A needs assessment for orthodontic care in Thames Valley (Buckinghamshire, Oxfordshire, Berkshire)

Transcription

1 A needs assessment for orthodontic care in Thames Valley (Buckinghamshire, Oxfordshire, Berkshire)

2 A needs assessment for orthodontic care in Thames Valley Version number: Final version First published: March 2017 Updated: (only if this is applicable) Prepared by: Anna Ireland, Consultant in Dental Public Health Classification: For local use only The National Health Service Commissioning Board was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the National Health Service Commissioning Board has used the name NHS England for operational purposes. Final version 2

3 Acknowledgements NHS England would like to thank all of the individuals, groups and organisations that supported this review in some way. We are particularly grateful to those who contributed data to the review and those who attended stakeholder meetings. NHS England would particularly like to thank the following people: Alison Marshman, Primary Care Commissioning Assistant Hugh O Keeffe, Primary Care Contracts Manager (Thames Valley) Business Services Authority Public Health England Knowledge and Information Team Anna Ireland, Consultant in Dental Public Health Jenny Oliver, Consultant in Dental Public Health Devika Vadher, Dental Public Health Clinical Fellow Members of the Thames Valley Orthodontic Managed Clinical Network Final version 3

4 1 Contents 1 Contents Executive summary Key issues Recommendations Introduction What is Orthodontics? Who gets orthodontics under the NHS? Aim of the needs assessment Objectives Exclusions What is meant by need in relation to orthodontic treatment Types of need for orthodontic treatment How do the interactions between types of need impact on service usage? Who needs orthodontic treatment? How many 12 year olds are there in TV and how does this vary by lower tier local authority? Number of 12 year olds in TV as a whole How much orthodontic need is in the population of the TV? Normative need Survey method to estimate normative need Stephen s method to estimate normative need The rule of a third to estimate normative need Comparison between methods of estimating normative need Perceived need and demand How much Orthodontics is being commissioned for Thames Valley residents in primary care? How much Orthodontics is being delivered for TV residents in secondary care How much Orthodontics is being delivered in Community Dental Services What are the differences between the levels of primary care orthodontic commissioned activity and estimated orthodontic need? Commissioned activity and future need Primary care Location of orthodontic practices Where are patients coming from? How does uptake of Orthodontic care vary in TV? Uptake of NHS orthodontic care is variable Variation in uptake by age Variation in uptake by socioeconomic status Variation in uptake of orthodontic treatment by gender What orthodontic care is being provided in primary care? Final version 4

5 10.1 Assessment and acceptance for treatment Severity of cases being treated in primary care Secondary care How long are patients waiting for orthodontic treatment? What is the NHS currently spending on Orthodontics in Thames Valley? Types of orthodontics services in Thames Valley Total spend on orthodontics services in TV Secondary care What are the workforce pressures on the Orthodontic system? Orthodontic consultant numbers and consultant training Impact of skill mix Orthodontic services in the community dental service? Orthodontic support to the wider system Knowledge gaps Public views on orthodontics Stakeholder feedback - national commissioning guide for orthodontics Conclusions Summary of findings Key issues Recommendations Appendices A. Postponed public engagement survey on Orthodontics in South Central (BGSW and Thames Valley) B. Recommendations from 2012 Thames Valley orthodontic needs assessment update on progress C. Explanation of the Index or Orthodontic Treatment Need D. The Essex Youth Forum discussion on orthodontics References Final version 5

6 1 Executive summary Objective 1. How much Orthodontic need is in the population of Thames Valley? 2. How much orthodontic care is commissioned for Thames Valley residents? 3. What is the NHS currently spending on Orthodontics in Thames Valley? 4. Where services are located and how accessible are they to residents? 5. How does uptake of Orthodontic care vary in Thames Valley? 6. What orthodontic care is being provided? Findings Various methods of estimating need. No method of assessing need is precise When the third method is used it is estimated that 8,447 people in Thames Valley have an orthodontic treatment need (based on 2016 population) 181,559 UOAs are commissioned from primary care 2,150 UOAs are commissioned from community dental services A specific number of courses of treatment are not commissioned from secondary care. Secondary care services are commissioned on a PBR (payment by results) basis using a national tariff 15.7% of the Thames Valley dental budget is spent on orthodontic care for Thames Valley 82% of this (( 11,482,911) is spent on primary care services Most secondary care treatment for Thames Valley residents is carried out by providers based in Thames Valley Primary care NHS orthodontics is provided across TV but there are areas with limited provision In most area of Thames Valley patients accessing primary care services travel no more than 15km There are some areas of TV where patients travel more than 15km The number of patients travelling certain distances was not available Local data on how uptake varies but gender and socio-economic status were not available Primary care Data suggest that most courses of treatment, provided meet the NHS IOTN threshold The average age of patients receiving treatment is approximately 13 years On average almost 94% of cases assessed are accepted for treatment There is limited variation in the proportion of cases which are abandoned or discontinued (range 8.5%-1.9%) Final version 6

7 The data available are submitted by practices and not independently verified The vast majority of contracts achieve band A for KPIs suggesting there is limited scope for efficiency gain within existing contracts 7. How appropriate are the cases being referred? 8. How long are patients waiting for Orthodontic treatment? 9. Are we commissioning enough Orthodontics to meet population need estimates? Secondary care According to SLAM data in 2015/16 hospital trusts provided 20,609 units of orthodontic activity to TV residents Activity data obtained directly from the providers show that in 2015/16 there were 285 new patient encounters and 2,294 treatment or follow-up encounters All triage is carried out by the receiving provider in primary and secondary care. There is no independent triage service. The referral criteria used by secondary care trusts and orthodontic specialists are not shared across TV Treatment data show that in the maim only cases which meet the IOTN threshold are receiving treatment Data are not available on how appropriate referrals are but again assess to accept ratios suggest in the main referrals are appropriate Collection of waiting time data for primary care has proved problematic. Responses to the questionnaire suggest that providers interpreted the questions differently. Therefore the responses from the questionnaire (below) should be treated with caution The wait for primary care orthodontic treatment varies between providers The number of patients waiting for assessment and treatment appointments varies between providers The maximum wait for an assessment is 12 months. The minimum is 1 week The maximum wait for treatment is 2 years. The minimum is 2 weeks If the third rule method is used to assess need it is estimated that at present the NHS is commissioning 196 (2%of total population need) more courses of treatment in primary care that are required to meet total need (assumes 21 UOAS per course of treatment) This is an under estimate of over commissioning as some of those with need will require secondary care services Final version 7

