Delivering the 18 Weeks Referral to Treatment Standard Output Report

Dental Specialties Task and Finish GroupDelivering the 18 Weeks Referral to Treatment Standard forDental SpecialtiesOutput ReportJanuary 2011

ContentsIntroduction 4Foreword 4Chair’s Reflections 6Context 718 Weeks Referral to Treatment Standard 7The 18 Weeks National Delivery Structure 7Task and Finish Groups 7Dental Specialties Task and Finish Group 8Dental Specialties’ Supply and Demand 9Current Waiting Times 10Identified Risks to Delivery 11Priority Task and Finish Group Improvement Actions 11Planning and Delivery 13Profile 13Measurement Considerations 13Monthly Management Information 14Treatments in Outpatient Departments 15Clinical Outcome Reporting 15Frequently Asked Questions and Scenarios 16Applying the Definitions 17Action Planning – Undergraduate Treatments 18Demand, Capacity, Activity, Queue Analysis 18Health Intelligence 19Influencing Referral Processes 24Dental Specialties Task & Finish Group – January 2011 2

Demand is not a given 24Effective Referral Management 25Advice Only Referrals 26Early Referrals 27Pathway Approach: Philosophy 27Referral Management Pathways for Orthodontics and Oral Surgery 28Index of Orthodontic Treatment Need 28Restorative Dentistry 29Scottish Dental Needs Assessment Programme 29Managing Patient Flows 30Servie Redesign and Transformation 31Tele-dentistry 32Dental Specialties’ Workforce Skills Mix 34Workforce Solutions Workshop 35Communication 37Stakeholder Groups 37National Events 37Conclusion: Action Planning and Ongoing Work 38Summary of Fundamental Next Steps for Boards 39Appendix One: Membership of Dental Specialties Task and Finish Group 41Appendix Two: Key Areas for Improvement 41Appendix Three: Orthodontic Referral Management Pathway Group 43Appendix Four: Oral Surgery Referral Management Pathway Group 44Appendix Five: Orthodontic Pathway and Referral Guidance 44Appendix Six: Oral Surgery Pathway and Referral Guidance 47Appendix Seven: Who is doing what Matrix 49Dental Specialties Task & Finish Group – January 2011 3

IntroductionForewordThe work of the Dental Specialties Task and Finish Group has been sponsored bythe Scottish Government’s 18 Weeks Referral to Treatment (RTT) OperationalDelivery Team, and ultimately by the Scottish Government’s Health DeliveryDirectorate. The Task and Finish Group, has, from a national perspective,considered how identified risks to delivery across these specialties may beproactively managed, and this report details outputs of this work.The core elements listed below are commended to you by the Operational DeliveryTeam for action. Every Board is therefore expected to ensure that each aspect isfully explored, progressed and embedded appropriately across their HealthCommunity to support timely and high quality patient care. It is essential that allopportunities for streamlined service management and ongoing improvement andtransformation are optimised, with the patient’s interest right at the centre. Deliveryand improvement require whole systems ownership and strong organisationalleadership – both clinical and managerial – in order to operationalise change on asustainable basis. For dental specialties, much of this will take place at theprimary/secondary care interface, as well as requiring a continuing focus on differentways of working in the acute secondary care sector.The core elements commended to Health Communities and NHS Boards forearly action are:1. Ensure high organisational profile of, and clear delivery expectations inrelation to Dental Specialties, with integration into Boards’ existing deliverysystems for all other specialties, including waiting times performancemonitoring and management, service redesign and pathway work.2. Proactively pursue accurate and fit for purpose data capture and its uselocally as a key source of health intelligence. Information should be used forservice planning, including managing the balance of capacity and demand; forhighlighting actions needed for service improvement; and for performancemanagement of waiting times targets. Accurate measurement of 18 weeksRTT for Dental Specialties is also reliant on the uniform application of ‘clockstarts’ and ‘clock stops’ which are set out in detail in the Dental Definitions &Scenarios : http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-and-finish-groups/dental-specialties/3. Drive uniform implementation of the agreed common pathways forOrthodontics and Oral Surgery, and ensure these are embedded right acrossthe health community on a sustainable basis, to support equity of access andcare. Implementation of these pathways as commended, will also influencereferral practices and referral thresholds, and engagement should thereforebe initiated with stakeholders across the whole care system to promoteadherence to the pathways.Dental Specialties Task & Finish Group – January 2011 4

4. Make the most of your workforce, by evaluating the responsibilities andcompetencies of the multidisciplinary team, and proactively enhancing theskills-mix of other professionals to complement existing roles and functions.It is expected that health communities will continue to develop and improvesecondary care dental services and pathways locally; there is still much to do tosafeguard sustainable and timely service provision. The Improvement and SupportTeam will continue to provide support to Boards in achieving the 18 Weeks Referralto Treatment target. The Summary of Fundamental Next Steps for Boards on page39 may provide useful guidance for service redesign.Should performance across any of the dental specialties prove unsatisfactory, theescalation process triggered by the Scottish Government could include further actionplanning with the Access Support Team, more detailed tailored support, interventionas needed and submission of detailed recovery plans.Robert CalderwoodChair of the 18 Weeks Operational Delivery TeamDental Specialties Task & Finish Group – January 2011 5

Chair’s ReflectionsHistorically there has perhaps been a feeling that Dental Specialties are lessimportant, or are considered to be a specialty sidelined from the main stream. Thisis not true. The quality and timeliness of patient care and the patient experienceremain paramount in all specialties, and the waiting times standards apply.Dental Specialties are not different.The 18 Weeks RTT therefore provides an opportunity, as well as a challenge, tobring secondary care dental specialties onto a par with all other organisationallearning and established systems and processes already embedded in otherspecialties, to ensure that all dental specialties are fully empowered to provide highquality and timely patient care on an ongoing basis.The best way to start addressing the issues is to begin with the basics and work upto ensure all the foundations are firmly laid which in some cases can bring somequick wins.In its discussions the Task and Finish Group considered some of the elements thatare generic across all dental specialties. Other elements and issues consideredpertain to specific dental specialties. This approach is reflected in this report too.Derek LeslieChair of the Dental Specialties Task and Finish GroupDental Specialties Task & Finish Group – January 2011 6

Context18 Weeks Referral to Treatment StandardThe Cabinet Secretary for Health and Wellbeing has pledged “a whole journeywaiting time of 18 Weeks from…referral to treatment by December 2011.”This applies equally to all specialties provided in secondary care, and thereforeincludes Dental Specialties.18 Weeks will therefore be the maximum wait from receipt of referral into secondarycare, to the start of the first definitive treatment, for all non-emergency conditions.The 18 Weeks National Delivery StructureIn order to ensure a cohesive approach between the Scottish Government andHealth Boards in the delivery of this target, while ensuring high quality patientfocussed care is maintained, a national delivery approach was established. The 18Weeks’ Programme Board oversees the work of four Delivery Teams – focussing onInformation, Emergency Access, Operational Issues, and Diagnostics. The detailedinvolvement of key stakeholders and ‘change-champions’ in this process brings aninformed mix of knowledge, expertise and experience to each specialist area.Task and Finish GroupsAs a consequence of analyses undertaken through the Operational Delivery Team, anumber of Task and Finish Groups were set up to concentrate on those specialtiesregarded as most at risk to delivering the 18 Weeks Referral to Treatment Target.Each of these short life working groups consists of a small number of expert advisors- clinicians, service managers and additional professionals involved in that specialty;the groups are also supported by members from the Scottish Government’s HealthDelivery Directorate. The first five ‘at risk’ specialties to see the establishment of aTask and Finish Group were: Audiology, Dental Specialties, Neurological Services,Orthopaedics and Plastic Surgery. More recently Task and Finish Groups have alsobeen established for Dermatology, Diagnostics and Capacity / DemandManagement. Although each of the Task and Finish Groups focus on particularissues relating to that specialty area, all groups work from a series of common workstrands, namely:• Measurement and Definitions• Demand/Capacity/Activity/Queue Analysis• Demand Side Solutions• Performance Management• Service Redesign and Transformation• Culture/Change• Workforce• CommunicationDental Specialties Task & Finish Group – January 2011 7

