Inquiry into orthodontic services in Wales

South West Wales Orthodontic Managed Clinical Network

Background.

IOTN[1] restricted Orthodontic interventions continue to provide an important preventive role, addressing the established health needs of a range of developmental problems that may otherwise result in tooth loss or dental disease.

Since the last Welsh Government reviews of Orthodontics the following developments have been made within the ABMU and Hywel Dda Health Boards:

1. Establishment of an advisory Local Orthodontic Committee (LOC) to:
2. 1. Advise on the local provision of orthodontic care, policies and protocols and standards of care
   2. Contribute to the development of strategies and care pathways.
   3. Represent the interests of all orthodontic providers within the MCN
3. Establishment of an Orthodontic Managed Clinical Network (OMCN), providing an interface between Health Board management, providers and Dental Public Health.
4. Implementation of a robust referral management system, including referral guidelines and care pathways (Appendices 1-3).
5. An accreditation process for Dentists with a Specialist interest supported by appropriate care pathways
6. A waiting time analysis (ABMU only at present).
7. Quality and Safety protocols

Despite these achievements, there remain number of unresolved issues.

There are over 5000 patients waiting for consultation in ABMU and, until recently, approximately 4000 patients in Hywel Dda.

Health Boards have, correctly, addressed the inclusion an orthodontic element within GDS contracts where the provider does not have DwSI or Specialist accreditation. This has involved a conversion of units of orthodontic activity (UOA) to units of dental activity (UDA) resulting in a significant loss of Orthodontic capacity in Hywel Dda and, to a lesser extent, in ABMU.

A further loss of orthodontic funding has resulted from tender processes in Hywel Dda in 2011. This is estimated to exceed £100,000.

Finally, fixed term contracts have made investment in specialist practice difficult and the business models of some corporate bodies has caused governance concerns within the UK. These must be resisted within Wales.

Access for patients to appropriate orthodontic treatment.

The referral guidelines developed within South West Wales have established distinct roles for primary and secondary care providers. Referrals to secondary care are subject to referral to treatment (RTT) targets leading to relatively low new patient consultation waits but longer waits for the treatment of a defined group of patients (>2years).

In ABMU primary care, a large number of patients (>5000) are waiting for consultation and there is currently sufficient contract to treat around 1600 patients per year. Waiting time for consultation is currently over 2 years.

Figure 1. Patients waiting for Orthodontic care in ABMU

(Primary care - patients waiting for consultation; secondary care - numbers waiting for treatment)

In Hywel Dda, resources have been directed to a reduction in new patient waiting times and the generation of treatment waiting lists. A similar approach is being considered within ABMU. Prioritisation of the treatment waiting list is also being considered, recognising that this may lead to some patients with IOTN scores above current NHS thresholds, not receiving treatment.

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.

A professional advisory body (LOC) and Managed Clinical Network (OMCN) were established in SW Wales in 2011. The LOC chaired by Stephen Gould has provided a forum for all providers within AMBU and Hywel Dda Health Boards to advise on policies, protocols and standards of care.

The OMCN reports directly to the ABMU Dental Services Strategy and Planning Group and sends representation to Welsh Government Strategic Advisory Forum in Orthodontics (SAFO). The OMCN has developed a robust referral management system, including referral guidelines referral forms and care pathways. The OMCN has also implemented quality and safety (QAS) protocols to monitor the quality of care and patient satisfaction.

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 need for orthodontic treatment in South West Wales (determined by national IOTN thresholds) currently exceeds the capacity to meet that need. Improved efficiency has been introduced through development of referral management process and contracting that establishes expected assessment to treatment ratios and allows the identification of inappropriate referrals.

Improved value for money could be achieved by increasing patient responsibility for incomplete treatment and failure to attend for care. Different funding models are currently being explored within OMCN and SAFO.