8 10. Are the services we are commissioning distributed equally? 11. What are the knowledge gaps? 12. What are the stakeholder views on what is going well and what is going less well The population of TV is predicted to increase over the next 20 years. Current levels of commissioned activity may not be sufficient to meet this growing need Current performance in primary care suggests that there is little room for efficiency in these services There are areas of TV which have a limited provision of care (see point 4) The capacity of currently commissioned services is not matched to the capacity required to meet need Not all current services are situated in locations which minimise travel for all patients, although some practices are situated in a location which minimises travel Type of care provided in secondary care provided for adults and children Waiting times in secondary care Accurate waiting times in primary care Patient/public views on what good orthodontic care looks like IOTN NHS threshold generally agreed with SLAM data does not reflect clinical activity Current levels of activity may not meet demand of growing population Not all CDS services have an in house orthodontic service Waits for hospital opinions for CDS patients can be a number of weeks The planning of future services should take into account that access to services for patients is not restricted by Local Authority boundaries 1.1 Key issues The Thames Valley commissioners have inherited an orthodontic system Orthodontic need is commonly assessed by estimating the need in the 12-year-old population. The location and capacity of current providers is largely historic and there has been little active commissioning of orthodontic services since the advent of the new contract in Location and capacity of services are not matched to need in all areas This is the first time there has been a formal assessment of whether the capacity and location of service meet need. The data show that there are some areas where services are limited and some areas where capacity is greater than need. Final version 8

9 Inequalities in access to orthodontic services Whilst most patients are able to access primary care orthodontic services within15km of their home some have to travel further than this. Travelling large distances may be particularly difficult for more deprived families and so will increase inequalities in access. Waiting times in primary care of variable. Lack of waiting time information, available to GDPs and patients, means that they may not be able to make choices which take into account waiting times. Lack of detailed data The secondary care data available to support this needs assessment was limited. It was not possible to obtain information on the ages of patients treated or the treatment provided. In primary care there is a lack of accurate information on referral sources, waiting times and numbers of patients waiting for treatment. Triage Triage is carried out by providers on the referrals they receive. There are no agreed referral criteria, referral forms or independent assessment of referrals. There is also no routine collection of referral data e.g. referral source. Referrals are not submitted electronically, as recommended in national guidance. Pathway There is no agreed orthodontic pathway, with a single entry point, in TV, as per national guidance. Final version 9

10 1.2 Recommendations Match capacity to need Ensure capacity meets future population growth Work in partnership with orthodontic clinical network to: o Identify a reasonable waiting time standard across TV o Validate waiting list information Ensure the location and capacity of service commissioned meets the local need and takes into account natural patient flows It is important to note that the number of UOAs needed is used as a proxy for need across the system. UOAs are not the currency used in secondary care and this must be taken into account when planning services otherwise there is a risk that the budget is spent on primary care UOAs only and orthodontic services may be over-commissioned. Improve monitoring and data collection across the system Agree definitions of waits for assessment and waits for treatment so that commissioners can compare waits between practices Routinely collect waiting time data from primary care providers Routinely collect waiting time data form secondary care providers Consider commissioning an electronic referral management service for orthodontic referrals. This will enable collection of data on source of referrals, appropriateness and outcome of referrals and the proportion of referrals meet NHS criteria. Contract management and improving quality Quality based KPIs should continue and be improved Aim to align KPIs and targets across South Central over medium term Work with the clinical network to agree how to support orthodontists struggling to meet DAF standards and how to share best practise Agree, with the clinical network, appropriate and meaningful PROMs and PREMs for monitoring quality Link all Orthodontic providers to clinical network which can lead and support them to improve quality, such as through peer review and audit Consider implementing PREMS that look at communication with young people in a caring, respectful and comprehensible way, including providing explanations throughout the course of treatment and answering questions. Pathway redesign Final version 10

11 Work with clinical network to agree referral criteria and referral form to ensure consistent processes, and good quality referrals, across TV Implement an electronic referral service to give single entry point to the pathway and provide the following benefits: avoidance of duplicate referrals, ongoing measurement of uptake of services, routine data collection, e.g. on source of referral, numbers waiting, waiting times, required level of provider. Work with HEE and the clinical network to support dentists to routinely include the IOTN score when referring patients for orthodontic treatment. Implement consistent referral management for secondary and primary care according to national commissioning guidance, ideally with electronic RMS so that data can be gathered and monitored. Work towards agreeing service specifications for secondary care services including minimum data set Reach consistent agreement on under what circumstances over 18s receive orthodontic treatment in secondary care Involve patients and public in the Orthodontic commissioning cycle, such as pathway redesign and evaluation Tackling inequalities Make use of opportunities in the future to distribute resources/capacity more according to need/population density. Prioritise areas where high numbers of patients are travelling long distances, particularly where patients are from lower deprivation quartile. Prioritise delivery of prevention activities in GDS contracts, e.g. application of fluoride varnish. This will help to improve oral health and therefore enable more people to be suitable for orthodontic care Involve patients and public in the commissioning cycle, such as pathway redesign and evaluation and in work regarding addressing inequalities in access to dental services. Actively monitor access to GDS Work with the LPN to explore how to encourage referral of more deprived patients Gather information on the local public view on Orthodontic services and apply findings to action plan. Review opening hours across the Orthodontic system and expand beyond school hours where necessary. Orthodontic support to the wider system Ensure commissioning of orthodontic treatment planning support to services treating: special care patients extractions under GA Final version 11

