A review of Orthodontic Service Provision across Cornwall and Devon

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1 A review of Orthodontic Service Provision across Cornwall and Devon Michael Cox Speciality Registrar in Dental Public Health Robert Witton Consultant in Dental Public Health PHE South West

2 Contents page Executive summary 1. Scope What is Orthodontics? 6 Orthodontic Treatment Risk and benefits of orthodontic treatment Risks of treatments When is orthodontic treatment performed? 3. Legislative / Contractual overview 8 The NHS Orthodontic Contract 4. Assessing Orthodontic need across Cornwall and Devon Clinical / Normative Need Subjective and Perceived Need Other considerations in relation to need 5. Estimating Orthodontic Need using the NHS 12 year old Dental Epidemiology Programme 11 Normative Need Subjective / Perceived Need 6. Stephens and Holmes formula Summary of needs assessment and limitations of data Commissioned orthodontics in specialist GDP practices matching need 15 Patient flow data 9. Quality Commissioned Hospital Orthodontic Services 20 2 P a g e

3 11. Summary Low demand option High demand option Considerations and recommendations 25 Appendix 1 Population changes across Cornwall and Devon Appendix 2 Locations of current Orthodontic Contractors Appendix 3 Business Service Authority Dental Assurance Framework Appendix 4 Commissioning options References 34 3 P a g e

4 Executive Summary and recommendations This report, which was commissioned by the Area Team, provides a review of orthodontic service in Devon and Cornwall in preparation for new national commissioning guidance from NHS England and the recommendations it will make for the future commissioning of orthodontics. The review provides an estimation of the population need for orthodontic treatment in Devon and Cornwall alongside data available on capacity in primary and secondary care. The development of the Index of Orthodontic Treatment Need (IOTN) has given clinicians a tool to prioritise those patients that will benefit most from treatment, and the NHS rations care usually for those children under the age of 18 at the start of treatment, that satisfy a minimum IOTN threshold and who are sufficiently motivated to comply with the requirements of the treatment. The index can also be used to assess need at a population level and it has been repeatedly shown in studies and surveys that about one third of all children have a clinical need (so called normative or clinician defined need) for treatment. However, translating this need into an appropriate level of commissioning activity is not linear or easy, because not all children with normative need will want treatment and some children will not achieve the required oral health standards for treatment to be beneficial, while other children may want treatment but not have a normative need. These present challenges for commissioners and providers to estimate need accurately. In this review we compare a number of predictive formulas to estimate the levels of commissioned primary care service in each of the four former primary care trust areas of Devon and Cornwall, assuming that on average, 22 units of orthodontic activity are required to identify and treat a case. Taking an average across the formulas used this has revealed the following: less provision than required in Cornwall need and provision are approximately equal in Devon slightly less provision than required in Torbay over provision in Plymouth These figures are covered in more detail in the report and need to be considered alongside historical patterns of patient flow which reveal for example, that Plymouth accepts patients for treatment from the surrounding areas of Southeast Cornwall and West/Southwest Devon and the contribution that secondary makes to local capacity in each area. At a population level and by considering activity in both primary and secondary care there is sufficient commission to meet normative need however, the distribution of activity is not uniform. Population projection data show that numbers of 12 year olds in Devon and Cornwall has been steadily falling since 2006 and will not pick up until 2017 when these numbers begin to rise again. Despite this during the course of the review the orthodontic community raised the important issue of growing pressure on waiting lists in certain areas. This tends to suggest that demand for treatment is likely to be at the top end of the predicted range i.e. approaching normative need. These figures are presented in the review. 4 P a g e

