Hospital Dentistry

A review of dentistry main specialty and treatment function codes is required to ensure they are fit for purpose and to better enable quality improvement, workforce planning and service re-design. The clinician responsible for care and the clinician who delivered the care should be identifiable. a The Faculty of Dental Surgery to work with NHS Digital to ensure that main specialty and treatment function codes are suitable to support attribution of activity to the clinician responsible for care and the clinician who delivered the care, such that this data is suitable to support workforce planning. Concurrently, GIRFT will continue discussions with colleagues regarding how SNOMED may be used to better identify dentistry within national data.

The type of anaesthetic used should be recorded and reported using OPCS4 procedure codes as part of the Commissioning Data Set. a Trusts to implement coding of anaesthesia using OPCS4 procedure codes for all dentistry day cases in the Commissioning Data Set.

Primary and secondary diagnoses (comorbidities) should be recorded for all activity in an outpatient setting, in order to quality assure the services being provided. a NHSE Dental Commissioning to consider with trusts how this data can be recorded with as little resource input as possible in SUS, and should consider agreeing a data quality improvement plan to guide implementation. Options may include administrative staff selecting diagnoses from a pre-determined list of codes based on referral letters.

Procedure code use should be reviewed and improved so that all colleagues have clarity on what they mean and they can be consistently applied across all trusts. a Trusts to implement new code definitions developed by the British Orthodontic Society and GIRFT. BOS should review uptake of this guidance. b GIRFT to use its work with the British Orthodontic Society to inform a similar review in restorative dentistry. This is currently underway, and we would hope for trusts to implement within 12 months of publication.

Dental referrals should be part of an e-referral management system to ensure they are managed in a consistent and co-ordinated way, for example whether from a general dental practitioner, general practitioner or the Community Dental Service. a Explore options for reducing the inconsistency between referral systems from area to area, and also between dentistry and the e-referral service. b Develop referral protocols aligned with the dental commissioning standards. c Based on 5a and 5b, develop a plan to support the implementation of the e-referral system. d Provide training for general dental practitioners and general practitioners to ensure they are aware of the referral criteria and the consequences of not referring patients correctly.

All areas should have funded and effective managed clinical networks (MCNs) in each dental specialty as set out in the dental commissioning standards, including representatives from primary care, public health, general practitioners and the Community Dental Service where relevant. MCNs should liaise with and feed into integrated care systems (ICS). a Develop a baseline of which areas have MCNs, in which specialties and how they are aligned with the commissioning standards. b In liaison with NHS England and NHS Improvement, identify the barriers to establishing MCNs (as set out in the commissioning standards) and develop a plan to mitigate these. c Audit the MCNs to ensure they are functioning effectively.

Workforce and training for each dental specialty should be reviewed to meet the current and future needs of the changing and ageing population in each location. The clinical academic workforce should be a priority to ensure that undergraduate and postgraduate training programmes can be delivered. a Following the NHS People Plan, and in conjunction the Advancing Dental Care review, investigate workforce requirements and innovative training solutions for each specialty. b Develop an implementation plan based on 7a.

Oral health should be recognised as an essential part of general health and wellbeing. There should be a holistic integrated approach, with particular emphasis on hard to reach groups, across secondary care, primary care dentistry, medicine and pharmacy, through integrated care systems (ICS) and primary care networks (PCNs). a Nationally, NHS England to develop clear policy direction on the inclusion of dentistry and oral health in the system transformation outlined in the NHS Long Term Plan. Regionally, NHS system leaders, commissioners of dentistry and Local Dental Networks should look to identify opportunities for the inclusion of dentistry in their local system design to support prevention, population health, personalised care and integrated services.

Local commissioning should ensure that patients with complex medical conditions referred for dental assessment from departments such as oncology, haematology and cardiology, should be seen in a timely fashion in the most appropriate setting. National guidelines should be developed to enable this. a Develop national commissioning standards for intra-trust referrals. b Use the commissioning standards to inform the local commissioning of pre-treatment dental examination. c Oversee the implementation of standards. d Carry out local audits to collect accurate data on referrals.

As part of measures to avoid repeat admissions for general anaesthetic, all referrals for children requiring GA for dental extractions should be accompanied by a robust and appropriate treatment plan. Dentists providing this, who are not specialists, must be aligned to a specialist-led paediatric dental MCN. a Develop an action plan to support the development of shared paediatric treatment plans between general dental practitioners and specialist-led paediatric dental MCNs. b Consider ways of reducing the number of general anaesthetics, for example by piggy-backing dental extractions onto other procedures such as ENT, where this is appropriate and will not lead to delays in treatment. c Establish a national audit and service evaluation of paediatric dental anaesthesia services, looking at access to services, quality, provision and need.

Waiting lists for children requiring exodontia must be reduced. There should be a clear aspiration that children at risk of oral infection should wait no more than 14 days from referral to treatment, and should not be prescribed multiple courses of antibiotics as a result of the wait. a Establish a working group to include providers and input from the Department for Health, Public Health England, commissioners and the wider paediatric community to come up with strategies and solutions for: - access to general anaesthetic facilities for children who need exodontia to reduce current waiting lists. - reducing waiting times for children over the longer term. b The group should collect and review data to include: - numbers of children waiting in three categories: 1. routine exodontia for fit and well children; 2. medically compromised children; 3. children who have been treatment planned for comprehensive care (restorations and extractions) under general anaesthetic - what percentage are in pain - what percentage have been prescribed antibiotics, number of courses, and by whom.

