Oldham Integrated Care Centre

Transcription

1 An Ideal Service Modelling Special Care Dental Services for Greater Manchester Friday 10 th December 2010 Oldham Integrated Care Centre

2 Contents Introduction...3 Purpose of the day...4 Outcome of the working groups...4 Aspiration for the future of Special Care Dentistry in Greater Manchester...4 Strengthening provision...5 Currency for measurement of patient complexity...5 A Model Service?...6 Morning sessions...7 Session Summaries:...7 Research and Needs...7 Creating an evidence based special care dental service...7 Patient involvement...8 Prevention and Support...8 Sedation for the provision of Special Care dentistry...9 General anaesthetic for the provision of comprehensive dental care...10 Routine Dental Care in Special Care Dentistry...11 Clinic based vs domiciliary option...11 Geographic Models & Service Models:...12 The special care team:...12 Staffing & skill mix:...12 Parallel workers:...12 Service Model SWOT...13 Service model - Consultant led - dental hospital / local district general hospital based...13 Service model - Consultant lead - community-based...13 Service model - Hub and spoke, In-reach...13 Service model - Non-consultant specialist service geography free...14 Service model- Clinical Director led CDS...14 Service model - generic manager and clinical lead service...15 General Dental Service led service...15 Participants...16 Page 2 of 16

3 Introduction Following an earlier meeting of Greater Manchester Special Care Dentistry Network and feedback to the dental commissioning leads group for Greater Manchester, two half day sessions were proposed by the Network. A morning meeting of the Greater Manchester Special Care Dentistry Network to, through facilitated group discussion and summary, address aspirations of clinicians towards service structure facilities and function within the footprint of the network and the services represented. An afternoon meeting of representatives of: Clinicians as represented by discussion group facilitators from the am session Commissioning Leads Deanery This document summarises the recommendations of the meting and provides a reference from the clinical serviced focus of the network meeting Page 3 of 16

4 Purpose of the day We aim to address with clinicians their view of the requirements for our patients of a Special Care Dentistry provision. In discussing with Commissioning leads we hope to open and succeed in communicating options for development of care provision. By the end of the session we intend to: Summarise outcomes of a collective meeting of clinicians Explore gaps in knowledge and understanding Set achievable development and participation targets Consider areas of future development and shared working in service provision and training Look forward to inclusion of patients and their support network in developing a patient centred health option Outcome of the working groups During these discussions the groups considered options for the provision of special care dentistry. The working groups considered that an ideal Special Care Dental Service will have access to consultants in Special Care Dentistry to lead and develop a service network. Staffing will be appropriate for the needs of the patients and will have planned access to sedation and general anaesthesia as required for the care of the individual patient There will be local access to primary dental care services whose staff are skilled and knowledgeable about the needs of the patients Local services will provide routine care for patients needs and develop skill mix and support networks to provide the patient and their carers with a holistic care service Aspiration for the future of Special Care Dentistry in Greater Manchester The meeting concluded that the future should include progressing towards consultant posts in Special Care Dentistry within Greater Manchester in order to: Facilitate training and development and including specialist trainees in support of succession planning for the speciality specialty Work with the commissioners to strengthen care provision Work with partners to transform service structures and provision for patients. Collaborate with the delivery on the provision and supervision of DF2 core trainee posts in support of succession planning for the service and speciality The network should continue to work with the Deanery towards the provision of succession planning for next generation of dentists within service and specialty. The network supports the development of training posts for core and specialist trainees in special care dentistry to progress the development of the speciality in Special Care Dentistry Page 4 of 16

5 Strengthening provision The network was asked to consider: Do we look to strengthen tertiary care provision sites? Can the network participate in work streams to address: 1 Training and development 2 The commissioning of services 3 General Anaesthetic services 4 Service structure and form? Deanery representatives highlighted that the North West was likely only to sustain 1 specialist trainee post and the question should be asked who can actually provide the required training for such a post? For future planning, deanery will need to know how many consultant posts are envisioned. Training need for Special care dentistry has been identified but not quantified. Deanery will need to be involved in the shaping of future services to facilitate the delivery of what the region needs. The Deanery view is that the clinical network figurehead for Special Care Dentistry in the future needs to be at consultant level It is noted that Liverpool, Sheffield and Birmingham had done substantial work on Consultants in Special Care Dentistry Forthcoming service reviews are likely to progress the agenda in the mid to long term future. It is unlikely that the issue of commissioning and provision of service will be addressed one PCT area at a time. The Transforming Community Services programme currently underway will have significant impact and commissioners will be asking what will success look like for Special Care Dentistry in the future? There is an expectation that the Transforming agenda will involve mapping services to ensure equitable provision of service for all rather than the historic footprint basis with an aim of reducing and stopping the dilution of services. It is clear that in the future constraints will need to be applied to ensure that the population is able to access the right services in the right places. Currency for measurement of patient complexity Questions were asked about the applicability of the currently available BDA case mix model as a measure for the future and whether it may be used in conjunction with for example SNOMED or Dental Sedation Assessment tools The needs assessment work (based on GA services currently provided) presented to the meeting is acknowledged. Clinicians and service managers highlighted that with increasing complexity of need for the patient Fail to Attend rates also historically increase Page 5 of 16