Dental Specialties Task and Finish GroupThe Dental Specialties Task and Finish Group had its first meeting in September2008, and ran as a short-life working group until September 2010. Membership islisted as Appendix One.The Task and Finish Group recognises the differences in service delivery betweenthe different dental specialties; however, this output report picks out common themesand approaches which largely apply, as well as specifics for the different specialties.Mythbusting:Fact: All Dental Specialties must deliver the 18 Weeks Referral to Treatment targetby 31 December 2011. There are no exceptions.Dental Specialties included within the 18 Weeks RTT Standard are:• Orthodontics;• Restorative Dentistry;• Oral Surgery;• Oral Medicine;• Paediatric Dentistry; and• All Dental Procedures carried out under General Anaesthetic.Maxillofacial Surgery (in or out of 18 Weeks RTT?)Maxillofacial surgery is technically not classified as a Dental Specialty and thereforeis outwith the remit of the Dental Specialties Task and Finish Group. Much of theactivity within this discipline is linked to Oral Surgery and therefore it is difficult toextricate the two. Clinicians and other stakeholders have therefore adopted anintegrated approach. Regardless, the 18 Week Referral to Treatment target stillapplies.Community and Salaried Dental Services (in or out of 18 Weeks RTT?)The complexities of patterns of service delivery in the different care settings are wellrecognised, influenced by the financial and other drivers which come into play. Theconsequent interaction between the different parts of the service can have asignificant impact on the provision of care.Nevertheless, consultations and treatment carried out by general dentalpractitioners, community dental practitioners or by specialist practitioners workingwithin the community and salaried services are not part of the 18 Weeks Referral toTreatment target.There are, however, two exceptions when community based interventions arepart of the 18 Weeks RTT Standard:Dental Specialties Task & Finish Group – January 2011 8

1. The planned procedure which is being carried out in the community is undertakenby a secondary care specialist.2. The procedure requires a General Anaesthetic.In these circumstances the intervention will be included in the 18 Weeks RTT target.Further clarification is given in the Dental Specialties Frequently Asked Questions:http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-andfinish-groups/dental-specialties/Dental Specialties’ Supply and DemandThe Task and Finish Group firmly recognises the variation in service supply indifferent parts of the country and acknowledges the affect that this can have uponmodels of care within different health communities and ultimately, where treatmentsare provided.It is recognised that some parts of the country do not have the same level ofpractitioners across primary and community care as others. In particular there isevidence of variation between central belt and the North of Scotland, such asperhaps more limited independent sector provision in the North.Similarly some parts of the country, often remote and rural areas, find it difficult toattract General Dental Practitioners. Within General Dental Practice itself, serviceprovision varies, for example a high street general dental practitioner may treat eitherNHS or private patients, or both. This creates varying dynamics and patient flowsacross different health communities.As a consequence, in some geographic areas, there is more reliance upon theprimary care salaried dental services (PCSDS) to provide fundamental dentaltreatment.As a result of such variation, alternative approaches to care have been adopted. Forexample, Forth Valley has two specialist orthodontic practices, which has had asignificant impact on keeping secondary care lists shorter, whilst Dumfries andGalloway has established an alternative model of care based around their primarycare centres. In the North of Scotland, a Primary Care Specialist in Oral Surgerytakes referrals directly from General Practice, which creates another different modelof care.Thus, a range of factors impact on the supply of care within the primary andcommunity setting, and can result in a high level of demand for basic dental care tobe provided within acute secondary care. This creates an imbalance of supply anddemand, which can result in long waiting times for some dental specialties.Patient flows are further affected in that currently just under 70% of Scotland’s adultpopulation is registered with a General Dental Practitioner. The remaining 30% aretherefore perhaps more likely to present to secondary care regardless of the severityof their condition.Dental Specialties Task & Finish Group – January 2011 9

during a return outpatient appointment. This is to be encouraged, but in manyinstances, current reporting systems mean that these treatments are not recorded aspart of the activity. Similarly currently they do not always ‘stop a clock’ as part ofmeasuring patient waiting times.One of the key challenges to these specialties therefore, is capturing and measuring,and then delivering all elements of the patient journey. This should facilitate anunderstanding and management of the true stage of treatment waiting times in orderto make progressive improvements to reducing waiting times.By reducing the component parts of the patient journey (i.e. outpatients, inpatients,daycases), achievement of the whole pathway, from receipt of referral to the start ofdefinitive treatment, within 18 weeks becomes more manageable. It is this deliveryrequirement that the Task and Finish Group has focused upon, across all thespecialties, and continue to address the identified risks to delivery and theconsequent challenges and opportunities as a core part of its outputs.Identified Risks to DeliveryFrom its inception, the Task and Finish Group highlighted a range of challenges forearly consideration:1. Long waiting times in some dental specialties.2. Interface between primary and secondary care and the financial drivers that canaffect this.3. Variations in referral practices and differing treatment pathways across the caresettings for a single condition (e.g. simple extraction of tooth).4. Variations in referral thresholds, especially for orthodontic treatments.5. Establishment of robust data collection and reporting systems to proactivelymanage dental specialties and associated waiting times.6. Uniform application of the definitions to ensure consistent and accurate recordingof patient journey times.7. Hidden waits for treatments undertaken in the outpatient setting which were notpreviously measured.8. Workforce considerations and further use of enhanced practitioner roles.9. Organisational profile and integration of dental specialties into waiting timesmanagement processes.Priority Task and Finish Group Improvement ActionsAs part of the methodology for minimising these risks, the Dental Specialties Taskand Finish Group identified the following priority actions for the Group:Dental Specialties Task & Finish Group – January 2011 11

1. Ensuring high organisational profile of, and clear delivery expectations in relationto Dental Specialties, with integration into Boards’ existing delivery systems for allother specialties.2. A critical success factor in the delivery of 18 weeks RTT is clearly recognisingthat 18 weeks applies equally to all Dental Specialties as to any other specialty.3. Embedding learning from other specialties regarding delivery e.g. thefundamental principles of waiting list management.4. Proactively pursuing accurate and fit for purpose data capture and its use locallyas a key source of health intelligence.5. Setting out and then encouraging the uniform application of ‘clock starts’ and‘clock stops’ to facilitate the accurate measurement of 18 Weeks RTT for dentalspecialties.6. Ensuring accurate recording of treatments undertaken in an outpatient setting(including return outpatient appointments) so clocks are stopped once firstdefinitive treatment is commended.7. Developing common pathways for Orthodontics and Oral Surgery, and drivinguniform implementation to ensure these are embedded right across the healthcommunity on a sustainable basis.8. Highlighting workforce opportunities in order to proactively enhance the skills-mixof other professionals to complement existing roles and functions.Dental Specialties Task & Finish Group – January 2011 12

Planning and DeliveryProfileThe organisational profile of Dental Specialties and the associated expectations ofdelivery are critical to the achievement of the waiting times targets and the provisionof high quality patient care.The Task and Finish Group has worked to raise the profile of Dental Specialties insecondary care and to emphasise their inclusion in the 18 Weeks Referral toTreatment Standard.Boards are asked to ensure that dental specialties are fully integrated into all aspectsof their 18 weeks RTT work, especially generic workstreams on information,performance monitoring and management, service redesign and pathway work.This will facilitate organisational learning and the adoption and spread of goodpractice waiting times management and delivery (i.e. reduce a tendency to reinventthe wheel).Dental Specialties should also be a standard part of each organisations’ regulardelivery management meetings, underpinned by high level leadership and support toaddress bottlenecks and improve access to services.MythbustingFact: Dental Specialties are no different to other acute specialties and are expectedto deliver to the national waiting times standards.Action Planning - Waiting Times Delivery ProcessesNHS Boards should continue to mainstream Dental Specialties into establishedwaiting times delivery processes, and learn from good practice approaches.Measurement ConsiderationsOne of the initial actions of the Task and Finish Group was to assess waiting timesinformation provided to the Information Services Division (ISD). The Task and FinishGroup has identified significant concerns with the existing data available for dentalspecialties. Although Boards have historically provided some Stage of Treatmentdata in their submissions to ISD, this is not deemed complete or sufficiently robust tofully inform day-to-day management and improvement actions. Validation systemsand processes are not embedded, and the data must therefore be treated withcaution.Dental Specialties Task & Finish Group – January 2011 13

