Health and Social Care Committee

Short inquiry into orthodontic services in Wales – Evidence from the Minister for Health and Social Services

Purpose

1. This paper outlines the background to the introduction of the current contractual arrangements for dentistry, the independent review and the previous inquiry into orthodontic services both completed in 2010/11, the current pressures on the service and work being carried out to address orthodontic capacity issues.

2. The paper also addresses the issues raised in the Committee’s terms of reference for the inquiry.

Background

3. Before 2006 the provider driven system in operation left all dentists, including orthodontists, to decide where and what level of NHS service they would provide. The system saw orthodontics accounting for high levels of NHS funding and the percentage year on year increases in orthodontic spend was well above that of other dental services. Some of the cases treated were on the lower end of treatment need.

4. In 2006 new contractual arrangements were introduced which saw three important changes in relation to orthodontics:

· the introduction of the Index of Orthodontic Treatment Need (IOTN) as a means of assessingthe need and eligibility for NHS orthodontic treatment on dental health grounds; this allowed LHBs to calculate the number and percentage of their resident populations that could be considered eligible/need for NHS orthodontic care;

· Local Health Boards (LHBs) were given responsibility for the provision of dental services to meet local needs; and

· there was a move away from a non-cash limited centrally held budget to a cash limited allocation to LHBs. 

5. In the past, there was often little consistency in the way that orthodontic needs were assessed. Under the new arrangements, all assessments are made using IOTN which provides a much fairer and more consistent way of assessing clinical need and defines the groups of patients for whom NHS orthodontic services treatment is considered necessary to secure their oral health.

Independent review of orthodontic services 2010

6. In 2010 an expert Review Group, chaired by Professor Stephen Richmond, Professor of Orthodontics at Cardiff University School of Dentistry, reported on the provision of orthodontics in Wales. This was in response to reported difficulties and followed a recommendation made by the NHS Dental Contract Task & Finish Review Group who highlighted orthodontics as an area requiring further consideration.

7. The Review report concluded that current spending on orthodontics in Wales was capable of largely meeting the orthodontic needs of patients. The report made clear there was little unnecessary treatment undertaken, although there was a need for improved validation and further confirmation regarding the quality of services provided. What also came over clearly was that the system of provision and management of orthodontic services in Wales contained inconsistencies and inefficiencies. In addition the location of and access to services was not uniform.

8. Welsh Government have asked Professor Richmond to conduct a further assessment and update of the data previously examined and reported on in 2010. This review commenced in April 2014 and is due to report by August 2014.

Health, Wellbeing and Local Government Committee inquiry into orthodontic services 2010/11

9. The Committee’s report broadly supported Welsh Government’s policy direction and also mirrored the findings and recommendations of the expert Review Group. The Committee made 17 recommendations covering service development, improving efficiency and effectiveness, along with better referral and monitoring. The recommendations and the action taken are summarised in Annex A.

Access for patients

10. The focus of a significant proportion of patients has moved from wanting to ensure their teeth are healthy and pain free, to a growing wish that they should also be cosmetically pleasing. This presents new challenges about where the boundaries should lie between treatment needed to maintain oral health- available for all who want it from the NHS - and cosmetic treatment.

11. Demand for orthodontic treatment has increased across the UK.The Welsh Government and LHBs also face spending pressures and orthodontic provision has to be placed in context with other dental health priorities. The expenditure on orthodontics within primary care dentistry represents 10% of the total funding of NHS dental services and 37.5% of the total expenditure on NHS dental services for children. It is therefore vital that continued funding is based upon sound needs assessment, prioritisation and an integrated approach between the orthodontic dental service providers.

12. Most recent (but as yet unpublished) data obtained from NHS Business Services Authority (NHS BSA) indicates that areas of concern highlighted by Professor Richmond’s 2010 report have started to improve. In 2012/13 LHBs commissioned additional Units of Orthodontic Activity (UOA) which led to an additional 500 patients per year starting treatment (6% increase). In addition the number of patients just receiving review appointments and no treatment was reduced by 59%. LHBs have started to concentrate their commissioning on a smaller number of specialist providers. These actions are important as the efficiency of the contract (value for money and productivity) will be improved as well as the quality of the outcome.

13. Despite improvements I am aware access difficulties for patients seeking orthodontic treatment remain in some parts of Wales with some patients waiting too long for treatment. A Welsh Government survey of each LHB (March 2014) provided the following data on current waiting times and the number of children accessing services in each LHB.

