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The Orthodontic National Group, 12 Bridewell Place, London EC4V 6AP
National Assembly for Wales
Health and Social Care Committee Inquiry
Orthodontic Services in Wales
Evidence on behalf of the Orthodontic National Group
Author: Debra Worthington, Chairman
Role of the Orthodontic National Group
Thank you for inviting the Orthodontic National Group (ONG) to assist the National Assembly of Wales into its Inquiry into Orthodontic Services in Wales. The ONG was formed in 1994 at the British Orthodontic Conference with the support of the British Orthodontic Society (BOS). Its objectives were to provide continuing professional development, education and training whilst liaising with all professional bodies.
In 2008 ONG became an affiliated organisation of the British Orthodontic Society. ONG works closely with BOS and actively comments on and participates in national discussions which affect orthodontic therapists and nurses. Most recently ONG met with the General Dental Council (GDC) and commented on the recent amendments to the Scope of Practice. ONG has also commented on the current consultation on continuing professional development.
Response to inquiry into the provision of appropriate orthodontic care in Wales:
- Access for patients to appropriate orthodontic treatment, covering both primary and secondary care orthodontic services, and whether there is regional variation in access to orthodontic services across Wales.
Waiting times are high, with secondary care waiting times up to 40 months. Waiting times in primary care are also high – up to 2.5 years.
We recommend that the Welsh Government funds a one- off waiting list initiative to clear the backlog of patients waiting for orthodontic treatment. We recommend that this be in the way of a face-to-face triage to validate the waiting list ensuring that patients on the waiting list fit into the appropriate Index of Orthodontic Need (IOTN) grade. The Index of Orthodontic Treatment need was developed in the late 1980s and this scale orders the severity of the malocclusion (deviation from normal “bite”) into 5 grades (Grade 5 having the highest severity) depending on the long-term threat it imposes to the longevity of the dentition and surrounding structures.
We further recommend that the face-to-face triage be undertaken by orthodontic therapists.
The recently revised GDC Scope of Practice states the orthodontic therapists can
“carry out Index of Orthodontic Treatment Need (IOTN) screening either under the direction of a dentist or direct to patients”
We recommend that the Welsh Government funds the training of orthodontic therapists to become calibrated in the use of the IOTN scale.
- The effectiveness of working relationships between orthodontic practices and Local Health Boards in the management of local orthodontic provision, and the role of Managed Clinical Networks in helping to deliver more effective orthodontic services in Wales (e.g. effective planning and management, improvement in the appropriateness of referrals and performance management, workforce arrangements).
Managed Clinical Networks have been established in North Wales, South West Wales and South East Wales. The MCNs in South East and South West Wales have robust referral management systems in place including referral guidelines and protocols and referral forms. The North West Wales MCN is in the process of producing a common referral form to be utilised across the network.
The new referral forms and protocols are working well with a perceived reduction in inappropriate referrals and with the patients being directed to the most suitable provider more quickly.
- Whether the current level of funding for orthodontic services is sustainable with spending pressures facing the NHS, including whether the current provision of orthodontic care is adequate, affordable and provides value for money.
The lengthy waiting times for orthodontic treatment, both in primary and secondary care has resulted partially from a chronic under-funding of orthodontic care.
Provision of orthodontic treatment in Wales is based on objective need (as determined by the Index of Treatment Need) not on demand. In South West Wales and some other areas the need still exceeds the capacity, despite measures to improve efficiency by development of the referral management process and other means.
We recommend that the threshold for treatment could be increased to IOTN 4 and 5 only therefore removing those with a moderate need for treatment (IOTN 3) that had a high (poor) aesthetic score and so concentrating funding for those with the highest treatment need.
We further recommend that the Welsh government funds training of additional orthodontic therapists to be employed in primary and secondary care, to work alongside consultant orthodontists and specialist practitioners, to provide treatments as required.
The use of orthodontic therapists is a more cost effective use of Government resources; the training is shorter than that of an orthodontist (3 years specialist training.) Following training the salaries paid to orthodontic therapists are also less than those paid to a qualified orthodontist.
The training course for orthodontic therapists is a one year course with a 4 week core course at the Centre, and 10 to 12 study days also in the centre all of which must be attended. The rest of the training is in a clinical setting where the trainee Therapist is working.
- Whether orthodontic services is given sufficient priority within the Welsh Government’s broader national oral health plan, including arrangements for monitoring standards of delivery and outcomes of care within the NHS and the independent sector.
Orthodontics as a profession has robust measures in place to monitor outcomes of care using the Peer Assessment Rating Index (PAR.)
Managed Clinical Networks have a role in facilitating close monitoring of treatment outcomes through PAR and are establishing a system where PAR score reductions are monitored independently on an annual basis for all providers. This provides evidence for quality of care. With the advent of relatively new orthodontic providers such as DwESs (dentists with enhanced skills) and Orthodontic Therapists it is particularly important to monitor the quality of treatment. DwESs are practitioners without specialist qualifications but who have been accredited to provide orthodontic treatments and hold orthodontic contracts.
Orthodontic care in the independent sector is not so rigorously monitored. Practitioners without specialist qualifications or local accreditation and who do not hold orthodontic NHS contracts can offer treatment on a private basis. There is no obligation for these providers to assess the quality of their care for patients, with the use of the PAR Index, for either the BSA or Local Health Boards.
- The impact of the dental contract on the provision of orthodontic care.
The contract fixes the volume of activity for each practice with no room for increased activity. Orthodontic contracts are fixed term which limits the opportunities for investment and development due to the uncertainty at the end of each contract period. Contracts renewals should be a minimum of 5 years, or preferably rolling contracts for well-performing practices, to ensure continuity of good care.
Summary and Recommendations
• We recommend that the Welsh Government funds a one-off waiting list initiative to clear the backlog of patients waiting for orthodontic treatment. We further recommend that this be by the way of a face-to-face triage to validate the waiting list ensuring that patients on the waiting list fit into an appropriate Index of Orthodontic Need (IOTN) grade.
• We recommend that the face-to-face triage be undertaken by orthodontic therapists.
• We recommend that the Welsh Government funds the training of orthodontic therapists to become calibrated in the use of the IOTN scale.
• We recommend that the threshold for treatment should be increased to IOTN 4 and 5 only.
• We further recommend that the Welsh government funds the training of additional orthodontic therapists, who would provide treatment in the secondary and primary care setting.
Debra Worthington
31st
March 2014