Applying 18 week rules to dental specialities

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Applying 18 week rules to dental specialities

• Natasha Dogmetchi

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Applying 18 weeks rule

• Principles of 18 week clock rules apply equally
  to pathways that involve, or could potentially
  involve care led by a dental consultant
• A maximum 18 weeks from point of initial referral
  up to the start of any necessary treatment
  includes referrals to clinical consultant-led
  services in dental specialities, ie
• Oral surgery, orthodontics, paediatric dentistry,
  restorative dentistry, periodontics,
  prosthodontics, endodontics, oral medicince and
  dental and maxillofacial radiology

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Applying 18 week rule

• What is happening locally
• What data is available?
• RTT data Admitted patients Oral Surgery
• Hospital Waiting Times QM08 outpatient
  referrals all dental specialties

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RTT Data Oral Surgery
Source RTT Data (www.18weeks.nhs.uk) England
data July 2007
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RTT Data Oral Surgery
Source RTT Data (www.18weeks.nhs.uk) England
data July 2007
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QM08 Referrals to Dental Specialties
Outpatients 2006/07
Source Hospital Waiting Times- Outpatient QM08
(http//www.performance.doh.gov.uk/waitingtimes/i
ndex.htm)
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Applying 18 week rule

• Consultant-led dental services
• Consultant retains overall responsibility for the
  patient, but does not mean
• that they are present for each appointment
• Setting in which care is provided in necessarily
  the secondary care

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Applying 18 week rule

• 18 week target applies to
• Consultant-led hospital services
• Consultant-led services provided in the primary
  care setting
• General anaesthesia services
• Patients under the care of all postgraduate
  dental students, including specialist registrars
  (SpRs)

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Applying 18 week rules

• 18 week target does not applies to
• Separate arrangements with consultants to work in
  primary care
• Patients seen by undergraduate dental students
• Referrals from one dental contractor to another
  .unless

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Applying 18 week rules

• Clock starts when referral is made to a
  consultant on the basis that
• the patient is to be assessed and then if
  appropriate treated, before being referred back
  and
• the patient will, or could potentially receive
  treatment from a consultant-led services.

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Applying 18 week rules

• Referrals to following start the 18 week clock
• Consultant-led dental services (in secondary or
  other setting)
• Oral cancer services (62 day cancer clock also
  for urgent suspected cancer cases)
• Diagnostic services, on basis that if
  appropriate, will be treated by a consultant-led
  service before referred back
• Referral management centres
• Specialist dental contractors, DwSI or dentists
  that hold advanced mandatory contracts if they
  are part of dedicated referral management
  arrangements

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Applying 18 week rules

• Referrals to following does not start the 18 week
  clock
• Services provided primary care dentists
• Salaried primary dental care services
• Services provided by specialist dental
  contractors, DwSI or dentists that hold advanced
  mandatory contracts where they are not part of
  dedicated referral management arrangements
• Services provided by undergraduate students in
  dental teaching hospitals or as part of outreach
  teaching

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Applying 18 week rules

• Whose referrals start the clock
• 18 week pathway can begin with a referral by an
• health professional or health body authorised to
• make referrals, including
• GDPs, specialist dental contractors, DwSI or
  dentists with advanced mandatory contracts
• Salaried primary dental care services
• Prison dental services
• Consultants (or consultant-led services)

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Applying 18 week rules

• What defines the clock-start date
• Date on which the provider to whom the initial
  referral is made
• (including management centres) receives notice of
  the patients
• referral. Referrals using Choose Book, is date
  on which the patients
• unique booking reference number (UBRN) is
  converted.
• For dentistry, most likely to be referrals by
  letter and therefore is the date on which the
  provider receives the referral later.

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Applying 18 week rules

• Clock stops
• The clock stops when a clinical decision is
  made that no treatment is required, or when first
  definitive treatment begins.
• First definitive treatment (with our without
  discharge)
• A decision not to treat
• A decision to embark on a period of watchful
  waiting or active monitoring
• A decision to refer patient for treatment in
  primary care (not consultant-led)
• Patient declines treatment offered to them

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Applying 18 week rules

• Clock stops
• First definitive treatment can be
• Inpatient treatment - date of admission
• Out patient or day-case treatment - date of
  attendance treatment
• Fitting of a dental device date on which
  definitive fitting or trial fitting begins
• First-line treatment ie dental treatment or
  management provided with the aim of avoiding the
  need for more invasive treatment. (new clock
  starts is a later decision is taken for more
  invasive treatment)