12 2 Introduction This needs assessment gives an overview of the current position of orthodontic commissioning in Thames Valley (TV). It outlines population need and orthodontic services currently commissioned before identifying gaps in services and knowledge. It also includes the views of local clinicians on the current orthodontic pathway in TV. Drivers for this needs assessment include: 1. National commissioning guide for orthodontics published by NHS England in Upcoming South-wide tender of orthodontic services (map 1. Shows the geographical area covered by NHS South) 3. Merger of Thames Valley and BGSW Area Teams into a single South Central local NHS England office 4. Update on needs assessment which was carried out in An update on the recommendations of the 2012 orthodontic needs assessment can be found in appendix B. Map 1 Geography of NHS South Source NHS England This report will introduce needs in the context of orthodontics before describing the potential numbers that could benefit from NHS orthodontics in TV. It goes on to consider where, what and how much orthodontic care is provided, and at what cost. It looks at whether sufficient orthodontic services are being commissioned for the population of Thames Valley and the distribution of these services. Tt summarises the key issues found and finally it makes recommendations that are designed to support commissioning of orthodontic services in the short and medium term. Final version 12

13 The Orthodontic Clinical Network in TV was very helpful in supporting this document. Their views are presented in speech bubbles throughout the document. 2.1 What is Orthodontics? Orthodontics is concerned with the development, prevention, and correction of irregularities of the teeth, bite and jaw, 3 known as malocclusions. This term is given to mouths that display natural variations from the ideal in how the teeth and jaws relate. The most common feature of malocclusions is dental crowding. 4 Orthodontic treatment often involves extraction of teeth (to relieve dental crowding) and the closing of resultant gaps with appliances. Three main types of appliance are used: removable appliances (to tip teeth into place), functional appliances (a bulkier removable appliance that aims to reduce the prominence of upper front teeth) and fixed appliances (use attachments and wires fixed in the mouth to move multiple teeth). Most treatment plans use fixed appliances, with or without other appliance types. Orthodontic treatment generally takes 18 months 2 years, and this is followed by long-term retention to prevent relapse. 2.2 Who gets orthodontics under the NHS? The Department of Health recommends that NHS orthodontics is commissioned for children, aged up to 18 years and under at the time of assessment, who are classified with the Index of Orthodontic Need (IOTN) at IOTN Dental Health Component (DHC) levels of 4 and 5 or DHC 3 where there is an Aesthetic Component (AC) of 6 and above. A full explanation of IOTN can be found in Appendix B. Most of us, as stakeholders, agree with the IOTN threshold. View expressed by a member of the TV Orthodontic clinical network Primary care delivered NHS orthodontic care is not usually available for adults, but may be provided on a case-by-case basis if needed for health reasons. Secondary care services provide care to both adults and children. 2.3 Aim of the needs assessment To give an overview of where are we now to support commissioning of orthodontic services in the short and medium term (figure 1). Final version 13

14 Figure 1 The cycle strategic planning Where are we now? Oral health needs assessment How do we get there? Action plan Where do we want to be? Commissioning strategy This needs assessment is just one stage in the commissioning cycle. While it answers some questions, a needs assessment will invariably generate more questions and it should begin an interactive process of analysis, stakeholder engagement and reviewing. It is crucial to work in collaboration with the Orthodontic clinical network to make sense of this needs assessment and to plan any necessary pathway or service redesign. Ultimately the needs assessment will require revisiting in time (figure 2). Figure 2 The needs assessment process Needs assessment report Interpretation with local stakeholders Strategic planning with local stakeholders Implementation of changes Review and evaluation Final version 14

15 2.4 Objectives To identify: 1. What is meant by need in relation to orthodontic treatment? 2. Who needs orthodontic treatment? 3. How much orthodontic need is in the population of TV? 4. How much orthodontic care is commissioned for TV residents? 5. What is the NHS currently spending on Orthodontics in TV? 6. Where services are located? 7. How does uptake of orthodontic care vary in TV? 8. What orthodontic care is being provided? 9. How appropriate are the cases being referred? 10. How long are patients waiting for orthodontic treatment? 11. Are we commissioning enough orthodontic care in the right location to meet population need estimates? 12. Are the services being commissioned distributed equally? 13. What are the views of stakeholders in TV? 14. What are the knowledge gaps? 2.5 Exclusions The following topics are excluded from the scope of this needs assessment: Private orthodontic activity Orthodontic need and care for people with a cleft lip or palate Orthodontic care associated with orthognathic care Comparison of need for Orthodontics versus other types of dental care or prevention. Final version 15

16 3 What is meant by need in relation to orthodontic treatment 3.1 Types of need for orthodontic treatment There are a number of ways of defining need (figure 3). While this may seem unduly complicated, it is a reflection of the unpredictable and subjective nature of need. As such it can be challenging to identify which person has the capacity to benefit from treatment and which does not. Figure 3 Types of need in relation to orthodontics Normative need Need as defined by orthodontists Commonly described using the Index of Orthodontic Treatment Need (IOTN) Perceived (felt) need The individual's assessment of his or her requirement for care For children this can be substituted by the parental assessment of the child's requirement for care Expressed need (demand) When percieved need is converted into action, by seeking professional care Comparative need Compare capacity to benefit between different population groups, e.g. ethnicity, socioeconomic, geographic, gender Compare population capacity to benefit from different interventions, e.g. orthodontics vs general dentistry, oral surgery or domiciliary care In relation to orthodontics, for example, people with a malocclusion do not necessarily want treatment and can often function well without treatment. As with any clinical intervention, it is important that the potential benefits of treatment outweigh any risk of harm. There are a number of risks of orthodontic treatment including root resorption, gum disease or recession, decay in tooth enamel and risk of relapse. Benefits of orthodontic treatment include removal of dental crowding, alignment of the teeth in the dental arches, reduction in the likelihood of damage to front teeth and improvement in facial aesthetics. In addition there is some evidence that poorly positioned teeth can make children targets for bullying and harassment and may be a cause of psychological distress. Treatment of a malocclusion can lead to an improvement of self-worth, confidence and psychosocial wellbeing. Some malocclusions can have health impacts but the presence of a malocclusion does not indicate that a disease process is present. This means that orthodontic Final version 16