5 The Area Team, with the support of the Managed Clinical Network (or working group) will need to agree on the most appropriate population need/methodology for the future commissioning of orthodontic services. By mapping provision, need and using local knowledge it is expected that this review will help guide commissioners to maintain an equitable and sustainable orthodontic service in Devon and Cornwall. As a result of this review, NHS England may wish to consider the following: Recommendations The new National Commissioning guidance for orthodontics should be implemented through the development of a working group with representation from the Area Team, Managed Clinical Network (MCN), Local Dental Network (LDN) and Local Dental Committee (LDC) The report identifies a number of options for the commissioning of orthodontic service provision. The Area Team in consultation with the MCN need to agree on an acceptable level of service commission. There is an important role for the MCN to set and maintain standards in orthodontic assessment and provision across Devon and Cornwall, and to ensure equity (not just demand) in provision to the public. A working party led by the MCN should investigate waiting lists, how patient choice is managed, and includes providers and patients perceptions of waiting lists/ times to be treated. The work should identify possible mechanisms for reducing these lists and reducing the wide variation between them The Area Team now receives regular information about its primary care contracts on delivery, assessment, treatment and outcomes. The MCN could do much to promote good outcomes from all providers, and in developing innovative ways to raise standards towards those of the best. Individual providers need to understand their claiming profiles, particularly for those who are in-excess of the Area Team s averages. In other parts of the Country capacity has been increased by operating pathways and services more efficiently The optimal configuration and contribution of secondary care orthodontic services is best decided once more data is available. A number of consultants commented during the review they would like more involvement in this work concerning the entire care pathway which this report fully supports. They are best placed to provide a better understanding of how secondary care supports primary care and will give the commissioner a more accurate picture of service capacity in the local system There should be regular reinforcement of orthodontic referral guidelines to General Dental Practitioners disseminated through the Local Dental Network, the MCN and through the LDC and any other communications channels with the local dental community. There should be a system whereby poor referrers are identified and help offered 5 P a g e

6 A service review of Orthodontics across Cornwall and Devon Scope The purpose of this service review is to investigate the current provision of orthodontic services across Cornwall and Devon. The outcome of this review will support the NHS England Area Team in ensuring that appropriate services are located in areas of identified need. 1. What is Orthodontics? Orthodontics is defined by Mitchell as that branch of dentistry concerned with facial growth, with development of the dentition and occlusion, and with the diagnosis, interception and treatment of occlusal anomalies. 1 It ensures the proper development of the occlusion and corrects and prevents occlusal abnormalities. The outcome of treatment is to produce a healthy, functional bite, creating greater resistance to disease and improving personal appearance, which contributes to the mental and physical wellbeing of the individual. Malocclusion itself is not a disease, but a set of dental variations, the majority of which have a limited impact on oral health. However, some malocclusions may have detrimental effects on oral health or are a significant aesthetic issue for which treatment is beneficial. The need for treatment is dependent on; o o risk factors for future oral health (which have to be professionally assessed) perceived need of the patient and relatives as to whether the aesthetics are such that treatment is desirable. 1.1 Orthodontic Treatment Orthodontics is an integral part of the NHS Dental Services taking up between 6% and 10% of the dental budget. As most treatment is undertaken on children, the treatment is normally free at the point of delivery. Most courses of orthodontic treatment begin with a referral from a General Dental Practitioner (GDP) to a specialist or in some areas a dentist with a special interest. Depending on the treatment need, most patients are seen by a specialist at a local dental practice. Where more complex treatment is needed or a consultant opinion is required, the case may be referred to a hospital consultant. Consultants also play an important role in the training of specialists and in dental teaching hospitals may also have teaching and research roles. General Dental Practitioners may also provide orthodontic treatment through an orthodontic contract with their Local Area Team. 6 P a g e

7 1.2 Risk and benefits of orthodontic treatment Orthodontic treatment is vital in the aesthetics and psychosocial wellbeing of individuals with craniofacial syndromes, e.g. cleft lip and palate 2. Adolescents who have completed orthodontic treatment have a better oral health related quality of life than those who have never had treatment 3. There is evidence from several studies that the risk of traumatic dental injuries increases with an increased overjet of more than 5mm and/or inadequate lip coverage 4,5,6. Temporomandibular (jaw) joint dysfunction is associated with a number of malocclusions 7, namely posterior crossbite, anterior open bite, Angle class III malocclusion and extreme maxillary overjet, however, there is no evidence from trials to show that active orthodontic treatment can prevent or relieve temporomandibular disorders Risks of treatments Enamel demineralisation is a common complication of orthodontics 8 Enamel trauma can occur during placement or removal of appliances or when parts of 9, 10 appliances are debonded Tooth surface loss may be caused when wearing an appliance 11 12, 13, 14 Pulpal (the living core of blood vessels and nerves) reactions 15, 16 Some degree of root resorption is inevitable with fixed appliance orthodontic treatment Inflammation of gums Allergy to the materials Soft tissue trauma Orthodontic treatment also carries the risks of failure, non-improvement or relapse over time For treatment to be ethically acceptable, benefits must outweigh risk of harm and the risk:benefit balance should be considered before patients are accepted for treatment. As orthodontic treatment is also largely elective in nature, it can only be justified where the patient has been appraised of the risks as well as the benefits and has therefore made an informed decision about whether or not to proceed. 1.4 When is orthodontic treatment performed? Most orthodontic intervention is carried out when the permanent dentition is established, usually between the ages of 12 and 14 years. Occasionally, interceptive orthodontic treatment is undertaken on younger children to address early a developing malocclusion. An increasing number of adults also seek orthodontic advice and treatment for problems that may have developed secondary to other oral disease or for problems that were either untreated or poorly treated in 7 P a g e

