In

1
In out-of-hours dental services considering
models of care

• 13th November 2007
• NHS North West

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Housekeeping

• Programme
• Fire Alarm
• Mobile Phones
• Badges
• E-mail evaluation

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Aims of the day

• Aiming for PCTs to
• Be aware of the national context associated with
  the provision delivery of in and out-of-hours
  dental services
• Examine the range of models and services in place
  across the sector and explored opportunities for
  improving these services in order that they
• consider the entire patient pathway
• are consistent
• best meet local needs
• Review quality frameworks, setting local
  benchmarks

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Aims of the day (contd)

• A vision and action plan regarding improvements
  to information available to local residents
• Set some out some clear plans for joint working
• Anything else

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Aims of the day

• Aiming for NHS PCC to
• Identify good practice case studies to share
  nationally
• Identify dental standards for a national model
  framework

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In out-of-hours dental services considering
models of care

• Natasha Dogmetchi
• November 13 2007

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In the former world
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Former out-of-hours requirements

• PCTs were responsible for having OOH in place for
  residents not registered with a dentist
• GDPs were required to provide an OOH service
  and/or treatment within a reasonable time for
  registered patients (treatment 24 hours, verbal
  response 6 hours)
• GDS Regulations fell on March 31 2006

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In the new world
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New Responsibilities (April 1 06)

• Responsibility for local patients whether or
  not are receiving a COT from local practices,
  also visitors to the area
• EDS expenditure devolved to PCTs (Section 56) -
  Nationally 17 million
• 175 (out of 303) PCTs received funding (54 PCTs
  more than 100k 4 PCTs more than 250k)
• Recall attendance fees less and 1k remained
  within practitioners baselines
• Recall attendance fees of more than 1k PCTs
  should have agreed forms of NHS activity

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New responsibilities

• Planning should have begun
• Sector wide basis and/or links with existing
  services
• Redistribution of associated resources
• Planning required
• Review current services provision, capacity use
• Consider new models
• Consider range of treatment
• Complementary in-hour services
• Inform local residents

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Key National Principles

• Aimed at
• URGENT DENTAL NEED - unable to wait until next
  available in-hour service
• Severe dental and facial pain not controlled by
  over-the-counter medication
• Dental and soft tissue acute infection

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Key National Principles

• Include OOH urgent services within overall
  planning frameworks
• Genuine dental emergencies are rare
• OOH advice can be provided for a large area by
  telephone triage a dentist on call with access
  to facilities
• OOH service not to be seen as a substitute for
  in-hour urgent dental care (sessions directly
  from dental contractors?)

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Key National Principles

• Dental OOH services integrated with medical OOH
  services, where appropriate
• A form of triage should be in place (form is up
  to the PCT)
• Patients should have access to advice ( does not
  have to be face-to-face)
• Patients should have access to clinical services

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A whole system approach
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The Commissioning Cycle
Review current service provision
Assess needs
Decide priorities
Design service
Patient and public feedback
Strategic planning Service redesign Managing
demand Managing performance
Shape structure of supply
Managing Performance (quality, performance,
outcomes)
Manage Demand and ensure appropriate access
to care
Clinical decision making
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Local models
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Local Principles?

• Services developed in line with population need
  (re-assurance for some)
• Urgent services should be full integrated with
  wider primary care services
• Services limited to those in pain only (clear and
  consistent assessment prioritisation)
• Flexibility in the system
• Clear about links to NHS Direct or local call
  handling services

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Model framework

• Whole system approach 3 components
• The gatekeeper to the OOH service (triage stage)
• Provision of dental OOH services (delivery stage)
• Complementary service provision during normal
  working hours

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The gatekeeper triage stage
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Triage stage

• Issues to consider
• Form of triage (open or closed door systems)
• Definitions of dental/urgent
• Outcome from triage stage

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Triage stage

• Advantages of a dental triage system
• Consistent with medical model
• Fairness
• Reduction in waiting times for those simply
  seeking advice fast tracking of those with most
  acute needs
• Filters false emergencies

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Closed Door

• Telephone triage by dentists
• Centrally managed call system (via NHS Direct or
  straight to dentist via a dedicated telephone
  number) triage undertaken on behalf of the
  sector
• Each service to have consistent telephone triage
  system. NHS Direct can be only or one source of
  referrals

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Closed Door

• Telephone triage undertaken by dentists
  options
• Provide sessional advice only (sector or PCT
  wide)
• Provide both advice and then subsequent care
  where required
• Based at OOH centre
• Based at on-call service or NHS Direct

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Closed Door

• Examples of dental lead telephone triage
  services
• Croydon 7 of calls are referred by NHS Direct.
  Dentist uses own clinical judgement
• Newcastle and Northumberland 100 of calls are
  referred via NHS Direct. Dental triage services
  have developed algorithms to complement NHS
  Directs

