3 - 20230824 - NAIJB Report Dental Access-FINAL
North Ayrshire Council · 24 August 2023
Back to Integration Joint Board — 24 August 2023 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 24 August 2023 Subject : Dental Services Update Purpose : To update members of the North Ayrshire Integration Joint Board (IJB) of the current position of access to dental services within the North Ayrshire Health and Social Care Partnership (NAHSCP). Recommendation : The members of IJB are asked to note to note the current position of access to dental services 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 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 and Arran PDS Public Dental Service 1. EXECUTIVE SUMMARY 1.1 This report provides an update on the provision of dental services including the current position in relation to access to dental services within the North Ayrshire Health and Social Care Partnership (NA HSCP). 1.2 The report highlights the ongoing recovery and remobilisation of NHS dental services which is at significant risk of stalling, with the potential of a reduction in the availability of NHS dental care. This is driven by a multitude of factors including availability of staff, reduction in NHS commitment as practices increase their private provision, ongoing uncertainty about the future contractual model for primary care dentistry and destabilisation of business models for dental practices.
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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 HSCP, through Lead HSCP arrangements, are responsible for the delivery of Primary Care Services across Ayrshire and Arran. 2.2 Dental Services is currently sub divided into specialities across primary and secondary care. Dentistry is delivered by General Dental Services (GDS), Public Dental Service (PDS) and Secondary Care Dental Service. NHS GDS is typically the first point of contact for NHS dental treatment. 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. An illustration of the structure of services is shown below.
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2.3 General Dental Services 2.3.1 The majority of the population receive their dental care from a General Dental Practitioner (GDP), a ‘High Street Dentist’ working in primary care. All dentists have to be registered with the General Dental Council in order to practice in the UK. GDP’s are independent businesses that range from a small single clinician owned and operated practice to a large multi-Practice, Global Investment Firm owned by Dental Body Corporates (DBC). The majority of GDPs choose to carry out a mix of private dental care and NHS dental care, as an Independent Contractor, which they are permitted to do so from the same practice. NHS Boards are not required to provide a full dental service to their populations however as per Section 25 of the NHS (Scotland) Act 1978, NHS Boards are required to maintain a list of dentists providing NHS services available in their area. Those GDP’s providing NHS services are expected to comply with the NHS (General Dental Service) (Scotland) Regulations 2010. As there is no contractual requirement for a dentist to provide a basic level of service, they are directly reimbursed for the treatments provided to their NHS patients as set out in the Statement of Dental Remuneration (SDR). It is worth noting the Scottish Government has committed to reforming the current payment structure from 1 November 2023.
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GDP businesses can decide at any time to reduce or withdraw their NHS commitment and become either a wholly private business or provide limited NHS commitment. For example, continuing to only treat children or adults, as this ensures they maintain the benefits of being NHS committed. 2.4 Public Dental Service 2.4.1 The PDS was formed in September 2013 by the merger of the Community Dental Service and Salaried Dental Service. The PDS is a clinical service that is directly run by the Health Board with Health Board employed dental staff. The service provides enhanced care to patients with complex physical, mental, medical and behavioural needs that cannot appropriately be provided in GDPs. The PDS also functions as a safety-net service that ensures emergency access to dentistry for patients who are registered and or not with a practice. The PDS mainly operates from three Hubs in Ayr Hospital, Ayrshire Central Hospital and Northwest Kilmarnock Area Centre. In addition there are currently clinics in, Cumnock, Patna, Lamlash, Crosshouse Hospital and HMP Kilmarnock. Although it is based in primary care, its services overlap with secondary care, public health and the Glasgow University Dental Hospital, by delivering ‘hands-on’ training for final year dental students. The PDS also currently operates dental practices in, Patna, Cumnock, Lamlash, Isle of Arran and Millport. It should be noted that Millport clinics only run twice yearly to those patients who cannot travel to the mainland due to their physical or mental health wellbeing. 2.5 Enhanced Dental Services – delivered via Public Dental Service 2.5.1 Anxiety Management The PDS offers a referral based service for phobic and anxious patients. These patients are initially assessed to determine their suitability within PDS with the overall aim for these patients to eventually be treated within a GDP. Using de-sensitising skills and techniques can sometimes allow a patient to receive dental treatment that previously the patient would not be able to tolerate, this would become part of their routine care. If these methods are unsuccessful then treatment with the use of a type of sedation would be tried, however it would be hoped that by using sedation and de-sensitising through time the patient would be able to have treatment normally.