8 childhood. Orthodontic treatment for adults however is not generally available on the NHS unless it is deemed as a necessary part of multidisciplinary treatment. 2. Legislative / Contractual overview 2.1 The NHS Orthodontic Contract Under the new NHS contract arrangements introduced in April 2006, Orthodontists or GDPs providing orthodontic treatment are paid an annual fee (Calculated Annual Contract Value) to provide a complete orthodontic service to a group of patients over that period of time. The contract includes the provision of assessments, treatment starts, repairs, retainer checks and the continuing care of an ongoing caseload. As a measure of activity, assessments and treatment starts trigger Units of Orthodontic Activity (UOAs) that are credited against the agreed contracted level of UOAs for the year. See Appendix two for the locations of contract holders. A case assessment generates 1 UOA and applies only to patients seen on referral who are provided with a clinical examination (often involving radiographs and clinical photographs) designed to establish whether orthodontic treatment is necessary and if so, when it should be undertaken. A course of treatment for patients between 10 and 18 years old generates 20 UOAs including definitive diagnosis, treatment planning and all the necessary care throughout the course of treatment. Under current arrangements it is largely left to the referring general dental practitioner to determine if, where and when a patient is referred. This is usually based on historic arrangements or established relationships and primary care dentists are often under pressure from patients and their parents to make a referral to specialist services even when clinical conditions are not ideal for this to occur. Nationally, long lists of referrals awaiting assessment have developed at many orthodontic providers resulting in early referrals being made, making it difficult for orthodontic providers to prioritise need and identify cases which require early intervention. These waiting lists perpetuate primary care providers behaviour to refer too early to ensure their patients hit the top of the waiting list at the optimum time for treatment to commence. 8 P a g e

9 3. Assessing orthodontic need across Cornwall and Devon area 3.1 Clinical / Normative Need The normative need for orthodontic treatment in a population is the actual clinical need in a population cohort as determined through an epidemiological examination by a clinician trained in diagnosis. Since April 2006 the need and provision of NHS orthodontic treatment has to be assessed using an internationally recognised Index of Orthodontic Treatment Need (IOTN). IOTN measures the severity of a case by looking both at a dental health component (DHC; graded 1-5) and aesthetic component (AC; graded 1-10). It measures clinician-defined (normative) need, indicates severity, but does not relate to the complexity of treatment. From April 2006 only those individuals that fall within IOTN 4 and 5 or IOTN 3 with an aesthetic component of 6 or greater are eligible for NHS orthodontic treatment, unless at the orthodontist s specific discretion. The IOTN defines orthodontic treatment need solely from a clinician s point of view and as such may not take into consideration the patient s perceived need either from an aesthetic or functional viewpoint. Other groups do receive orthodontic treatment but the number of adults qualifying for orthodontic treatment on the NHS is low as is the amount of interceptive orthodontics carried out on younger children. Unlike dental caries there is no social gradient in terms of normative orthodontic need, the same prevalence of malocclusion will occur in all social groups. As the majority of orthodontic treatment is carried out when all permanent teeth have erupted, the prevalence of malocclusion in the 12 year old population is commonly used as the point prevalence for quantifying orthodontic treatment need in the whole child population. Data from the decennial Children s Dental Health Surveys which took place every 10 years between 1973 and 2003, show the prevalence of objective need in the UK to be reasonably consistent over the past four decades (although levels were lower in the 1993 sample, in both 12- and 15-year-olds). This is set out in Table 1 below. Table 1 Prevalence of Need for Orthodontic Treatment in the UK Over Time* Taken from Children s Dental Health in England and Wales London, HMSO year-olds 37% 33% 27% 35% 15-year-olds 27% 25% 15% 21% * These figures exclude 8% of 12-year-olds and 14% of 15-year-olds currently undergoing treatment and is therefore likely to be an underestimation of objective need. It cannot be assumed however that all those undergoing treatment would have had an objective need as defined by the cut-off point of IOTN DHC Grade 4/5 and/or IOTN AC Grades The assessment of orthodontic treatment need was not made using the IOTN until Previous to this an appropriate index was not available therefore the opinion of the examining clinician was used to determine whether or not a need for orthodontic treatment was present. The 1973 Survey examined only children in England and Wales. Surveys were broadened to cover the whole United Kingdom from P a g e