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Integrated National Model (OOH)
Ambulance
AE
OOH Medical Services
Pharmacy
Advice
Dentist on telephone

• Face-to-Face consultation
• By dentist
• At home

Patient makes a single call Forwarding with an
explanatory message
Call Management Nurse
Triage
Self care
General or dental information service
Advice
Dentist calls back patient
Appointment to attend OOH centre
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Closed Door

• Factors that can complicate a telephone based
  triage service
• Complex medical history
• Limited used of the English language
• Access to a telephone (refugees/homeless)
• Not being able to visualise the problem
  (site/size of lesion)
• Developing and standardising questions and
  outcome of phone based triage

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Open door

• Clinical led advantages disadvantages
• Advantages
• Accurate assessment of clinical presentation,
  minimal training required to implement triage,
  patients more likely to comply with triage
  outcome
• Disadvantages
• Less cost effective, time consuming and may
  reduce no of patients that can be seen, decision
  making process may vary according to clinical
  experience, increased work load on clinician

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Open door

• Nurse led triage advantages disadvantages
• Advantages
• Seen by some as being as effective as triaging by
  dentists, cost effective, saves dentists time
• Disadvantages
• Less accurate assessment of clinical
  presentation, increase in nursing duties burden,
  addition cost of training nursing staff,
  increased manpower

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Defining emergency/urgent care

• National standardisations
• Dental emergency
• Uncontrollable dental haemorrhage following
  extractions
• Rapidly increasingly swelling around the throat
  or eye
• Trauma confined to the dental arches

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Defining emergency/urgent care

• National standardisations
• Dental urgency
• Severe dental and facial pain not controlled by
  over-the counter preparations
• Dental and soft tissue acute infection

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The delivery stage
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Delivery stage

• Location of services
• Dental OOH site/s equitable accessibility
• Safe and appropriate
• Capacity
• Cost effective good value for money
• Proximity and links to A E Departments
• Accessibility for disabled patients
• Proximity to a pharmacy

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Availability of OOH services

• Urgent
• OOH service and/or treatment within a reasonable
  time - treatment 24 hours, verbal response
  within 6 hours
• Does this translate into?
• Weekday evenings advice/treatment
• Weekends day time advice/treatment
• Outside these times advice

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In-hour urgent dental provision
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In-hour dental provision

• Complementary service available from
• Local dental contractors
• Open access sessions included as part of local
  PCT practice agreements
• Dental Access Centres, salaried dental services
• CARE PATHWAYS are they clearly set out?

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In-hour dental provision

• Complementary services
• How can the PCT best commission in-hours
  complementary care?
• How can the PCT ensure that patients are getting
  access to routine care in-hours after an
  out-of-hours urgent care episode?

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Additional OOH Models Northumberland Tyne Wear
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OOH Dental Service Northumberland Tyne Wear
All GDP practises salaried other points of
referral only accepted by
Referral to next stage only 1800 -2300 hours
weekday evenings 24 hours weekends
Population 900,000
Calling NHS Direct Level 1 Triage
Caller triaged using National dental
algorithm gt3 then referred on
Patient information sent electronically
(via ASTRA) to OOH call handling service (NDUC)
OOH call service calls dentist on-call from
rota. Dentist calls patient directly at home
Patient referred on to OOH treatment
centres Dentist also travels to treatment centre
still contactable by mobile phone
Total of 2 OOH Centres across the SHA Nurse
receptionist remain at centres throughout
opening times
Mandatory Dentist informs Call Centre of call
outcome
Dentist uses own Clinical judgement to consider
if intervention is needed
Centres are open 1800-2300 weekday 0900-1800
weekends 1000-1600 Bank holidays
Level 2 Triage
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Dental OOH Dental Model for 6 PCTsRecommended
Option
Consideration4 Availability of Level 2 triage
Consideration1 Points of referral
Consideration2 1st Level Triage
Consideration3 2nd Level Triage
OOH call handling Service a) Same as NHSD b)
Refers calls To dentist/nurse FOR SECTOR
Weekday even Weekends, bank holidays
All Calls routed via NHS Direct ONLY
NHS Direct
Individual at home
Individual at OOH service
Clinician undertaking triage agrees time and
session
Patient referred to AE, In-hour sessions

• Closed Door
• must have
• had Level 2
• triage

a) One Stop Centres b) Near hospital Services
in line with GP OOH
2 Centres Across the Sector (max)
Mandatory Dentist informs Call Centre of call
outcome
Consideration8 Number location of services
Consideration 9 What happens outside of Level
2 triage or availability of clinics
Consideration5 Referrals to Centres
Consideration6 Access to services
Consideration7 Location of services
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Developing a whole systems approach to access in
out of hours NHS dentistry

