South East Coast SHA Commissioning Orthodontic Services Study Day

1
South East Coast SHACommissioning Orthodontic
ServicesStudy Day

• Ramada Plaza, Gatwick
• Wednesday 20th June 2007

Christopher Allen Consultant Dental Public Health
2
Orthodontics in the Community

• The present situation
• To look at the demographics and service provision
  across the SHA
• To discuss changing demand for treatment
• IOTN and expectations
• Commissioning of services

3
Orthodontic treatment

• Only looking at NHS provision
• Private provision unknown
• Using number of 12 year old children as proxy for
  treatment need
• Orthodontic Workforce Study. U.Sheffield 2005
• Concentrating on South East Coast SHA

4
Orthodontics in the Community

• The present situation
• To look at the demographics and service provision
  across the SHA
• To discuss changing demand for treatment
• IOTN and expectations
• Commissioning of services

5
Proxy Population
ONS Population Statistics database
6
Population growth (12 Year old)
Overall growth 3.3
ONS Population Statistics database
7
Deprivation across SEC SHA
8
Service Provision

• General Dental Practice
• Specialist Practice
• Salaried services
• Hospital

9
Service provision
10
Orthodontic practices and acute trusts
11
Orthodontic practices and acute trusts
Deprivation by ward
12
Orthodontics in the Community

• The present situation
• To look at the demographics and service provision
  across the SHA
• To discuss changing demand for treatment
• IOTN and expectations
• Commissioning of services

13
Changing demands for treatment
Number of Orthodontic Claims by Year
14
Changing demands for treatment
Fees authorised for orthodontic treatment (
millions)
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Orthodontic treatment as a proportion of total
item of service fees

• 1991/1992
• GDS expenditure 1,041,289,918
• Orthodontic treatment 30,692,000
• 2.95

• 2004/2005
• GDS expenditure 1,228,917,668
• Orthodontic treatment 146,354,413
• 11.91

16
Changing demands for treatment
of principal dentists by no of orthodontic
appliance claims 2004-2005
17
Orthodontic trend

• Proportion of GDS expenditure risen significantly
  now 12
• But - 72 of dentists provide no orthodontic
  treatment
• And 19 provide lt10 appliances per year
• Move to more specialist activity
• Rise in orthodontic activity may account for GDS
  growth in some areas

18
Orthodontic trend New contract

• Move to more specialist activity
• Rise in orthodontic activity may account for GDS
  growth in some areas
• Less work in General Practices
• No further growth in some areas

19
Orthodontics in the Community

• The present situation
• To look at the demographics and service provision
  across the SHA
• To discuss changing demand for treatment
• IOTN and expectations
• Commissioning of services

20
Index of Orthodontic Treatment Need - IOTN

• The index originated from 1986 Schanschieff
  report into unnecessary dental treatment
• The report drew attention to the varied standard
  of orthodontic care in GDS
• In 1987 the then Occlusal Index Committee
  proposed the development of indices that would
  measure treatment needs and outcome
• Resulted in the development of IOTN and the Peer
  Assessment Rating (PAR)

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IOTN

• IOTN designed to quickly assess malocclusion
  clinically or from clinical models it is most
  widely used clinically
• There are two components to IOTN
• Dental Health Component
• Aesthetic Component

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IOTN- Dental Health Component

• Uses a ruler
• Guides observer to single worst feature
• M Missing Teeth
• O Overjets
• C Crossbites
• O Overbites
• D Displacement
• of contact point

• Five Categories
• Grade 5 Great Need
• Grade 4 Need
• Grade 3 Borderline
• Grade 2 Little need
• Grade 1 No need

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IOTN - Aesthetic Component

• Grade 1- 4 little or no treatment required
• Grade 5-7 moderate or borderline treatment
  required
• Grade 8 -10 treatment required

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IOTN Agreement with ranking

• Grading 2-9 varied greatly
• Grading 1 10 complete agreement
• Grade 1,2 and 8-10 good agreement on treatment
  need
• Majority considered 5 7 should be treated with
  6 borderline

Evaluation of the aesthetic component of the IOTN
by Swedish orthodontists Johansson AM, Follin ME.
EJO 2005
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Objectivity v Subjectivity - difficult

• Dependant on
• Socio-economic group
• Ethnicity
• Gender
• Lay v professional
• Who you ask

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National Child Dental Health Survey 2003
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Abdullah Rock.Community Dental Health - 2002

• Perceptions of dental appearance using IOTN (AC)
  assessments
• 720 Malaysian school children
• IOTN (AC) graded by an orthodontist, children
  and parents
• As Definite need for treatment

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Abdullah Rock.Community Dental Health - 2002

• Results Definite need for treatment

• Children and parents scored much lower
• than orthodontists

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Hunt et al. European J Orthodontics 2002

• The aesthetic component of the IOTN validated
  against lay opinion
• 215 university students in Belfast
• Ask to select the level of aesthetic impairment
  when they would seek treatment
• Only 4.3 recorded beyond grade AC 5
• Most common was grade AC 4
• no need for treatment Should be grades AC1-3

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What measure?

• Index of Orthodontic Treatment Need (IOTN)
• Index of Complexity, Outcome and Need (ICON)
  Daniels and Richmond
• Index of Orthodontic treatment Complexity (IOTC)
  Stewart, Ahmad Rock
• Child Oral Health Quality of Life Questionnaire
  (COHQOL) Johal et al

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Orthodontics in the Community

• The present situation
• To look at the demographics and service provision
  across the SHA
• To discuss changing demand for treatment
• IOTN and expectations
• Commissioning of services
• (Not contracting)

32
Assessment of Normative Need

• Stephens method uses proxy population
• Accept IOTN (DHC) 4 5 need treatment
• A proportion of IOTN (DHC) 3 justify treatment
• IOTN 4 5 declining treatment offset 3s
• Some interceptive (9) and adult treatment (4)
  is factored in

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Stephens formula

• Normative treatment need

12 Year Old Population X 100Interceptive
Factor (9)Adults (4)
3
100
12 Year Old Population X 1.13
3
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Normative treatment need
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Treatment undertaken in SHA

• Data from
• Business Services Authority, Dental Practice
  Division (BSA, DPD)
• FP17 returns
• Hospital Episode Statistics

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Referral outcome in practice
FP17 data
37
PCT hospital contracted activity
Hospital returns data
38
Hospital appointments

• First appointment number of patients
• Follow-up appointments treatments
• Treatment takes 18 month
• Number of visits 6 weekly
• Number of visits per patient 13
• Follow-up visits / 13 number of patients

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PCT hospital contracted activity
40
PCT hospital contracted activity
41
Patients treated v normative need
42
Patients treated / normative need
FP17 hospital returns data
43
Practice Patient Flows
1
29
15
31
4
19
14
27
BSA DPD figures April 06 Mar 07
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Patient Flows
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Normative need and Treatment
46
Success across the SHA

• Normative treatment need 20,310
• Patients accepted for treatment 20,618

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But who are the missing patients

• Assess and review 38,021
• Assess and accept 9,284
• Total 47,305

From primary care only
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Conclusions

• Normative need appears to be addressed
• There may be many more in the system
• These people need identifying as to who they are
  and why they are there
• Too many inappropriate referrals
• There is an obvious need for a common approach to
  handling the orthodontic treatment challenge

49
South East Coast SHACommissioning Orthodontic
ServicesStudy Day

• Ramada Plaza, Gatwick
• Wednesday 20th June 2007

Christopher Allen Consultant Dental Public Health