10 A number of formulae have been devised to calculate normative need in the 12 year old population of which the Stephens 17 and Holmes 18 methodology are those most frequently used. More recently the result of an NHS Epidemiological Survey undertaken in 2008/09 on 12 year old children in Cornwall and Devon is now available to provide local data 19. For the first time, this survey examined the clinical need for orthodontics at a PCT level on a representative sample of 12 year old children by examiners trained in IOTN. An assessment was also made of the likely uptake of treatment if offered, however this was without providing information to individuals or their parents about the nature of their malocclusion, the potential benefits of treatment or the type of treatment necessary. 3.2 Subjective and Perceived Need IOTN defines objective need from a clinical point of view without taking into account the perception of need or the social impact of malocclusion from the patient or parents. Research has clearly shown a difference between clinically defined need and the perceived need of patients/parents and some research has suggested combining IOTN with Quality of Life indicators to identify treatment need. A recent study has shown that dental conditions resulting in visible incisor differences are associated with higher levels of aesthetic dissatisfaction and impact negatively on a child s oral health related quality of life, particularly when changing from primary to secondary schools Other considerations in relation to need Only those patients with good oral hygiene and with controlled caries are suitable for orthodontic treatment. Across Cornwall and Devon approximately one third of the 12 year old child population have experienced dental decay and about 17% have untreated dental decay 21 ; this latter group would not be suitable for orthodontic treatment until their oral health has improved. GDPs are the gatekeepers for orthodontic treatment and so referral will be dependent on a child s attendance patterns and motivation to maintain good oral health. This varies from locality to locality and is often determined by social factors. On average child attendance rates between March 2013 and 2014 was 71% for Cornwall and Devon. We can therefore assume that about one third of children who might benefit from orthodontic treatment do not have the opportunity to receive it because they do not access NHS primary care dental services regularly. Furthermore, it is more likely that these children are also carrying much of the untreated decay and therefore might not be suitable for orthodontic treatment. If access to general practice improves and is more equitable, demand for orthodontic treatment might correspondingly increase. Even if all the children needing orthodontic treatment became dentally fit, had good oral hygiene and attended the dentist regularly and were therefore referred, there will still be a proportion who do not take up the offer of orthodontic treatment. Demand for treatment will therefore always be less than perceived need. Whilst there is no social gradient for orthodontic normative need it can be assumed that there will be a social gradient in terms of perceived need, oral health and attendance rates, meaning that less demand is likely in deprived areas. 10 P a g e