Provision of orthodontics in primary and secondary dental care

Local Health Board	Primary Care Waiting Times (latest available data)	Secondary Care Waiting Lists (latest available data))
Abertawe Bro Morgannwg ULHB	Referral to Treatment: Average 24 months (5,257 patients, includes 1,067 u/11 years of age - as at December 2013).	26 weeks/189 patients (as at December 2013).
Aneurin Bevan LHB	Referral to Assessment: 3-36 months (1,827 patients). Assessment to Treatment: 2-36 months (960 patients).	Referral to Assessment: 2-3 months (19 patients). Assessment to treatment: 18-36 months (28 patients).
Betsi Cadwaladr ULHB	Referral to Assessment: 6-24 months (average 16 months). Assessment to Treatment: 0-2 months (average 6 weeks).	767 patients (as at 6 April 2014).
Cardiff & Vale ULHB	Referral to Assessment: 12-24 months (4,019 patients). Assessment to Treatment: 0-2 months.	Referral to Assessment: 2-5 months (177 patients) Referral to Treatment:18-20 months (919 patients)
Cwm Taf LHB	Most patients are referred to practices in Cardiff (included in Cardiff & Vale ULHB figures).	Referral to Assessment: 2-8 months (416 patients). Referral to Treatment: 18-24 months (384 patients).
Hywel Dda LHB	Referral to Assessment: Average 9.6 months (2,145 patients). Referral to Treatment: 2.4 years (1,584 patients).	Referral to Assessment: 4 months (141 patients). Referral to Treatment: 7-8 months (59 patients).
Powys Teaching LHB	Referral to Treatment: 6-18 months	Up to 42 months (South Powys) – reflects recruitment issues (100 patients).

14. As the data indicates, there is wide variation in waiting time for both assessment and treatment across Wales. There are a number of reasons for this variation.  Inefficient, inappropriate and early referral processes inhibit practitioners from providing orthodontic treatment, and assessment appointments clog up appointment books. Evidence from NHS BSA suggests that a significant number of patients treated in 2009 (average 13% of all treatments provided across Wales) were retreated between 2012 and 2013. In addition during 2012/13, 624 patients abandoned or discontinued their treatment.  If these two areas can be reduced or eliminated then the system will be able to treat more patients per year and significantly reduce waiting times.

Effectiveness of working relationships between practices and LHBs

15. Welsh Government has heeded the recommendations of the Health, Wellbeing and Local Government Committee inquiry into orthodontic services 2010/11and has overseen the development of a series of regionally based Managed Clinical Networks. These were established in 2011 and have brought LHB officials and clinicians from both primary and secondary care together. Even in the relatively short time that they have been working some notable achievements have been delivered. These include the development of cogent referral protocols and processes, the refinement of the clinical quality monitoring system and the development of an accreditation process used to identify dentists with enhanced skills and capable of delivering high quality NHS orthodontic care

Funding for orthodontic services

16. LHBs receive funding for each of the NHS contracts delivered in their area. There are more orthodontic providers located in Cardiff and Swansea than anywhere else in Wales, consequently there is variation in funding levels for orthodontics in each LHB. For example, Cwm Taf Health Board have very little orthodontic activity or funding. However, the vast majority of their residents are treated in Cardiff. Professor Richmond’s 2010 report indicated that the NHS funding for orthodontics was adequate to meet the need.

17. NHS orthodontic treatment remains part of the LHB general dental services cash limited allocations with a total spend of £13.5 million (2012/13). Just over £12 million of this sum is spent on providing treatment and the balance is spent on assessment and repairs of appliances. It currently costs the taxpayer £1,300 to treat each individual patient. LHBs must develop more effective commissioning mechanisms to ensure that orthodontic treatment remains good value for money and remain affordable

Priority for orthodontics with the National Oral Health Plan

18. Together for Health: A National Oral Health Plan for Wales was published in March 2013. This is a five year plan and tasked LHBs to produce a local oral health plan. Orthodontics was highlighted as a priority within the National Plan. A number of specific actions were produced regarding orthodontics including the intention to review (alongside England) the current NHS orthodontic contract by 2016/17. The specific actions included the need for LHBs to:

· work closely together to develop regionally agreed referral and care pathways which will allow general dental services, Community Dental Services (CDS) and Hospital Dental Services to better work together;

· develop clear plans on how their residents will access specialist dental services based in primary care (specialists and dentists with enhanced skills), the CDS and/or secondary care, and ensure an integrated approach to the delivery of these services; and

· work to the Welsh Government’s Guidance on Management of NHS Orthodontics in Primary Care.

