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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Some background on the variations in the systems for administering and delivering oral healthcare in the EEA


There are wide variations between EEA member states. Examples include the nature of the organisations that register dentists and are responsible for their professional standards. In Malta, Ireland and the UK they are known as dental councils and are largely independent of both the Government and the dental profession. In the Nordic countries registration is the responsibility of Government departments and a number of organisations (the dental associations, the universities and the Government) are responsible for professional standards. In many other member states both registration and professional standards are the responsibility of the dental association/order/chamber and there is often very little, if any, Government or lay involvement. In these countries dentistry and other healthcare professions are frequently referred to as “liberal” (self-regulating) professions. Dentists who come to the UK from EEA member states with “liberal” professions may not be aware of the powers of the GDC and find them surprising.

The use of team dentistry provides another example where there are surprising variations. In the Netherlands this concept is very well developed with all dentists working with full-time chair-side nursing assistance and numbers of dental hygienists and clinical dental technicians working in independent practice. Whereas in Belgium, a few kilometres away, the concept of team dentistry is poorly developed, there are no dental hygienists, nor clinical dental technicians and only a minority of dentists work with a chair-side assistant.

There are also variations between the systems for the provision of oral healthcare between the former Eastern Bloc countries, many of whom have changed from a purely public dental service to a purely private system and from a stomatological training, in which dentists first completed medical training before clinical dental training, to the typical North-Western European odontological training. These changes have caused significant tensions and have lead to a situation in which the background and experience of young graduates from these member states is very different to those who have been qualified for more that 15 years. Annex 2 summarises many of the differences in a table.

There are undoubtedly cultural issues that some dentists from EEA member states are likely to encounter when they work in the UK. For example, although it is usual in the UK to discuss treatment plans with patients and to encourage them to arrive at a final decision in partnership with the clinician concerned, this is not the case in a number of EEA member states. Communication is frequently a cause for patient complaints. Language can play a key role and although an EEA dentist may speak adequate English under normal conversational circumstances, he or she may have considerable difficulty understanding a regional accent or in explaining dental terms in language that a patient can understand. Such issues are not dealt with directly in this resource and can equally apply to some UK graduates.



There are considerable differences between member states in most aspects of the provision of oral healthcare and in the education of all members of the dental team. These differences can lead to difficulties for dentists and other dental team members who come to work in the UK. In many EEA member states the concept of clinical governance is defined differently to that in the UK and it may be unusual for a patient to challenge a dentist’s treatment planning recommendations.


Country : Belgium


Population: 10,951,266 (2011)

Number of registered dentists : 8,350 (2009)

Number of active dentists: 7,800 (2009)

Qualified overseas : 118 (2007)

Number of dentists registered in the UK in 2007: 53 in 2008: 51 in 2009: 51 in 2010: 49 in 2011: 46

Background

Three languages are spoken in Belgium; Dutch (just under 60 per cent), French (just under 40 per cent of the population) and German. In the main, those who live in the North of the country (Flanders) have Dutch as their first language and those in the South (Wallonia) French. There is a small German speaking community in the East of the country. Belgium is a federal state. The fees and refunds for dental treatment falls under the authority of the federal state, whereas education (including the training of dentists) and prevention campaigns fall under the authority of the communities.
There are five dental schools: two in Flanders (KU Leuven and Ghent University), two in Brussels (Universite Libre de Bruxells and Universite Catholique de Louvain la Neuve) and one in Wallonia (Universite de Liege).
The level of dental caries appears to be fairly low in Belgium, but some groups experience a high level of disease. People in these high risk groups often have limited access to oral health care. The oral health workforce is limited mainly to dentists working in private practice. There is a reduced emphasis on prevention which auxiliaries might bring if team care was practiced. A public health approach is limited at present. Nevertheless, efforts are being made to improve the system and eliminate some of its variations (6).
In 2009, the total number of registered dentists was 8,350, and 48 per cent were female (4). The national government limited the number of dentists admitted into the profession every year during the period 2002 – 2010. The number is still fixed at 140 per year (84 from the Flemish part of the country and 56 from the Wallonian part). There is an additional mechanism in Flanders to reduce the numbers of new entrants to dental schools. It takes the form of a compulsory entrance examination which has reduced the yearly intake of dental students to about 100 for the whole country (6).
Dental services, both preventive and restorative, are almost exclusively delivered within private dental practices, by private practitioners, and only to a small extent (< 5 per cent) in public clinics, which are usually hospital based. Most dentists in general practice are self-employed and earn their living through charging patient fees (5).
Since 2002, amalgam separators have been mandatory. There are specific regulations defining radiation protection. A dentist is the competent person for radiological safety in each practice.
A dentist is required to register with the Federal Ministry of Health in order to practice dentistry in Belgium. In 2008, the cost of registration was 550 Euros (5).