11 4. Estimating orthodontic need using the NHS 12 year old Dental Health Survey 4.1 Normative Need In 2008/9 an NHS epidemiological oral health survey of 12 year old children was undertaken across England including Cornwall and Devon. As well as a surveying oral health, orthodontic need was also assessed giving for the first time a PCT based epidemiological orthodontic needs assessment. The examiners were all calibrated with a Regional and National standard and trained in IOTN assessment. The defining level for identifying orthodontic need to be present was a Dental Health Component (DHC) IOTN score of 4 or above (the same level used in the 2003 National Child Dental Health Survey) or an Aesthetic Component (AC) of 8 to 10 at lower DHC scores or both. Table 2 below shows the amount of Normative need found to be present in the Cornwall and Devon samples. Table 2: Normative (Clinically Defined) Orthodontic Need in Cornwall and Devon Source: NHS Epidemiological Survey of 12 year olds children 2008/9 NW Public Health Observatory 2010 Former PCT 12 year old population Sample examined (%) % already wearing an appliance Estimated numbers of the 12 year olds not already wearing an appliance Normative Need in those not wearing an appliance % DHC >1 Or AC 8-10 (Average) Estimated number of children with orthodontic need not wearing an appliance (e) x (d) a b C d e Cornwall % (30 %) 1745 Devon % (30%) 2479 Plymouth Teaching % % (30%) 759 PCT Torbay % % (30%) year olds in Cornwall and Devon with CLINICAL NEED and no brace 5689 Table 2 shows the amount of Normative need found. The prevalence of orthodontic need in the sample examined was between 12% and 40%. The range is wider than might be expected when compared to national figures which are between 30-33% 22 and therefore an average for the Area Team was used in summary calculations. Children with poor oral hygiene or active caries were not excluded from the assessment and so the data could therefore overestimate those that should or could receive orthodontic treatment. 4.2 Subjective / Perceived Need Prior to the examination, the children in the survey were asked if they were wearing a brace. If they had a brace they were classified as already receiving orthodontic treatment and were not involved in the survey any more. The remainder were asked if they thought their teeth needed straightening. If they replied yes, they were asked if they would wear a brace. From this an estimate of patient 11 P a g e

12 perceived need can be made which gives an indication of how many of these children with clinical need might seek treatment (Table 3). It should be pointed out that prior to reaching their decision the children were not provided with any information in regard to the potential outcomes of orthodontic treatment which could increase the proportion wanting to go ahead. It can be seen that in all PCTs the proportion of children thinking they needed orthodontic treatment (b) was higher than those actually identified with clinical need and willing to wear an appliance (c). Table 3: Subjective or perceived Need Nos. of children examined needing and wanting orthodontic treatment Source: NHS Epidemiological Survey of 12 year olds children 2009/10: NW Public Health Observatory 2010 Former PCT Estimate Numbers not already wearing a brace Percentage of children who think their teeth need straightening and are prepared to wear a brace % children with IOTN >4 and/or AC 8-10 wanting treatment and not wearing an appliance and wish to have treatment (average) Estimated nos. of children with clinical need who want treatment and are prepared to wear an appliance %(c) of (a) a B c d Cornwall % 15 (18%) 1047 Devon % 22 (18%) 1487 Plymouth Teaching PCT % 25 (18%) 455 Torbay % 9 (18%) year olds in Cornwall and Devon with both clinical and perceived orthodontic need 3233 The table demonstrates that there are a lower percentage of children who have a normative need and are prepared to undergo orthodontic treatment. The range across the Area Team from the survey data for normative need and wishing to wear an appliance was 9 to 25%. Again an average for the Area Team of 18% was used in summary calculations. 12 P a g e

13 5. Estimating Orthodontic Need using the Stephens and Holmes Formula Stephens 17 used a predictive method involving assessing need based on the year old population. In a typical school population he felt that 33% of children would fall into IOTN categories 4 & 5. Stephens considered that those in DHC 3 needing treatment is largely offset by the proportion of cases in categories 4 & 5 who despite a normative need for orthodontic treatment decline care. Additional factors were included by Stephens for those who need interceptive treatment (9%) and also an adult factor as well (4%). This formula can be expressed as: 12 year old population x interceptive factor + adult factor (Where interceptive factor = 9; adult factor = 4) Holmes 18 estimated that 36.3% of year old children had an IOTN 3 and an AC 6 or higher. These have been combined into Table 4. Table 4: Normative need using Stephens and Holmes calculations Former PCT 12 year old Holmes estimation Stephens formula Survey data as a population (36.3%) comparator a B c D Cornwall Devon Plymouth Teaching PCT Torbay year olds in Cornwall and Devon with Normative calculation methods Stephens formula has additional factors for those who require interceptive treatment (9%) and for adult treatment (4%) and therefore tends to overestimate the percentage of population meeting NHS criteria for treatment. Additionally these formulae do not account for patients who are willing to wear an orthodontic appliance. Therefore these formula tend to overestimate treatment need compared to the epidemiology data. 13 P a g e

