Dental Services Update
North Ayrshire Council · 9 May 2024
Back to Integration Joint Board — 9 May 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Integration Joint Board 9 May 2024 Subject : Dental Services Update Purpose : This paper is presented to update members of the North Ayrshire Integration Joint Board (IJB) of the current position of dental services. The paper also outlines the actions and measures that have been taken forward in the last six months to further sustain service delivery as well as the current status with the ongoing review for the vision of dentistry across Ayrshire and Arran. Recommendation : Members of the Integration Joint Board are asked to: i. Note the current position of access to dental services across Ayrshire and Arran. ii. Note the ongoing review work to establish clear aims and objectives for the vision for dentistry across Ayrshire and Arran. Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required x 2. North Ayrshire Council 3. NHS Ayrshire & Arran 4. North Ayrshire Council and NHS Ayrshire & Arran Glossary of Terms AGP Aerosol Generating Procedures DBC Dental Body Corporates DHSW Dental Health Support Worker EU European Union GDC General Dental Council GDP General Dental Practitioner GDS General Dental Service HIS Health Improvement Scotland HSCP Health and Social Care Partnership IJB Integration Joint Board NAHSCP North Ayrshire Health and Social Care Partnership NHS AA NHS Ayrshire & Arran OOH Out of Hours PDS Public Dental Service SIMD1 Scottish Index of Multiple Deprivation (ranking – 1 as most deprived)
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1. EXECUTIVE SUMMARY 1.1 Previous updates to the IJBs and NHS Board highlighted the risks associated with dental access and the wider impact on general health, especially to those in vulnerable groups and those in deprived areas. Although General Dental Services (GDS) remains a risk to due to workforce availability and financial sustainability, the Dental Management Team have not noticed any significant shift in demand or increased risk following the last update in August 2023. There has been a focus on business continuity and trigger tool approaches to understand as early as possible if a practice is going into difficulty. The processes and tools that have been put in place has allowed greater understanding at a practice level. Overall there has been an increase in the number of General Dental Practitioners (GDPs) who are accepting new registrations although there are waiting lists. Initial feedback from the new payment structure has been positive, but as this has only been in place since November 2023, it will take until around May 2024 to measure the impact of this. The Public Dental Service (PDS) continues to be a safety net service for those patients who cannot access their own GDP in an emergency, or are not registered. Although there is variation month to month, demand is not increasing at the rate that was anticipated to the PDS. It was proposed in 2023 the service may need to consider introducing dental access centres, but the current demand, as well as local intelligence from the GDPs has not indicated a need for these at this stage. Recognising the workforce and access challenges, as well as the opportunity to enhance what we can deliver in Ayrshire and Arran collectively across all dental services, representatives from the Dental Management Team, Public Health, Area Dental Professional Committee and clinicians working across the service have engaged in a programme of work from December 2023 to consider the future vision and ambitious service model. 1.2 This report has also been presented to: i. East Ayrshire IJB – 20 March 2024 ii. NHS Ayrshire & Arran Board – 25 March 2024 iii. South Ayrshire IJB – 3 April 2024
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2. BACKGROUND 2.1 The Public Bodies (Joint Working) Scotland Act 2014 provides a legislative framework for the delivery of Primary Care Services in Scotland. East Ayrshire Health and Social Care Partnership (HSCP), through Lead HSCP arrangements, are responsible for the delivery of Primary Care Services across Ayrshire and Arran. In addition NHS Ayrshire & Arran directly commission East Ayrshire HSCP to conduct Primary Care Contracting on behalf of the Board, this being a function that cannot be delegated to IJBs at this time. 2.2 NHS GDS is typically the first point of contact for NHS dental treatment for patients within the community. People register with a dentist in order to receive the full range of NHS treatment available under GDS The PDS acts as both a specialised and safety-net service providing care for individuals who are unable to obtain care through the GDS such as those with special care needs or patients living in areas where there were few NHS dentists providing GDS. Secondary care is a referral based service which supports referrals from medical and dental practitioners. For example, maxillofacial surgery which specialises in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck. Those patients who are unable or not suited to be treated locally are referred to the General Dental Hospital who not only specialist on oral health care but deliver education and research in West and Central Scotland. 3. CURRENT POSITION 3.1 The Vision for Dental Services in Ayrshire and Arran 3.1.1 A programme of work commenced in November 2023 to reset the vision and strategy for Dental Services in Ayrshire and Arran. The aim of this work was to allow greater understanding of the population need, the current status of all services within dental, and determine what a future delivery model for dental services in Ayrshire and Arran. There was acknowledgement that the current challenges being faced with workforce retention and access also provided opportunity to ensure our services are in the right place to deliver care wrapped around individuals. Three workshops took place between December 2023 and February 2024. These looked for ways to improve access for patient care within dental practices taking into account views of service providers and users. The workshops included representation from across GDP and PDS services, public health, the dental management team and the Area Dental Professional Committee.