In order to progress these issues outlined above, ISD convened an internal ‘dentalinformation group’. This group has initially focussed on the further analysis of currentdata to ascertain its completeness and accuracy.As part of this approach, the Task and Finish Group continue to prioritiseengagement with colleagues from ISD to support all stakeholders in developingmethodologies for accurately capturing data. Work continues to identify andestablish improved measurement and data collection systems for all dentalspecialties, based on locally-derived information sources. Such a data set isessential to provide a sustainable measurement and reporting system that can beused for three primary purposes – for service planning, for service improvement andfor performance management, each at the local, regional and national levels.Discussions at the data masterclass held on 28 th September 2009 provided a furtherinsight into how existing data sources and collection systems might be improved andaugmented. As well as performance management, other factors that will help focusthe need for comprehensive data were identified as:• Managing Did Not Attend (DNA) rates.• Assessing variation in referral rates by general dental practices.• Understanding who could potentially be best treated in primary care or insecondary care.• Ensuring general anaesthetics are recorded for all patients, irrespective of whomretains responsibility for the patient.Action Planning - Data CollectionHealth Boards need to action and embed a robust and sustainable measurementand reporting system that can be used at different levels for service planning, forimproving the patient journey and for performance management. NHS Boards needto consider how they mainstream this information for everyday operational use.Monthly Management InformationAs an interim approach, pending measurement of the full 18 Weeks journey, NHSBoards have been asked to use their local intelligence to provide Dental MonthlyManagement Information (MMI). Specifically, Health Boards have been asked tocomplete information on the number of new patients waiting longer than 9 and 12weeks for assessment in the outpatient setting and the number of patients waitinglonger than 9 and 18 weeks for return out-patient treatments, covering the fiveDental Specialties and General Anaesthetics. At present though, not all HealthBoards are regularly submitting their spreadsheet, and not all those received arecomplete. Further emphasis on completion and accuracy of this information hasbecome critical; without this it is difficult to significantly progress performance,service redesign and improvement. To support this process, and to build on existingorganisational learning the Dental Monthly Management Information should becompiled, verified and submitted centrally by each Board’s information departmentalong with the main MMI.Dental Specialties Task & Finish Group – January 2011 14

Action Planning - Dental MMINHS Boards should create drivers to ensure the collection and submission of theDental Monthly Management Information (MMI), co-ordinated by their InformationDepartment.Treatments in Outpatient DepartmentsA cause for increasing concern is the high proportion of dental treatmentsundertaken within an outpatient setting that are not recorded. Often, only theoutpatient first assessment and inpatient or daycase treatment is recorded but notthe treatment activity specifically undertaken as a return outpatient, nor the length ofwait and time of ‘clock stop’ for this cohort of patients. The waiting times targets stillapply to this group of patients, but due to such measurement difficulties it has notalways been possible to tightly manage them. Long waits are been reportedanecdotally and urgent data capture is needed to understand the activity required totreat this group of patients within national waiting times.Action Planning - Data CaptureThere is an urgent need to ensure accurate data capture of all treatmentsundertaken within an outpatient setting, to ensure compliance with national waitingtimes.Clinical Outcome ReportingThe uniform application of clinical outcome reporting is an important aspect ofcapturing Dental treatment undertaken in an outpatient setting. Even if this iscaptured initially on paper, the resulting intelligence should be electronicallyrecorded, manipulated and interrogated. Work continues via the Improvement andSupport Team (IST) and local 18 Weeks RTT teams to ensure that clinical outcomesare recorded within Health Boards, across all specialties.A number of Boards are already diligently completing their clinical outcomes acrossthe Dental Specialties; others need to roll out this system more widely. Local auditsof completeness and accuracy of the data captured a) on paper, and b)electronically, are being considered in some areas.Action Planning - Clinical OutcomesEnsure capture of your clinical outcome codes for all stages of the patient journey -first assessment and return outpatient appointments whether for treatment or review.As part of the 18 Weeks RTT Standard, to be achieved by December 2011, wholejourney measurement must be developed for Dental Specialties in line with all otherDental Specialties Task & Finish Group – January 2011 15

services. The national targets for both non-admitted and admitted datacompleteness and performance and ongoing improvement in, and reliance on, thesewhole journey measures continues to receive a high priority nationally.MythbustingFact: Dental Specialties are part of 18 Weeks RTT reporting and must therefore bepart of the whole journey data completeness process in Boards.Members of the Dental Specialties Task and Finish Group continue to work withcolleagues from ISD to help NHS Boards create a robust data capture system for allparts of the journey, and particularly in the measurement of waiting times for returnout-patient treatments.Given this essential requirement for robust and fit-for-purpose data and information,a ‘Dental Specialties Data Quality Improvement Group’ has recently beenestablished, based on a model previously used for New Ways and Audiology dataquality improvement. This group will focus on working proactively with keystakeholders in NHS Boards to improve and embed Dental Specialties informationand understanding. Initially this revolves around a scoping exercise to ascertainnational and local data requirements and then to identify systems and processes forcollecting and verifying data capture for detailed use at a number of levels.Action Planning - Local Information ExpertiseUse local expertise within your Board’s information department to helpsupport and improve Dental Specialties data quality, data collection and analysis.Frequently Asked Questions and ScenariosThe application of common definitions is fundamental to the accurate measurementof waiting times in all specialties, including dentistry. The generic clock start/stopdefinitions apply, as set out in 18 Weeks: The Referral to Treatment Standard –Principles and Definitions (issue 2.0, January 2009).http://www.18weeks.scot.nhs.uk/how-to-measure-and-monitorperformance/principles-and-definitions/The Information Delivery Team advises that this document is currently being revised.The Task and Finish Group has compiled a series of Frequently Asked Questions(FAQs), with a view to enhancing the understanding of how the 18 Weeks RTTPrinciples and Definitions apply to Dental Specialties. The challenge is to apply theprinciples and definitions universally.The Dental Definitions & Scenarios is intended to address any inconsistencies inunderstanding and common application of the definitions right across NHSScotland,Dental Specialties Task & Finish Group – January 2011 16

and may be accessed at: : http://www.18weeks.scot.nhs.uk/how-to-achieve-andmaintain-18-weeks/task-and-finish-groups/dental-specialties/MythbustingFact: 18 Weeks RTT applies to the five secondary care Dental Specialties andGeneral Anaesthetics, namely:• Paediatric Dentistry• Orthodontics• Restorative• Oral Surgery• Oral Medicine• General AnaestheticsApplying the DefinitionsAn 18 weeks journey is measured from receipt of referral into secondary care, to thestart of definitive treatment. It is important that all localities continue to apply andrecord the clock starts, pauses and stops in the same way. The measurement clockstarts on date of receipt of referral into secondary care. The clock stops at the startof first definitive treatment.An ongoing programme of treatment, once commenced, is not part of 18 weeks RTTmeasurement. However it is a fundamental aspect of service provision and importantto recognise in capacity planning.Additionally, there are occasions when a clock will be paused or reset. These aredescribed in the Dental Definitions and Scenarios.MythbustingFact: An 18 Week journey is measured from receipt of referral into secondary care,to the start of definitive treatment. Accurate and uniform application of clock startsand stops will ensure that journeys do not seem longer than they actually are.Patients who choose to be reviewed and treated in a Dental School as part of anundergraduate training programme are not subject to the 18 Weeks RTT standard.This is because assessments and treatments required for training purposes may notnecessarily be required to be treated in a secondary care setting. Additionally,patients may experience a longer wait to accommodate the timing of theundergraduate curriculum.However, if a patient is seen in the Dental School by any other grade their waitingtime clock will continue to count down until their first definitive treatment is delivered.Dental Specialties Task & Finish Group – January 2011 17