14 6. Summary of needs assessment and limitations of data This paper has provided a number of methods to illustrate the potential need for orthodontic treatment across Cornwall and Devon. This data is based on point prevalence in the population of 12 year olds. The area populations are estimates only as Office for National Statistics hold data for year age bands. It is acknowledged that children will commence interceptive orthodontics at an earlier age. Additionally it should be recognised that delayed access to General Dental Services may mean that some children commence treatment after the age of 12 years but this need has been previously identified at an earlier age by using point prevalence. Table 5: A summary table Former PCT 12 year old population NHS Dental Epidemiology Programme (Normative need) NHS Dental Epidemiology Programme (need and compliant) Stephens and Holmes Assessment Range of calculations a b c Lower Upper Holmes Stephens estimate estimate Cornwall Devon Plymouth Teaching PCT 990 Torbay Totals b This columns contains the data collected from the NHS Epidemiology program and is the estimated figures of 12 year old children who have a DHC>4 AC This is effectively the under range of service demand. c This columns contains the data collected from the NHS Epidemiology program and is the estimated figures of 12 year old children who have a DHC>4 AC 8-10 and are willing to undergo treatment. This is effectively the lower range of service demand. Holmes / Stephens are population prediction calculations and tend to overestimate need. These estimations have provided a range of population estimates. The lower figure is based on the proportion of children who clinically need orthodontic treatment (IOTN) and wish to undergo treatment. The upper range is derived from the total population who have a clinical need (IOTN) and an assumption is made that all these children will want to access treatment. 14 P a g e

15 7. Commissioned Orthodontics in Specialist or GDP practice matching need Area Teams need to align the number of UOAs of Orthodontic care that are commissioned with the needs of the population. It is possible to estimate the number of UOAs required in meeting these needs. The Department of Health recommend that 22 UOAs need to be commissioned for every new case. This is based on 21 UOAs for each assessment and case start to which is added 1 UOA to allow for some interceptive treatment, assessment and reviews and assessment and refusals etc 23. Appendix 4 contains a series of tables looking at the different population estimates/need compared to the current commissioned activity. Table 6 provides a global summary for the former different PCTs in the region. Table 6: Summary table comparing the various assessment methods with UOAs commissioned Please note under-commissioning is shown in red Former PCT 12 year old populati on UOA Nos. of New Cases commissioned 22 Cases required to meet need estimates Need and want Need (Stephens (epidemiology formula) upper programme) Lower estimate estimate Cornwall Under provision of Under provision of 50 cases 1314 cases Devon Surplus provision of Under provision of cases cases Plymouth Surplus provision of 321 Surplus provision of cases 893 cases Torbay Under provision of Under provision cases cases Summary table comparing the various assessment methods with UOAs commissioned Mean Under provision of 869 cases Under provision of 95 cases Surplus provision of 540 cases Under provision of 332 cases 7.1 Patient flow data Area Teams when commissioning orthodontic services need to make an assessment of the likely need and match this need with the amount of orthodontic activity that they commission. In making this assessment they also need to consider the amount of outflow and inflow of patients into the area for orthodontic treatment. Patients are prepared to travel further for specialist treatment and particularly in urban areas it can be expected that there will be a considerable amount of cross boundary flow. 15 P a g e

16 (a) Cornwall Cornwall & IoS Devon Other Plymouth Cornwall & IoS Plymouth Devon Other Figure One Demonstrating Flow in Figure Two Demonstrating Flow out Figure one demonstrates that the majority of Cornwall Orthodontic contracts provide treatment to the resident population of Cornwall Figure two demonstrates flow out that is, the location of where patients are receiving their treatments according to their home postcode. Plymouth provides orthodontic services to Cornwall residents due to the proximity of the city to South East Cornwall. (b) Devon Figure 3 demonstrates that there is a cross flow of patients travelling into Devon Orthodontic practices for treatment, notably Torbay. Devon Torbay Other Cornwall & IoS Plymouth Devon Plymouth Other Torbay Figure three Demonstrating Flow in Figure four Demonstrating flow out 16 P a g e