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An agreed purpose was set out from the first workshop to: • Develop a clear vision for the service which takes into account both the views of service providers and users • Identify a base level of appropriate and equitable access. • Support patients to manage their oral health for better health outcomes. • Invest in the development of our workforce. In addition to the workshop sessions, public health colleagues led a Health Needs Assessment with a number of focus groups established to understand the needs of the population. A number of early priorities and suggested proposals to think about more integrated care across all the dental services from Public Health, GDP, PDS, and Specialist Services have come out of the workshops. The last workshop only took place at the end of February therefore outputs have not been shared widely with the networks aligned to them. The health needs assessment survey also closed on 29 February and will be used to inform next steps with the proposals. 3.2 Determination 1 – Dental Remuneration 3.2.1 The Scottish Government launched a new dental payment reform on 1 November 2023 - Determination 1, which went live with the stated purpose of supporting the oral health needs of every patient in Scotland. The aim of the reform is to make it easier for patients to understand what treatments are available. To simplify the remuneration for practices themselves, the items list has reduced from 700 to 45 items. All items can now be claimed for both adults and children unless stated otherwise, and there will no longer be a distinction between treatments available to registered and non-registered patients. The new fees also incorporate the Doctors and Dentist Review Body uplift of 6% on fee items and Capitation and Continuing Care payments. This was backdated to 1 April 2023. Patients who pay for treatment will continue to pay 80% of the cost with a maximum fee per treatment now introduced at £384. The revised payment structure was shared as part of a national campaign as well local communication campaigns. There is no data available locally or nationally to determine the impact of the new payment structure, but feedback throughout various forums indicates this has been positive for practices and their income, as well as greater clarity for patients.
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3.3 Access in North Ayrshire 3.3.1 Since the last update in August 2023, six of the 28 GDPs listed with the Health Board who are committed to providing NHS care within North Ayrshire are accepting new NHS registrations – four of these are accepting both NHS adults and children with two practices only accepting children. This is an improvement from four practices reported in August 2023, although it should be noted there is a waiting list to first assessment of up to six months, but can be less. The Dental Team continue to keep in regular contact with GDPs to understand in detail the status of their service delivery to be aware of any issues early to be able to resolve and support where possible. The service also continues to prioritise prevention and oral health improvement to reduce the possible burden of dental disease and mitigate the impact of reduced dental access. The Dental Management Team have developed a comprehensive risk and resilience plan which contains a detailed data set and early warning triggers to identify areas which may be at risk of reducing or experiencing challenges in accessing dental services. The plan also sets out the steps that would be taken should a practice or body corporate seek to de-register patients. This includes how the PDS services would re-structure their service provision to maintain a sustainable services as well as support wider access to emergency dental care if required. 3.4 Public Dental Service 3.4.1 The PDS core function operates Monday to Friday with emergency appointment slots available as a safety net for practices who are unable to offer emergency appointments. The service has increased the number of available slots available per month from July 2023 due to a projected increase in demand. There has not always been the workforce to cover these sessions, but on a monthly basis overall, the demand for emergency appointments has not increased, with the exception of December 2023 where there was a slight increase. On average between 127 and 147 patients are seen per month with the majority of attendances being non-registered patients. Only 30% of the total number seen are registered patients seeking to use the service when they can’t access their own registered dental practice. The Out of Hours (OOH) service has seen an increase in the number of registered patients attending the weekend emergency dental service for an appointment since August 2023. The service operates Saturday and Sunday 9 am – 3 pm with 44 appointment slots available. Some weekends the service will get near to capacity but has not exceeded capacity. The service has contingency arrangements in place for a stand by team should the reach capacity. The OOH service is accessed via NHS 24 and on review of the national reporting, demand has not increased to NHS 24 from Ayrshire and Arran.
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3.5 Wider PDS 3.5.1 Prison Service The current waiting time is 19 weeks to treatment with 21 patients awaiting treatment. This is an improving position from the previously reported 22 weeks to treatment. Emergency appointments are being seen in the prison and where possible routine work that does not include aerosol generating procedure as the site is still not fit for purpose. The wait time is being impacted due to prisoners not being brought down on time for their appointments at 8:30am. It was agreed the clinic times would commence at 10am. The prison healthcare team are keen to support how the dental team can maximise the clinical session on site as the number of people who can be seen has reduced. There is a plan in place to appoint the 21 patients awaiting assessment and treatment which should in turn further improve the waiting time. 3.5.2 Paediatric Service The total number of paediatric patients on the waiting list as at end of February 2024 is 1225. The waiting time for this service is 18 weeks to initial assessment and 19 weeks to treatment thereafter. 504 of the 1225 patients currently on the list are awaiting initial assessment – this broken down by locality area below. • 154 - South Ayrshire • 194 – North Ayrshire • 156 – East Ayrshire The remaining 721 patients are now on an active treatment plan. Examples of the ongoing treatment plans are noted below: • 143 of the 721 patients are waiting to be treated under general anaesthetic at University Hospital Crosshouse. • 420 of the 721 patients are being treated by a dental therapist. These patients will be allocated an appointment at a clinic closest to their home if possible or next available date. • 158 of the 721 are receiving treatment under the Paediatric Senior Dental Officer or a PDS dentist either at North West Kilmarnock or Ayrshire Central Hospital sites. 3.5.3 Sedation Service The number of patients currently waiting for treatment under the PDS sedation service is 171 compared to 74 in August 2023. Work continues with local GDPs to confirm if there any alternative methods to support patients due to the number of patients now waiting.
