Achieving 18 weeks for Oral Surgery Services

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Achieving 18 weeks for Oral Surgery Services

• Ken Wragg Consultant in Dental Public Health
  Derbyshire

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Aims of the presentation

• Background
• Issues involved in achieving waiting targets in
  Oral Surgery
• Lessons learned from the Derbyshire MOS service

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Definitions

• Maxillofacial Surgery
• is concerned with the diagnosis and treatment of
  diseases affecting the mouth, jaws, face and neck
• Oral Surgery
• Deals with the diagnosis and treatment of
  conditions of jaw and mouth structures that
  require surgical intervention
• Surgical Dentistry
• Deals with the diagnosis and management of
  irregularities and pathological processes of the
  teeth and their supporting structures

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Issues in oral surgery

• Spectrum of complexity
• Skill Mix
• Optimal use of work force
• Doubly qualified OMFS consultants
• Specialists in minor oral surgery
• Dentists with a special interest in MOS
• General Dental practitioners
• Local solutions for local problems
• Historical referral patterns - shaped
  configuration of services
• New factors

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Oral surgery services

• Primary Care
• GDS SDR / Mandatory services
• PDS Specialist services
• Secondary Care
• Broad spectrum of complexity overlap with
  Mandatory services
• Training location
• Mixed economy
• Independent sector NHS Private
• Directly delivered services CDS / PDS / HDS
• Effective use of the total public resource
  skill mix

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Issues in minor oral surgery

• Oral surgery skills of new graduates and some
  overseas graduates
• Lack of willingness to carry procedures out in
  practice perceived as not a practice builder
• Historical referral patterns developed to a
  degree for commercial rather than clinical
  reasons
• Management of waiting lists 18 week wait
• Cost PBR
• Increasing referral rate to secondary care for
  minor procedures

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Referrals to Mayday Hospital, Croydon for Oral
Maxillofacial Surgery in three year period from
April 2004
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Referrals to Mayday Hospital, Croydon for Oral
Maxillofacial Surgery in three year period from
April 2004
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• Audit of 150 non-urgent referrals received in one
  week during August 2007 showed
• 54 were for dento-alveolar surgery
• 22 third molars
• 16 for oral medicine and dermatology
• 8 TMJ problems.

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Derbyshire MOS Service

• Commenced November 1998 (after pre-pilot)
• Recurrent funding patient charge
• Long waiting times for MOS in secondary care
  esp 3rd molars
• Unattractive GDS fee scale / MOS not a practice
  builder
• Initially 2 (later 3) GDPs with specialist
  skills in MOS
• Major issue - vicarious liability clinical
  standards
• Admission to specialist list a defined surgical
  standard
• SAAD independent audit used to define sedation
  standards
• Worked closely with specialists to develop and
  refine process that reflects NICE guidance

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Derbyshire MOS Service(2)

• Referral made directly to PDS practice by GDP
• Patients aged 18 and over
• Initially 3rd molar surgery apicectomies on
  previously root filled canines and incisors
  since 2002 all procedures listed in SDR
  (mandatory services) are carried out
• Treatment under LA with or without sedation
• Medically compromised patients - ASA categories 1
  2 only

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Patients Treated 1998 to 2003
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Cases Treated 2002 - 2005
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Costs
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Cost per case
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• Payment By Results
• Maxillofacial surgery, Code 144
• Adult First Attendance - 127
• Adult Follow Up - 66
• HRG C04 minor mouth - 543
• HRG C58 intermediate mouth - 785.

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• Inappropriate referrals to Secondary care
• Cases moved to primary care, with funding
• Inappropriate referrals to secondary care
• Passed by consultant to MOS practice via PCT
  commissioners
• Pro forma letters suitable for primary care sent
  to the referrer
• List of providers provided
• If the GDP is unsure e.g. patient on Warfarin
  they are encouraged to speak to the specialist
  primary care provider
• PCT facilitates this process

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Improved service for Patients, referrers PCTs

• Geographical access
• Waiting times
• Retains simpler procedures in primary care
• Known operator continuity from assessment to
  surgery

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• Patient Flow Issue

• Will PCTs be willing to invest their local
  resources in a PDS referral service that can be
  accessed by any patient regardless of where they
  live?
• Will PCTs collaborate over the commissioning of
  primary care based specialist services?

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Potential alternatives to PDS

• Local service level agreement
• Each PCT invests as it sees fit
• Applies to all primary care based specialist
  dental services that provide treatment on
  referral?
• Post code lottery?
• Collaboration essential

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Conclusions

• MOS service is a success!
• Is in the public interest.
• Provides a tool that can be used elsewhere in the
  right circumstances
• It reduces costs and waiting times
• Needs to be taken forward in a spirit of
  partnership
• PCTs need to consider the best framework locally
  for delivering services on referral in primary
  care
• Local solutions to local problems

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• Workshops discussions

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Format

• Short presentation
• Discussions on tables considering key
  challenges solutions
• Feed back to the workshop group from each table
• Entire workshop group to agree the top points to
  be fed back to the main conference room

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Each table to consider

• Main challenges for providers commissioners in
  meeting the 18 weeks target
• AGREE 3 KEY CHALLENGES
• Main steps/solutions to help meet the 18 weeks
  target
• AGREE 3 KEY STEPS/SOLUTIONS

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Feedback from previous event

• Manchester Event 11th March 2007
• Key Challenges
• Increasing referrals from Primary to Secondary
  Care
• Issue of appropriateness of referrals
• Training and Teaching (specialist and GDP
  training)
• Building capacity

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Feedback from previous event

• Manchester Event 11th March 2007
• Key Solutions
• Tackling inappropriate referrals by agreed
  pathways and protocols / guidelines / triage
• Establishing joint working across sectors PCTs
  have key role in defining needs / demands
• Training and Teaching (specialist and GDP
  training)