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2.5.2 Special Care Dental Service Patients in this category include those with a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability. The service seek to meet the individual’s needs through the provision of dental hubs and highly skilled staff. Through acclimatisation and desensitisation appointments trust can be developed between staff and patient to successfully treat patients and have a positive outcome. Staff have further developed their skills by attending training specific to this patient group. Staff have researched and purchased aids which have made a significant difference in engagement from children and adults with additional needs/learning disabilities. 2.5.3 Inhalation Sedation Service This service is provided at all three hubs to both paediatric and adult patients who require a mild form of sedation in order for them to be able to tolerate dental treatment. 2.5.4 Intravenous Sedation Service This service is assessed at all three hubs to adult patients who require a stronger form of sedation in order for them to be able to tolerate dental treatment however those requiring treatment are only provided at Ayr hub. This service is time intensive with treatment appointments lasting between one and a half to two hours to allow the patient to be sedated, have treatment and then recover enough to be able to go home. The PDS has been under increased demand with limited resources which makes providing this time consuming service challenging. Across all the above services there is on average 30 patients per month referred with the longest wait being six weeks. 2.5.5 Domiciliary Care Domiciliary care is provided throughout Ayrshire and Arran covering 64 residential Care Homes. The PDS provides dental care to 57 out of the 64 residential care homes in Ayrshire with the remaining seven care homes covered by independent practices. In addition domiciliary care is provided to those patients who are unable to travel to dental clinics. This service has been gradually restarting post COVID with currently 40 patients on average per month receiving treatment in their own homes. 2.5.6 Paediatric General Anaesthetic Service The service operates from Crosshouse Day Surgery Department two days per week, providing treatment sessions in the morning and assessment clinics in the afternoon. The service is to treat children (aged approximately between 1 year and 14 years) who have pain and/or sepsis as a result of decay, abscessed teeth or trauma that require extraction. These children would not be able to tolerate treatment in a general practice setting. At the assessment clinic within Northwest Kilmarnock, a Dental Health Support Worker provides advice to the child and family to help ensure positive oral health
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messages are reinforced. Links between the dental department and Health Visitor or School Nurse are in place to ensure follow-up where required. There is on average 130 referrals per month received per month with a 13 week wait time. 2.5.7 Adult General Anaesthetic Service The service operates from Crosshouse Day Surgery Department. Sessions are delivered one day per week and are mainly for phobic and anxious adults and for adults with additional needs; these patients can be challenged by general treatment and therefore require a general anaesthetic for examination and comprehensive dental treatment that ensues. There are on average 30 referrals per month to this service with only four patients currently on the waiting list to be appointed. 2.5.8 Out of Hours and Weekday Emergency Dental Service The weekend service operates 9am – 3pm. Patients are triaged and appointed to this service by NHS 24. The service is provided by GDPs and PDS through an agreed rota. The dentists rostered on provide overall clinical guidance and basic perational management for the service to operate supported by dental nurses. The data for this is collected quarterly with the first quarter of 2023/24 reporting just under 1800 patients treated. Approximately a quarter of these patients were registered with a dentist with the remaining unregistered. In terms of weekday emergency care, pre pandemic, the PDS blocked out one hour slots across the three sites for any registered and unregistered emergency appointments; any cancellations would also be offered out as emergencies. Since the pandemic, the PDS now offer a total of six emergency appointments across all three sites, two at each site, in additional to cancellations. We also now offer a full day Monday session at Ayr hospital, which equates to approximately 10-12 appointments. In the first quarter PDS have treated a total number of 65 PDS registered patients and 433 unregistered patients, of those 372 were unregistered and 61 were registered with a GDP. Since 2022, there has only ever been one complaint received regarding the service with the majority of feedback received being positive.