Strategies from the Children's Oral Health Improvement Programme Board (COHIPB) should be implemented at provider and commissioner level. Children's oral health should be treated as a high priority as part of the overall paediatric wellbeing agenda and be included in the work of the newly-created Paediatric Surgery Operational Delivery Networks (ODNs). a Liaise with the COHIPB Board to support the development of strategies to reduce inequalities in children's oral health. b The designated children's lead in each trust to include paediatric dentistry as part of their brief, including reporting on the number of extractions performed on children under general anaesthetic, linking with the ODNs. This supports the recommendation in the GIRFT report on paediatric surgery to ensure the children's voice is heard. c Develop and implement plans which will support dental care and oral health of children which includes: - providing simple preventative advice to families of children; - championing the British Dental Association's 'Was Not Brought' safeguarding guidelines; - ensuring that the dental part of the Personal Child Health Record is completed by midwives and health visitors and that they have good knowledge of child and baby oral health improvement; - making sure that waits of over 18 weeks are on the trust risk register; - making sure that child dental lists are not cancelled, including those run by the CDS; - establishing or supporting a child oral health programme; - championing initiatives such as Smile4Life and Dental Check by One.

Outpatient and day case prices for dental procedures should be reviewed to ensure they support clinically appropriate choices of setting and remove perverse incentives for inaccurate recording. Specifically, a day case setting should only be used and recorded where clinically necessary, for example where general anaesthetic or sedation requiring recovery is used. a NHS England and NHS Improvement, with case-mix colleagues in NHS Digital, to review outpatient and day case prices, once Recommendation 2 on coding of anaesthetics has been implemented and the definition of an outpatient procedure has been reviewed (as recommended by the GIRFT report on Oral and Maxillofacial Surgery).

Forthcoming revised guidance from the Royal College of Surgeons should be used to provide general dental practitioners and general practitioners clarity on when to refer TMD patients to secondary care. The guidance should also be used to consider whether more care currently provided in hospitals could be provided by a level 2 service based in primary care. This should be supported by action to reduce barriers to treatment in primary care and embed the guidance into everyday practice. a Establish a national multidisciplinary working group to be chaired by an expert in TMD who has sufficient depth and breadth of knowledge to deliver on the national scale but also to learn lessons from other countries and their systems of care. b Review barriers to treating TMD in primary care, including the high cost to patients of some appliances, as part of the contract reform process. c Update and revise the Royal College of Surgeons guidelines for primary care management of TMD, with guidance on how services should be provided for TMD patients across primary and secondary care. This should take into account existing research such as the NIHR-funded DEEP study and on-going international collaborative research into self-management.

Dental and non-dental hospitals and primary care should work together in regional oral medicine networks to manage referrals and deliver care to shared standards based on a hub and spoke model and clearly defined pathways as outlined in the NHS England commissioning standard. a Oral Medicine MCNs to be set up to include hospital OMFS and oral surgery units, tertiary oral medicine consultants, GDPs and GPs so that shared standards and care pathways can be agreed. b Develop a plan for change.

All head and neck cancer, cleft lip and palate and hypodontia MDTs should have a consultant in restorative dentistry as a core member of the team from the outset. The consultants from each specialty should ensure that the patient can move through the treatment seamlessly, without system delays that can cause iatrogenic damage. For children under 18 a paediatric dentist must be involved. a Review the number of MDTs with a consultant in restorative dentistry. b Explore how to attract new consultants to work in non-dental hospital trusts. Consider linking with the RD-UK consultant and specialist group, which provides clinical excellence networks for cleft lip and palate, hypodontia and head and neck cancer. These networks provide education and improvement programmes to support delivery of high quality care. c Develop a plan which is aligned with the specialised commissioning of head and neck cancer to fill the gaps and support future needs.

Where orthognathic surgery or oral surgery is planned after orthodontic treatment has already begun, patients should not have to wait more than 18 weeks for the surgery, so as not to unduly extend already lengthy orthodontic treatment times and increase the risk of iatrogenic damage. a Review British Orthodontic Society audit data on waiting times for orthognathic surgery, tooth exposures and extractions required as part of the orthodontic treatment process. b Based on 17a, if the wait is longer than three months, put a plan in place to investigate the causes and reduce waiting times. c Participate in national audits of orthognathic treatment outcomes.

The Peer Assessment Rating Index should be recorded for every completed orthodontic case with robust external audit of outcomes reported and reviewed through the managed clinical network. a Establish a champion to enable the monitoring of orthodontic treatment outcomes.

Trusts should work with general dental practitioners and the Community Dental Service (CDS) to provide joined-up and co-ordinated dental care for children and people with special care needs, identifying and breaking down traditional barriers between settings as envisioned by NHS Long Term Plan. a Develop a working group including Public Health England, NHS England, Health Education England, NHS Business Services Authority and specialist societies to: - Develop a clinically-led review of the CDS and the General Dental Service - Understand current barriers and how to break them down to enable shared care of special care patients - Explore different models of collaborative working between secondary care, general dental practitioners and the CDS, such as sharing advice by telephone or email on how to treat patients with medical complexity. b Put a plan in place for system change to support shared care arrangements.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and by sharing best practice. a Use sources of procurement data, such as the NHS Spend Comparison Service and relevant clinical data, to identify optimum value for money procurement choices, considering both outcomes and cost/price. b Identify opportunities for improved value for money, including the development of benchmarks and specifications. Locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. c Use Category Towers to benchmark and evaluate products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs.

Reduce litigation costs by application of the GIRFT Programme's five-point plan - see actions 21a-e. a Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts would have received this information in the GIRFT litigation data pack. b Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d Claims should be triangulated with learning themes from complaints, inquests and serious untoward incidents (SUI)/serious incidents (SI)/patient safety incidents (PSI) and, where a claim has not already been reviewed as SUI/SI/PSI, we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all front-line clinical staff in a structured format at departmental/directorate meetings (including MDT meetings, morbidity and mortality meetings where appropriate). e Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT we will be asking national clinical leads and regional hubs to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.