MythbustingFact: Procedures performed by undergraduate dental students are not covered bythe 18 Weeks RTT Standard.Action Planning – Undergraduate TreatmentsSystems should be set in place to ensure that patients are aware of their exclusionfrom 18 Weeks RTT when opting to be treated as part of the Undergraduate TrainingProgramme.Demand, Capacity, Activity, Queue AnalysisAccurate data input and capture of the resulting health intelligence is integral torobust demand, capacity, activity, queue (DCAQ) analysis. Understanding, and thenmanaging, the balance of capacity and demand for each of the secondary careDental Specialties is fundamental to every health system’s ability to deliver.Action Planning - Managing Capacity and DemandUndertake Demand, Capacity, Activity and Queue (DCAQ) analysis for each DentalSpecialty in order to understand and then manage the balance of capacity anddemand.Boards need to prioritise DCAQ management for their Dental Specialties, ensuringthat all actions are taken which may influence this. Important elements to considerand carefully manage include the proactive management of seasonal variations,booking systems and treating routine patients in turn.In order to deliver a sustainable and equitable service across secondary care DentalSpecialties, it may be necessary to undertake some one-off backlog removal to bringservices into balance. However, this should only be done on the basis of achieving asustainable balance between capacity and demand, ensuring that continuousoptimal use is made of the resources available. The Task and Finish Group hasidentified a range of areas where the uniform application of good practice will offeractivity gains and as a result of working smarter, not harder, an increased level ofactivity may be achieved.Action Planning- Board Capacity PlansDevelop a detailed local capacity plan including managing variation, making betteruse of available capacity, and where appropriate one off back-logremoval.Dental Specialties Task & Finish Group – January 2011 18

NHS Boards can utilise the following tools to help manage DCAQ:• Waiting List and booking Process Demonstrator:http://www.nodelaysscotland.scot.nhs.uk/Resources/ResourceGuideItems/Pages/ISTWaitingListBookingProcessDemonstrator.aspx• Capacity and Queue Calculatorhttp://www.nodelaysscotland.scot.nhs.uk/Resources/ResourceGuideItems/Pages/CapacityandQueueCalculator.aspxHealth IntelligenceThe following charts provide an assessment of the risk as of June 2010 to showsome of the variations in supply and demand to be overcome. These are sourcedfrom Information Services Division’s QueSsTCap information, which analyses queueshape, size, trend and capacity using national waiting times data. This informationoffers an important insight into the balance of capacity and demand for secondarycare Dental Services, and an indication of how sustainable the current lengths ofwait are likely to be.Dental Specialties Task & Finish Group – January 2011 19

Figure 1: New Outpatients on the Waiting List1. Total number of patients on the waiting list at month end (census)New Outpatients - NHS Scotland - Oral Medicine1400120010008006004002000Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecSource:New Ways data, as at 30 Jun 20102008 2009 2010Using Oral Medicine as an example, this graph shows the total number of patientson the waiting list for a first appointment during 2008, 2009, and up to and includingJune 2010. This shows that there was a greater number of patients on waiting listsin 2008, whereas 2009 and 2010 gives reduced numbers.Since March 2010, all source referrals form part of the 18 Weeks Referral toTreatment Standard. These include referrals received from an individual, team,service or organisation on behalf of a patient, or a patient may refer him/herself.Typical referral sources to secondary care include:• Accident and Emergency Department• Emergency Dental Service• General Dental Practitioner• General Medical Practitioner• Salaried Primary Care Dental PractitionerDental Specialties Task & Finish Group – January 2011 20

Figure 2: Distribution of Waits3502. Distribution of ongoing waits at Jun 2010New Outpatients - NHS Scotland - OrthodonticsAll Referral Sources30025043%33%20018%1506%1005000

Figure 3: Additions and Removals3003. Waiting List Activity - Additions to list & removals from list within monthInpatients - NHS Scotland - Oral Surgery250200150100500-50-100-150Jan 2008Feb 2008Mar 2008Apr 2008May 2008Jun 2008Jul 2008Aug 2008Sep 2008Source:New Ways data, as at 30 Jun 2010Oct 2008Nov 2008Dec 2008Jan 2009Feb 2009Mar 2009Apr 2009May 2009Jun 2009Jul 2009Aug 2009Sep 2009Oct 2009Nov 2009Dec 2009Jan 2010Feb 2010Mar 2010Apr 2010May 2010Jun 2010Gap betw een additions/removals Additions to list Removals to listThis graph illustrates variation in additions and removals from the waiting list in thespecialty of Oral Surgery. It highlights some months where removals did not balanceadditions and waiting lists grew, or vice versa. Overall it highlights a relative balancebetween capacity and demand. It is essential for NHS Boards to understand theirown variation and plan sustainable capacity accordingly.Dental Specialties Task & Finish Group – January 2011 22

Figure 4: Weeks to Clear4.b) Estimated total number of weeks to clear Waiting List at month endbased on monthly activityNew Outpatients - NHS Scotland - Orthodontics by month14.012.48.99.99.59.79.68.38.57.29.89.87.612.010.08.06.04.02.00.0Jul2009Aug2009Sep2009Oct2009Nov2009Dec2009Jan2010Feb2010Mar2010Apr2010May2010Jun2010Weeks to clear allow ing for unavailabilityPeriods of unavailabilitySource:Total w eeks to clear = w eeks to clear allow ing for unavailability + average w eeksNew Ways data, as at 30 Jun 2010Using orthodontics as an example, this graph calculates the indicative number ofweeks required to clear the new outpatient waiting list for NHSScotland based ontheir recent activity. This is a measure of all activity including waiting list initiativesas well as core activity. If the indicative number of weeks required to clear the list issignificantly greater than the stage of treatment target (e.g. 12 weeks) this indicatesrisk; if the indicative number of weeks to clear is less than the stage of treatmenttarget this does not guarantee there is no risk – for example, activity could be beingincreased by unsustainable waiting list initiatives.It is important for boards to understand the level of activity required for ‘business asusual’, i.e. to meet appropriate demand as opposed to the one-off activity requiredfor ‘back-log clearance.’Together this health intelligence must be used at a local level to understand thedetail of specialty queues, size and shape, the balance of additions and removalsfrom the list, and weeks to clear. Each element, and the combined effect areessential building blocks of capacity / demand management which must beproactively used for each dental specialty to maximise capacity gains and keep theservice in balance.Dental Specialties Task & Finish Group – January 2011 23

Influencing Referral ProcessesPart of the philosophy of NHSScotland is ensuring that each patient is seen by theright professional, in the right care setting, at the right time, first time. This maxim isparticularly relevant to dental specialties where a variety of patient pathways for thesame condition have been witnessed. This may be addressed to a great extent byadopting standardised pathways as described in the section ‘Pathway Approach -Philosophy’, but also by influencing the referral process into secondary care, with thepatient right at the heart of this. It is therefore important to understand who iscoming into secondary care, why are they coming in, is this the best place for thepatient to be, and what are the influencing factors for each referral?Demand is not a givenIt has been suggested that a high proportion of patients are assessed and treated inthe wrong care setting.In 2007-2008 approximately 45% of oral surgery procedures performed in one NHSBoard were coded as ‘simple’ extraction of tooth. Simple extractions can beperformed in the primary/community care setting which would reduce demand onhospital services.Simple extractions are often referred to oral surgery departments within secondarycare, as some General Dental Practitioners (GDPs) refer in, choosing not toundertake this procedure themselves. Variation in service supply in different parts ofthe country and the impact that this may have upon models of care within differenthealth communities has already been recognised. However, there remains scope fordeveloping a clearer understanding of referral patterns by practice, along withvariation in rates of referral for different dental conditions. The outputs of this workcould be used locally to:• Develop referral thresholds, which should usefully be linked to clinical standardsabout where thresholds lie.• Influence the type and the quality of referrals e.g. tick box stationery.• Explore the scope for increased continuing professional development, educationand training to overcome recurrent referrals in specific areas.• Feedback to originators regarding the quality of referrals and data regarding thepurpose and timeliness of referrals.• Discuss different referral patterns with outlying practices to consider alternativeapproaches.This is occurring in other clinical specialties and is the subject of one of theworkstreams of the Capacity / Demand Management Task and Finish Group. It hasDental Specialties Task & Finish Group – January 2011 24