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2.5.9 Prison Dental Service The PDS currently provides four (previously six) dental sessions per week within HMP Kilmarnock which is made up of dentists and therapist time. The needs of these patients are high and demand for this care is significant. Currently HMP Kilmarnock is not fit for purpose in terms of ventilation and therefore aerosol generating procedures (AGP)’s have not yet been reinstated and only routine or emergency care is being provided. There is currently an average waiting list time of 22 weeks. 2.5.10 Inpatients and Support to other Specialities The PDS provides care as required to inpatients within any ward across all hospitals in Ayrshire and Arran. Currently a clinic operates at Crosshouse Hospital twice monthly treating medically compromised patients who require to be made dentally fit prior to surgery. Links are in place with Consultants in Haematology and Oncology providing training and support to staff on best oral health practice. The PDS has also provided advice and support to the Intensive Care Unit at Crosshouse Hospital on how to provide effective oral healthcare to their patients as improving oral cleanliness during critical illness has been to shown to reduce the incidence of ventilator acquired pneumonia. The PDS has further rolled this training out to the wider Intensive Care Unit team at Ayr Hospital and continue to support the teams to deliver effective oral healthcare. Each unit continues to be provided with oral care packs for each patient admitted. 2.5.11 Additional Needs Schools Within Additional Needs Schools, the PDS provides several services, these include resources for the school to operate a daily tooth brushing programme, a monthly visit from our hygienists to undertake a hands on tooth brushing and de-sensitising session, bi-annual fluoride varnish programme and provide the staff with any training or development they require to help support the child’s oral health. 2.5.12 Undergraduate Outreach Service Since 2007 the Teach and Treat Dental Centre in Northwest Kilmarnock has provided an Undergraduate outreach service in conjunction with the University of Glasgow, which allows final year dental students to gain experience in providing care in a dental clinic rather than in a teaching hospital environment. The service operates during university term time with eight (previously four) students providing free dental care to their patients while gaining the valuable competencies they require to ensure they have the necessary skills to treat patients upon graduation as a dentist. These are often new patients, non-registered emergencies or a patient who has been advised to phone by their GDP; this is not a referral based service however on average 4-5 appointments are provided by students per day. .
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3. CURRENT POSITION 3.1 Recovery, Remobilisation Both the PDS and GDPs continue to face exceptional challenges with increased demand month on month. GDPs were instructed to close throughout the pandemic with the PDS instructed to cease core operational activity and deliver care based on clinical need. Red, Amber and Green clinics were setup to reduce the risk to both the public and to practice staff, and reduce the transmission of COVID. Practices were advised in line with national guidance to follow the infection, prevention and control guidance. This ensured that practices complied with the guidance issued and measures that General Practice took to protect patients and staff. Full dental services were among the last to return to normal because of the infection risks of the AGPs and the requirement to leave time gaps between patients. Many procedures involve AGPs (high speed drilling and water spray) and time is required to fully ventilate consulting and treatment rooms between patients (fallow periods). This has affected GDP’s and the PDS differently. Due to the current practice delivery model, some GDP practices have chosen to reduce their NHS commitment due to a variety of reasons, including difficulties recruiting dental staff, or practitioners within practices opting to work reduced hours as well as associated costs with workforce and supplies. The Scottish Government has committed to implementing the NHS dental payment reform from 1 November 2023. The relevant part of the new Determination 1 of the Statement of Dental Remuneration (SDR) and the associated fees was issued to practices on 27 July 2023. The NHS reduction is particularly affecting adult patients who are being encouraged by their practice to transfer to private plans. The majority of practices will continue to treat children. The dental management team have no influence over this. Those patients who are being deregistered are encouraged to register with another GDP practice, however this is not always possible and as a result those patients will rely on the PDS to provide emergency care. The PDS has experienced an increase in emergency appointments with additional sessions being implemented in addition to the level of routine care being reduced in order to support emergency appointments. The prison dental services has been unable to return to full capacity due to current premises not being fit for purpose. Waiting lists have increased across each of the services mentioned above despite the offer of additional hours, providing mass assessments, offering late night appointments and numerous attempts to recruit additional staff. There has been a