Similarly, if orthodontic funding is not increased, some form of treatment prioritisation may need to be considered within the IOTN framework. However, this would potentially establish different access criteria to care in Wales compared to other UK areas. If the removal of the IOTN 3 with aesthetic component above level 6  was considered, it may have a limited impact on the numbers needing treatment (1.7% of an audit of 754 patients accepted for treatment in one ABMU primary care practice[2]). This proportion may be larger in other practices and regions and may exceed 30% of patients accepted for care in some areas of England.

Figure 2 – OMCN audit of patients accepted for care in a primary care setting²

The removal of all IOTN level 3 and 4 categories would have a greater impact (81% reduction). However, this would exclude a large number of patients from NHS funding who have an established treatment need and may be significantly disadvantaged by their malocclusion. At the same time, some patients with IOTN level 5 would be eligible for complete treatment when a simple extraction alone would remove their need for treatment.

Figure 3 – OMCN audit of patients accepted for care in a primary care setting²

If a refinement of the access criteria for Orthodontic NHS funding is considered, a review of the ‘4d’ category would appear to offer the greatest impact. Further work within the 3 OMCNs and SAFO is required to determine who would benefit most from limited resources.

In secondary care, access criteria within the Welsh MCNs may vary due to the availability of specialist services locally and the requirement to accept more routine cases for StR training.

In ABMU a very small number of cases are accepted for training, the remainder meet established acceptance criteria.

Figure 2 – OMCN audit of patients accepted for care in ABMU secondary care²

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.

Malocclusions requiring orthodontic treatment are largely inherited and are independent of patient life-style and choices (unlike dental caries which is preventable). Orthodontic treatment is supported by evidence-based interventions that deliver a quantifiable health gain and should be maintained as a priority with the Welsh Government’s Oral Health plan.

Orthodontics is one of the few dental specialities that has a quantifiable measure of outcome and the SW Wales OMCN has developed QAS protocols to record the quality of outcome alongside patient satisfaction with the process.

Despite this, regional Oral Health plans do not always reflect the value of, and unmet need for orthodontic intervention.

The impact of the dental contract on the provision of orthodontic care.

The 2006 dental contract correctly differentiated between Orthodontic interventions that delivered health gain and those that did not, allowing the identification of treatment need with the regions. However, orthodontic treatment capacity was fixed using a snapshot of activity at the time. A number estimates of treatment need suggested that sufficient capacity existed to meet need and previous Welsh Government reviews indicated that additional resources would be required to address the ‘backlog’ of patients waiting.

Current waiting time audits indicate that previous estimates of the balance between need and capacity to treat may not have been accurate. Additional funding to address the backlog of patients waiting has not been provided and the loss of capacity / funding (through conversion of UOAs to UDAs and tender processes) has made the situation worse.

Fixed term contracts have severely limited the opportunity for providers to secure funding for the development and refurbishment of their practices and the tender processes (imposed in some regions but not in others) may have offered increased opportunities for large national dental corporate bodies.

Summary and Recommendations

· Orthodontic treatment has proven short and long-term dental health benefits and provides value for money within the NHS financial framework both in primary and secondary care

· The Orthodontic MCN and professional advisory bodies are functioning well

· Standard of care monitoring is quite robust within primary and secondary NHS services.

· Long waiting lists for orthodontic treatment in primary and secondary care remain

Ø Additional capacity is required to meet established need.

· Fixed volume and short–term contracts limit the investment in primary care.

Ø Consideration needs to be given to rolling contracts in well-performing practices.

Appendix 1

The Provision of NHS Orthodontic Care across South West Wales

Service Description

Service Aims and Objectives

This Service Description sets out the general requirements of the ABMU and Hywel Dda Local Health Boards for the provision of NHS orthodontic services (both primary and secondary care) across South West Wales.

The main objective of the proposed new service is to provide a single care pathway across primary and secondary care for NHS orthodontic services within the region. The care pathway will support a flexible, timely, patient-centred orthodontic service for those eligible for treatment. This will require implementation of a care pathway for the provision of NHS orthodontic services which utilises the provision of services more effectively and informs the future planning and provision of NHS specialist dental services.