also been recognised that there may be regional approaches that could be initiatedto overcome variation in the nature of referrals to secondary care.MythbustingFact: Demand into secondary care is not a given: it can be driven down. Anysecondary care practitioner has the right to refer a patient back to the referrer e.g. ifthe procedure would be more appropriately carried out within the primary orcommunity care setting, or if alternative care pathways can be initiated.Effective Referral ManagementThere is likely to be further scope for shifting the balance of care by proactivelytriaging patients and reinforcing appropriateness of patient flows. An example ofgood practice in the area of referral management and triage is Greater Glasgow andClyde’s Referral Hub within their Dental Hospital.Sharing Good Practice - Glasgow Dental Hospital (GDH)In 2007, an electronic referral pilot was commenced for referring patients from theGeneral Dental Service (GDS) to acute Dental Services. The aspiration is that allreferrals to acute salaried and community dental services are made to a virtualreferral centre for triage to the most appropriate location. The key benefit of this isthat referrers know the referral has been received. The recipients are provided withcomprehensive information that allows efficient triage. Mandatory fields must becompleted, thereby ensuring relevant demographic and clinical information isincluded.To date all specialties can now be referred to acute services using the electronicreferral. 50 GDS and Salaried and Community Dental Service (SCDS) locations canuse electronic referrals with a further 50 poised to go live in early 2011. In addition,daily vetting has now been established for paper and electronic referrals whichensures prompt appointing to the appropriate clinic.Training is scheduled for clinicians and health records staff for electronic triage. Thiswill have additional benefits for GDS, as the referrer will be able to view on screenwhen the patient has been triaged and appointed to a clinic.Currently GDH are also pursuing the possibility of ensuring that SCDS locations canhave their clinics included on the acute hospital’s patient information system. Thiswill allow patients for acute services and SCDS to be referred to GDH. The referralswould then be triaged electronically to the most appropriate locations.Protocols will be developed to ensure consistency in triage. This currently is in placefor referrals to adult sedation services where all patients are referred to GlasgowDental Hospital and then triaged by a Consultant and a Salaried GDP before beingappointed (for assessment and treatment) to the most appropriate clinic. Fullinformation will be provided to referrers on which groups of patients each SCDSclinic treats. Clinic templates will be reviewed and systems for cancellation andDental Specialties Task & Finish Group – January 2011 25

changes to templates will be made, consistent with the acute services, in terms ofcomplete introduction of 6 weeks clinic cancellation policy across all services.There are some challenges associated with this service. The roll out of the electronicpilot has been slow, partly as a consequence of the unavailability of CHI to thereferrers. This has resulted in health records staff having to input this informationmanually on receipt of referrals. Dental reference files are not routinely updated inthe same way that GMP files are, therefore this also impacts on health records staff.These issues are being addressed.More recent issues raised (as a result of asking GDPs with access to electronicreferrals why they do not consistently use them), are IT issues. Whilst practices werefunded for N3 connection with one PC per practice, the PC tends to be at receptionand additional PCs in surgeries are not always connected to the same network.The project has been supported by IM&T staff who have been the key links withGDS staff.Advice Only ReferralsIt should be acknowledged that secondary care practitioners are under no obligationto see and assess all patients referred. To see all comers for assessment can createa ‘revolving-door syndrome’, confuse patient expectations, undermine the quality ofthe patient experience and can swamp available capacity with a knock on effect onother users of the service.In other specialties, a clinician may refer a patient directly back to General Practicewith advice for further care in a community setting, if the patient is not ready fortreatment or if the referral threshold applied is not appropriate for secondary care.In some instances, referrals into secondary care can be made in order to obtain acare plan, which may then be carried out in primary care. Therefore, there may bescope for further development of an ‘advice-only’ route, which does not necessitatethe patient presenting for assessment in secondary care and ‘using up’ a clinic slotand does not start the 18 Weeks RTT ‘clock.’This practice offers an important feedback loop for professionals and facilitates eachpatient receiving their care in the most appropriate care setting. This has becomestandard practice and can be supported by referral protocols for specific conditions.A number of NHS Boards set this out clearly in their Service Information Directory,and engage in ongoing dialogue with individual practices should they showsignificant variation in their approach to referrals.Action Planning – Advice OnlyConsider developing an ‘advice-only’ route, which does not necessitate the patientpresenting for assessment in secondary care and ‘using up’ a clinic slot and does notstart the 18 Weeks RTT ‘clock.’Dental Specialties Task & Finish Group – January 2011 26

Early ReferralsA referral should only be made when a patient is symptomatically ready fortreatment. Existing referral practice as a result of historically lengthy waits forassessment and treatment across Dental Specialties has however resulted inreferrers making early referrals into secondary care in an attempt to counteract thelikelihood of a long wait. Additionally some referrers make referrals when the patientis not orally fit to undergo a procedure or commence treatment.Consequently, artificially high numbers of patients are listed at any one time. Thissituation can be exacerbated by dual referrals to two different services in an effort tocombat anticipated long waits. This used to be the case in many others specialties,but with a steady reduction in waiting times, there has been a linked reduction in theperceived need for referrers to refer early. Patients should only be referred tosecondary care once they are ready for treatment. A patient referred prematurelyshould be referred back to their GDP or GP for referral at the appropriate point intime.MythbustingFact: Patients should not be on waiting lists unless they are fit to commencetreatment.Action Planning – Early ReferralsEnsure that any patient referred prematurely or inappropriately is referred back totheir GDP or GP to be re-referred at a more appropriate time.Pathway Approach: PhilosophyThe Task and Finish Group, along with other stakeholders, have highlightedsignificant variation between patient pathways for individuals with the samecondition. Whilst there may be clinical reasons for variation, in the main it isconsidered that variation is normally the result of other drivers, such as individualGDPs referral practices, the length of individual consultant’s waiting list or financialinfluences for either the practitioner or the patient. It is also acknowledged that manypatients assessed and treated in secondary care dentistry, may be moreappropriately cared for in the community setting.Equity of access for all patients should be a fundamental consideration, and thereremains further scope for changes in the way which patient journeys are managedand the care setting in which this occurs. This may be managed through a pathwayapproach using a common schematic to standardise or streamline the patientjourney whenever appropriate, minimising bottlenecks and smoothing handoffs.Dental Specialties Task & Finish Group – January 2011 27

Referral Management Pathways for Orthodontics and Oral SurgeryThe Task and Finish Group commissioned two focused referral managementpathway groups for Orthodontics and Oral Surgery, to develop and agree astreamlined pathway approach. As well as reducing unnecessary variation intreatment plans for the same condition, the pathways aim to facilitate more equitablereferral patterns and common thresholds for referrals to secondary care.Each pathway group had clinical representation. The Orthodontic pathway hadrepresentation from primary and community care GDPs, a primary care specialistorthodontic practitioner and secondary care consultant Orthodontists. The OralSurgery pathway had clinical representation from primary care specialistpractitioners, secondary care oral surgeons and secondary care oral and maxillofacialsurgeons. Membership of these groups can be found in Appendix three andfour.These national pathways represent a clinical consensus across NHSScotland. Theyhave been endorsed by the professional bodies: The Scottish OrthodonticConsultants’ Group and the Scottish Oral and Maxillo-Facial Society amongst otherstakeholders. As a result, there is already sign up and expectation for theirimplementation and embedding. The pathways should be tailored to accommodatelocal provision of these services, and although the fundamental principles mustapply, local issues should be addressed accordingly. It was also found that key tothe success of delivering a pathway approach is likely to be the management ofpatient expectations.Action Planning - Implementing national pathwaysNHS Boards should ensure that the national pathways for Orthodontics and OralSurgery are promoted across both primary and secondary care and that there isadherence to the thresholds for referral indicated. The pathways are attached asappendices Five and Six and may be accessed at:http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/patient-pathways/dentalspecialties/There may be further scope for education and training. Targeted continuingprofessional development may assist GDPs in confidently applying referralpathways. There could be a role for National Education Scotland (NES) to develop awider programme of education.Index of Orthodontic Treatment NeedThe Index of Orthodontic Treatment Need (IOTN) is generally regarded as a helpfultool in prioritising patients for referral and treatment to appropriate care providers i.e.specialist practitioners in primary care and clinicians in secondary care. IOTN usesboth an aesthetic and clinical component in order to assess an IOTN score, althougha higher IOTN score is not necessarily indicative of complexity of treatment required.Dental Specialties Task & Finish Group – January 2011 28