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3.5.4 Domiciliary Service There are currently 29 patients awaiting treatment with routine lists growing month on month. This is slightly higher than 27 patients that was reported previously in August 2023. 3.5.5 Adults with Additional Support Needs There are currently 26 patients awaiting treatment. This is slightly higher than 19 patients that was reported previously in August 2023. As the service continue to keep protected emergency slots available on each of the three PDS sites, this does impact on the activity that can be scheduled. It is also difficult to quantify how long emergencies can take which also impacts on the actual clinical capacity available for routine work. 3.5.6 Oral Health Prevention Oral Health prevention is a key priority across Ayrshire and Arran. The Oral Health Improvement Team continue to strengthen links within the community, delivering local training programmes, educating the population on good oral health practices with a priority on prevention and providing support for local groups and events. The team deliver training and interventions for priority groups following recognised national training programmes. The training programmes are tailored to individual needs of the population within each of the priority groups. At a population level this includes: • Providing training materials for nursery, primary and secondary schools (these can be borrowed free of charge) • Promoting how the benefits of good oral health can improve general health via training and social media • Actively participate in National Oral Health Improvement initiatives such as National Smile Month and Mouth Cancer Action Month. In addition, directed support targeting priority groups in greatest need through: • Deliver the Caring for Smiles programme to every care home in Ayrshire • Provide Caring for Smiles training for care home staff • Provide Mouth Matters training and interventions for prisoners and prison staff • Provide Open Wide training and interventions for adults with additional needs • Provide Smile4Life training and interventions for homeless/addictions
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• Facilitate a referral service (Dental Access Programme) for homeless/addictions to the Public Dental Service • Deliver bespoke training and interventions for children with additional needs During April and December 2023 there were 328 training sessions carried out involving 6,395 individual staff. There has also been agreement with HMP Kilmarnock to resume the oral health support programme for prisoners. A start for this has still to be agreed. 3.5.7 Childsmile Programme The Childsmile Toothbrushing Programme is a supervised programme aimed at helping children develop an important life skill at an early age, supporting positive development in their immediate social and physical environment. Across Ayrshire the program is delivered in:- • 135 Early Years/nursery schools • 9 Additional Support Needs (ASN) schools • 98 Primary 1 & 2 classes in all priority primary schools. - Current School year August 2023 – June 2024 The Childsmile Fluoride Varnish Programme is delivered in all priority Early Years/nursery schools and primary schools from age 2 through to P4, again targeted to areas of highest dental decay and deprivation. Fluoride varnish is applied to participating children twice in the academic year. The Childsmile team also have a dedicated team of Dental Health Support Workers (DHSW) who support family’s additional support and oral health advice. In total 6,641 children have received one fluoride varnish application between August 2023 and January 2024. A breakdown of the number of schools visited is noted below: • 42 in East Ayrshire – 11 still to complete before submission in early June. • 50 in North Ayrshire – with 20 still to complete before end of May • 42 in South Ayrshire – with 11 still to complete before end of May A total of 1,288 children receiving fluoride varnish were then offered additional support from the Childsmile team. Following the COVID-19 pandemic the Childsmile Programme was given additional funding by Scottish Government to reduce oral health inequalities and to specifically target 0 - 5 year olds in SIMD1 areas and ethnic minority groups.