19. In addition the development of a Strategic Advisory Forum in Orthodontics has enabled Welsh Government to obtain expert clinical advice on the development of national orthodontic policy for Wales. NHS BSA continues to provide the clinical monitoring of NHS orthodontic contracts. During 2012/13 a random selection of orthodontic contracts were examined, and action taken to rectify poor quality care was advised on 1 provider (29 provider contracts were monitored)

Impact of the dental contract on the provision of orthodontics

20. LHBs and providers find it easy to monitor delivery of UOAs and agree that the contract is simple to administer. Providers prefer the current regular ‘up front’ payment mechanism in comparison to old ‘fee per item’ system. The introduction of the IOTN criteria for NHS orthodontics has also clarified issues of who is eligible to access NHS orthodontics.

21. In terms of future areas for action the following issues need to continue to be targeted.

· Further work is required on developing a robust data collection system.

· High number of treatment incompletion rates, inappropriate use of UOAs in orthodontic assessments and poor treatment outcomes. It is difficult to impose a financial or contractual penalty when poor quality care is delivered. There are challenges in finding the best way to monitor and manage such matters and further work is underway to improve the position.

· The capacity of LHBs to monitor results beyond UOA delivery requires careful consideration and there is a need to develop a patient report outcome measure (as a measure of quality).

· LHBs continue to commission general dental services contracts which have small quantities of orthodontic elements within them. These contracts are inefficient and often have relatively large assessment to treatment ratios. In addition when these contracts are reviewed/replaced there is some loss of orthodontic activity as LHBs convert orthodontic activity into general Units of Dental Activity i.e. non orthodontic courses of treatment.

· The current system needs to do more to actively encourage use of skill mix. For example, use of orthodontic therapists in delivering some aspects of orthodontic care; and finally

· When treatment is abandoned/discontinued by a provider the current contract is not clear on responsibility for treatment completion so LHBs can be faced with paying twice for the same patient if they start treatment with one provider and complete their treatment with another provider. We are considering changes to the Regulations to address this issue. 

Mark Drakeford AM

Minister for Health and Social Services

Annex A

Recommendations from the Health, Wellbeing & Local Government Committee report into orthodontic services 2010/11

