dental technicians;

  • May have some experience of working within the wider team of dental care professionals;

  • May not appreciate that continuing professional education is a requirement for continuing dental registration in the UK;

  • May not appreciate that amalgam separators are mandatory in the UK;

  • If they have graduated in the last two years, are likely to have experienced difficult in obtaining a job in Spain.






Country : Sweden


Population: : 9,415,600 (2011)

Number of registered dentists: 15,236 (2009)

Number of active dentists: 7,457 (2009)

Qualified overseas : No data

Number of dentists registered in the UK by 2007: 996 in 2008: 988 in 2009: 980 in 2010: 968 in 2011: 925

Background

For a number of years there has been a net loss of dentists from Sweden. Most of the Swedish dentists who have emigrated have moved to the United Kingdom and Norway. However, by 2008, the trend of movement out of the country appeared to be ending. During 2004 and 2005 the net immigration of dentists was positive (5). In the mid 1990s, the Government reduced the number of undergraduate places in dental schools by 40 per cent. As a result, the number of active dentists is currently decreasing and the number retiring is increasing. Furthermore, the number of dentists emigrating is higher than the number of dentists moving to Sweden. However, the loss of retired dentists is balanced by the newly-qualified. The main reason for the reduction in the numbers of active dentists has therefore been due to emigration (5).


In 2009 there were 7,447 active dentists, 3,982 working in public dental care and 3,475 in private dental care There is no information about any unemployment amongst Swedish dentists (5).
The Public Dental Service (PDS) began in 1938. Initially, its purpose was to establish a systematic oral health care system for children and teenagers. At present, the PDS offers dental care to all children up to the age of 19 years and specialist treatment for both children and adults. Adults of all ages also have the right to use the PDS within available resources. A new financial Support System for oral health care for people aged 20 and over commenced in 2008. The support consists of a dental care voucher (a general dental care allowance), which can be used as part payment for a dental check-up at any dentist or dental hygienist, and a high-cost protection scheme. The dental care voucher is issued every other year. Not all types of dental care are reimbursable under the new Support System. Based on a diagnosis made by the dental care provider or a predefined condition, certain measures qualify for dental care support. Preventive measures and treatment of diseases are given high priority. Reimbursable dental care is required to be both cost-effective and socio-economically efficient (26). Continuing education is optional and continuing education and training in radiology is not mandatory (5). Vaccinations are not compulsory for the dental workforce, but there is a general recommendation to undergo certain vaccinations such as Hepatitis B, (5)The use of dental care professionals is well developed in Sweden and they undertake a considerable proportion of dental care (5).


Summary of relevant points

1. Regulatory Mechanisms

  • The principal regulatory body for Qualification and Education is a government department, the National Board of Health and Welfare (NBHW) which maintains the register of dentists, and awards the licence required in order to practice as a dentist.

  • Dentists do not need to re-register annually, and the cost of registration in 2008 was 64 Euros.

  • The Social Insurance Office also keeps a register of practitioners who are affiliated with the national social insurance scheme, and dentists must be on this register before they can claim social insurance fees.

  • The Swedish Dental Association (SDA) has formulated a number of ethical guidelines for its members.

  • The Swedish Association of Private Dental Practitioners has also formulated an ethical code for their members.

  • No standard contractual arrangements are prescribed for dental practitioners working in the same practice, but they are highly recommended by the professional organisations.

  • Vaccinations are not compulsory for the dental workforce, but there is a general recommendation for certain vaccinations such as hepatitis B (5).

  • For the most commonly used X-ray machines (up to 75 kilovolt intraoral receiver), no specific regulatory permission is required. However, to operate the equipment, a dentist must satisfy the requirements as defined by the Swedish Radiation Safety Authority.

  • Dentists are able to form limited liability companies. Non dentists may fully or partly own these companies.

2. Education and Training

  • All four dental schools are state owned and financed. They are part of the Faculties of Medicine of the respective universities.

