Primary Care interface with 18 week wait. In Orthodontics. PCC event 24th May 2007

1. Primary Care interface with 18 week wait. (In Orthodontics).PCC event 24th May 2007 Roger Anderson Dental Lead, Primary Care Team of the Commissioning Directorate. Torbay Care Trust

2. Why am I presenting this today! Because I have a big mouth and Carla Miller has good ears! I think we have learning to share. Recognise that there are opportunities to develop Primary Care services in delivering 18 weeks wait that all areas must achieve. Please note, I am not an expert on 18 weeks wait.

3. Thirteen Local Health Communities (LHC) have committed to becoming Early Achievers for 18 weeks. Two further health communities have agreed to deliver on a number of specialties. The aim of Early Achievers is for the LHC to deliver and sustain 18 weeks by December 2007 across all specialties, to demonstrate that the target, although tough, is achievable. Achieving early is defined as delivery of 18 week pathways for a minimum of 90% for admitted pathways and 95% for non-admitted pathways 

5. Earlier relief of symptoms, pain or discomfort Improved outcomes due to earlier intervention Less disruption to normal life through prompt attention and convenient appointments Fewer hospital appointments as tests/treatments are synchronised Reduced anxiety due to earlier diagnosis, including when no treatment is needed Less time spent in hospital for tests and treatments, more services provided by GPs and in the community Greater confidence in NHS � the right treatment is available without unnecessary delay

6. Hospital and Primary Care Clinicians, and other NHS staff Satisfaction from providing improved services More productive use of time, less time spent managing queues Consultants and specialists only seeing patients who require their skills Opportunity to improve services in primary care and prevent unnecessary referral to hospital Closer working between hospital and primary care clinicians and staff Fewer patient complaints and improved working life from dealing with more satisfied patients

7. Useful web site for detailed information on 18week wait. www.18weeks.nhs.uk As effective as Temazepam!!

8. End waiting, change lives South Devon Health and Social Care Community

9. What is happening in South Devon? Sign up by the whole South Devon Health Community to �early achiever� status by December 2007, ahead of national timetable of Dec 2008. Local community � main referrers from Torbay CT and Devon PCT Commitment to deliver this in support of Torbay Hospital.

10. Surely 18 week wait is a Secondary Care target? Yes it is, but there are opportunities for review:- Whole systems examination. Referrals from Primary Care practitioners (GDPs) affect the waiting list. Where is work done, by whom and why, at what cost? Where would patients choose to be treated. Develop a comprehensive commissioning strategy, across primary and secondary care.

11. 18 weeks wait and Orthodontics. Orthodontics not an urgent service, initial disbelief that Orthodontics would be included. But it is! Treatment Waiting list in Torbay Hospital is a year. In Primary care orthodontic treatment waits are mixed, can be greater or less than a year down to 6 months.

12. Where are orthodontic treatments carried out? In Hospital with a Consultant led service. In independent dental practices by specialist practitioners. In Independent dental practitioners by dentists with an interest, who may have a mixed contract for orthodontics and general dental care.

13. Costs of Hospital Ortho treatment Based on PBR:-

14. Cost of Ortho treatment in Primary Care setting. Based on a national UOA value of �55

15. Recent changes in Orthodontic treatment provision in S. Devon. Introduction of nGDS / nPDS contracts:- Existing activity and payments transferred to a new currency. Separation of Orthodontic and General dental care. No immediate transferability. Activity limited by the value of the contract in �s and UOAs expectations. Take out the dabblers!

16. Other possible factors affecting Orthodontic treatment demand. Has the demand for treatment increased? Are we seeing a temporary blip? Overall since April 06 an increasing number of patients accessing a PC dentist? Private and NHS. Patients on a waiting list gaining access to a dentist after many years of no dental access. Anecdotal. No GDP no treatment! Both likely to increase referrals.

17. What questions raised in overall issue? What is the overall need for orthodontic treatment in South Devon? DH Gateway Ref No: 7105 Advises on calculating a need for orthodontic treatment, based on 35% of 12 year olds. (Evidence based on 2003 National Child Dental survey) Numbers of 12 year olds in Torbay, South Hams and Teignbridge districts used as crude baseline. Calculate the numbers of treatments per year.

18. Considerations in addressing the 18 week wait. Reduce the backlog in the Hospital waiting list, increase capacity (if qualified staff available) by:- In the Hospital- Additional sessions of a dentist who was a Specialist practitioner in the community. In Primary Care -by transferring patients off the Hospital list, purchase additional treatments in a block.