Summary of relevant points

1. Regulatory Mechanisms

  • A dentist is required to register with the Federal Ministry of Health in order to practice dentistry

  • Dentists are required to work under one of two different, but congruent ethical codes, dependant upon which dental association (Dutch or French speaking) they belong to

  • Vaccination against hepatitis B is compulsory during dental training, and is administered by the Ministry of Health

  • Dental indemnity insurance is compulsory for dentists, and covers dentists working abroad

  • There is an initial payment for the registration of radiation equipment, of about 275 Euros. There is an additional annual maintenance subscription of 160 Euros

  • Dentists are permitted to form companies in Belgium. These must be registered at a specific address. Non-dentists may be shareholders or fully own the company

  • There are no limitations to the number of associate dentists, or other staff in a dental practice. Premises may be rented or owned, and can be opened anywhere. No state assistance is provided to establish a new practice, thus dentists must negotiate commercial loans. A practice must be registered at a specific address. Some health insurance systems fund their own polyclinics.

  • There are no specific contractual requirements between practitioners working in the same practice. However a dentist’s employees are protected by the National and European laws on equal employment opportunities, maternity benefits, occupational health, minimum holiday entitlement and health and safety

2. Education and Training

  • There are two titles awarded for clinical dentists graduating from Belgian dental schools:

  • Flemish Tandarts

  • French Licencie en sciences dentaires

  • Since 2002, vocational training has become mandatory. A federal law has limited the number of places for vocational training to 155. No Foundation Training programme exists.

  • There are three registered dental specialties; general dental practitioner, periodontology and orthodontics (6). Patients may go directly to a specialist, without referral (5).

3. Support Systems

  • Chambres Syndicales Dentaires (CSD) for French-speaking dentists

  • Société de Médecine Dentaire (SMD) also for French-speaking dentists

  • Verbond der Vlaamse Tandartsen (VVT) for Dutch speaking dentists

  • Membership is not compulsory, and in 2007, membership was approximately 67 per cent of the dental workforce

4. The Dental Team

  • Recently the number of dental assistants has gradually increased since their training has been organized. However, many learn their skills “on the job” and the majority of dentists still do not employ a dental nurse

  • Dental technicians have a protected title, as defined by the Ministry of Economic Affairs, and complete training in specialised schools (for three years), or in the dental laboratories. They are registered with the Ministry of Health

5. Dental care delivery

  • Dental services, both preventive and restorative, are almost exclusively delivered within private dental practices, by private practitioners, and only to a small extent (< 5 per cent) in public clinics, which are usually hospital based

  • The system is based on a compulsory social insurance system covering all aspects of healthcare, including dental care. Working adults, both salaried and self-employed, make compulsory payments through deductions from their wages or income, which contribute to the health and social services provided by the National Health Insurance scheme. Employers also contribute additional sums for their employees (6).

  • There is an agreed scale of fees for dental treatments (known as the convention), which is jointly agreed by the dental associations and health insurance organisations. Dentists generally charge patients for each item of treatment, and then patients can obtain reimbursement for part of the costs

  • Within the framework of the National Health Insurance System, reimbursement of 75 – 79% of the nationally agreed fee is provided to all inhabitants for preventive and restorative care, removable dentures and minor oral surgery. For budgetary reasons, age limitations have been installed for the reimbursement of certain treatments (e.g. removable dentures are reimbursed from the age of 50 years); these limitations have changed over time. For individuals with disabilities, reimbursement of oral care is increased up to 90%. “Free” oral health care (i.e. full reimbursement) was begun for all children up to 12 years in September 2005, extended to 15 years in July 2008 and finally up to 18 years in May 2009. It covers the majority of preventive and restorative care; but reimbursement of orthodontic treatment remains limited.

  • Approximately a third of the population attend a dentist regularly, one third when necessary and the remainder almost never, or only in an emergency.

6. Quality assurance mechanisms

  • Since June 2002, continuing dental education has been mandatory in general medicine, radiology, prevention, practice management, conservative dentistry, orthodontics, prosthodontics and radiation protection. The requirement is 60 hours over six years. Dentists must also undertake at least one and a half hours of radiation protection training every five years (5).

  • There are several ways in which standards of dental care are monitored. The Institute of Health has an administrative body which regulates the non-clinical administrative forms used in dentistry. It also has an independent control department staffed by medical doctors (not dentists) which checks that the treatment codes recorded agree with the actual treatment undertaken. The convention also defines quality standards (5).

  • Patients may complain to the Provincial Medical Council. Within the Dental Associations there is an ethical commission which also manages complaints. However this mostly handles disagreements between dentists, and aims to mediate in these cases.





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



Dentists qualified in Belgium:


  • Have limited experience of a publicly funded health service;

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

  • If they qualified before 2002, will probably not have undertaken vocational or foundation training in Belgium;

  • May have limited experience of working with a dental nurse (chair-side assistant);

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

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

  • May have no knowledge of registration for dental care professionals other than dentists.



Country : Bulgaria


Population: 7,364,570 (2011)


Number of registered dentists: 8,240 (2011) Number of active dentists: 8,240 (2011)

Qualified overseas : 38 (2011)

Number of dentists registered in the UK in 2007: 45 in 2008: 116 in 2009: 167 in 2010: 243 in 2011: 300

Background

Some 73 per cent of the population is described as urban and the other 27 per cent live in rural areas. The country is divided into 28 districts; each has administrative offices for the Health Information Centre and local insurance fund (5). Between 2001 and 2011 the population of Bulgaria decreased by 564,331, two thirds of this decrease was due to deaths and one third to emigration.