17 treatment is almost always elective. It can therefore be difficult to decide when and if orthodontic treatment is required. 5 It is important to note however; that population levels of perceived or expressed need are subjective and therefore changeable. Perceived and expressed need can be influenced by external factors, such as changes in societal norms on the acceptability of crowded teeth, awareness of entitlement to treatment (or lack thereof) or availability of an NHS dentist. As such, they can influence inequalities in uptake of care. Finally it is important to consider comparative need: in a context of increasing need and limited resources it is relevant to look at the added value of different interventions, e.g. what population needs will be met by spending on orthodontics versus spending on domiciliary care or prevention programmes. It is also crucial to look at inequalities in need and attempt to address those through any resulting action plan or strategy, e.g. inequalities in access to Orthodontic care by deprivation quartile. 3.2 How do the interactions between types of need impact on service usage? Where people have a normative need for Orthodontic care, and there are services available to meet that need, but they do not want treatment they will not present for treatment or accept referral (termed unwilling recipients). Where, on the other hand, there is a need and demand but insufficient service capacity to meet that need, waiting lists will grow. Where there is demand and supply but no normative need, such as the NHS IOTN threshold is not met, patients may seek private treatment. 4 Who needs orthodontic treatment? Most orthodontic treatment is carried out in children in the early teenage years (12-13 years old). This is because most treatment requires all permanent teeth to be in the mouth. It is also thought that treatment is facilitated by pubertal growth. In some cases, treatment on younger children can be helpful to remove, or reduce, the need for treatment later (interceptive orthodontics). Orthodontic treatment can also be carried out in adults. Where there is a gross difference between the sizes of upper and lower jaws orthodontics alone is not able to correct the malocclusion. These cases, if treated, require multidisciplinary care to deliver a treatment plan that includes both surgery to move the jaws (orthognathic surgery) and orthodontic appliance treatment to move teeth. In these cases treatment is delayed until the patient has stopped growing usually at age years old. Final version 17

18 Unlike most oral conditions, malocclusion does not vary between genders or between socioeconomic groups. To a small extent, racial characteristics mean that there is some ethnic variation. In the NHS the majority of orthodontic treatment is carried out in children aged years. A small number of younger children receive interceptive orthodontic care, and a small number of adults receive treatment. 5 How many 12 year olds are there in TV and how does this vary by lower tier local authority? This chapter details the current population estimates of 12 year old numbers both in TV as a whole, and in each of the lower tier local authorities therein. 5.1 Number of 12 year olds in TV as a whole This section focuses on 12 year olds as the population which has the most potential need for treatment. Twelve year olds are the group that epidemiological surveys tend to focus on when measuring prevalence of orthodontic need. The rationale for this is that at 12 years old, most permanent teeth are in place but treatment has rarely commenced by this age. Figure 4 shows the size of the population, by lower tier local authority, in TV and the size of the 12 year old population. Figure 4 General population and population of 12 year olds, by county in TV (2016 estimates 6 ) Source: Office for National Statistics Local Authority Population all ages Population 12 year olds Reading 163, Bracknell Forest 120, Slough 147, West Berkshire 156, Windsor and Maidenhead 149, Wokingham 161, Aylesbury Vale 189, Chiltern 94, South Buckinghamshire 69, Wycombe 177, Cherwell 146, Oxford 161, South Oxfordshire 138, Vale of White Horse 126, West Oxfordshire 109, Total 1,926,365 25,345 Final version 18

19 12-year-old population OFFICIAL These data in figure 4 are shown in graphical form in figure 5. Figure 5 Comparison of numbers of 12 year olds, by local authority (2016 estimate) Source: Office for National Statistics Local Authority There is a large variation in population sizes of local authorities across TV, which is reflected in the size of the 12 year old population. This ranges from 817 in South Bucks to over 2,345 in Aylesbury Vale. The population of 12-year-olds in Thames Valley is not expected to remain stable over the next 25 years. Population projections for are shown in figure 6. Final version 19

20 Estimated number of 12 year olds in the population OFFICIAL Figure 6 Population projections for 12 year olds in TV 2016 to 2037 (based on 2012 estimates) Source: Office for National Statistics 35,000 30, ,00023,291 30,697 29,337 20,000 15,000 10,000 5,000 0 Year The number of 12 year olds in TV is predicted to peak in 2023 at 30,697 followed by a slight drop by Overall this amounts to an increase in numbers of 12 year olds by 6,046 over the next 20 years across TV (figure 6). 6 How much orthodontic need is in the population of the TV? There are various methods of estimating need for orthodontic care, particularly in relation to normative need. No method of assessing need however, is precise, and subjective needs (felt need and demand) are changeable. Regardless of which method is used, they can only provide an estimate of the existing level of need. It is important therefore that any estimate of need in TV be considered within the context of the system as a whole (for example, people accessing orthodontic services across NHS boundaries). Estimations of normative need, perceived need and expressed need (demand) are given below. Final version 20

