Walking the ethical tight rope
Recent news reports have highlighted the shortcomings of the Enhanced Primary Care (EPC) scheme and inappropriate referrals made under its guidelines. The scheme is available for people with chronic conditions and complex care needs, on referral from a medical practitioner. Eligible patients receive up to $4250 in Medicare benefits for dental services over two consecutive years.
The ADA has long welcomed additional funding for patients with chronic medical complaints. Many of these patients would benefit from dental care provided by the public purse to improve both their general health and quality of life.
Understandably, health professionals become exasperated  and disillusioned when there are allegations of misuse of public funds. These reports are both disheartening and damaging as they fail to acknowledge the positive work that is done, whilst focusing abuse of fundsby a small group.
Attention has focused heavily on the misappropriation of government
funding in the home insulation scheme. As a result, their industry has suffered damage including to their public image. This serves a timely reminder that we must ensure our profession is not similarly exposed to costly damage.
In practice we are faced with the dilemma: you’re damned if you do, and you’re damned if you don’t. If you decline treatment, patients are often upset and see you as obstructing them from receiving benefits of care provided for by the public purse. Conversely, if you do treat them, you may be perceived as too willing to make use of public funds, even though the care provided fits within the guidelines of the EPC scheme.
All schemes are exposed to potential misuse. Even though there are only a few who will abuse them,  the cost of misuse can be high and can result in funding blow outs. Prior to the implementation of this scheme we expressed grave concerns regarding potential funding blow outs. The scheme was implemented without further consultation or tightening of its guidelines.
The vast majority of practitioners appreciate the benefits of directed funding and demonstrate philanthropic and community-minded practice behaviour.,
The handful of practitioners who allegedly abused the scheme may be
accountable to professional service review panels for breach of the guidelines and – if proven - their conduct will be subject to further investigation.

I urge members to impress upon patients and the referring GPs the responsibility we have in providing publicly funded care. As a professional body, we have and will continue to lobby for tighter guidelines to prevent misuse of funds by all facets of the referral chain ensuring sufficient funds are available to treat ALL patients in need.
 

Baton change
Australia’s population, as in so many developed countries, is ageing. Over
the next several decades, population ageing is expected to have significant
implications for Australia including health, labour force participation, housing and demand for skilled labour. (Productivity Commission 2005, Economic Implications of an Ageing Australia, Research Report, Canberra). As a corollary to our ageing population, many members approach the twilight of their careers and face increasing difficulties in navigating the exchange of their often long tended practice and patient base to new practice owners. This can be an incredibly stressful process that can take years, if not decades, to cultivate in one of the longest baton changes in a professional domain.
Some of the difficulties include differences in expectations between the two parties and this may encompass the subtleties between generations. The temptation for the ‘grey army’ to make the change due to increasing burdens of practice compliance and administration may result in hasty exit from practice and increases the possibility we will see more practices managed by corporate organisations employing our members to care for the patients with whom they wish to do business. As a professional group we need to mindful of the implications of this and carefully plot our course with yet another
third party.
With the likelihood of practitioners winding up private practices whilst they are at the prime of their knowledge and experience I would encourage you to make full use of your talents and stay connected with the profession in some way.

Opportunities in the public oral health sector
You will recently have received a letter co-signed by DHSV, ADAVB and the Melbourne and LaTrobe dental schools. The open invitation extends practice opportunities to practitioners that may be winding down from full-time private practice or are otherwise under utilised but are wanting to work more hours. It may be an attractive arrangement for those who do not wish to incur further administrative impost or commitment.
With the increase in the number of dental students and dental schools training our future colleagues, there are overwhelming pressures on our academics and upon general practitioners to oversee the clinical development of our dental students. This is especially so in regional areas where training facilities operate. Visits I have made to our regional groups have highlighted for me the pressure country practitioners face. With greater
involvement from willing volunteers, the educational support of our future peers might be better tended and the burden lightened on our rural colleagues.
Breaking down some of the walls between public and private practice offers people an opening for professional enrichment and personal satisfaction. Hopefully it will contribute to making our educational model more sustainable and provide our future dentists with access to experienced and passionate mentors in the same way we benefited through our undergraduate courses.
It is an invitation, and, whilst I encourage people to consider how these opportunities may be of personal and professional benefit,
I am also mindful that many of you are already engaging in professional activities of this ilk and you should not feel these activities go unnoticed.
 