6 A Model Service? Greater Manchester Special Care Dentistry Network Dialogue is required between all parties to develop suitable models and apply effective plans to ensure positive changes in service provision acknowledging that some centres may require specific consideration of needs and provision. It was noted by all present that working within the current and future changes in NHS and services, commissioning and provision will become increasingly challenging and dental treatment as part of holistic care will require Intelligent and adaptive commissioning and provision. The morning meeting constituted an opportunity to gain the clinicians voice from a self selecting group of individuals involved in the provision of special care dental services in the greater Manchester area. The development of a service for provision of special care dentistry on a primary care basis must also involve the patients voice and the managers and clinical directors of services currently commissioned and provided within the Greater Manchester footprint. Salaried services, in many cases also involved in the provision of services to a range of age and target groups, also provide an effective source of outreach undergraduate teaching and opportunities exist for the development of these services. Consultant services in Paediatric Dentistry are already in place, based primarily in tertiary care and the transition between Paediatric and Special Care dental provision must become seamless for patients with effective communication and cooperation between the specialties. This is in many cases already in place with salaried services having specialist practitioners in place for both specialties but clarity on the commissioning and provision responsibilities have historically been a challenge for this group of patients. Page 6 of 16

7 Morning sessions During the am sessions breakaway groups were facilitated addressing the following topics: Research and needs Prevention and Support GA and Sedation & Consultant leads Routine Care Geographic Models & Service Models Session Summaries: Research and Needs Creating an evidence based special care dental service In developing and providing services for the target group a body of evidence that services are evidenced based already exists. Though this is in place it is not currently used for commissioning. National library of medicine listing is a work in progress for the international Journal of Disability and Oral Health. Of particular importance are impact factors in obtaining and maintaining oral health for individuals and for the provision of such care as required. Research is not currently leading to clinical service changes. There is a perceived lack of evidence which may have been used historically to stall development of services. Moving forward researchers need to collect evidence of health needs and address already available health needs assessments. This research would need to be commissioned Of particular challenge is the limited understanding of population needs: Who is the population? There is no register of special care patients and patients DLA Case mix captive CDS patient base but what about those not seen within CDS type services? Severity / affect Disorder There are opportunities for multisite audits within the Greater Manchester network but support will be required for these audits. The GMSCD network will be encouraged to flag up with reference to guidelines, areas for research and systematic (Cochrane) reviews. Support will be required from and offered to strategic health authorities, BSDH, consultants and Trainees in SCD. Page 7 of 16

8 There are opportunities for case series across the Network Group for example with groups of patients having similar problems. Patient involvement In identifying opportunities for patient and public involvement, the inclusion of non-dental interest groups such as local LINKS Groups, LD Partnership Boards and Representatives of patient interest groups may facilitate effective patient public involvement. PPI involvements should also explore the use of Expert Patients. Caution is expressed however about the appropriateness of the use of carers in proxy (this may demonstrate poor correlation to the wishes of patients). Using individuals whose dental special care needs are of a lower level may allow some extrapolation to form a measure for those with higher needs. PPI activities will be affected by available funding. A range of PPI activities will be required and may include, focus groups, patient representatives and carer involvement. A range of techniques may be utilised and will form part of the KPI process. Involvement of local focus PPI teams will be necessary to achieve effective communication and validation of techniques, methods and outcomes. Prevention and Support The members of Greater Manchester Special Care Dentistry Network actively support the use of Delivering Better Oral Health and Valuing People s Oral Health. It is perceived that effective prevention will be: Provided in an holistic approach and include the support and training of carers Facilitated in a range of locations including home or clinical. Working towards having dent Prevention incorporated in care plans. Effectiveness in this process will require frequent reinforcement from clinical and OHP teams and buy in from patients and care providers. In providing evidence based prevention, the use of high fluoride toothpaste and extended duties Dental Nurses for topical fluorides application in a variety of locations will be part of effective provision. The Special Care Dental Service should cooperate with OHP teams and provide training, mentoring and supervision for staff working in this area. Identifying barriers to communication and care in addition to the classical barriers for individuals, the reliance on family and carer support and availability is significant and currently un-quantified. Commissioner support to deliver programmes and evaluation Page 8 of 16