  • There is no post-qualification foundation training. Although this was required prior to 1993.

  • There is specialist training in eight disciplines : Orthodontics, endodontics, paedodontics, periodontology, prosthodontics, oral radiolography, stomatognathic physiology and oral surgery.

3. Support Systems

  • The Swedish Dental Association (SDA) has four member associations: the Swedish Association of Private Dental Practitioners, the Swedish Association of Public Dental Officers, the Swedish Association of Dental Teachers, the Swedish Association of Dental Students.

4. The Dental Team

  • The use of dental auxiliaries is well established in Sweden, and they undertake a considerable proportion of dental care.

  • After qualification all hygienists are licensed by the NBHW, and they are able to work independently. Their duty of care includes the diagnosis of caries and periodontal disease, placing temporary fillings and giving local anaesthesic.

  • After qualification, dental technicians are licensed by the NBHW, but they do not require to be registered to be able to work.

  • Orthodontic operating auxiliaries can carry out specified procedures, but must work under the direction of an orthodontist.

  • Since January 2008, a standardised national education programme for dental nurses has been implemented. No registration is required.

5. Dental Care Delivery

  • The Public Dental Service (PDS) provides free dental care and specialist treatment for children and young adults up to the age of 19 years.

  • Adults and elderly people, who are not entitled to free care from the PDS, can obtain subsidised dental care from the PDS or dentists in private practice.

  • A new national insurance scheme was introduced in July 2008. This new state dental care financial Support Systems is for people aged 20 and over and involves the use of a dental care voucher within a high protection scheme to provide compensation equal to 50 per cent of a patient’s dental care costs between 321 – 1,590 Euros, and 85 per cent of costs exceeding 1590 Euros. The first 320 Euros is always paid by the patient. Compensation levels are based on “reference prices” which enable patients to compare dental prices more easily. Not all kinds of dental care are reimbursable; preventive measures and disease treatment are prioritised.

  • Dentists in private practice set their prices themselves.

  • Patient fees, both in the public and private sectors, are not regulated by the government and the price for the patient may vary depending on their choice of dentist/dental hygienist.

6. Quality Assurance Mechanisms

  • In 2007, The NBHW started to develop national evidence-based guidelines and these standards are monitored by the Regional Departments of the NBHW. They were planned to be finished in 2011.

  • The dental service also works using a system called Lex Maria, where all incidents that have caused or could have caused serious injury, are to be reported.

  • The monitoring of dentists in the PDS is the same as that for dentists in private practice

  • Continuing education is optional and continuing education and training in radiography is not mandatory (5).

  • If a patient complains, and the dentist cannot resolve the matter directly, there are two bodies through which the issue may be considered:

  1. Local Boards for Private Practice (composed of dentists), and Local Boards for Public Dental Services (may consist of people from another profession than dentistry)

  2. Medical Responsibility Board (HSAN), on behalf of the National Board of Health and Welfare.




Key Points to Consider When Inducting or Supporting a Dentist Qualified in Sweden



Dentists qualified in Sweden:


  • Mainly work in private practice and have contracts with the public insurance scheme;

  • May have considerable experience of working in a multi practitioner environment;

  • Will not have undertaken foundation training in Sweden unless they qualified before 1993;

  • Will have no experience of working with a dental therapist or a clinical dental technician in Sweden;

  • Will have experience working with an orthodontic therapist;

  • May not appreciate the need to register annually with the GDC in the UK;

  • May not appreciate that continuing professional education is a requirement for maintenance of dental registration in the UK;

  • May not appreciate that hepatitis B vaccination is compulsory in the UK;

  • If they have graduated since 2000, may have little or no experience of placing amalgam fillings,

  • May not appreciate that dental hygienists in the UK have to work under the supervision and legal responsibility of the dentist;

  • May not appreciate that dental care professionals in the UK have to be registered in order to be able to work.

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