Dentistry10
Work on our bi-annual convention is progressing and members this month will each receive a copy of the Dentistry10 registration brochure through the post. If you do not receive a copy, contact the Branch or go online to see the PDF version. The online registration form is available website 
 

Best practice framework for clinical learning
ADAVB last month commented on the latest draft of the Department of Health’s Best Practice Framework for Clinical Learning. The framework is intended to be useful and relevant to the majority of health professional disciplines and health service settings in Victoria.

The Branch welcomed the framework’s provision of ‘guidance’ to health services and education providers in jointly exploring effective and appropriate mechanisms to achieve high quality clinical training experiences for learners.

The ADAVB supported the key elements that underpin a quality clinical learning environment:
 An organisational culture that values learning
 Best practice clinical practice
 A positive learning environment
 A supportive health service-training provider relationship
 Effective communication processes
 Appropriate resources and facilities.

Endorsing the principles supporting the framework, ADAVB commented:
1: Patient (or client) care is an integral component of quality clinical education.
• Dental students must have access to a full range of patients in preparation for graduation when they will be presented with all sorts of cases.
2: Learning in clinical environments is an essential component of training all health professionals.
• The need for sound pre-clinical experiences is essential for clinical students to be able to provide safe and effective services for patients. This is of particular importance in dentistry where invasive and non-reversible surgical procedures are provided by students. The framework should acknowledge this.  Not to do so runs the risk of placing students and patients in situations which produce poor clinical outcomes.
• Use of simulation laboratories is an essential and efficient means of introducing clinical work to undergraduates, but once the students’ basic skills have been developed, nothing prepares them for treating people better than treating patients in normal clinical settings.
3: Registration, accreditation or competency standards set down by professional bodies (where these exist) are the appropriate mechanism for ensuring that clinical education arrangements meet minimum standards for educational or training outcomes.
• The new Dental Board of Australia will determine professional standards to be met by all dental care providers. There should not be any other body seeking to establish a second set of standards.  Were this to happen it would lead to conflict, confusion, unnecessary cost and potential risk to patients.
• ADAVB endorses the use of standards set by professional bodies.
4: Many different models of clinical education and training exist and successfully produce health professionals of required competency and standard.
• There is nothing to be gained from a ‘cookie-cutter’ approach to clinical training, where everyone is expected to complete identical exercises.
• Diversity of educational approaches is healthy and necessary because of the differences in rural and metropolitan training facilities.
• Adequate exposure to various clinical cases is vital to ensure appropriate training and a concomitant standard of patient care.

ADAVB also emphasised:
• A preference for the framework to include the term “mentor” in addition to “educator” because the best supervisors have both skills, but not all do.  The success of dental outplacement programs relies on having a good mixture of both.
• Students are not a workforce and nor are they a solution to a shortage or mal-distribution of oral health care providers. 
• Consideration must be given to the value of information collected and how it would be used.
• The notion that an educator/health service provider's position description should include a career structure related to being an educator is worthy but is not practical. The draft framework states that 'There is a documented strategy for career progression for staff involved in educational activities’. This is related to external factors rather than internal ones. This is because State awards and remuneration levels are not set by the health services. The government supports funding for educators in health services but there is no link to remuneration levels. The principle of continuity in providing educational experience is worthy and can be achieved by health service educators receiving training from the training provider partner to develop their educational skills.
• Support should be for permanent educators, either full or part-time rather than visiting staff.
• Disincentives for dentists to become educators:
o Lack of career structure and remuneration
o Competing productivity targets which detract from the educator focusing on teaching
• Lack of continuity of teaching as many educators were not trained by the training provider for their initial qualification.
• For output funded programs like dental, there is little funding to enable the development of educators to provide high quality educational clinical placements.  This creates a conflict between productivity targets and teaching time.  Resolution is usually because of the organisational culture of the individual health service - not government funding.
 

The Victorian Government is being urged to provide oral health services to nursing home residents.
In a Budget submission to the State Government, the Australian Dental Association Victorian Branch says that there is good evidence that improved oral hygiene and frequent professional oral health care reduces the progression or occurrence of various diseases among high-risk elderly people living in nursing homes, especially those in intensive care units.

The ADAVB welcomes the invitation to comment on the Best Practice Framework for Clinical Learning Environments, Version 2, December 2009.