9 The Inclusion of Oral Healthcare assessment in care plans will help identify and target individuals and groups through contacts with health and social care services rather than the historic dental patient cohort. Oral Health Promotion support is required for dental care providers and health and social care providers, particularly in the training and enabling of care staff to support good oral health practices for their clients. An identifiable point of access to support for healthcare professionals will facilitate support and access to dental care services. OHP support will also enable the facilitating of GDP staff in providing access for patients suitable for care in General Dental Practices Sedation for the provision of Special Care dentistry A variety of techniques must be available within a managed clinical environment ranging from behaviour management through inhalation sedation, trans-mucosal sedation and intravenous techniques. Staffing and facilities must be suitable for the provision of sedation services with a high margin of safety and effectiveness of outcome. Various service models exist for the provision of simple dental sedation on an accessible basis. Sedation services falling within the definitions of simple dental sedation may be provided in clinics planned and structured to provide such services, complex sedation and General Anaesthesia may be provided in a hospital environment. The team required for the provision of a comprehensive sedation service will include: Named special care specialist dental lead, Dentists with special interests in special care dentistry and/or sedation, other dentists Anaesthetists (more than one but practised and familiar with client group) Dental Nurses trained in dental sedation nursing Page 9 of 16

10 General anaesthetic for the provision of comprehensive dental care Provision of Dental Care The provision of dental treatment under General Anaesthesia for patients with Special Needs will be provided by dentists with a range of clinical operative skills, equipped to provide care in a comprehensive manner. The team will have access to a senior clinician / Consultant for treatment planning support advice and mentoring. Appropriate training and support for dental staff to ensure non-reliance of a team on the skills of a single individual operator. The team required for the provision of a comprehensive service will include: Named Special Care specialist dental lead, Dentists with special interests, other dentists Anaesthetists (more than one but practised and familiar with client group) Dental Nurses Theatre staff Support from non theatre staff tams will be required including from Learning Disability hospital liaison team, Physical Intervention team (for planning and process as appropriate) For the provision of care to a population there will be age appropriate teams children on children s ward / facility, adults in adult focussed facilities Comprehensive dental care using General Anaesthetic should be available for special care adult and child patients. It may also be appropriate for the service to provide care as part of a patient pathway for phobic patients and those for whom Inhalation Sedation care has been unsuccessful. Clear guidance on need and provision of care will also, needs must, include those for whom there are historic gaps in care: patients with dementia and transition (paediatric/scd) patients to ensure equity of access and care. Waiting list management will ensure prioritised, timely access to care. Historic issues to be addressed include: The disparity between local waiting lists, The limitations of skill sets of anaesthetists in managing patients with challenging behaviour, Lack of control of lists and proposed treatments for non-hospital based clinicians. Facilities will need to be available for in patient stay if required where community based care service was formerly provided Page 10 of 16

11 Routine Dental Care in Special Care Dentistry Provision of dental care for patients with dental special care needs will be patient focussed, provided as part of a holistic care of the whole patient, integrating and cooperating with patient carers and support services. Facilities and equipment will be appropriate and accessible to patients and carers. The staff team will need to be experienced, trained, committed and enthusiastic staff supported by specialist and consultant practitioners. A range of clinical Techniques will be required to manage the patient and provide comprehensive dental care. Whilst patient needs will frequently be met by the application of routine behaviour management techniques, the facility to move on to more complex and advanced methods including sedation and General Anaesthesia must be available, though not necessarily at all sites. Wherever possible location of care must be within reasonable travelling distance and method for the patient group (allowing for patient choice where practicable). Multi surgery clinical sites offer a practical option for care provision and will need to include a facility for a quiet environment as required for patient waiting, treatment and where necessary recovery. Dental surgery size is significant and SCD dental surgeries must allow suitable space for the safe manoeuvring of patients and specialist equipment e.g. patient hoist, wheelchair platform, moving aids and suitable access/egress for mobility challenged patients. Facilities for bariatric patient care are increasingly in demand and a suitable number of sites equipped to manage such patients will be necessary. Patient parking must be suitable for the client group Clinic based vs domiciliary option Domiciliary dental services will need to be available locally to ensure that patients unable to access dental surgeries for care can have this access. This is a costly provision and may be provided by willing providers. Where patients are more challenging, commissioners and providers must work together to facilitate effective and appropriate care for patients with such needs. The ideal location for dental care is however a dedicated For patients with SCD needs, transport may be a particular challenge and Transport facilities eg ambulance services should be available through commissioning. Page 11 of 16