The main aims of the service are:

• To ensure continued achievement of national targets within secondary care and maintain current waiting times at acceptable levels across both primary and secondary care
• The provision of a service with equitable, high quality and timely access to NHS orthodontic treatment for all people eligible for NHS orthodontic care.
• Patients being seen in the most appropriate place by the most appropriate provider(s)/performer(s).
• To encourage efficiency and communication improvements for both patients and referrers.
• Support the timely advice and completion of NHS orthodontic care in ensuring efficient and successful outcomes for patients

· Ensure value for money

All Providers and/or Performers of NHS orthodontic care will be expected to deliver NHS orthodontic services in line with the new care pathway. All Providers and/or Performers of NHS orthodontic care will be on the GDC Specialist List for Orthodontics, or be an accredited DwSI in Orthodontics, or, with the agreement of the LHB, be working towards accredited DwSI in Orthodontics status but under supervision of a Specialist Orthodontist.

Specific Functions of the NHS Orthodontic Care Pathway

Service Description

Referrers (General Dental Practitioners) will assess a patient to decide whether onward referral is needed as part of GDS/PDS mandatory services.

Referrers will refer directly to their provider of choice using an appropriate referral form. Relevant radiographs should be attached/enclosed with the referral

Referral guidelines will assist the referrer to indentify if the patient requires referral to primary or secondary care.

Poor quality referrals (i.e. insufficient information/incomplete template) will be returned to the referrer with the information to be provided clearly identified.

The Orthodontic provider will log and process all NHS Orthodontic referrals received. Providers will act to support the LHBs in collating information to inform the management and future planning of NHS orthodontic provision and provide relevant information regarding waiting times to referrers.

Patients requiring an urgent consultation (defined within the referral guidelines) will be identified and given priority. These patients should be seen within 12 weeks of referral. Where providers are unable to offer a consultation within 12 weeks, the patient should be offered a consultation with an alternative specialist in primary or secondary care if this clinical capacity exists.

Patients that do not require an urgent consultation should, where possible, be seen within 20 months of referral. Where providers are unable to offer a consultation within 20 months, the patient should be offered a consultation with an alternative specialist in primary or secondary care, if this clinical capacity exists.

Referrals Out of Area

Secondary care referrals can be received from ABMU and Hwyel Dda LHB areas.

Primary Care Referrals received from outside of the area should be monitored against historical patient flow data recorded at the outset of the new dental contract. ABMU and Hwyel Dda primary care providers should not accept referrals for residents outside of their LHB area that exceed these numbers unless appropriate cross border contracting is in place.

Information to Referrers and Patients:

To keep the General Dental Practitioner (GDP) and the patient informed of the progress of the referral Orthodontic providers will be required to:

• Provide the referring practitioner with an acknowledgement of referral within 30 days of receipt
• Provide the LHB with the details of all patients currently on their new patient and treatment waiting lists every 4 months
• Provide the LHB with an estimated waiting time for assessment every 4 months
• Provide the LHB with an estimated waiting time for treatment every 4 months

The LHBs will be required to:

• Collate estimated waiting times for assessment and start of treatment for all South West Wales orthodontic practices.
• Provide referrers with an estimate of current assessment and treatment waiting times for all providers within South West Wales
• Provide patients with alternative options for care should the proposed waiting time for assessment be deemed unacceptable.
• Where appropriate, provide patients (and referrers) with information concerning appeals against ineligibility for treatment.
• Provide useful local information to patients about Orthodontic practices such as the location, directions and parking facilities.
• Where possible, take into account the location of services to ensure access to care within a reasonable travel distances.

Appeals relating to the acceptance criteria for NHS orthodontic care

Where a patient appeals against a decision to refuse care, due to them not meeting the acceptance criteria for NHS orthodontic treatment, an opportunity for a second opinion with a different specialist provider will be made. If the second assessment also fails to identify treatment need and the patient or referrer still considers that there is an argument for exception to the acceptance criteria for NHS orthodontic treatment, the case for Independent Patient Funding Request (IPFR) will be submitted to the LHB on a specific referral form.

