Orthodontic Managed Clinical Network
History of Orthodontic Provision
Traditionally in the UK orthodontic treatment has been provided in a variety of settings. These have included hospital orthodontic departments, specialist orthodontic practices, general dental practices, and community dental clinics. There has been little, if any, coordination of these various orthodontic providers.
General dental practitioners have acted as gatekeepers for orthodontic referrals and sent patients to the orthodontic provider, which they deemed the most appropriate. There has been a significant increase in the demand for orthodontic treatment, and orthodontic providers have become more specific in relation to the categories of patient they would accept for treatment. This situation is heightened by the new dental contract with it’s restriction of orthodontic provision to patients who meet Index of Orthodontic Treatment Need (IOTN) categories 4 and 5, as well as 3 with an aesthetic component of 6 or more.
The introduction of the new dental contract, for provision of services within the primary care sector, will impact heavily on the provision of orthodontic care. Previously, specialist orthodontic practitioners had no limit on the number of cases they could treat within practice. However, contracts will now specifically dictate how many patients can have their orthodontic care provided through the NHS, in any given financial year. Furthermore, the introduction of the specialist list registered with the General Dental Council, has increased both the public’s perception and the profession’s perception of which practitioners should be carrying out active orthodontic care.
For all these reasons it is recommended that the provision of orthodontic care, within any given locality, is coordinated in a more robust, prescribed and effective manner than has previously been the case. It is recommended that orthodontic managed clinical networks are established to ensure the efficient and effective provision of orthodontic care in any given geographical area.
Primary Care Trusts have become responsible for the allocation and management of dental contracts, including those relating to orthodontic provision. It will therefore be essential for the orthodontic managed clinical network to have established working relationships with the dental contract managers, at their local Primary Care Trust(s).
Orthodontic Managed Clinical Network (MCN)
The orthodontic managed clinical network should comprise orthodontic practitioners as well as referring practitioner and funding agency (PCT) representatives. The orthodontic practitioners will consist of consultant orthodontists, specialist practitioners and primary care dentists with a special interest in orthodontics (DwSIs). When appropriate, the local university teaching department should also be represented. The lead will usually be a consultant, or specialist practitioner.
The aims of the Orthodontic MCN are to:
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Ensure the highest standard of orthodontic care is provided by the local orthodontic workforce.
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Develop short, medium and long-term strategies with regard to maintenance and development of orthodontic provision.
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Assure access for patients to the most appropriate orthodontic care.
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Enhance communication between providers.
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Act as a source of advice on orthodontic provision.
Access to appropriate orthodontic management should be comprehensive and may include private (independent) sector care. Additionally as patient involvement becomes increasingly important, consideration should be given to means of scoping patients’ opinions, in relation to the quality and availability of the local orthodontic care.
The orthodontic network will work with the relevant PCT’s and orthodontic providers to ensure appropriate needs assessment, development of the service and monitoring standards of delivery and outcomes of care. The makeup and balance of the MCN will vary depending upon geographical location. Differences in the distribution of orthodontic specialists and DwSIs will influence the geographical area covered by an orthodontic MCN, in addition to the number of members. It may be appropriate for the orthodontic MCN to cover a similar geographical area to the local dental committees.
Local Orthodontic Committee
It is recognised that many areas in the UK have already established local orthodontic committees following BOS recommendations, several years ago. It is recommended that in areas where the local orthodontic committees are well established that committee should be responsible for establishment of the orthodontic MCN. In areas where no local orthodontic committee exists, then discussions will need to be held between the local consultant and orthodontic specialist to establish a lead.
Service Specification and Quality Assurance
The index of orthodontic treatment need (IOTN) will be used in the assessment of treatment need within the clinical network. Those patients falling into categories of IOTN dental health component grade 5, 4, and greater or equal to 3.6 would be eligible for assessment and provision of NHS orthodontic treatment if appropriate. Additionally some patients with lower levels of treatment need may be offered treatment by trainees if the treatment is deemed to provide a good teaching resource for undergraduate and postgraduate students. Where necessary, patients can also be referred to the PCT exceptional funding panel.
The Peer Assessment Rating (PAR) will be used to assess outcome. Under new contractual arrangements with the PCT, orthodontic providers in specialist orthodontic practice and general dental practice will be required to assess a proportion of their cases utilising the PAR index. Those practitioners with limited contracts would be expected to assess 100% of their cases with PAR.
Clinical governance and monitoring arrangements will be based on national and locally determined guidelines. For routine cases, current standards suggest that 75% of cases should exhibit a reduction in PAR score greater than 70%, with 3%, or fewer cases having a reduction in PAR less than 30%. This standard excludes patients with clefts of the lip and palate, orthognathic surgery cases and hypodontia cases where more careful interpretation is required.
Appraisal
All orthodontic providers should undergo an annual appraisal by an appropriate authority. The system which currently operates for consultant orthodontists in NHS Trusts could provide a model of this process. Appraisal of hospital consultants is a contractual requirement. This requirement will also soon affect specialist orthodontic practitioners and DwSIs. The organisation of appraisals for practitioners in primary care presents a particular challenge to the PCT who would accept responsibility for that process. Some aspects of the appraisal process could be managed through the orthodontic MCN with particular reference to analysis of the PAR scoring.
Monitoring of the Orthodontic Service
The PCT(s), in reviewing the service and the orthodontic delivery (through clinical governance, annual appraisal, annual review of the contract and future revalidation requirements), will seek evidence to the following:
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that the terms of the NHS contract and the guidelines for use of the service are being followed.
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that the caseload is appropriate.
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of relevant continuing professional development in general and special interest area and in clinical audit.
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that there has been an exploration of the views of patients, carers and other health professionals.
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of peer observation and compliance with future revalidation requirements.
Referral Pathways
The gatekeeper for referral of orthodontic treatment remains the general dental practitioner. The GDP can refer direct to the hospital consultant, specialist practitioner or DwSi, according to the needs of the patient and the relevant specialist skills of providers.
Any service development needs to be sensitive to teaching and training requirements in the locality, and should not prejudice undergraduate and postgraduate teaching and training.
Support for the Orthodontic Managed Clinical Network
The managed clinical network will require support, including some funding. The PCT could help by providing meeting accommodation and secretarial facilities. It is relevant to note that from April 2005, responsibility for supporting the implementation of PwSI services has rested with the Strategic Health Authorities
* NHS publication: “Dentists with Special Interests (DwSIs). A step by step guide to setting up a DwSI service” p25. 2006