21 6.1 Normative need There are various methods of estimating orthodontic normative need. No method however, is precise. This report describes three methods: 1. Survey method 2. Stephen s formula method 3. The rule of a third The findings of these analyses are discussed below. 1.1 Survey method to estimate normative need Orthodontic need is not routinely measured through dental epidemiological surveys. There are two sources of epidemiological data for Orthodontics in England: national Children s Dental Health Surveys and Local Dental Epidemiology Programme surveys (DEP). Both surveys assess need using a modified Index of Orthodontic. The survey does not recognise a child with an IOTN as having a treatment need, whereas a child with this IOTN would be eligible for treatment on the NHS. This means that these figures will slightly underestimate the need for Orthodontic care according to NHS IOTN threshold National epidemiological survey Nationally the proportion of children identified as having a need for Orthodontic treatment in the Children s Dental Health surveys is around 40% (figure 7). Figure 7. Summary of level of treatment need as measured by consecutive Children s Dental Health Surveys, 2003 and 2013 Year % in treatment % treatment % total need need Not gathered Not gathered Local epidemiological survey The most recent Dental Epidemiology Programme survey that included an orthodontic element was in 2008/9. It involved the examination of a sample of children attending mainstream schools who were aged 12 years at the time of the survey. 7 One of the conditions looked at in this survey was orthodontic need and demand. This survey did not produce TV level results as NHS boundaries in 2008/9 did not match today s boundaries. The survey did however, give results by local authority and, from this, weighted estimates can be calculated for TV (figure 8). Final version 21

22 Figure 8 Proportion of 12 year olds with a definite need for orthodontic treatment (NHS DEP 2008/9 survey) PCT area (a) % of 12 year olds examined with definite orthodontic need (b) % 12 year olds already wearing a brace (c) % of those with a need who would be prepared to wear a brace (d) % 12 year olds who are wearing a brace and % who have a need and would be prepared to wear a brace overall need (c+b) Berkshire East West Berkshire Buckinghamshire Oxfordshire Thames Valley weighted mean South Central (old Strategic Health Authority area) England The 2008/09 survey found that just fewer than 30% of 12 year olds in TV had a need for orthodontic treatment. In addition approximately 11% of children surveyed were already wearing braces. If it is assumed that all the children wearing braces had a need for orthodontic treatment then the data suggest that 41% of children in Thames Valley had a need for orthodontic treatment. However, not all of the children with an identified need (not already wearing braces), when asked, were prepared to wear a brace. When the proportion of those already wearing a brace are added to the proportion of those with a need who would be prepared to wear a brace then the figure for the overall need is 29% (column d in figure 8). At a local old PCT level, the estimate of need varied from 25.9% to 34.4%. The higher the proportion of 12 year olds examined, the more likely the figure given represents the true population need. Based on the sample size, it is unlikely that the differences between the local authority levels of need are statistically significant, i.e. not representative of true differences in the populations. Final version 22

23 By extrapolating the proportion of the population of 12 year old with need and demand to the current population size it is possible to estimate the numbers of 12 year olds that may benefit from treatment (figure 9). Figure 9 Estimated number 12 year olds who would benefit from treatment, using survey method (NHS DEP 2008/9 survey) Number of 12 year olds Overall need Number of 12 year olds requiring treatment Thames Valley 25,345 29% 7, Stephen s method to estimate normative need 8 Stephen s method is one of a number of formulaic methods of estimating need. This method defines a person with need as having an IOTN dental health component of (DHC) 4 or 5 (which again differs slightly from the NHS IOTN threshold) (figure 10) Figure 10 The formula for Stephen s method of estimation of need 12 year old population X Interceptive factor (9) + adult factor (4) The theoretical rationale for this formula is as follows: In a typical school population, one third of the children fall into IOTN DHC 4 and 5. A number of these cases will decline to have treatment This number (the proportion who have a normative need but decline treatment) will be offset by a combination of each of the following: % children in Dental Health Component (DHC) 3 who would also justify treatment (3.6 to 3.10) % children who would require interceptive treatment (calculated at 9%) Some adults for whom treatment could be justified (4%). Stephen s formula calculation for TV 25, year olds X Interceptive factor (9) + adult factor (4) = 8, x 1.13 = 9,547 Final version 23

24 Therefore the Stephen s method estimates that 9,547 individuals in TV will have need for treatment. 3.1 The rule of a third to estimate normative need Evidence from national surveys and literature suggest that around 33% of 12-yearolds have an objective need for orthodontic treatment (figure 11). In a typical school population, one third of the children fall into IOTN categories 4 and 5. This method of estimation is supported by the NHS England commissioning guide for orthodontics. 1 Figure 11 Levels of normative need in 12 year old children in published studies Author Date Country Sample size Age of children (years) Percent with definite treatment need* Brooke and Shaw England % Holmes England % Wang et al China % Abdullah and 2001 Malaysia 5, % Rock 12 Abu Alhaij et al Jordan 1, % *Definite need for treatment as defined by the IOTN Dental Health Component Grades 4 and 5 and/or Aesthetic Component Gradings 8-10 Figure 12 shows the estimated levels of normative in TV using this principle of a third. Final version 24

25 Figure 12 The estimated number of 12 year olds requiring treatment using the rule of a third method by lower tier local authority Local Authority Population 12 year olds (2016) Number of 12 year olds with treatment need (1/3) Reading Bracknell Forest Slough West Berkshire Windsor and Maidenhead Wokingham Aylesbury Vale Chiltern South Buckinghamshire Wycombe Cherwell Oxford South Oxfordshire Vale of White Horse West Oxfordshire Total 25,345 8, Comparison between methods of estimating normative need There is significant variation in estimated numbers of 12year olds requiring orthodontic treatment using the three methods. There are many reasons why there is a substantial variation in estimated levels of need between the three methods. Some of these are outlined below: Stephens s formula takes into account interceptive and adult orthodontics rather than just need in 12 year olds. The local survey was undertaken on a small sample of children and there may have been bias introduced due to the consent process and access to schools. The criteria for objective need were based on IOTN 3.8 and above for the local survey, whereas the national criteria for treatment is IOTN 3.6 and above. The local survey considers demand and perceived need, as well as normative need, which is likely to be more realistic for commissioning purposes NHS England does not commission adult orthodontics in primary care These key differences are summarised in figure 13. Final version 25