To inform the IPFR request, the LHB will request the findings of the initial and subsequent Orthodontic assessments. The case for IPFR will be submitted to the LHB by the General Dental Practitioner (GDP). However, the patient will be required to provide the GDP with the justification for exception in writing and also provide the GDP with any supporting information, such as Medical reports.

The LHB will not accept direct patient requests, or routinely enter into any correspondence with patients and/or their families unless as part of the statutory NHS Complaints Procedure. The referring clinician should act as the patient’s representative as responses to referrals considered by the LHB appeals process will be made direct to the referrer. It is the referrer’s responsibility to communicate the outcome of this appeal to the patient concerned.

Appendix 2

The Provision of NHS Orthodontic Care across South West Wales

Referral for Orthodontic treatment - Guidance for referrers

ELIGIBILITY

Patients must meet the requirements of the Index of Treatment Need (IOTN) Dental Health Components 4, 5 or 3 with an aesthetic component of 6 or above, to be eligible for NHS treatment.

The patient should be less than 18 years of age on the date of the referral to be eligible for NHS orthodontic treatment in primary care. This will be based on the date the referral form is signed by the referrer.

For those patients that are judged to be ineligible for treatment, an appeal can be made to the LHB. Please see additional guidance for further details. 

GENERAL INSTRUCTIONS

Referrals can only be made by General Dental Practitioners and associated dental clinical professionals. Please note that General Medical Practitioners cannot refer a patient for NHS orthodontic treatment in primary care and GMPs should advise patients to see a General Dental Practitioner in the first instance.

All sections of the referral form must be completed, including the dental health component of the IOTN by ticking the appropriate box.

If an OPG radiograph is available a copy should be included with the referral form. Where possible an OPG should be taken as this information will support the patient’s assessment.

Please note all sections of this form must be completed. If all sections are not completed, the form will be returned and the patient’s treatment may be delayed.

PROCESS

Should the patient be assessed and deemed eligible in line with national criteria, the provider will assess the complexity of treatment needed and either accept the patient for treatment or refer the patient to be seen by an alternative provider.

Should the patient be assessed and not deemed eligible in line with national criteria, the referrer and patient will be advised. The appeals and IPFR processes are described separately

ADVICE TO PATIENTS

Due to eligibility criteria and other considerations, it is essential that referrers inform their patients that a referral does not guarantee treatment.

Referrers should advise patients that should they be assessed as eligible for treatment, they will be offered an appointment with an appropriate provider of NHS orthodontic treatment that can provide the complexity of the treatment needed. This may be either within a Hospital or within Primary Care.

GUIDELINES FOR ORTHDODONTIC REFERRAL

General Considerations

Most orthodontic patients will benefit from referral during the late mixed dentition.

For those requiring appliance therapy it is expected that patients:

• Have an adequate level of oral health.  Active dental caries should have been treated and the patient should demonstrate that they are able to maintain satisfactory oral hygiene.
• Are aware of the reasons for referral and are prepared to wear orthodontic appliances, if indicated. 

The Hospital Dental Service will receive referrals for diagnosis and treatment planning but will normally only accept patients for treatment that require multidisciplinary care and the management of significant skeletal discrepancy. Other cases may occasionally be treated where complexity is high. Specialists in primary care, provide treatment for the majority patients who are eligible for NHS care.

Early Referrals

Early referrals will be accepted for orthodontic assessment as follows:

· Where there is obvious Hard or Soft tissue trauma resulting from the malocclusion, for example: wear to incisal edges in the case of a cross-bite; localised gingival recession resulting from labial displacement of a lower incisor.

· Where there is significantly delayed eruption

· Where it is known that there are missing teeth, this will allow the earliest possible planning of the complete dentition.

· Class II and III malocclusions where there is an underlying skeletal pattern.