12 The Equipment for provision of domiciliary dental care is of significant cost to purchase and maintain and treatment plans need to reflect the location of care provision There are a number of health and safety and staffing issues in providing domiciliary dental care and it must be acknowledged that working off site requires additional time for each appointment. Successful and effective use of triage will identify patients in need of dental care on a domiciliary basis as opposed to those preferring domiciliary care Geographic Models & Service Models: A range of Geographic and Service models options were considered and a simple SWAT analysis carried out. The main concerns are maintaining patient focus whilst providing accessible care. A key issue is that of clinical leadership with concerns about the potential for dilution of effect over larger footprints In particular future arrangements will aim to develop a seamless service for all Special Care patients regardless of location and age. Further discussion is recommended with service users, providers and commissioners to ascertain the most effective local model applicable to the Greater Manchester footprint. The special care team: The team will include a clinical leader who may be a consultant level appointment but certainly with access to consultant support and advice. The role will include that of trainer in special care dentistry and work in support of and together with specialists in Special Care Dentistry, DWSIs in Special care Dentistry and sedation and other dentists. Extended competency dental nurses dental hygienists and therapists will be appropriate and support from the Oral Health promotion team, focussed on the patient group (and their support network) will be required Staffing & skill mix: Provision of comprehensive dental care will require a dental team including Oral Health Promotion Support and access to consultant / Specialist support. This will allow of mentoring and training to include undergraduate and Post Graduate training and continuing professional development for mainstream dentists, hygienists, therapists, Dental Nurses encouraging the facilitation of comprehensive care for patients suitable for management within GDS arrangements on a sole or shared care basis, giving increased opportunity for partnership with GDPs Parallel workers: Community Learning Disability teams Community Mental Health teams Community Paediatric consultant Social care support staff Patient carers and families Page 12 of 16

13 Service Model SWOT Greater Manchester Special Care Dentistry Network Service model - Consultant led - dental hospital / local district general hospital based Strength expertise clinical responsibility credibility training staff / career pathway Weaknesses lack of local focus cost medical model disconnects from other services against shift towards community-based Opportunities training staff / career pathway Threats figurehead reliant charisma dependent against shift towards community-based Service model - Consultant lead - community-based Strength expertise clinical responsibility credibility training staff / career pathways Opportunities skill mix training staff / career pathways Weaknesses Need for clinical understanding in managing community services Threats Service model - Hub and spoke, In-reach Strength In-reach clinicians follow patients expertise skill mix Opportunities concentrate high-level facilities support the periphery Weaknesses vulnerable travelling / multiple sites coordinating overview / network accountability Threats vulnerable travelling / multiple sites coordinating overview / network Page 13 of 16

14 Service model - Non-consultant specialist service geography free Strength Weaknesses lack of focus dilution of voice lack of credibility lack of organisation vulnerability Opportunities Threats lack of credibility lack of organisation vulnerability Service model- Clinical Director led CDS Strength patient focused managing clinicians local knowledge Opportunities Service development to ensure seamless provision within geographical footprint Weaknesses Political will Threats TCS agenda Page 14 of 16

15 Service model - generic manager and clinical lead service Strength Clinicians released to local performance Opportunities interaction between secondary care services / hospital care Weaknesses pure management lack of clinical focused role - lack of clinical focus lack of clinical understanding interaction between secondary care services / hospital care / barriers Threats Service model General Dental Service led service Strength Access to Gen dental practitioners Opportunities Weaknesses l Lack of interaction with secondary care Access to Gen dental practitioners focus on care of patient skills gap Threats lack of ability to network Page 15 of 16

16 Participants Session Leads: Chair and Facilitator Alistair Docherty Breakaway Group Leads Simon Tiller Douglas Gunn Louise Hopper Susan Maddock Michelle Slater Commissioner Representatives Ben Squires Charles Brown Dental Public Health Colette Bridgman Gill Davies Deanery Dr Craig Barclay Other participants attended the morning workshop sessions including members of the Greater Manchester Special Care Dentistry Network: Jane Leahy Stephen Collins Suzanne Smith Sabina Bangue Angela Brown Michelle Bates Archana Prasad Page 16 of 16