Healthcare in Bulgaria is based on mandatory health insurance which is designed as a state monopoly and is known as the National Health Insurance Fund (NHIF). About 98 per cent of dentists in Bulgaria work in general practice, although some also work in hospitals and dental faculties. Dental services are delivered either within the NHIF or privately. Among all Bulgarian dentists, over 5,500 have contracts with the NHIF. There is a significant difference between the big cities (with an excess of dental practitioners) and the rural areas (where there is a shortage of dental practitioners). The average age of dentists in Bulgaria has risen from 39.7 years in 1997 to 41.7 years in 2008 (4). 64 per cent of dentists in Bulgaria are female, this has declined from 1998 when it was 74 per cent. At present, there appears to be no risk of overproduction of new dentists. There is no reported information about unemployment among Bulgarian dentists (5).
The dental procedures in the NHIF are on a co-payment and fee-for-service base. The scope and the extent of co-payments are different for children and adolescents on one hand, and adults on the other. Insured patients are entitled to a specific package and volume of dental procedures, covered by the Fund. The additional dental services are fully paid for by the patients (5).

The NHIF monitors the quality of dental care in the system of mandatory insurance, according to criteria negotiated with the Bulgarian Dental Association (BgDA) and included in the National Framework Contract. The quality of dental care in private practice is not actively monitored. Some control is carried out by BgDA on the basis of the Ethical Code and the Rules of Good Medical Practice in Dental Medicine. Like most European countries, professional liability insurance is mandatory according to the Law of Health, and the Regional Colleges of BgDA cover the insurance of their members which is not covered for Bulgarian dentists working overseas.


Dental graduates in Bulgaria are entitled to registration immediately upon graduation. Continuing professional education is mandatory.
In summary, about (90 per cent) of dentists in Bulgaria work in individual general dental practices. There is little publicly funded dentistry; most payments for oral health care are made privately by patients themselves. Dentists generally do not work with dental nurses. There are no dental hygienists. For historical reasons, dentists are called dental physicians in Bulgaria


Glossary of Terms

Allergology

The branch of medical science that studies the causes and treatment of allergies



Summary of relevant points

1. Regulatory Mechanisms

  • The principal regulatory body in Bulgaria is The Bulgarian Dental Association (BgDA). It administers the registration of dentists through its Regional Colleges. The registration of dental practices as medical institutions is administered by the Ministry of Health through its regional bodies - the Regional Centers of Healthcare

  • There are no mandatory vaccinations against Hepatitis B or other diseases.

  • Professional Liability insurance is mandatory according to the Law of Health, and the Regional Colleges of BgDA cover the insurance of their members

  • The law assumes that the primary dental qualification allows dentists to work with ionising radiation and take radiographs.

  • Individual and group dental practices may be owned and managed only by dentists.

  • The disposal of hazardous waste is regulated by the Law of Waste Management, plus secondary legislation. Amalgam separators are only advised and they are not yet mandatory

2. Education and Training

  • There are three dental schools; the school in Varna opened in 2005.

  • The undergraduate course lasts for five and a half years and was fully “EU compliant” on Bulgarian accession to the EU in 2007.

  • There is no postgraduate vocational training. There is a six month mandatory pre-graduate practical training in the dental schools.

  • There are numerous dental specialties in Bulgaria each with a training period of three years, post registration.

3. Support Systems

  • In 1999 the Law of the Professional Organisations of Physicians and Stomatologists (later: Physicians in Dental Medicine) established the new professional organisation: The Association of Stomatologists in Bulgaria (ASB), which, after the accession of Bulgaria in the EU, regained the title Bulgarian Dental Association (BgDA).

4. The Dental Team

  • Dental care is delivered by dentists. There are no dental hygienists

  • Dental technicians in Bulgaria graduate after three year’s training. The dental laboratories are 100 per cent private and must register with Ministry of Health. Their activities cover dental and orthodontic appliances. Dental technicians are not entitled to undertake any form of clinical work.

  • Since 1989, no specific training has been available for dental chair-side assistants (dental nurses). In 1989 there were about 6,000 dental chair-side assistants, but there were very many fewer by 2008 (3000) – the number in dental clinics is small and most dentists now work without a chair-side assistant. Those who originally trained as general care nurses are registered as such. However, there is no register for dental nurses.

  • There are no clinical dental technicians (denturists), dental hygienists, or dental therapists in Bulgaria (5, 2).

5. Dental care delivery

  • Voluntary health and oral health insurance is at a rudimentary, initial stage. Most of the dentists in Bulgaria work in general practice and deliver oral health care either through the NHIF or privately.

  • The Bulgarian Dental Association has drafted a national programme for prevention of oral diseases in children 0-18 years.

  • The entire working population of Bulgaria is required to have health insurance with the NHIF. Theoretically, the NHIF covers dentistry. However, oral health care for adults funded by NHIF is limited

  • Virtually all Bulgarian dentists work in the private sector on a self-employment base, i.e. in general practice. Most work single-handed in one chair practices.
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