Initially it is expected that orthodontic colleagues will be the main user of IOTN and intime a uniform approach can be more widely applied.Action Planning - Index of Orthodontic Treatment NeedRaise awareness of IOTN and how it can be used in referral decisions by primarycare practitioners.Restorative DentistryScottish Dental Needs Assessment ProgrammeA National project is underway within Restorative Dentistry via the Scottish DentalNeeds Assessment Programme (SDNAP) and details of the remit of the project aredetailed below:AimTo conduct a needs assessment of specialist restorative dentistry service provisionin all the Health Boards across Scotland and make recommendations.Objectives1. Study the current service delivery model in Scotland.2. Determine demand for the specialist restorative service in NHS.3. Analyse workforce to support the current service model and potential servicemodels.4. Consider the cost of the current service model and potential service models.5. Determine perception of patients about the current service model.6. Determine perception of the service providers about the current servicemodel.7. Consider the current service model in the light of any Equality ImpactAssessment (EQIP)Progress to date• Completion of the current patient journey and current referral pathway (currentservice model), this will be explained in detail in the report along with quantitativedata.• As there is no detailed data available to inform the report, SDNAP is conductingprospective data collection in all four dental hospitals. The data collected will helpinform the report and wider community about referral protocols, workforce, andDental Specialties Task & Finish Group – January 2011 29

implementation of 18 Weeks RTT Standard.• The pilot data collection was conducted in the first week of November 2010 atGlasgow Dental Hospital. The aim of the pilot was to test the feasibility of thedata collection form and to make amendments, if need be. The data collectionform has been changed due to feedback received by the consultants. Actual datacollection will start in all the four Dental Hospitals i.e. Aberdeen Dental Hospital,Dundee Dental Hospital, Glasgow Dental Hospital, and Edinburgh Dental Instituteform 15 November to 10 December 2010 (four weeks). The data collection formwill completed by the restorative consultant at the first out patient appointment forall the new patients. Margie Taylor (Chief Dental Officer) has kindly written lettersto the four hospitals requesting that they comply with data collection.• Almost completed: the in-depth interviews with restorative consultantsabout their views about the service and also completed, a few interviewswith GDPs.• Undertaken four patient focus groups across Scotland based on thelocation i.e. urban, rural, remote etc.• Equality Impact Assessment has been done in conjunction with NHS QISand methodology followed is a literature search.• Report to be written (summer 2011).West of Scotland Dental Regional Planning GroupWest of Scotland NHS Boards are working together to develop a new regional modelof delivering restorative dentistry. A linked aim is the desire to improve access to theservice and enable referral to treatment standards to be met. This project is due tocommence imminently and it is anticipated that the objectives will be to define a newservice model, gain regional agreement and implement regional standardised highvolume pathways.Managing Patient FlowsGiven long waits for treatment in certain dental specialties in a few areas, it is veryimportant to ensure that all lists are proactively managed, including validation ofpatients waiting and each patient’s actual need to be on a list.It is suggested that waiting lists can be managed more effectively by ensuring, forexample:• Effective booking systems are utilised• Treating patients in turn• Pooling listsDental Specialties Task & Finish Group – January 2011 30

• Managing DNA rates• Not listing patients until they are ready for treatment• Referring for advice only• Managing return appointments differently to influence high new : return ratiosGoing back to basics and ensuring that good practice is firmly followed on a day today basis may result in some further quick wins in terms of maximising the use ofcapacity already available. Systems and processes should be continually reviewedto reduce bottlenecks and to allow smooth patient flows.Similarly, the use of the ‘what if’ analysis commended by the Orthopaedic ServicesTask and Finish Group, could be another useful device to improving productivity byworking smarter, not harder. For further information, please refer to theOrthopaedics Task and Finish output report pages 24 / 25:http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-andfinish-groups/orthopaedic-services/It is clearly recognised that much can be achieved by smoothing the hand-offs andreducing rate-limiting steps through all parts of the journey. Boards’ local 18 WeekTeams and Service Improvement Managers are skilled in applying these conceptsand continue to provide fundamental guidance and support.Service Redesign and TransformationThe Task and Finish Group has close links with the national Improvement andSupport Team who offer direct support to NHS Boards, organising training anddevelopment to build capability and capacity for sustainable improvement.To support local visioning, pathway design and process improvement at the locallevel, the Task and Finish Group have sponsored ‘Key Areas to focus Improvement.’This is detailed in Appendix Two, and should be used as a device for planningservice redesign. Additionally in order to share the learning of other Board areas, a‘Who’s Doing What?’ matrix has been created, giving examples of work undertakenand contact details; this is detailed in Appendix Seven.Much of the key to success is about working smarter, not harder and about reevaluatingand updating key systems and processes.Action Planning - Service Redesign and TransformationEach Board should make best use of the service redesign methodologies andsupport available. This will help identify priority areas to focus improvement work.• The Task and Finish Group has explored opportunities to promote tele-dentistryacross Boards, particularly in remote and rural areas.Dental Specialties Task & Finish Group – January 2011 31

• Managed Clinical Networks to promote information sharing and developing andsharing good practice e.g. Tayside’s Orthodontic Managed Clinical Network.• Visioning days for Dentistry e.g. Forth Valley and Fife.• Consultants do not have to see all return patients; some patients could bereviewed by extended scope practitioners.• Increasing the number of ‘see and treat’ clinics.• Altered triage arrangements.• More regional working/services.For more examples of good practice, see the ‘Who is Doing What’ Matrix, attachedas Appendix seven.Tele-dentistryElectronic Orthodontics within the North of Scotland:Aspirations and Achievements to DateThe vision for the North of Scotland is to develop a common platform delivered onN3 to link Consultants working in hospital-based services, Primary Care DentalPractitioners, Information Services Division (ISD), the Scottish Dental Practice Board(SDPB), NHS Education Scotland and the North of Scotland’s Boards collaboratingin a Managed Clinical Network for Orthodontics. The overarching aim of the projectis to improve the quality of patient care by embracing technology, resulting in betteraccess to dental health information, ‘joined-up’ primary care and hospital servicesand quicker access to a unified dental record and imaging. However, it is not justabout technology, it is about modernising processes and encouraging new ways ofworking.Maximising existing and implementing new communication technologies to supportthe North of Scotland Managed Clinical Network (MCN) for Orthodontics is essential.Developing a system for information retrieval, collation and activity monitoring will bea high priority for the MCN and is seen as fundamental to the Network’s success.A phased approach to implementation has been agreed. The capital required for ashort pilot (proof of concept) for Stage I and II was agreed by the North of ScotlandBoards.Stage I – Electronic Triage• Triage of orthodontic referrals sent by GDPs, Experienced Practitioners (SOP),Rural Fellows, etc, to a Consultant Orthodontist.• Preferred number of trial sites: five or six.• Functions required:o e-transfer of referral letter/form and response (store and forward);o ability to attach digital images (photographs, PACS images), 3-D images, linksDental Specialties Task & Finish Group – January 2011 32

with CHI number, address book.• Information/Data Capture: Patient details including Date of Birth, address,referring clinician, demographics, etc.Timescale: Stage I has been completed.Stage II - Treatment Planning/Advice• Treatment Planning and Advice returned from a Consultant Orthodontist toexperienced practitioners, rural fellows, GDPs etc.• Preferred number of trial sites: five or six.• Functions required: as for Stage I, and to include:o video conferencing/video assessment function;o recommendations/assessment report.• Information/Data Capture: As for Stage I, plus secure electronic patient recordwhich is accessible to Consultant, Dentist, AHP and other clinicians involved indirect patient dental care, as appropriate.Timescale: To be arranged.Stage III - Training and Education• E-Orthodontics will be evaluated as a tool to support education and training atundergraduate and post graduate levels.• Interest in developing an MSc in e-Orthodontics has been expressed byProfessor James McDonald, Glasgow University.• It is envisaged that the e-orthodontics system will provide online help andtutorials• Functionality required: as for I-III above, plus:o dictionary items;o on-line help screens;o full audit trail across the spectrum of treatment modalities, by referringpractice or discipline, financial aspects etc.Timescales: To be arranged.Stage IV - EDI in Primary Care• From Primary Care to ISD and the Scottish Dental Practice Board (SDPB)• Preferred number of trial sites: five or six• Function required: As for Stage I-III and to include:o Record of Services provided;o dental claim form to include authorisations required, etc.Ultimately, the intention is to utilise the NHS Scotland building blocks; N3, SCI Store,Gateway and the Generic Clinical System to develop a multimedia, and multidisciplinarycare record from which the Information Statistics Division (ISD), theScottish Dental Practice Board (SDPB) and the North of Scotland Managed ClinicalNetwork for Orthodontics will be able to access and exchange relevant information inorder to facilitate the commissioning, monitoring and delivery of orthodontic care.Dental Specialties Task & Finish Group – January 2011 33

