Specialist Dental Services

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Specialist Dental Services
Sandra WhiteConsultant in Dental Public Health
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Learning outcomes

• Have an understanding of needs assessment
• and the commissioning cycle
• Understand the different dental specialties and
• special services
• Have considered how applicable the
• examples from one PCT are to others in the SHA

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World Class Commissioning

• World class commissioning is the way of obtaining
• the best value and health outcomes for local
• citizens by understanding their needs, and then
• specifying and procuring services that deliver
  the
• best possible health and social care provision
  and
• outcomes within available resources.
• Commissioners will work with their local
  partners,
• including local authorities, and providers from
  all
• sectors to establish long-term strategies for
  understanding
• and addressing the needs of the people they
  serve.

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Needs assessment

• 3 key steps (1)
• Epidemiological
• Comparative
• Corporate (Consultative)
• Stevens A Rafterty J ( 1997) Health Care Needs
  Assessment, Radcliff e Medical Press, Oxford

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Steps..

• Define the population?
• What are the health needs of the population ?
• What services are provided at present ( capacity
  and quality)
• What services will be needed?
• How do we meet the gap? ( procure/ provide?)
• How do we ensure quality services for good health
  outcomes?

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Resources to assist PCTs
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Regional Profiles 2007

• See enclosure
• SEPHO website Health profiles by local council
• http//www.communityhealthprofiles.info/
• DH - Red, amber and green http//www.dh.gov.uk/en/
  Publicationsandstatistics/Publications/Publication
  sStatistics/DH_079716

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Specialist dental care

• Dental and maxillofacial radiology
• Dental Public Health
• Endodontics
• Oral medicine
• Oral microbiology
• Oral Pathology
• Oral Surgery (Oral and maxillofacial surgery)
• Orthodontics
• Paediatric Dentistry
• Periodontics
• Prosthodontics
• Restorative Dentistry
• Surgical dentistry ( Minor oral surgery)

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Simplified!

• Dental Public Health
• Orthodontics
• Paediatric Dentistry
• Restorative Dentistry
• Periodontics
• Prosthodontics
• Endodontics
• Oral Surgery (Oral and maxillofacial surgery)
• Surgical dentistry ( Minor oral surgery)
• Dental and maxillofacial radiology
• Oral medicine
• Oral microbiology
• Oral Pathology

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In addition special services

• Epidemiology surveys
• Oral health promotion/ prevention
• Patients with special needs
• Prisons
• Domiciliary care
• Dental treatment under sedation

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Dental public health function (1)

• Apart from accessing impartial dental public
  health there is a need to commission
• Surveillance - oral health surveys
• Oral health promotion and prevention of disease
• (1) DH. The Functions of Primary Care Trusts
  (Dental Public Health) Statutory Instrument 2006
  no 185. 2006

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Surveys (and screening)

• Screening?
• National BASCD co-ordinated 5-year-old surveys
  every other year
• (http//www.bascd.org/)
• Alternate years (needs of the population?)
• Child Dental Health surveys every 10 years
• (http//www.statistics.gov.uk/CHILDREN/dentalhealt
  h/downloads/cdh_Summary.pdf)
• Adult dental health survey every 10 years
• (http//www.statistics.gov.uk/ssd/surveys/adult_de
  ntal_health_survey.asp)

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Good news!
Dental health of 12-year old children (average
number of Decayed, Missing and Filled teeth),
European comparisons (as at 2004) WHO Global
Database
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More good news!
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And more good news
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• But inequalities
• still exist

• pictures

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Dental Caries Experience 5 Year old children
2005/06
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Summary for commissioning surveys

• New - resourced national co-ordinated protocol
• Calibrated examiners
• Epidemiological skills
• Dental Survey Plus 2
• Sample size?
• Watch quality
• Disseminate results

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Improving oral health

• An Oral Health Plan for
• England
• Department of Health 2005
• Enabling people to make healthy choices for
  themselves
• Integrate oral health into general public health

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Key areas for action

• Fluoride
• Improving diet and reducing sugar
• Encouraging preventive dental care
• Reducing smoking / sensible alcohol use
• Increasing early detection of oral cancer
• Reducing dental injuries

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What do we need to do?
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Summary for commissioning OHP

• Fluoridation?
• Oral health promotion teams
• What they are doing?
• Develop a framework for OHP teams in line with
  Choosing Better Oral Health (see enclosure)
• Working with partners ( smoking cessation / LAs /
  obesity lead / Sure start etc)
• Commission dental services so that they work to
  Delivering Better Oral Health

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Supplementary resources

• Smokefree and smiling
  May 2007
• Delivering Better Oral Health
  September 2007
• Improving Oral Health for Children and Adults
  with Impairment and Disability November
  2007
• Improving oral health in ethnic minority
  populations
• Spring 2008