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Applying 18 week rules

• Clock stops
• Dental examples - outpatient
• Orthodontic treatment clock stops when
• Patient referred back to the dentist in primary
  care for removal of a tooth
• Patient needs to be referred when older (clock
  stops when clinical decision made and referring
  dentist informed to commence waiting)
• First definitive treatment is fitting of a dental
  brace

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Applying 18 week rules

• Does not stop the clock
• A first or subsequent outpatient appointment or
  assessment that does not involve treatment or the
  fitting of a dental device
• Pain relief treatment or other steps to manage a
  patients condition in advance of definitive
  treatment
• Consultant-to-consultant referrals were the
  underlying condition remains unchanged

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Service transformation whole system review
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Service transformation

• Merely doing things faster will not
• achieve the 18 weeks target for
• consultant-led dental services

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Assessing needs demands
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Service transformation

• Assessing needs demand
• Important relationship between provision in
  primary care dental services (not subject to 18
  weeks) and consultant-led services (subject to 18
  weeks)
• Through assessing oral health needs, PCTs should
  have set agreed relative priorities, in both
  short long terms across primary secondary
  care
• Priorities should be considered in relation to
  current capacity, in both short long term
  across primary secondary care

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Service planning
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Service transformation

• Service planning
• Redirecting resources may be essential locally
• Shifting work that has traditionally taken place
  in hospitals to specialist or DwSI in primary
  care
• Treatment reviews what can only be done in
  secondary care
• Whole system approach involves considering
  referrals and quality frameworks across primary
  and secondary care
• Capacity v workload should be assessed in
  relation to referral patterns and types

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Developing capacity in primary care
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Service transformation

• Developing capacity in primary care
• Growth in specialist care particularly
  orthodontics
• Feedback that no shortage of contractors seeking
  new/extended contracts, although local capacity
  is not always readily available
• Tendering and new contracts provides the
  opportunity to tailor services in line with local
  needs
• Tendering exercises
• Orthodontics
• Minor oral surgery

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Establishing clinical networks
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Service transformation

• Establishing clinical networks
• Establishing networking of GDPs, specialists
  across primary and secondary care key. Is there a
  need to review it in light of
• Need to include all local stakeholders
• Attaining 18 week requirement
• Latest good practice information
• PCT/SHA benchmarking information
• Latest information regarding referral patterns
  patient flows
• Capacity implications
• To consider effective referrals and treatment
  criteria across the system

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Managing patients expectations patients
public involvement
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Service transformation

• Managing patients expectations
• Need to communicate to patients what they can
  expect and entitlement to treatment
• Clarity about referral criteria and service
  delivery will support this
• Responsibility of PCTs to actively engage with
  patients and the public during the course of
  their decision-making process

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Patient and Public Involvement

• A Stronger Local Voice (2006)
• PPI to form central role in future
• commissioning decision-making
• Will apply to health social care
• sectors
• Local Government Public
• Involvement in Health Act (2007)

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Patient Public Involvement

• Key Changes
• Introduction of LINks
• Replacement of Patient Forums CPPIH
• Patient initiated petitions
• Patient Prospectuses
• Overview Scrutiny Committees

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Patient Public Involvement

• Some Implications
• Consultation and involvement will become a
  standard requirement.
• PPI mechanisms need to be built into
  decision-making processes
• Greater feedback
• Joint Strategic Needs Assessment

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Patient Public Involvement

• Useful Information
• PCC website
• DH website
• NHS Centre for Involvement
• PPI Exchange Network (PPIX)
• Workshops and Seminars

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Changing the pattern of provision
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Service transformation

• Changing the pattern of provision
• May be a need to implement short term action
  whilst considering a longer term vision
• Short term actions may include
• Commissioning short term contracts to take
  patients off existing waiting lists
• Agreeing joint commissioning strategy with
  neighbouring PCTs
• Validating secondary care waiting lists
• Putting in place
• Changing capacity may be longer term,
  particularly where there this cannot be procured
  locally

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Effective refferrals
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Service transformation

• Effective referrals
• Referral patterns significant effect waiting
  lists for secondary care dentistry
• Need to have local communication strategy with
  primary care contractors that sets out referral
  process criteria
• Training should be offered by PCT or both primary
  secondary care referrals

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Service transformation

• Effective referrals
• Number of referral management systems
• Referrals to secondary care via primary care
  specialists first
• Dedicated primary care referral management
  centres/processes (18 weeks rule)
• Standardising local referral protocols

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Improving secondary care throughput
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Service transformation