26 Figure 13 Key differences between three methods of estimating need for orthodontic treatment in the population Takes account of need in adults (although not how limited NHS treatment is for adults) Considers interceptive orthodontics Considers demand Stephen s method Epidemiology survey method Rule of 1/3 X X X? X Considers private sector X X X Uses NHS IOTN threshold X X The rule of a third is clearly less detailed than the Stephen s method or the epidemiology survey method but is often considered the most pragmatic method. In some needs assessments a number of methods are used and the findings averaged. While this makes sense mathematically, it does not necessarily provide a more accurate estimation of local need than any of the methods on their own. There is a difference between the results generated by the three methods (figure 14). The estimated number of 12 year olds requiring treatment ranges from 7,350 to 9,547 depending on method used. Figure 14 Summary of comparison of methods showing estimated numbers of 12 year olds with Orthodontic need, and number of UOAs needed, in TV Estimated number of 12 year olds requiring treatment in TV Survey method 7,350 Stephen s formula 9,547 Rule of 1/3 8,447 This illustrates that there is no precise way of estimating need. These estimations are just that: it is therefore crucial that these data are interpreted with local stakeholders. These data alone are an insufficient basis from which to commission Final version 26

27 services and must only be used in the context of understanding the strengths and weaknesses of the wider Orthodontic system. For the purposes of this needs assessment the figures obtained by using the third rule are used in calculations in this document. This is to ensure that this document is consistent with the NHS England orthodontic commissioning guide and the other needs assessments being completed across the south of England as part of the NHS south wide orthodontic procurement project. This method also gives and estimation of need which represents the mid-range of the three methods. 6.2 Perceived need and demand Perceived need varies between individuals, is inconsistent even at the same IOTN, and is difficult to predict with accuracy. Demand for orthodontic treatment has increased substantially and continues to increase. 1 Demand is likely to be greater in females and children from higher socio-economic groups. 15 It is therefore not possible to predict demand by looking at levels of normative need alone. Children with a more extreme malocclusion are more likely to demand treatment than those without. That said, demand can be absent in children with a high need and present in others with no objective need. This means that there are groups in society who do not receive orthodontic care but who may benefit from it. 14 The NHSDEP 2008/9 survey provides local data on perceived need and demand. In the survey, 12 year olds were asked a number of questions 7 : 1. Have you got an orthodontic brace or appliance? 2. Do you think your teeth need straightening? 3. Would you be prepared to have treatment and wear a brace if it were necessary? Question 2 relates to perceived need. Question 3 indicates potential demand. The findings are summarised in figure 15. There are no routinely collected data on demand in TV. The only estimate available is from the 2008/09 survey which suggested that (figure 15): In all areas of Thames Valley there are more children who want to wear a brace than actually need it. This finding is most pronounced in Oxfordshire where 21% of children examined said they would like and prepared to have orthodontic treatment but did not have an identified need. Final version 27

28 Figure 15 Estimated level of demand in those without identified need in 12 year olds (NHS DEP 2008/9 survey) Old PCT area Number of children examined A Number involved in ortho measurement (A - number already wearing a brace) B Number who said they want their teeth straightening and who would be willing to wear a brace C Number who need ortho IOTN classification of 4 or 5 or aesthetic component of 8,9 or 10 and demand D Number who have a demand but no need (C-D) E Proportion of sample with expressed demand but no need (E/1099)*10 0 F Oxfordshire 1,181 1, % West Berkshire 1, % Berkshire East 1, % Buckinghamshire 1,249 1, % Thames Valley weighted estimate 4,571 4,041 1, % England 89,442 82,328 31,681 17,238 14,443 17% * Assumption made here that all children wearing a brace had a definite need for treatment. These data may not reflect the current picture. The survey is somewhat out of date and views may well have changed over this time. Final version 28

29 Aylesbury Vale Bracknell Forest Cherwell Chiltern Oxford Reading Slough South Oxfordshire Vale of White Horse West Berkshire West Oxfordshire Windsor and Maidenhead Wokingham Wycombe Contracted UOA OFFICIAL 7 How much Orthodontics is being commissioned for Thames Valley residents in primary care? The commissioned level of orthodontics for TV varies by local authority and is summarised in figure 16. The greatest number of UOAs is commissioned from practices located in Reading, Wokingham, Cherwell and Wycombe. Figure 16 Contracted UOAs by local authority (based on practice location) in TV 2013/ /16 Source: BSA data* 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5, *South Bucks is excluded from the figure as there is no contracted activity provided from within the local authority. 7.1 How much Orthodontics is being delivered for TV residents in secondary care Specialist orthodontic care is also commissioned from secondary care providers. There are four secondary care hospital trusts located in Thames Valley which provide the majority of care to the residents of Thames Valley. Hospital trusts are contracted to provide a certain amount of activity for an agreed contract value. They are paid on a national tariff basis for activity completed; PBR (payment by results). This is monitored via SLAM (Service Level Agreement Monitoring) data. The 2015/16 SLAM data for all hospital trusts which provided orthodontic care to Thames Valley residents is shown in figure 17. Final version 29