17 (c) Plymouth Plymouth Cornwall & IoS Devon Other Plymouth Devon Cornwall & IoS Other Figure Five Demonstrating Flow in Figure Six Demonstrating flow out The data seems to demonstrate that Plymouth orthodontic services provide treatment to a fair proportion of Devon and Cornwall population. Plymouth residents generally seek orthodontic treatment within the city. (d) Torbay Torbay Devon Other Devon Torbay Other Figure Seven Demonstrating Flow in Figure Eight Demonstrating Flow in A large proportion of Torbay orthodontic patients travel outside of the Torbay boundary for treatment. 17 P a g e

18 8. Quality The quality of the services provided can be assessed using Maxwell s Dimensions of Quality 24. Effectiveness One predictor of success is the use of clinically effective orthodontic techniques. At the present time dual arch fixed appliances are generally considered more effective than functional or removable appliances in correcting malocclusion. The BSA measure the rate of removable appliance use per 100 fixed appliances over a twelve month rolling period for both proposed and completed treatment. At September 2014, the rate of use of removable appliances within the Area Team was slightly lower than the national average indicating efficient use of clinical techniques. Abandoned treatment rates in the Area Team are lower than the national average. Peer Assessment Rating (PAR) score can also be used to look at effectiveness. The PAR index was developed by the orthodontic profession to objectively assess orthodontic treatment outcomes. As a result, under the new contract arrangements orthodontic providers are required to measure outcomes using the PAR index before and after treatment. Providers are able to select their own cases for review. If an orthodontic provider/performer treats 20 cases or less, all of these cases should be PAR scored. Those providers/performers providing more than 20 cases of orthodontic treatment in a contract year should PAR score 20 cases plus an additional 10% of their remaining cases. At September 2014, nationally 66% of GDS/PDS completed cases of orthodontic treatment had a PAR score taken. The average for the Area team was 77% Efficiency This relates to cost per case and will be discussed later. Acceptability It must be assumed that given provision of orthodontics and demand for treatment across Cornwall and Devon has increased; orthodontic treatment is acceptable to individuals receiving treatment and those wanting it. Access Access to services in Cornwall and Devon appears acceptable if travelling times for those patients in active care is analysed. Some practices/providers of orthodontic treatment have longer waiting times than others which could produce a barrier to care for some As highlighted in the report the Okehampton area has under provision with patients having to travel over 15 miles to access NHS orthodontic services most likely in Exeter. Cost effectiveness 18 P a g e

19 The PAR index is one method of trying to determine cost effectiveness 25. Further development of cost effectiveness approaches to orthodontic treatment need to be developed, incorporating measurements of other outcome measures such as patients perspectives on treatment, quality of life and long-term health gain. 19 P a g e

20 9. Commissioned Hospital Orthodontic Services Consultant Orthodontists have extended training enabling them to provide treatment for complex cases with high need, often when a multi-disciplinary care pathway is required, for example where there are dento-skeletal anomalies or cleft lip and palate. They also provide advice for GDPs and orthodontic specialists and are responsible for the training of specialists and some undertake teaching and research. Because of the greater complexity of the cases they see and the need to involve clinicians from other disciplines, they are likely to treat fewer patients than orthodontic specialists in primary care. The UK Orthodontic Workforce Survey in 2013 estimated that a whole time equivalent consultant orthodontist working a 10 session clinical week could be expected to treat on average 142 cases / year, a university teacher will treat on average 58 cases / year and a specialist orthodontist in primary care 400 cases/ year. Unlike primary dental care, orthodontic treatment is also available to adults and approximately 20-25% of hospital caseload is for adult patients. In addition, secondary care provides services for those patients requiring multi-disciplinary input from other hospital based specialists. The type of data collected in secondary care is different to that in GDS/PDS. The contract measures from GDS/PDS are not transferable and most hospital units measure activity by case assessments and case starts. The hospital providers were contacted in January 2015 to provide activity data. Some of these data relate to 20013/15 although activity is reported as stable with minor fluctuations due to changes in consultant and/or trainee numbers. Table 7 contains all the available data provided. If data is not present in the table it meant it could not be provided. 20 P a g e

21 Table 7; Data from Secondary Care services across Cornwall and Devon North Devon District Royal Devon and Exeter Plymouth South Devon Cornwall 2013/ / / / / / / / /15 New Patient Assessments (projected) (projected) (e) New Case starts Number of patients in active 202 (27/1/15) 644 (20/01/15) 600 treatment Orthognathic (Active (e) 60(e) 24 treatment) Complete Orthognathic cases (e) 30(e) Context WTE 0.5 Consultant available WTE 1:95 (3 trainees under supervision Estimated (e) 21 P a g e