• Eric Rooney
• Consultant in Dental Public Health
• Sharon Rourke
• Dental Public Health Project Manager
• Cumbria Lancashire PCTs

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The context

• Local context in Cumbria Lancashire
• Specific local PCT issues
• Solutions

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Aim

• Provide one single point of contact for the local
  population of Primary Care Trust to improve
  access to NHS Dentistry both in out of hours

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Objectives

• Provide advice and support to all service users
  wishing to access
• NHS dentistry
• Triage service users
• Co-ordinate access and control the flow of
  service users into
• through local dental services
• Direct service users to the most appropriate
  dental service based on need
•  

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Objectives

• Provide a network of services to provide care
  pathways for patient to access the most
  appropriate dental service
• Monitor the flow service users in and out of the
  system
•   Regularly collate and update local information
  databases
• Act as local intelligence gathering of all
  dental services

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Cumbria Lancashire

• First pilot OoH pilot developed in East Lancs
  in partnership with NHS Direct, incorporated
  dental nurse triage into OoH services
• Build on the model to develop an in out of
  hours model (Morecambe Bay PCT)
• First pilot went live on 15th November 2004
• Rolled out across Cumbria and Lancashire
• Following PCT reorganisations some help lines
  have been reviewed and reorganised on the new
  footprint

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The Service

• Two elements
• In Out of Hours care - Advice, triage and
  access to treatment
• Access Database Provides information to
  inform future commissioning decisions
• Service
• Dental nurse led triage

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NHSDirect

Local
PCT HQ

Press

GDPs

GPs

Dental
Helpline

LOCAL GDP
Integrated into existent Medical or PCT
infrastructure


LOCAL GDP


PCT

DS
DACs
OoH

EDS
Patient enquiry
Patient placement


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Process
Dental Call
Recipient of call dependent on telephone system
Request routine dental care
Request dental treatment
Access database
Dental triage
Transfer of pt details
Dental info
Pt transferred to newly commissioned service
Pt demand info
Appointment booked
Dental advice
New service commission
Management of clinical service
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ANALGESIC ADVICE
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Access database

• Central Lancashire PCT 4,452 (1/12/2005
  current)
• North Lancashire PCT 14,173
• Cumbria PCT
• Carlisle district 23,303
• Eden Valley 13, 474
• West Cumbria 4,547
• South Lakes 17, 761
• Total 59, 085 patients

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Developing the service Five key components

• Structure Governance
• Premises
• ICT
• Training Professional Support
• Workforce

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Structure Governance

• Provider of service Who?
• Relationship to organisation clear
• Structure clearly defined
• Good systems of communication
• Robust policies and procedures
• Avoid confusion

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Premises and ICT

• Premises - location, comfortable setting
• ICT
• Telephone system - decision tree, call
  recording, queuing systems
• Software SoE, Exact system
• Access database (Microsoft)
• SOEL Health, incorporate access database

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Training Professional Support

• Overview service
• Customer Care
• Conflict resolution (telephone based, Call North
  West)
• Call handling
• Triage
• Analgesic and dental advice
• Scripts
• IT training, software

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Workforce

• Design around the ICT system
• 3 potential models

MODEL 1
Database
Dental Nurse
Call
Triage, treatment
MODEL 2
Decision Tree Press 1 Routine Press 2 Dental
problem
Call
MODEL 3
Access Database
Call
Call Handler
Dental Problem
Transfer to dental nurse
Triage
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A dental service management and information
system

• Continual learning experience
• Become more sophisticated
• Review service redesign
• Build on service (18 week wait, other referral
  management specialist)
• Integrate into other areas

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Strengths/Weaknesses

• Economies of scale v local knowledge
• Dentist v Dental nurse led triage
• Cost v benefit
• Integration v stand alone
• Managing pt expectations v service available
• Managing pt choice v service capacity

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A whole systems approach

• Commissioning
• Oral Health Strategies commissioning plans
• Integration of plans service
• Fitting it all together

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Secondary Care
Resto- rative
Specialist Practice PDS Contract and
OMFS
GDS Contract PDS Contract (generalist)
Special Care
AE NHS Direct
Out of Hours
Trust provided
DWSI
Trust provided
Ortho
Paediatric
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Thank you
Questions?
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Session 2 11.15 12.45

• Stock take of urgent in and out-of-hours services
  across the SHA
• Highlighting strengths weaknesses of approaches
  in light of local needs and access to mandatory
  services

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Session 3 13.30 15.00

• Consider current local quality frameworks for in
  and out-of-hours services
• Consider benchmarking associated standards for
  local services in relation to national models

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Session 4 15.15 16.00

• Review local information available to residents
• Set out a clear local action plan
• Round-up and close