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• An evidence based toolkit for every primary care
  dental clinic

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Special treatment needs assess need

• Children and adults with medical, mental and
  physical health problems and behavioural problems
• Socially disadvantaged
• Homeless
• Travellers
• LAC
• Special services
• Domiciliary
• Sedation
• GA
• ( South central data base for collecting
  community waiting times)

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Salaried dental services

• Doing what many GDPs dont have the skills for
• Review the service (see enclosure)
• Retain the skills, develop the leadership, check
  efficiency

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Special treatment services

• Domiciliary care (see enclosures)
• How much is needed ( Transport? Perceived need?)
• Risk assessment
• Checklist for providers
• Criteria for domi care
• Sedation services DH guidance (1)
• Build in rehabilitation of the patient
• Prison care DWSI remember OHP!
• (1) DH. Commissioning Conscious Sedation Services
  in Primary Dental Care. Gateway 8338

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Oral Surgery - Summary

• Assess need?
• Audit what is happening (benchmark)
• Evidence based referral guidelines ( enclosed)
• Monitor referrals central referral service
• Triage
• 2 week wait and urgent care and 18 week wait
  pathways
• Tender where appropriate watch costs!
• Commission and monitor quality (specialist list)
• Evaluate the process

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Worked example

• Following tender exercise
• Milton Keynes PCT Picked 4 providers (
  including the general hospital) providing primary
  care oral surgery
• Bucks PCT Hospital won the tender on
  competitive price and quality
• Needs of the population and local circumstances
  important not a one size fits all.

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Orthodontics

• To treat or not to treat, that is the
  question.

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No!

• IOTN 1 IOTN 2

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Yes

• IOTN 4 IOTN 5

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Maybe!

• IOTN 3.3 IOTN 3.7

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The child as an individual

• We dont want to be able in 20 years to tell the
  social class of a whole generation!

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Assessing need?

• Clinical need Perceived need . Demand
• Formula
• Number of 12 year olds X (32.7 (1) 35 (2) )?
• X 21 UOAs and add a bit for assessments..!
• Not that simple!
• (1) P Brook and W Shaw. The development of an
  index of orthodontic treatment need. 1989.
• (2) I chestnutt et al. The orthodontic condition
  of children form Childrens Dental Health in the
  UK 2003

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Quick and dirty worked example

• 1/3 of population of 12 year olds in MK and Bucks
  PCTs 3320
• Had 48,732 UOA from reference year ( 2320
  patients at 21 UOAs per course of treatment)
• Plus salaried service orthodontics 100 treatment
  cases
• Plus hospital services -1500 treatment cases
  patients per year
• Total theoretical treatment capacity 3820
  patients

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But..

• More
• Interceptive treatment in earlier life
• Assessment treatment ratio
• Re-treatment
• Cross border flows

• Less
• Not all of the third will perceive the need for
  treatment and attend
• Oral hygiene and other factors preventing
  treatment
• Transfer to private care
• Cross border flows

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Key local issues

• UOA value?
• Who holds the waiting lists?
• Secondary / primary care interface
• Training
• Quality!
• PAR -Competency of providers
• Start to finish times
• Assessments to treatments

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Restorative care

• Endodontics (root treatment)
• Periodontics (gums)
• Prosthodontics (dentures, crowns, implant
  retained/supported restorations )

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Worked example
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Where are we?

• Demography population keeping their teeth into
  older age
• Current treatment data What and where?
• New contract impact - Trend data shows increasing
  number of referrals!
• Costs primary and secondary care
• Working with others Bucks PCT / Secondary care
• Consultation

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Nationally - Where do we want to be?

• Our health , our care , our say
• Community based care closer to home.
• Our NHS our future The Darzi Review
• Fair Personalised Effective Safe

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Locally - Where do we want to be?

• Good quality, accessible restorative dental
  services closer to home where the patients can
  receive the individual care they clinically need,
  the staff can feel valued in what they do, and
  the training and development of the wider primary
  dental care providers is enriched.
• Oh.. and it would be nice if it was vfm too!

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Result

• 3 days a week of Consultant in Restorative
  dentistry
• Shared between primary and secondary care
• Working across two PCTs
• Training opportunities for primary care dental
  teams
• Operation plan
• Set up costs / salary / laboratory costs / line
  management etc.

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Next steps ?

• Capacity/ competency to deliver commissioning
  agenda?
• Dental public health advice?
• Commissioning?
• Contract/ performance monitoring (including
  DPAs)?
• OHNA or JSNA?
• Key priorities across the patch?
• Opportunities for joint working?
• Common procedures and policies?
• benchmark specialist services?