Robust evaluation will be carried out at the end of each stage. After which, themultimedia, and multi-disciplinary care record will be available to roll out to supportother NHS Boards and Orthodontic MCNs and link them to a national Network.The multimedia and multi-disciplinary care record will be readily adaptable to meetthe requirements of other emerging MCNs in dentistry.Dental Specialties’ Workforce Skills MixWorkforce considerations can inevitably impact on the ability of any service to delivertimely, high quality patient care.The Task and Finish Group clearly recognises recruitment difficulties faced in someNHS Boards. It is acknowledged that workforce issues in the central belt are quitedifferent to issues in, for example remote and rural areas, where a different range ofsolutions may be required. This, however, is even more reason to explore andaddress the skills mix and competency base within the existing workforce.NHS Boards are encouraged to review their workforce capacity and competencyprofile, with a view to strengthening roles and responsibilities of differentcontributors, to ensure that each task is undertaken by the most appropriate person.Increasing use of members of the multi disciplinary team, and development ofenhanced roles will free up considerable amounts of consultant time for direct patientcare. Given the existing multi-disciplinary workforce and the range of servicesprovided, many Boards have identified new ways of working to optimise the use ofand the skills-mix of available practitioners. This allows the development of existingcompetencies to support identified care pathways and streamline systems andprocessesIt is paramount for NHS Boards to have accurate activity data to ascertain workforcerequirements for each stage in the patient journey. Aspects of this approach form anelement of the Chief Dental Officer’s Workforce Review.Certain strategies could be adopted to assist with current workforce issues:• The role of the Dental Support Worker could be developed under protocol, butthis would require additional education and training. This could be facilitated inconsultation with NHS Education Scotland.• Orthodontic Therapists are a new group of professionals who can assist with theclinical workload e.g. taking dental impressions and fitting brackets. Courses arecurrently available in Edinburgh and Coatbridge. There is also scope to use theseprofessionals’ in return Orthodontic appointments to free up consultants’ time fornew appointment slots.• There may be opportunities within secondary care to up-skill dentists inprocedures where they may have previously lacked confidence, and theseprocedures can therefore be efficiently managed in the primary care setting.Dental Specialties Task & Finish Group – January 2011 34

Action Planning - WorkforceNHS Boards should review their workforce capacity and competency profile, with aview to strengthening roles and responsibilities of different contributors. Boardsshould make reference to the Chief Dental Officer’s Workforce Review to underpinworkforce planning assumptions and workforce development plans locally andnationally.Workforce Solutions WorkshopThis workshop took place in November 2009. A clear message from the day was toensure that services are designed to meet patients’ needs and workforce planningneeds to support this key principle, which is also fundamental to sustainable deliveryof the 18 Weeks RTT Standards. Principles that can assist with promoting thisconcept include:• Designing pathways to support the delivery of optimal care and patientexperience, and these should be evidence based.• The design of a patient pathway should be used to determine the skills,competencies and roles required. The demand, and therefore capacity required,at each stage in the patient pathway needs to be quantified.• There should be an assessment of who does what at each stage in the pathway.There is evidence that professionals can be operating at the lower end of theircompetency range, despite training and development. Workload and productivityshould be reviewed. This may provide some opportunities within current staffingfor increased capacity. Data from clinical outcoming may assist with this process.• Where new roles are developed there is a need for standardisation of titles,responsibilities, skills and competencies and consideration of nationalaccreditation and validation.• More attention needs to be focused on administrative and clerical roles to supportpathway and patient flow management.All these considerations should be used as a basis for informed workforce planning,both nationally and locally to facilitate provision of a workforce fit for the future, with asufficient number of dental undergraduates. Encouraging further training of GDPsand a multi-skilled allied-professional workforce who are able to maximise theircompetencies in providing high quality and timely dental care will contribute to thepatient experience. However, there is a need to focus on the initial management ofthe patient journey and what can be done in primary care to prevent the need foronward referral, especially if we are going to imbed the principles of Shifting theBalance of Care and delivering care closer to the patient’s home.Dental Specialties Task & Finish Group – January 2011 35

Action Planning - Specialist RolesNHS Boards to explore the scope for specialist roles and different ways of workingacross Dental Services. Evaluate skills mix and which professionals are best placedto undertake which functions. Where necessary this may be done under protocol.Dental Specialties Task & Finish Group – January 2011 36

CommunicationStakeholder GroupsIn considering the issues for Dental Specialties and suitable methodologies fortackling the risks identified, care was taken by the Task and Finish Group to link asclosely as possible with key stakeholders (both individuals and groups), including:• North of Scotland Strategic Planning Group has co-ordinated considerations inthe North and facilitated joint service planning, including the development ofcomprehensive action planning.• West of Scotland Dental Consortium• Chief Dental Officer’s Dental Lead Officers’ Meeting• Dental Stakeholders’ Group• Scottish Consultants’ Orthodontic Group• Scottish Oral and Maxillo-Facial Surgeons’ GroupNational EventsThe Improvement and Support Team hosted a series of national Dental Specialties’events on behalf of the Task and Finish Group, in order to engage with the dentalcommunity. Each provided an important forum for considering delivery expectations,sharing best practice and different approaches, and considering how NHSScotlandmight collectively overcome key bottlenecks (e.g. information gathering) in creating acritical path for delivery.Half day visioning events and Masterclasses took place which built on previousvisioning work. These event allowed colleagues to share good practice andfacilitated networking opportunities and collaborative working. A national DentalSpecialities event was held on the 25 March 2010.Action Planning - NetworkingAll Boards should continue to find ways to continue to network, linking withstakeholders across primary and secondary care to debate and deliver timely Dentalservices for the benefit of the patient.Dental Specialties Task & Finish Group – January 2011 37

Conclusion: Action Planning and Ongoing WorkThis Dental Specialties Output Report is intended to provide a blueprint for futureimprovement and delivery of dental services. Members of the Task and FinishGroup have focused in on the key issues which they feel may have the maximumimpact. Each Board is now expected to use this to design a critical path for theunequivocal delivery of the 18 Week Referral to Treatment Target for dentalspecialties, and this report commends a series of key actions to Boards to underpinsuccessful delivery. Individual Boards will be performance managed through thecoming months where delivery expectations are not being met.Some of the issues considered are easily implemented, leading to quick wins orearly gains e.g. ensuring the application of basic principles of waiting listmanagement. Some will be iterative in their application, and may needed to betested using the Plan-Do-Study-Act methodology to close the loop on improvementsproposed to allow optimum benefits. Others may rely on communication andembedding practice e.g. common application of definitions/ clock stops in order toaccurately record a patient’s journey time. Much will be dependent on theorganisation profile for these services and the integration into existing waiting timesstructures and delivery mechanisms. Individual Boards will be performance managedthrough the coming months if delivery proves elusive.The Task and Finish Group recognises and wishes to encourage scope for regionalapproaches to delivering timely dental services. The three Regional Offices haveeach given a high priority to their at risk dental specialties, and an ongoingcollaborative approach is being used to provide a focus on issues and solutionsacross each region. The North of Scotland Planning Group for example hasdeveloped a detailed action plan to address service shortfalls within dentistry.Dental Specialties Task & Finish Group – January 2011 38

