HSC(4)-17-14

Paper to note 1

Health and Social Care Committee

Inquiry into orthodontics services in Wales

Additional information provided by the British Orthodontic Society and Local Health Board representatives
Additional information from Peter Nicholson, British Orthodontic Society

Health & Social Care Committee

Inquiry into Orthodontics

Follow up to Oral Evidence 8^th May 2014: Peter Nicholson

Thank you for the opportunity to provide additional information as requested and to clarify some points.

Specialist Practice waiting lists

We discussed the many benefits of shifting the waiting lists from those for initial assessment to validated treatment waiting lists and why a one off funding might not be appropriate. We didn’t discuss how this might be managed in a practical way.

Any shift would have to take place gradually, probably over the course of a 3 or 5 year contract. It would require additional funding if, during that period, current treatment levels are to be maintained. Even so there would need to be adjustment to Key Performance Indicators (KPIs) such as ratios of assessments to treatment starts during that period.

The detailed management of how that process could be undertaken is exactly the sort of role that the Chief Dental Officer’s Strategic Advice Forum for Orthodontics is ideally suited.

Early referrals

I was asked to supply the data from the audit of over 600 new patients undertaken by the SE Wales Local Orthodontic Committee in 2011.

• 15% of Hospital and 23% of Specialist new patients were referred at least 1 year early
• 13% of Hospital and 13% of Specialist new patients were referred at least 1 year late
• 5% of patients referred to both services were deemed to be totally inappropriate
• 25% of referrals to hospital units should have been referred to specialist practice
• 12% of referrals to specialist practice should have been referred to hospital.
• 15% of hospital and 20% of specialist referrals had an IOTN <3.6

The figures for misdirected referrals provide another powerful reason for bringing these initial assessment waiting times down.

Corporates

There is no evidence at this stage to suggest that corporates are providing an inferior service but their service delivery model may promote a specialist to therapist ratio that has, elsewhere, resulted in detrimental effects on outcome and patient safety. In addition, the corporate model may also result in difficulty to recruit quality UK specialists due the level of overhead imposed and expected volume of contract delivery per specialist.

Designed to Smile

I appreciate that my comments regarding Designed to Smile could have been interpreted as suggesting that there should be disinvestment in that scheme and that was not my intention. As a working clinician I am all too aware of the dental health problems within Wales.

Nevertheless there are controversies within Dental Public Health regarding the eficacy and long term benefits of these schemes. 1,2 , and clinicians involved on the ground in some areas have also reported poor response rates for consent amongst the most deprived groups.

While these preventive interventions are unproven at this stage I would counsel against disinvestment in other services in order to further increase that funding.

Non-completion of treatment

The question was asked in the second session and was tied up with true non-completion of treatment rates and non-completion of forms. The apparently high rates of both groups were much discussed at the SE Wales LOC and were contrary to the perception of the three large Cardiff Specialist Practices.

The point made by Darren Hills in his response para. 5.7, and perhaps misunderstood by Prof Richmond, is that the start and completion of treatment are submitted to the NHSBSA on separate forms (whether on paper or electronically). The slightest typographic discrepancy, never mind an actual change of address, in the demographics between those forms leaves them not consolidated and the start of treatment form left open. This has been erroneously interpreted in some quarters as a failure to complete treatment. This problem has been raised with the NHSBSA.

Missed appointments and patient responsibility

Missed appointments are a problem throughout the NHS and represent a waste of resources for hospitals and independent contractors alike. They are a source of frustration to clinicians with long waiting lists.

There are various possible sanctions including charging for missed appointments and discontinuation of treatment. Engagement and establishing ground rules are a way forward and the patients in my unit sign a patient “contract” the text of which I have appended

Retreatment

I was surprised to hear Prof Richmond report that there are high retreatment rates but have no reason to doubt his expertise. My own view is that other than in exceptional circumstances the NHS should only offer one course of treatment. Indeed I had assumed that it was the case. This is another area where the Strategic Advice Forum for Orthodontics should look to establish common protocols and mechanisms across Wales and advise Health Boards.

1. Kay & Locker “A systematic review of the efectiveness of health promotion aimed at improving dental health” Comm Dental Health 1998 Sep; 15(3): 132-44

2. Watt RG “Emerging theories into the social determinants of health: implications for oral health promotion” Comm Dent Oral Epidem 2002 Aug; 30(4): 241-7

Appendix 1

FIXED APPLIANCE AGREEMENT

Now that I have been fitted with my fixed appliance and have been given instructions, I am aware of the following:

· I must avoid all hard or sticky sweets and food, fizzy drinks and drinks that are high in sugar.

· I must thoroughly brush my teeth and brace morning and night and if possible after every meal with a suitable toothbrush.

· I should use a fluoride mouthwash on a daily basis to help prevent tooth decay occurring during my brace treatment.

· I must check my brace daily for breakages, if my brace is broken, I must contact the department straight away.

· I must attend every appointment.

· I understand that I will miss some school time during the course of my                treatment and this cannot be avoided.

· I understand that at the end of treatment I will have my brace taken off and retainers provided.

· I understand that retention is an essential part of my treatment.

· I understand that I should continue to attend my general dentist on a regular basis

I have read the above and understand that if I do not follow the instructions my teeth may be damaged during treatment. My brace will then have to be removed before treatment is complete.

I also understand that it is Health Board policy that only one course of treatment will be provided under the NHS.

Parent Signature     ..............................……

Patient signature     ......................................

Date                      ......................................

Additional information from Professor Stephen Richmond, Cardiff and Vale University Health Board

Response to Chairman’s request.

For the year 2013/14 there were 16832 orthodontic attendances in the University Dental Hospital.

There were 1847 DNA’s and 735 cancellations.

Many thanks,

Stephen

Additional information from Karl Bishop, Abertawe Bro Morgannwg University Health Board

I was asked, subsequent to appearing in front of HSCC, to provide information on missed appointments within the hospital orthodontic services in ABMU.  The following data has been provided by ABMU IT department for the year 2013-14.

Number of Appointments	NEW	FOLLOW UP	Grand Total
Grand Total	2086	14091	16177
Missed Appointment DNA %	19.88%	10.85%	12.00%

I hope this is helpful

Kind regards