• Improving throughput of secondary care
• Feedback from Trusts, that PCTs are not willing
  to engage in discussions on dentistry
• Is local data being reviewed
• Process mapping support identifying limiting
  steps without causing unanticipated consequences
• Important to note that not all referrals will be
  for treatment ie treatment planning advice

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Recruitment skill mixRole of DwSI
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Service transformation

• Tackling recruitment changing skill mix
• Difficulties in recruitment of specialist
  clinical staff in secondary care
• Primary care feedback is that less of an issue
• Need to assess workforce recruitment plans
  across both and consider in context of service
  reconfiguration and skill mix
• New skill mix opportunities in primary care
• Therapists
• DwSI

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Role of Dentists With a Special Interest
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Summary

• Practitioners with a Special Interest the
  policy and principles
• Accrediting Dentists with a Special Interest
  (DwSIs)
• The role of the PCT
• Commissioning for DwSI services

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PwSIs - Common Principles

• Draws on generalist skills as a gatekeeper to
  more specialised services
• Must be able to work without supervision
• Competences required will always be greater than
  a generalist
• Appropriate qualification may be one way of
  demonstrating competence but must not be the only
  way
• Accreditation essential
• Local Ts Cs agreed with PCT

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DWSIs - General Principles

• Used in clinical areas where delivery and health
  needs require a local solution
• Contractual arrangement between PCTs and primary
  dental care practitioners to provide specialised
  skills within the PCT area
• PCT appointment to nationally agreed selection
  criterion
• Ideally part of a consultant led clinical network
• Type of contract to be decided locally normally
  by number of cases seen.

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DwSIs the key concepts

• DwSI concept of enhanced practitioner,
  sub-speciality level but retaining primary care
  generalist profile
• Recognition of existing levels of special skills
  through portfolio of evidence and/or taught
  diplomas and certificates
• Appointed by PCTs after assessment of competency.

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Advantages of DwSIs in a Patientled NHS

• Greater convenience
• Faster access
• More choice
• Avoidance of inappropriate referrals

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Advantages for Dentists

• Formal recognition by the NHS of special skills
  obtained through experience and/or training
• Development of a recognised referral pathway for
  their patients within NHS primary dental care.

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Advantages for the NHS

• Close strategic fit with the NHS Dentistry
  Agenda by
• Providing PCTs with greater flexibility in terms
  of local commissioning of dental services
• Encouraging dentists to develop their practice
  within the NHS.

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DwSIs Next Steps

• Clinical Competency Frameworks and appointment
  guidelines published-2006
• Step by step guide for PCTs published -2006
• Model Patient leaflet published- 2006
• Appointment of DwSIs
• Second wave competencies to follow

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(No Transcript)
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DWSIs First Areas for Development

• Orthodontics
• Minor Oral Surgery
• Periodontics
• Endodontics

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DWSIs Second Wave
Competencies in Development

• Conscious Sedation- Chair David Craig
• Prison Dentistry- Chair Helen Falcon
• Dental Public Health ?
• (Awaiting review of capacity and
  capability)

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Commissioning DwSI services

• Reviewing current services
• Identifying what is needed
• Designing the service
• Establishing Clinical Governance
• Putting Audit Evaluation in place.

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Step 1 review current services

• Health needs assessment
• Engage variety of stakeholders
• Involve patients public (PPI)
• Examine existing referral patterns
• Be clear of objectives of setting up DwSI

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Step 2 What you will need

• Establish commissioning group
• Impact assessment
• How will service fit integrated commissioning
  strategy
• Identify resource needs and locations.

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Step 3 Design the Service

• Scope of service
• Clarify range of care type of conditions to be
  treated by DwSIs
• Administration arrangements
• Clinical Network
• Consider suitable contract arrangements including
  remuneration method of payment.

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Step 4 Clinical Governance

• Lines of accountability
• Continuing professional development
• Accreditation
• Risk assessment
• Maintaining records

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Step 5 Audit Evaluation

• Service specification
• Monitoring arrangements
• Performance
• Outcomes

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Commissioning for Additional DwSI Services

• Commissioning must be contestable
• - specification of service required
• - tender
• Contract for completed cases on referral
• Patients charge levied by referring dentist
• Enhanced data set

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DwSI - Selected examples of competency criteria
for Orthodontics

• Requirement Sources of Evidence
• Understanding of occlusion BDS, DVT, GPT
• its development
• Diagnose malocclusion Clinical Assistant
  training
• know when to intervene scheme or clinical
  attachment
• Understand limits of Peer group assessment,
• appliance therapy present treated cases
• Maintain quality of treatment verifiable CPD,
  attendance
• standards at orthodontic courses