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significant amount of work done to improve the anxiety management pathway through acclimatisation and desensitisation appointments. Outreach Teach and Treat have been able to take on more students than previous years to support those student who were unable to complete their academic year. The Dental management team continue to work closely with GDP colleagues to help support with any concerns. For example, meetings to discuss any concerns or fears around the new payment structure within GDPs have been arranged, though initial thoughts around the new payment structure are positive. 3.2 North Ayrshire Update Out of the 26 GDP practices listed with the Health Board who are committed to providing NHS care, four of these practices are accepting new NHS registrations, both NHS adult and children, but have large waiting lists. Largs, Irvine and Saltcoats are areas of particular concern in where there is little or no access to NHS committed practices due to a high level of recruitment issues, large waiting lists and practices choosing to become private. The current position fluctuates daily and the Primary Care Dental Management team are in regular contact with all practices and GDP champions. To ensure maximum support is given, the dental management team are reliant on GDPs keeping them informed on their current position. As highlighted previously, GDPs are independent businesses therefore not all GDPs provide NHS dental care however those practices on the dental lists held by the Board are supported by the dental management team. The dental management team are in frequent contact with practices, particularly those vulnerable practices, and are encouraged to contact the management team should they have any concerns. All NHS committed practices are also provided both pastoral and governance support from the Dental Practice advisors who are contracted/employed by the Board. 3.3 Impact on PDS Should more GDP practices continue to go private this puts the PDS at risk of increased out of hours and weekday emergency care for registered and unregistered patients. Maintaining core PDS provision for vulnerable populations and referral based services is key however if dental access reaches concerning levels current staff would need to be redistributed from other areas within the service to treat emergency patients whilst still providing the minimum core services to ensure long term sustainability. Reducing core service and unscheduled care to support non registered care would substantially increase wait times across the Board. This would reverse the hard work that has been done to date to try and recovery the PDS to a level of service that was similar to pre- pandemic status.
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4. PROPOSALS 4.1 Anticipated Outcomes and Measuring Impact It is proposed at this time that there is close monitoring of Dental Services across Ayrshire and Arran due to the current risks to service delivery and patient outcomes. There are a range of actions that the dental management team are undertaking such as scoping and developing the need for dental access centres across Ayrshire and Arran. This scoping exercise will determine when and how many centres would be required. The Dental Team are in regular contact with GDPs where possible to understand in detail the status of their service delivery and also sighted on any issues early to be able to resolve and support where possible. At present a mapping exercise is being undertaken to identify the core requirements of a sustainable service moving forward this will include identifying key geographical areas of concern, articulating the core requirement for the PDS function and different operating models for dental access centres should this be required. 5. IMPLICATIONS 5.1 Financial During the COVID-19 pandemic the Scottish Government allocated NHS Boards monies for ventilation improvements and to purchase of dental tools within GDP practices. In March 2022, NHS Ayrshire & Arran Dental services carried forward £718,954 of Practice Improvement Funding. Since April 2022, a total amount of £462,645 has been spent on practice improvements. This left a total of £256,000 within the budget for year 2023/24. It is projected that there will be further improvement funding claimed to the value of £178,000 by the end of September. This will leave a remainder of £77,814 to be allocated. Practices that received this funding committed to continue providing NHS care to patients for a further two years depending on when monies were received. The allocation of these monies relieved the pressure on both the General and Public Dental Service to a degree however the demand for NHS care within GDP services continues to outweigh capacity. There is widespread recognition that the PDS has a finite resource and any further dental access issues would have a significant impact on the operation of the PDS and its ongoing provision of care to vulnerable patients and referral based services. The PDS currently have limited estate therefore any expansion or new centres would require a bid for additional funding to Scottish Government would be necessary.