19. Considerations in addressing the 18 week wait. Address the capacity required to sustain delivery of the 18 week wait. What is the need of the patients in the community from which patients referred? Does this work need to be in the Hospital? What must be delivered in a Hospital? Multi disciplinary work, training for junior doctors.

20. Considerations in addressing the 18 week wait. There is a need for a whole systems review in looking forward at capacity requirements. :- What treatments should be provided in both settings in total. What are the relative VFM? Quality issues.

21. What are the risks of reducing the waiting times in Hospital? We could produce instability in that:- GDPs refer in expecting a 1 year wait, system could clog with patients not ready. Patient choice through CAB could increase demand from outside S. Devon. Plans blown out of the water! An 18 week wait for treatment in Hospital, but still a year in primary care! Not sustainable, and could see a shift to Hospital referrals.

22. How is the 18 week wait issue being addressed in orthodontics? Under the umbrella of the Service improvement group from TCT DPCT and SDHCT. Specific facilitated event days. One day 11th May for orthodontics included Consultants, Specialist practitioners, GDPs, Commissioning managers from TCT, Primary Care contracting managers from TCT and DPCT. Service managers from SDHCT

23. Purpose of the day. Understand present referral patterns, from referring GDPs through to both Hospital and Specialist Practitioners. From those present. Understand implications of 18 week wait. Explore options to deliver 18 weeks by December and sustain that. Achieve sign up of everyone.

24. Strategic outcomes. (1) Despite perceived irrelevance of 18 weeks for orthodontics, this is a target that we are signed up to for the Hospital. Achieving this by December is a task that cannot be achieved by the Hospital alone. Agreement that although there is no equivalent target for primary care waiting times, in the longer term they will need to/should be reduced.

25. Strategic outcomes. (2) Sign up that patients on the hospital treatment waiting list could be transferred to Specialist practitioners. That the good professional relationships between all dentists offering Orthodontic Treatment should be supported. The existing Local Orthodontic Network asked to develop information, and encourage communications. Criteria for treatment (IOTN) should be the same wherever patient treated.

26. What did we learn (1)? GDPs have a variable understanding of who treats orthodontic patients locally. GDPs have a limited understanding and skill in assessing IOTN, and despite training this will always be limited. Quality of some referrals is inadequate. GDPs need basic information clearly laid out re referral criteria. Need information to share with patients relevant at the time of referral.

27. What did we learn (2)? The processes used in hospital and primary care post receipt of referral vary. Process in the Hospital administration systems involve larger numbers of steps. The type and complexity of orthodontic work carried out in both settings is predominantly the same. Numbers of patients seen per session varies hugely. 11 to 25.

28. What did we learn (3)? That hospital systems are geared to prioritise work streams with targets. Orthodontics has been largely untouched, due to the absence of any target. There are opportunities for redesign and introducing more efficient processes. That open questioning from peers opens up more critical thinking in Hospital departments. An 18 week wait for Orthodontics has brought Primary Care Orthodontic provision to the fore.

29. What did we learn (4)? There are a large number of patients who do not go on to treatment. Acceptance that referral for advice and a decision �whether to treat� by a �specialist� is appropriate. Interesting opportunities for team approach in Dentistry being tested. Despite different philosophies and requirements between Consultants and Independent Contractors there is broad agreement to work together cooperatively to improve waits.

30. What have we put into action so far? We have approached Primary Care practitioners with UOA contracts as to whether they can offer additional Orthodontic treatments to reduce Hospital backlog. We have agreed to set up one contract so far with a Specialist Practitioner to take on 120 treatments off the Hospital treatment waiting list before December.

31. What work is being done now. Evaluating the evidence we have for referrals to all orthodontic providers. Are there trends, how do the numbers of completed treatments compare with the expected demand based on population figures? LON has agreed to develop information packs for patients and GDPs to improve referrals and patient expectations as patients are referred on.

32. What are the next steps. Identify with Independent contractors with UOA contracts how we can reduce their waiting lists in line with Hospital 18 weeks. Identify what additional capacity, if any, is required long term to meet the need. Decide where that work should be done. Put out to tender. Move Hospital Consultants out of the hospital?

33. Suggestions I want to make to you pre December 2008. You must have sign up between Hospital and local PCTs at Chief Executive level as to achieving this together. Question where decisions are made for secondary care commissioning, particularly where there are opportunities for treatments to be transferred to primary care practitioners. Transfer funding into primary care budgets?

34. Thank you. If you want further information, I can be contacted in the following ways:- By telephone: 01803 210544 By e mail: rogeri.anderson@nhs.net