Summary of Fundamental Next Steps for BoardsAction Planning – Points to ImplementMeasurementand Definitions• Ensure that generic 18 Weeks RTT definitions are applied todental specialties at the highest level.• Use the bespoke FAQs and dental scenarios to ensure thatclock starts and stops are fully understood and universallyapplied.• Promote organisational learning and training on the applicationof these definitions, especially among medical records,medical secretaries and clinic staff.• Pursue clinical outcome coding as the norm across all dentalspecialties.• Continue work to capture all treatment activity undertaken inan outpatient setting – especially in a return outpatient slot (notalways traditionally captured).• Promote the importance of accurate data capture andrecording across all dental specialties as a basis for serviceplanning, improvement and performance.• Ensure accurate, complete and validated Dental MonthlyManagement Information is returned to the ScottishGovernment and also used locally for management andimprovement).• Work with national stakeholders to improve data quality andcompleteness of national data returns, both for stage oftreatment (outpatients and inpatient/daycases) and wholeDemandCapacityActivity QueuePrimary CareSolutionsPerformanceManagementServiceRedesign andTransformationjourney 18 weeks measurement.• Use improved data sets as the basis for detailed capacitydemand planning for each of the dental specialties.• Use DCAQ tools and methodologies to plan and optimise useof available slots.• Use QueSSTCap to predict and manage capacity gaps.• Pathway management.• Use professionally-developed and endorsed pathways tomanage variations in referrals across practices, and toimplement common thresholds for equity of access.• Drive uniform implementation and embedding of pathwaysacross the whole health community.• Promote and apply common referral thresholds fororthodontics (based on IOTN score).• When appropriate, request advice only treatment plan – thiswill not start an 18 Week RTT.• Use data to identify trends and risks and to manageperformance. Use ‘Key Areas to Focus Improvement’matrix toidentify areas for further work.• Use ‘who is doing what matrix’ to identify examples of goodpractice that can be transferred to your service.• Do not list patients until they are suitable to commencetreatment.Dental Specialties Task & Finish Group – January 2011 39

• Analyse referral practices and consider teaching and practicalsessions for GDPs with routine procedures with which theymay lack confidence.• Manage DNA rates e.g. text messaging reminders.• Promote, where appropriate ‘see and treat’ services.Cultural • Assure a high organisational profile for dental specialties.• Reinforce, culturally, that all Dental Specialties are part of 18weeks RTT, including all treatments undertaken in anoutpatient setting.• Ensure strong high level leadership to support developmentsto secondary care dental services, with a strong culturalexpectation of delivery.Workforce • Review roles and competencies of dental specialties’ multidisciplinary teams• The design of a patient pathway should be used to determinethe skills, competencies and roles required. The demand, andtherefore capacity required, at each stage in the patientpathway needs to be quantified.• Consider increased use of enhanced roles (under protocolwhere appropriate) to free up consultant time.• Use the Chief Dental Officer’s Workforce Review to underpinworkforce development plans locally and nationally.Communication • Sharing good practice e.g. via Managed Clinical Networks.• Consider adopting practices from the ‘Who is Doing What’matrix and liaising with Boards to ascertain best practices andhow to avoid pitfalls.Dental Specialties Task & Finish Group – January 2011 40

Appendix One: Membership of Dental Specialties Task and FinishGroupMemberDerek Leslie (chair)Board and RoleArgyll and Bute CHCP, General ManagerAlex Bowerman Scottish Government, Health Directorate,Programme DirectorJacquie Dougall Scottish Government, Health Directorate, ProjectManagerMaura Edwards NHS Ayrshire and Arran, Consultant in DentalPublic HealthTom FerrisScottish Government, Deputy Chief Dental OfficerJanet HarrisKevin HillLaura JonesJim McDonaldRobert NaysmithHelen StrachanMargie TaylorScottish Government, Health Directorate, ServiceImprovement ManagerNHS Greater Glasgow and Clyde, Oral HealthDirectorScottish Government, Health Directorate, NationalManager, 18 Weeks ProgrammeNHS Fife, Consultant OrthodontistNHS Lothian, Clinical Director, Community andSalaried Dental ServiceNorth of Scotland, Regional Manager, Oral Healthand DentistryScottish Government, Chief Dental OfficerAppendix Two: Key Areas to Focus ImprovementSee diagram on next pageDental Specialties Task & Finish Group – January 2011 41

Dental Specialities Task & Finish GroupKey Areas to focus ImprovementDental Specialties have been highlighted across a number of NHS Boards as presenting a risk to delivery of 18 Weeks RTT.Orthodontics Oral Surgery Oral Medicine RestorativePaediatricsGeneral AnaestheticsThe NHS 18 weeks Service Redesign and Transformation Programme has developed a series of key changes which NHS Boards should considerwhen transforming services to improve the patient experience and to support delivery of 18 weeks RTT. These key changes focus on:• End to end planning of patient centred pathways delivered by the right person, at the right time, in the right care setting, ensuringquality at all times;• Working across organisational boundaries to utilise and develop the skills of the workforce to optimise clinical time to care;• Removal of waste and non-value adding steps and creation of flow;• Identifying, capturing and recording information flows which support and optimise both clinical and administrative processes.These key areas for improvement below are intended to provide a reference point to support organisations in ensuring service provision is being maximised fordental specialties in order to support delivery of a quality service, reduce patient waits and ensure patients are seen and treated in the appropriate care setting.REFERRAL• Understand referrals into your service for alldental specialities and sub-specialities• Consider whether patients are placed on theappropriate pathway• Consider whether there is potential foralternative management within generaldental practice rather than secondary care• Consider appropriateness of referrals withIOTN of

Appendix Three: Orthodontic Referral Management Pathway GroupNameMargie Taylor (chair)Joyce DalgleishJacquie DougallChristina HainingJanet HarrisDavid MorrantMark McCutcheonGrant McIntyreRobert NaysmithHelen StrachanBoard and RoleScottish Government, Chief Dental OfficerScottish Government, Health Directorate,Communications ManagerScottish Government, Health Directorate, ProjectManagerOrthodontist, Specialist Practitioner, Primary CareScottish Government, Health Directorate, SIMNHS Ayrshire and Arran, Consultant OrthodontistNHS Lothian, General Dental practitionerNHS Tayside, Consultant OrthodontistNHS Lothian, Clinical Director, Community andSalaried Dental ServiceNorth of Scotland, Regional Manager, Oral Healthand DentistryDental Specialties Task & Finish Group – January 2011 43

Appendix Four: Oral Surgery Referral Management Pathway GroupNameMargie Taylor(chair)Roger CurrieHelen DevennieJoyce DalgleishJacquie DougallChristine GoodallMaura EdwardsTom FerrisJanet HarrisAndrew MeeVeronica MeeAvril NeilsonJulie SavinBoard and RoleScottish Government, Chief Dental OfficerNHS Ayrshire and Arran, Consultant Oral andMaxillofacial SurgeonNHS Highland, Oral Surgeon, Primary CareScottish Government, Health Directorate,Communications ManagerScottish Government, Health Directorate, ProjectManagerNHS Greater Glasgow and Clyde, Consultant OralSurgeonNHS Ayrshire and Arran, Consultant in Dental PublicHealthScottish Government, Deputy Chief Dental OfficerScottish Government, Health Directorate, SIMSpecialist Primary Care PractitionerSpecialist Primary Care PractitionerNHS Tayside, Consultant Oral SurgeonNHS Fife, Specialist Practitioner, Primary CareDental Specialties Task & Finish Group – January 2011 44

Appendix Five: Orthodontic Pathway and Referral GuidanceDental Specialties Task & Finish Group – January 2011 45

Dental Specialties Task & Finish Group – January 2011 46

Appendix Six: Oral Surgery Pathway and Referral GuidanceDental Specialties Task & Finish Group – January 2011 47

Dental Specialties Task & Finish Group – January 2011 48

Appendix Seven: Who is Doing What MatrixDental Specialties Task & Finish Group – January 2011 49