Urgent Referrals

Patients demonstrating the following anomalies will receive priority:

· Decision on management of recently traumatised teeth

· Unerupted maxillary incisors at age 7-8 years (IOPA radiograph required)

· Impacted maxillary canines that are placing the maxillary incisor roots at risk (OPT required)

· Patients below the age of 11 that have crowding and require a GA for the extraction of an acutely symptomatic first permanent molar

· Significant class II skeletal discrepancies in patients approaching the pubertal growth spurt

• Patients with significant medical or social history

Other referrals that will receive priority in secondary care include:

• Referrals from specialists and accredited DwSIs in primary care
• Patients in treatment

Appendix 3

REFERRAL FOR NHS ORTHODONTIC ASSESSMENT

Please complete this form for any patient in need of NHS orthodontic treatment that meets the requirements of the Index of Treatment Need (IOTN) Dental Health Components 4, 5 and 3 (with an aesthetic component of 6 or above) and is less than 18 years of age at the point of referral for primary care treatment

• Please include a copy of an OPG and any other relevant radiographs (if available)

Please see accompanying notes for further details

SECTION ONE – Patient Details

Patient Name	Address
Date of Birth
Contact Tel(s):
	Post code:

SECTION TWO –Referral Details

Name of Referrer	Practice Stamp (Address and Contact Tel):
Signature
Date
Has this patient been referred before for NHS orthodontic treatment?	Yes                   If Yes, please specify where No
Enclosures:                        OPT                                         Ceph                                          Models                     Preferred provider (if appropriate):

Urgent referral

	Please tick
Decision on management of recently (within 1-2 weeks) traumatised teeth
Unerupted maxillary incisors at age 7-8 years (IOPA radiograph required)
Impacted maxillary canines that are placing the maxillary incisor roots at risk (OPT required)
Significant class II skeletal discrepancies in patients approaching the pubertal growth spurt
Patients below the age of 11 that have crowding and require a GA for the extraction of an acutely symptomatic first permanent molar
Significant medical or social history

Reason for referral: Opinion                                  Treatment                                Transfer                    

IOTN	Occlusal features
5c	Defects of cleft lip or palate and other craniofacial anomalies	Secondary care
5m	Reverse overjet greater than 3.5mm with reported masticatory and speech difficulties
5a	Increased overjet greater than 9mm with no growth potential
5a	Increased overjet greater than 9mm with growth potential	Patient referred to Primary or Secondary Care for assessment, depending on complexity
5h	Extensive hypodontia with restorative implications (more than one tooth missing in any quadrant) requiring pre-restorative orthodontics
5i	Impeded eruption of teeth (excluding third molars) due to crowding, displacement or the presence of supernumerary teeth, retained deciduous teeth or pathology
5e	Submerged deciduous teeth
4x	Presence of supernumerary teeth
4l	Posterior lingual crossbite with no functional occlusal contact in one or both buccal segments.
4m	Reverse overjet greater than 1mm but less than 3.5mm with recorded masticatory and speech difficulties
4h	Less extensive hypodontia requiring pre-restorative orthodontics or orthodontic space closure to obviate the need for a prosthesis	Patient usually referred to Primary Care for assessment
4a	Increased overjet greater than 6mm but less than or equal to 9mm
4b	Reverse overjet greater than 3.5mm with no masticatory or speech difficulties
4c	Anterior or posterior crossbites with greater than 2mm discrepancy between retruded contact position and intercuspal position
4d	Severe contact point displacements greater than 4mm
4e	Extreme lateral or anterior open bites greater than 4mm
4f	Increased and complete overbite with gingival or palatal trauma
4t	Partially erupted teeth, tipped and impacted against adjacent teeth

Other Reason for Referral (e.g. IOTN aesthetic component >6, teeth of doubtful prognosis, significant medical or social history):

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[1] Index Of Treatment Need – dental health score indicates a developmental anomaly that would offer health gain from correction.

[2] South West Wales OMCN audit 2013