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For 2023/24 a total of 554 children were identified under this programme and offered support by the Childsmile Dental Health Support Workers. They contacted the families, signposted them to dental services, assisted with dental registration and offered oral health advice. 3.6 Key Priorities 2024/25 3.6.1 To support sustainability of services, the priorities will be: • Continue to ensure the appropriate skill mix and workforce to maintain core PDS provision for vulnerable populations to access these referral based services. • Continue to explore organisational resilience and how necessary processes could be supported and expedited such as recruitment and procurement. • Identification of funding sources and financial incentives for recruitment, retention and ongoing service provision. • Continuing to prioritise prevention and oral health improvement to reduce the possible burden of dental disease and mitigate the impact of reduced dental access. 3.7 Anticipated Outcomes 3.7.1 The main aim for dental services is to provide a prompt and seamless experience for citizens across Ayrshire and Arran as well as support people’s ongoing oral health needs. The learning to date offers important opportunities seen in the context of the aim of the Caring for Ayrshire programme which is to design a fully integrated system wide approach to ensure people are able to access the right care at the right time in the right place. 3.8 Measuring Impact 3.8.1 Continuous review of general dental services and public dental services is undertaken to evaluate impact and effectiveness to ensure improved patient journeys which will benefit citizens of Ayrshire and Arran to access appropriate care. 4. IMPLICATIONS 4.1 Financial There is still a financial risk that a large body corporate organisation could de-register large numbers of patients and the NHS Board would be responsible for their dental care. Due to the current financial position, it is unlikely there will be ready available funds to quickly step up dental centres or scale the PDS up to cope with the demand without
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additional financial investment. The Dental Management team are in regular contact with GDPs to assess their financial sustainability and any expected risk would be escalated via the local governance route. Unscheduled care is one of the main drivers for long waiting lists across GDPs and PDS. As noted above under the vision work that is being taken forward, there is consensus across the dental professional groups that a consistent access route for emergencies would relieve the pressure across all services. The plan for this will be taken forward under the reform work, but would require investment. 4.2 Human Resources There continues to be a national risk with dental recruitment due to availability of workforce. There was a pause in dental students progressing through the Universities across Scotland during the COVID-19 pandemic, due to the restrictions imposed. This pause meant that dental students did not graduate for one year, and therefore left numerous Associate posts unfilled. This, coupled with a number of practitioners choosing to retire early due to the pandemic and uncertainty in the profession has resulted in a decrease in workforce. Despite the challenges, the PDS has recently recruited a dental practitioner based on Arran. As dental recruitment is a widespread issue across the country there is greater competition in recruitment, with many practitioners choosing to stay closer to cities rather than moving to Ayrshire and Arran. Brexit has also impacted the balance of practitioners in Scotland, as fewer individuals are choosing the UK as a place to work and many have chosen to leave the UK and return to the EU. The General Dental Council (GDC) had suspended their Overseas Registration Exam for a period of over two years, meaning that any inflow of clinicians from other parts of the world has stopped. The Overseas Registration Exam has now recently restarted, but, since the process takes several months or years to complete, this will not be an immediate or short term solution. There is also a risk in recruiting Dental Nurses due to a number leaving the profession during the pandemic. Feedback is the current pay structures for a trainee Dental Nurse in GDP is not attractive against the other competing job opportunities currently available. The service has increased the number of training places from 15 to 18 on the dental nurse training programme. This is a Modern Apprenticeship programme for trainee Dental Nurses in Ayrshire and Arran, enabling them to gain the required professional qualification which meets the GDC criteria for mandatory registration as a fully qualified Dental Nurse.
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4.3 Legal None. 4.4 Equality/Socio-Economic There is a risk that those who already experience socio-economic deprivation will be disproportionately affected by dental access issues as they will be unable to pay for private dental care. The financial and social impacts of additional travel to access dental care should not be underestimated. Comprehensive Equality Impact Assessments will be in place for any service developments and equality should be a primary driver in the work to secure dental access. 4.5 Risk Sustainability of Public Dental Services - The uncertainty of GDS will continue put the sustainability of PDS at risk. This impacts on PDS being able to deliver on all aspects of the PDS. Long waits across GDP practices may result in an increase in registered and unregistered patients attempting to access emergency dental care via OOH and PDS. 4.6 Community Wealth Building The wellbeing of people and communities is core to the aims and successes of Community Planning. Ensuring we sustain access to NHS dental services for our citizens in Ayrshire and Arran is an integral part of the Wellbeing Delivery Plan, Integration Authorities Strategic Commissioning Plan of both the NHS and Council, will contribute to support this wellbeing agenda. 4.7 Key Priorities The strategy and programme outlined in this report will assist the IJB to deliver the following Strategic Objectives from its Strategic Plan to: • Provide early and effective support • Improve mental and physical health and wellbeing • Develop and support our workforce 5. CONSULTATION 5.1 Consultation has taken place through current structures across dental services as well as regular engagement with the Area Dental Professional Committee.
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Ongoing communication with all Stakeholders and the population will be critical as implementation and reform progresses. No public consultation is planned at this time, but should the need for public consultation arise, due process will be followed in line with service guidelines and governance structures. Report by: Vicki Campbell Head of Primary and Urgent Care Services Vicki.Campbell@aapct.scot.nhs.uk Implementation Officer and Person to Contact: Claire McCamon Senior Manager Primary Care Services Claire.McCamon@aapct.scot.nhs.uk 07 March 2024