6.1 Local adaptation and implementation

This is a nationally agreed guideline which may require adaptation to meet local conditions and restraints. For example parts of the national guideline may have to be adjusted to conform with the structures set out in the general dental service contract or in practice protocols. The framework and contents of this national guideline should therefore be adapted actively to local situations so that the guideline can best influence the clinical care of children across Scotland.

A model is presented in figure 1 which was successfully used to produce and implement local guidelines following publication of the SIGN guideline on prevention of visual impairment in diabetes.

Figure 1

Example model for guideline implementation

Produced with the kind permission of Dr Janet McCarlie, Clinical Epidemiologist and Local Audit Co-ordinator for General Practice, Ayrshire & Arran Health Board

6.2 Health service implications of implementation

This guideline is consistent with the policies and priorities set out in the Scottish Executive's Action Plan for Dental Services in Scotland.¹¹³ Implementation of this guideline will help ensure a more consistent approach towards primary and secondary caries prevention across Scotland. Successful implementation requires the full involvement and co-operation of other primary care professionals, who have an undeniable role to play in caries prevention. Appropriate training and support will be required by the primary care team, which will have resource implications for both Health Boards and Trusts.

If the guideline is to be successfully implemented at both national and local level, Health Improvement Programmes (HIPS) and Trust Implementation Plans (TIPS) need to address caries prevention and the recommendations in this guideline. In addition, implementation will require close collaboration within the dental profession between the general, community and hospital dental services, as well as between the dental profession and other health care professionals.

Successful implementation of the guideline will contribute to a lower prevalence of dental disease amongst the target age group and drive down costs associated with treating the disease. In 1997/98 the cost to NHS General Dental Services of amalgam (silver) fillings alone was £2.3 million for Scottish 0-17 year olds.¹¹⁴ Investment in prevention may reap savings to the NHS in the future. It is hoped that current methods of payment will not adversely influence implementation of the recommendations made in this guideline, as studies have shown this to be a factor.¹¹⁵

Many sugar free medicines cost more than those containing sugar. Increased prescribing of sugar free medicines will initially increase the NHS spend on drugs. However, it is hoped that the increased demand for sugar free medicines will encourage drug companies to increase the manufacture of such products, driving down production costs.

Successful implementation and audit of any guideline requires time. At present, general dental practitioners do not receive an income if they are not actually treating patients. Health Boards and Trusts should make appropriate arrangements to reimburse practitioners during implementation and audit of local guidelines, as part of their clinical governance activities.

6.3 Implementation issues for local discussion

The following issues were raised by specialist reviewers during development of the guideline and might provide a starting point for discussions as part of the process of local implementation of the guideline:

• Catch phrases
  During a recent pilot of implementation of locally agreed guidelines based on the draft SIGN guideline, the use of small catch phrases was particularly liked by members of the dental team. For example, "SPIT DON'T RINSE" was a short snappy phrase widely used and disseminated. Further use of appropriate catch phrases might prove a useful implementation tool.
• Patient information
  This guideline contains a wealth of valuable information for the dental profession and non-dental professionals. As the trends in health care move to self empowerment, this might be used as a tool to encourage personal responsibility for dental health by development into specific advice and guidance for interested parents, carers, or teachers. Dissemination of appropriate information into the public domain with loud clear messages of personal responsibility and how to effectively apply this may be helpful in counterbalancing the oral effects of a huge change in social (including dietary) habits over the past 10 years.
• Parental/carer responsibility in oral hygiene.
  Publicity would be useful for the important and effective contribution of supervision/encouragement and/or physically providing regular oral hygiene routines in the child's own environment.
• Radiography
  Frequency of bitewing radiographs is an essential element of prevention in children at high caries risk and might be given greater prominence in local guidelines.