30 Figure 17 SLAM data for 2015/16 for hospital trusts providing orthodontic care to TV residents Provider Name Sum of Activity Actual Sum of Price Actual Buckinghamshire Healthcare 5, ,092 Frimley Health 3, ,863 Oxford University Hospital NHS Trust 7, ,727 Royal Berkshire 3, ,458 Kings College 33 6,008 Milton Keynes ,127 North West London ,969 UCLH ,811 *Guys & St Thomas 99 17,842 *Hillingdon ,612 *Royal Surrey County Hospital NHS FT ,911 Total 20,609 2,599,420 *data are incomplete The activity counted as part of SLAM data relates to Health Resource Group (HRG) codes. This means that a patient undergoing a procedure coded to one HRG code will be counted as one unit of activity. A single patient undergoing two separate treatments coded to two HRG codes will be counted as 2 units of activity. The SLAM data show that, of the four main providers, Oxford University Hospital Trust carries out the greatest amount of activity and has the correspondingly highest total cost. A limited amount of activity is carried out by trusts located outside Thames Valley. Orthodontic care provided in secondary care consists of new patient assessments, treatment appointments and review appointments. The complexities of the secondary care data coding system means that it is difficult to identify the number of patients for whom orthodontic treatment is carried out from SLAM data alone. It is also not possible to identify the ages of the patients treated or the type of care they received. For this needs assessment the main secondary care providers were asked directly for data. These data are shown in figure 18. SLAM data does not reflect actual clinical activity View expressed by a member of the TV Orthodontic clinical network Final version 30

31 Figure 18 Number of orthodontic encounters delivered by secondary care providers in Thames Valley (2015/16) Secondary care provider Bucks Healthcare (Amersham and Stoke Mandeville) Royal Berkshire Hospitals (RBH and West Berkshire) Oxford University Hospitals Frimley Health (Heatherwood and Wexham Park) New patient encounters Treatment encounters Follow-up encounters N.B. the above figures relate to appointments and not individual patients. 7.2 How much Orthodontics is being delivered in Community Dental Services The delivery of orthodontic care to the patients of Community Dental Services (CDS) is not consistent across Thames Valley. The CDS in Berkshire and Oxfordshire offer in house orthodontic care whereas Buckinghamshire do not have this facility. A summary of the orthodontic activity commissioned and delivered form the Community Dental Services in TV is given in figure 19. Figure 19 Summary of activity commissioned and delivered for CDS services in Thames Valley (2015/16) Community Dental Service Activity commissioned (UOAs) Activity delivered (UOAs) Buckinghamshire nil nil Oxfordshire 1,850 2,020 Berkshire What are the differences between the levels of primary care orthodontic commissioned activity and estimated orthodontic need? One key question that this needs assessment has been asked to address is whether the current level of commissioned activity meets the current need of the population in Thames Valley as a whole and by lower tier local authority. Figure 20 summarises the amount of activity currently commissioned in primary care compared to the current orthodontic need by practice location. Final version 31

32 Local Authority Population 12 year olds ** Number of 12 year olds with treatment need (1/3) ** OUAs commissioned in primary care Courses of treatment commissioned (22 UOA/pat) * Courses of treatment commissioned (21 UOA/pat)* Gap/ excess between total activity commissioned and need (number of children) OFFICIAL Figure 20 Orthodontic need and activity commissioned in primary care by the lower tier local authority 1 where the practice is located. UOAs CoT CoT Bracknell Forest ,843 6,929 Reading ,639 Slough ,474 3,599 West Berkshire ,631 Windsor and Maidenhead ,468 5,265 5,391 Wokingham ,657 Berkshire total 11,095 3,697 95,455 4,339 4, Aylesbury Vale ,736 2,940 Chiltern South Buckinghamshire Wycombe ,867 3,579 19,286 Buckinghamshire total 6,688 2,230 35,746 1,624 1, Cherwell ,323 12,740 4,482 Oxford ,784 4,670 South Oxfordshire ,021 Vale of White Horse ,803 West Oxfordshire ,487 Oxfordshire total 7,562 2,520 50,310 2,287 2, Total 25,345 8, ,511 8,250 8, * Proxy for number of patients for whom treatment is commissioned (assumes one course of treatment per patient and no commissioning for assessment only cases). Calculations using 22 UOAs per course of treatment are included at the request of the Thames Valley Orthodontic Clinical Network. **Uses 2016 population estimates. 1 NB. Orthodontic contracts are not commissioned to provide care for patients of specific local authorities. Final version 32

33 At the request of the NHS England commissioners the calculations in figure 20 are based on the assumption that each course of treatment will attract 21 UOAs. The table does not include activity commissioned from secondary care and community dental services so underestimates the total orthodontic activity commissioned. From the data in figure 20 it can be seen that currently across Thames Valley the estimated orthodontic need of the population is met by the activity commissioned in primary care. There is an estimated excess of 166 i.e. it is estimated that there are 166 more courses of treatment commissioned in primary care than the estimated need. This equates to 2% of the total population in need. As activity provided by secondary care and community dental services are not included in table 20 the figure of 166 underestimates the excess activity commissioned compared to need. The data also show that when need and commissioned activity are looked at by lower tier local authority the picture is variable. The data suggest that in Berkshire there is more commissioned activity than need whereas in Buckinghamshire and Oxfordshire there is less commissioned activity than need. However, the orthodontic contracts in Thames Valley are all PDS (personal Dental Service) contracts. This means that there are no geographical restrictions placed on them and they can draw patients from any local authority area. Patients do not recognise local authority boundaries when seeking care and will travel to the practice which is the most convenient for them or choose to seek care from a practice because of reputation or waiting times. Therefore using local authority boundaries for the planning the future location of services may not be appropriate. The current geographical distribution of orthodontic practices in Thames Valley is not due to active commissioning; that is practices were set up, prior to 2006, in locations determined by providers. These practices have continued with little change since the advent of the new dental contract in With the decision to re-commission services across Thames Valley there is an opportunity to re-visit the geographical distribution and ensure that practices are located in the most appropriate areas. When planning future services it is necessary to take into account that patients do not access care within the confines of the local authority in which they live and that new contracts will also be PDS contracts and so will not have geographical boundaries...need to look at population density as patient flows don t just happen within local authority boundaries. View expressed by a member of the TV Orthodontic clinical network Final version 33

