Health Department

St Andrew's House
Regent Road
EDINBURGH
EH1 3DG

Dear Colleague

GUIDANCE ON GENERAL ANAESTHESIA AND SEDATION FOR DENTAL TREATMENT

Purpose

1 . Further to NHS:2001 PCA(D)1 which informed Primary Care Trusts and Island Health Boards of the deletion from the Statement of Dental Remuneration from 1 April 2001 of all item of service fees for the provision of general anaesthesia, this letter advises NHS Trusts and Health Boards that, with effect from 1 April 2001, general anaesthesia for dental treatment must be undertaken in a hospital setting. It also advises that hospital services for general anaesthesia for dental treatment should be reviewed, to ensure that they are designed and appropriate for children and those adults with incapacity.

Background

2. In November 1998, the General Dental Council (GDC) amended their ethical guidance on the standards required by dentists involved in dental treatment under general anaesthesia either through referral of patients or through the provision of such treatment. The GDC distributed its amended guidance to Health Boards. In cooperation with the GDC, the Royal College of Anaesthetists agreed guidelines of anaesthetic care of such patients.

3. PCA(D)15 1998 asked Health Boards to report on the provision of general anaesthesia in their area, to review the need for general anaesthesia and alternative forms of anaesthesia in their area and to prepare a strategy for delivery of these services. PCA(D)5 1999 sought a further update on the position. Following the Sheriffs determination regarding the fatal accident inquiry into the death of Darren Denholm at the Peffermill Dental Practice, the Minister for Health and Community Care gave an undertaking that general anaesthesia in primary care dental practice would be phased out as soon as planning allowed. The Scottish Executive have informed the Scottish Dental Practice Committee that no item of service fees for general anaesthesia will be included in the Statement of Dental Remuneration from 1 April 2001.

5th April 2001

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Change in practice

4. In the 1960s and 1970s, general anaesthesia was the main method used for extracting teeth with an estimated 200,000 general anaesthetics a year for dental treatment mainly in general dental practice. Service provision has changed considerably, and by 1997 the estimated number of general anaesthetics for dental treatment had fallen to 45,000-50,000. Present estimates are around 20,000-25,000 per year, with the main service provider being the Community Dental Service using hospital facilities.

Facilities Required for General Anaesthesia

5. The facilities considered most suitable would be within a hospital complex with critical care available, where specialist surgical teams deal regularly with surgical cases either as day cases or inpatients. In these units, it would be expected that a trained and experienced support team would be available to assist the anaesthetist with resuscitation of a collapsed patient and that there would be facilities and staff able to support and maintain such a patient pending recovery or supervised transfer to an Intensive Care Unit (ICU) or High Dependency Unit (HDU).

6. The report "Better Critical Care", was issued to the service recently. It recommends that each Acute Trust establish a Trust-wide Critical Care Delivery Group, to include the key professions and specialties which use and deliver the service. Trusts should use these Groups to advise on the suitability of facilities and staff providing general anaesthesia for dental treatment and on the support staff and facilities available for patients who collapse following such treatment.

Children

7. The majority of cases for dental treatment under general anaesthesia are children under the age of 16 years. Dental treatment under general anaesthesia for such children should be undertaken only where there is clinical need. Children requiring general anaesthesia for dental treatment should be offered treatment within a hospital which has a child friendly environment and where children are regularly treated for surgical procedures.

8. We recognise that hospitals where children are presently receiving treatment to the appropriate clinical standards may not be a suitable environment for the best treatment of children. These services should be reviewed. Trusts should ensure that children are assessed by dental practitioners skilled and trained in the treatment of children prior to general anaesthesia. Services should offer, where indicated, a range of alternative treatments. Where general anaesthesia is offered to children for dental treatment, Trusts should review the need for paediatric anaesthetist, paediatric nursing and consultant led paediatric support services. Dental services for children should be fully integrated within the local child health strategy/plans.

Adults with Incapacity

9. General anaesthesia is often used in this group of patients to facilitate dental treatment. Trusts should review the hospital facilities and staff where these patients are treated. Trusts must ensure that these patients are fully assessed and, where indicated, offer alternative treatments to general anaesthesia. Facilities and support staff should be equivalent to those highlighted in section 5 and 6 above.

Current Position

10. Health Boards and Trusts with hospital or community facilities where the criteria outlined above are not currently met will require to give immediate consideration to alternative arrangements.

Action

11. Health Boards and Trusts are asked to:

11.1 note that general anaesthesia for dental treatment should be offered only within a hospital complex from 1 April 200 1;

11.2 plan their services to ensure appropriate access, setting and standards as outlined in paragraphs 5 and 6 and 9 above;

11.3 note that where general anaesthetic facilities for dental treatment of children are provided facilities should meet the standards of care outlined in section 5 and 6 above. Provision of such services should be reviewed and future service provision identified within the local child health strategy/plan and any recommended change in provision should be operational at the latest by 2004;

11.4 collaborate on the development of conscious sedation services for dental treatment as an alternative to general anaesthesia;

11.5 ensure that referred patients who are considered as urgent cases for either general anaesthesia or conscious sedation services for dental treatment receive treatment within time limits and standards set down within local protocols;

11.6 ensure that all services fully assess patients for dental treatment under general anaesthesia and are able, where indicated, to offer a range of alternative treatments;

12. Health Boards are asked to forward by 31 December a report jointly agreed with Trusts outlining for their area how general anaesthetic and conscious sedation provision for dental treatment is structured, organised and fully integrated into hospital services and into local child health plans/strategies. The report should be sent to the Chief Dental Officer at the Scottish Executive.

Yours sincerely

GODFREY ROBSON
Director of Policy