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The Dental Management team are in regular contact with GDPs to assess their financial sustainability and any expected risk to service which is reported to the Senior Dental Management team. 5.2 Human Resources There is a national risk in terms of dental recruitment due to availability of workforce. During the COVID-19 pandemic, there was a pause in dental students progressing through the Universities across Scotland, due to the restrictions imposed on the use of AGPs. This pause meant that a full year’s worth of dental students did not graduate, and therefore left numerous Associate posts unfilled. This, coupled with a significant number of practitioners choosing to retire early due to the pandemic and uncertainty in the profession has resulted in a marked decrease in workforce. As this 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. A further factor is that the General Dental Council had suspended their Overseas Registration Exam (ORE) for a period of over two years, meaning that any inflow of clinicians from other parts of the world has stopped. The ORE has now recently restarted, but, since the process takes several months or years to complete, any potential of bolstering the profession from abroad is still quite far off. It is not just the dentist workforce that is an issue, shortages exist at all levels of the profession. Dental Nurses are an essential part of the team, but a significant number left the profession during the pandemic, and the current pay structures for a trainee Dental Nurse in GDP is not proving attractive against the other competing job opportunities currently available. Dental Hygienists and Therapists working in General Practice are, in the main, self- employed. Many left the profession during the pandemic, and those that remained are mostly delivering private treatment. Dental Technicians are the people who make prosthesis, such as dentures, crowns, bridges etc, for Dentists. They are independent businesses, and during the pandemic, they were not entitled to the same financial support that GDPs received. Several of their laboratories did not survive the pandemic, and there was also an exodus from the profession. For several years NHS Education Scotland (NES) have been training only eight Technicians per year in Scotland, and this is in Aberdeen. 5.3 Legal None
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5.4 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. 5.5 5.5.1 5.5.2 Risk Dental Body Corporates There is a rise in the number of practices owned and operated under DBC schemes across Scotland. This business model poses a business continuity risk should these companies either cease trading due to financial difficulties or decide to move wholescale away from NHS provision. The impact of one of these organisations making a decision to move away from NHS care could leave thousands of patients without a viable alternative. There are 15 DBCs across Ayrshire and Arran. Sustainability of Public Dental Services There is a risk of not being able to deliver on all aspects of the PDS, as well as longer waiting lists should GDP practices continue to reduce or stop providing NHS care which will result in the number of registered and unregistered patients attempting to access emergency dental care via the PDS. 5.6 Community Wealth Building None. 5.7 Key Priorities The priorities will be: • Identifying early warning triggers and a comprehensive data set for ongoing monitoring of dental access across the Health Board. • Maintaining core PDS provision for vulnerable populations and referral based services. • Keeping any access services established through this process separate from core PDS provision to reduce the long term financial liability to the Board and allow a disinvestment at the appropriate time when GDS function has stabilised. • 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. • Operating within a pan-Ayrshire, Caring for Ayrshire framework, ensuring access is as equitable as possible across the Health Board, with the needs of patients at the forefront.
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• Continuing to prioritise prevention and oral health improvement to reduce the possible burden of dental disease and mitigate the impact of reduced dental access. 6. CONSULTATION This paper is being tabled for information and awareness raising. Consultation has taken place through current structures across dental services as well as regular engagement with the Area Dental Professional Committee. 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 Author: Claire McCamon Senior Manager for Primary Care Claire.McCamon@aapct.scot.nhs.uk