34 An alternative way of determining the need and future location of practices across Thames Valley is via mapping. The Thames Valley orthodontic clinical network made the suggestion that future services should be provided from areas with high population density and close to secondary schools. They asked if it would be possible to provide a map of the main towns in Thames Valley with a circle drawn round them (representing the area from which patients are drawn). A radius of 10km was chosen for this map as it was felt that this was a reasonable distance for patients to travel. The following towns were chosen: a. Aylesbury b. High Wycombe c. Buckingham d. Amersham e. Banbury f. Bicester g. Abingdon h. Oxford i. Witney j. Thame k. Kidlington l. Reading m. Newbury n. Slough o. Bracknell PHE were approached to provide the mapping and the resulting map is shown in figure 21...need to look at acceptable travel distance radius around each practice. View expressed by a member of the TV Orthodontic clinical network Final version 34

35 Figure 21 Map of main towns in Thames valley with a circle of 10kn radius drawn round them the 12-year-old population for each circle is shown. Source PHE. Final version 35

36 The 12-year-old population of each of the circles is shown. It should be noted that because of overlap the total population within the circles is greater than the actual total 12-year-old population. The map in figure 21 shows that there are some areas of Thames Valley which are not included within the circles. These are largely rural areas. When considering the location of lots for the future procurement of services the NHS will need to consider how to address the gaps in these areas. As the population density is relatively low in most of these areas one option is to accept that patients in these areas may have to travel more than 10km to access specialist care. Local knowledge about patient flows will also need to inform the choice of lots. The findings from the map need to be considered along with the findings in figure 20 when choosing the location and particularly the size of lots. For example if the town of Reading is looked at, figure 20 suggests that the current services commissioned are considerably in excess of the need (1,554 courses of treatment commissioned compared with a need of 559). However, if the need is expanded to a population within 10km of Reading it increases to 1,354. This is much closer to the current commissioned activity. The above map was shared with the south orthodontic procurement working group and it was considered to be a useful tool to inform the development of lots. It has been agreed that similar maps will be requested for the whole of NHS south. These maps will inform the decision on how much activity will be commissioned as part of the procurement and where services will be commissioned from. The map for Thames Valley, requested as part of the south procurement, has been amended slightly from the one in figure 21. The epicentres and radii on the new map are aimed to reduce overlap and ensure coverage of the whole of Thames Valley. There will be one single map produced for the NHS South Central area 7.4 Commissioned activity and future need The population of twelve-year-olds in Thames Valley is predicted in increase over the next seven years peaking in 2023 at 30,697 (see section 5). This equates to an increase of 10,232 compared to the population of Working on the assumption that a third of this increase will have an orthodontic need there will be an additional 1,785 children in Thames Valley with a need for treatment by If primary care orthodontic activity continues to be commissioned at 2016 levels then there will not be sufficient orthodontic activity provided in primary care to meet this additional need. However this gap assumes that all activity is delivered in primary Final version 36

37 care and as the data in section 7.1 show there is a considerable amount of activity delivered in secondary care. However, secondary care data has limitations and ideally there should be further analysis of these data so that it can be determined whether the current level of commissioned activity is sufficient to meet the need of the growing population. 8 Primary care 8.1 Location of orthodontic practices The location of the current NHS primary care orthodontic contracts in TV is displayed in figure 22. This figure also shows the location of any NHS primary care orthodontic contract located within 20km of the TV boundary. Figure 22 Map of NHS primary care orthodontic contract locations and contract size within TV (including orthodontic contracts within 20km of the TV boundary) 2015/16* *Locations shown are based on the contract address as stated on Payments Online; this can differ from the practice location Final version 37

38 Aylesbury Vale Bracknell Forest Cherwell Chiltern Oxford Reading Slough South Bucks South Oxfordshire Vale of White Horse West Berkshire West Oxfordshire Windsor and Maidenhead Wokingham Wycombe OFFICIAL The map shows that whilst most areas in Thames Valley have orthodontic contracts there are some areas which do not. These include South Buckinghamshire, Bicester area, North Buckinghamshire, North West Oxfordshire and the area between Abingdon and Newbury. 8.2 Where are patients coming from? The majority of children in nine of the 15 local authority areas in TV access orthodontic care within their local authority of residence (figure 23). Figure 23 Proportion of patients receiving orthodontic care within the LA of residence (BSA data). % of Patients resident receiving Orthodontic Treatment within local authority of residence ( ) % of Patients 10 0 Patient Resident However, the majority of patients living in Bracknell Forest, Chiltern, Slough, South Bucks and South Oxfordshire travelled outside of their LA for NHS orthodontic care. This may be a matter of choice but is also likely to be linked to local availability of services. There is substantial variation in the distances that TV residents travel for NHS primary orthodontic care as shown in figure 24. Final version 38

39 Figure 24 Map showing average distance travelled (km) by patients resident in a ward calculated by measuring a straight line between the home postcode and the contract location (BSA data April 2013-March 2015). The map shows that in most areas in Thames Valley patients accessing primary care based orthodontic services travel no more than 15km to access care. There are some areas in TV where patients travel, on average, more than 15km. Not surprisingly there is some correlation between the distances travelled and the location of orthodontic practices. 9 How does uptake of Orthodontic care vary in TV? 9.1 Uptake of NHS orthodontic care is variable NHS orthodontic care is available, without charge, to all children who meet the appropriate clinical criteria, the NHS IOTN threshold, and are at an appropriate age for treatment to begin. Not all children who would benefit from treatment, however; go on to receive it. There are a number of reasons for this: The child may not wish to have treatment Child may not know how to access care Final version 39