RECOMMENDATION	COMMENT/CURRENT POSITION (April 2014)
1. Welsh Government commissions further research to assess the orthodontic treatment need, ensuring that contracts for orthodontic treatment are adequate to meet demand	Managed Clinical Networks (MCNs) have been established across Wales covering SE, SW and NW Wales (Powys links in to NW MCN). MCNs contribute to the work of the Strategic Advisory Forum (SAF) on Orthodontics established by the Welsh Government (WG) in July 2011 to take forward the recommendations of the Inquiry and the WG’s Task and Finish Group. Role of MCNs is to liaise with the Local Health Boards (LHBs) to establish appropriate clinical pathways and be responsible for appropriate standards of clinical care. Where there is an unmet need for orthodontic care, the LHBs in conjunction with the local clinical network, should test the use of an appropriate skill mix to assess needs and priorities for care.
2. LHBs improve the efficiency and effectiveness of orthodontic services delivery through effective procurement processes This should include ensuring that contracts contain details about the number of treatment starts and treatment completes per year in each contract	Similar to the Independent Task and Finish Group Report (T&F Report) recommendation 2. Welsh Government issued interim guidance to LHBs in March 2011 on the effective and efficient commissioning of orthodontic services. The guidance covers a range of issues including: the use and interpretation of data for improved contract management particularly in relation to assessment/review/treatment starts; Peer Assessment Rating (PAR) and specific contractual information requirements. Feedback from LHBs and MCNs confirms that the guidance is being used and working well. Guidance was reissued to LHBs May 2013.
3. Welsh Government produces guidance for LHBs on the effective and efficient procurement of orthodontic services This should include guidance on developing agreements based on the number of treatments provided per year, quality of services, orthodontic treatment outcomes and value for money	Similar to T&F Report (rec 2). Covered by WG guidance - reissued to LHBs May 2013.
4. Welsh Government discusses with the Welsh Consultant Orthodontic Group how to introduce standardised Unit of Orthodontic Activity (UOA) rate to address the disparity in UOA value and volume of treatment provided	Although there is some variation in rates, the value of a Unit of Orthodontic Activity (UOA) is relatively uniform across Wales, average £62 with a range from £58-£74. Standardisation of the UOA might create additional capacity but it could also destabilise the service if such a move was adopted overnight. Orthodontists have fixed term contracts and changes can only be negotiated when they are due for renewal. There are financial implications if the value of the UOA is standardised at a higher level than the current average value. LHBs have considered UOA value outliers as part of negotiations on contract renewal.
5. LHBs review contracts identified as delivering orthodontic assessments only or mainly assessments and very few treatments	Covered by WG guidance – reissued to LHBs May 2013.
6. LHBs introduce specific contractual changes to take account of treatment provided rather than just delivery of UOAs This should include consideration of whether practitioners should be allowed to claim for a repeat assessment within a short period of time unless it is clinically justified	Covered by WG guidance – reissued to LHBs May 2013.
7. Welsh Government facilitates the development of an electronic referral system in line with Recommendation 6 of the Government‘s national review, which will allow records to be monitored centrally	Similar to T&F report (rec 6). WG is continuing to encourage LHBs and General Dental Practitioners (GDPs) to use electronic data pending a change to the current contract/regulations. LHBs will also benefit from the additional funding the WG is making available from the Health Technologies and Telehealth Fund to support, amongst other things, e-referrals.
8. LHBs support the establishment of local MCNs in orthodontics with the view of improving patient care MCNs should take lead responsibility for reducing early, multiple and inappropriate referrals in line with Recommendation 12 of the Government‘s national review	Similar to T & F Report (rec 12). Inappropriate referrals covered by WG Guidance. MCNs have been established across Wales and have overseen the development and implementation of new referral management processes. Initial feedback suggests an improved position but it is too soon to the measure the real impact. The SAF will continue to monitor the situation as part of its regular work programme.
9. Welsh Government funds a one-off waiting list initiative to clear the backlog of patients waiting for orthodontic treatment	No additional funding provided due to other pressures/demands on budgets. Any additional funding to be met from efficiency savings and improvements to the current system.
10. Welsh Government discusses with the General Dental Council (GDC) how to ensure that the issue of inappropriate referrals is addressed and whether IOTN training should be mandatory for all GDPs	The curriculum for undergraduates includes Index of Orthodontic Treatment Need (IOTN) training and dentists are expected to keep abreast of all clinical issues through mandatory Continuing Professional Development (CPD) processes. The curriculum for undergraduate training already contains a module on IOTN and dentists are expected to keep abreast of all clinical issues through the mandatory CPD. WG also funds dental training at Cardiff University which provides both undergraduate and postgraduate training. Undergraduates are trained regarding diagnosis, when and how to refer using IOTN, PAR, and the use of removable and fixed appliances. Postgraduate courses in orthodontics provide advanced orthodontic training. Inappropriate referrals covered by WG Guidance. Improved software helping to address issue as IOTN is automatically triggered on inputting information.
11. Welsh Government amends Regulations to include a contract penalty for practitioners who persistently refer patients early or making a high volume of inappropriate referrals in order to encourage them to change practice	The requirement for such an amendment will be considered when changes are made to  the current contract/regulations based on the evidence coming forward.
12. LHBs set out clear contractual arrangements with DwSIs including close monitoring of treatment outcomes, with a view to the development of specific orthodontic Personal Dental Services agreements	The establishment of MCNs has seen a move to the development of Dentists with a Special Interest (DwSIs) providing orthodontic services N.B. DwSIs now referred to as Dentists with Enhanced Skills (DES). Accreditation Schemes for DES have been established across Wales. SAF monitoring as part of its regular work programme.
13. LHBs work with local MCNs to introduce a local accreditation scheme and continuing professional development for DwSIs	See recommendation 12 above.
14. Welsh Government facilitates the development of the skills base of the orthodontic workforce	The Accreditation Schemes for DES will aid the development of the skills base (see recommendation 13 above).
15. Welsh Government strengthens the current GDC guidance to ensure orthodontic therapists must be supervised by an orthodontist on the specialist register as opposed to a general practitioner at all times	The General Dental Council (GDC) is the regulatory body and assesses competence.  Situation changed since recommendation made. New GDC guidelines addresses this issue.
16. Welsh Government amends Regulations to include a contract penalty for poor quality treatment (based on PAR and excluding those cases where the patient was not compliant with the treatment)	Contract sanctions already exist for poor quality work. WG guidance contains guidance on PAR.
17. Welsh Government develops an implementation process to facilitate close monitoring of treatment outcomes through PAR and establish a system where PAR score reductions are monitored independently on annual basis for all providers	Guidance on PAR is covered in the WG guidance. PAR forms part of the role of MCNs to address.  PAR monitoring in place across Wales via MCNs with SAF also monitoring as part of its regular work programme.