22 It is not possible at this time to compare the commissioning costs for treating the same type of case in primary and secondary care. It is however possible to give an approximate cost per case, which is based on the assumption that on average a course of treatment involves 1 case assessment and 20 further treatment appointments. Using such an assumption to calculate costs does result in higher costs for secondary care but it must be recognised that service provision in the two environments is different. In secondary care there are other elements to consider as part of service provision. These include teaching and training requirements, education and mentoring and research. The case mix in secondary care is also different from primary care with hospital orthodontic departments acting as a referral centre for cases that are too complex to be treated by the skill level available in primary care, or which need input from a multi-disciplinary team which at present, is only available in the secondary care environment. Secondary care practitioners also provide advice on treatment planning for colleagues in primary care, with patients referred back to their primary care dentists after a treatment plan has been provided by the consultant. Table 8: comparative costs of orthodontic treatment Child Adult Primary care Secondary care Primary care calculations based on per Unit of Orthodontic Activity (UOA) 2 Secondary care calculations based on current national tariff for initial ( 214) and follow up appointments ( 83) 22 P a g e

23 10. Summary This review has been written within the context of data that was available and based on a number of reasonable assumptions. There are a number of different methodologies for calculating orthodontic need and if the epidemiology survey data is used as the most up-to-date measure then overall there appear to be enough UOAs commissioned to meet orthodontic need across the region. However, planning needs to begin now for uplift in commissioning to account for the increase in the 12 year old population from 2017 (an increase in the range of 5-10% between 2017 and 2020 should be planned). The report identifies a number of areas where there is under and over provision of orthodontic services. This needs further local investigation by the working group of the MCN to decide on how to prioritise commissioning decisions. The Business Service Authority is responsible for collating a Dental Assurance Framework (DAF) in orthodontics. The DAF contains data about a Provider s claiming profiles. There are a number of Providers across the area that exhibit claims in excess of the Area Team average (Appendix two provides further detail). This in excess if reduced to the area team average would create additional orthodontic capacity in primary care. The location of orthodontic providers adequately covers the geography (see Appendix two). The map demonstrates no provision in Salcombe and Okehampton. However the resident population of year old in these areas is small (below 3000). Assuming that, on average, 18% of the population would be eligible and willing to wear an appliance; it may not be feasible to contract a service in these locations and other options should be considered. The table below details the current commissioning picture across primary care orthodontics based on the mean of the different predictive formulas. Table 9; overall summary of provision PCT Mean of Contracted Estimated no. % of commissioned primary care activity calculations UOAs cases(b/22) available to meet mean (c/a%) a b c Cornwall % Devon % Plymouth % over Torbay % In terms of primary care orthodontics, 5,136 cases are currently commissioned annually to meet population need in Devon and Cornwall. At a population level this falls slightly short in meeting the normative need identified in the population from the NHS Epidemiology survey 20018/09 of 5689 cases and the mean of the predictive formulas of 5892 cases required to meet clinician defined need. Most of this additional need is in Cornwall. Appendix 4 identifies other areas in Devon where 23 P a g e

24 based on the local population size there is a genuine undersupply of activity (i.e. patients are not receiving care in another area based on the established and historical patterns of patient flow). In addition it is important to consider the contribution to meeting need that secondary care orthodontic services provide. When this capacity is considered there is sufficient activity to meet normative need requirements in the population. The data presented in this report proposes two broad options Low demand option This is where orthodontic services are commissioned at the level specified in the NHS epidemiology survey in 2008/09 this is the most up to date indicator of both need and want available locally. One of the considerations of this is that the survey did not take into account parental views, peer pressure and the possibility children reappraise their options as they get older High demand option This is where orthodontic services are commissioned at the level of normative need in the population. This is stable and consistent in the population at around 30% and is well documented. However, the calculation, as discussed does not take into account factors such as poor oral health and motivation for treatment and therefore could potentially lead to an overestimation of capacity required. Pressure on waiting lists in certain areas tends to suggest that demand for treatment is likely to be at the top ends of the predicted range i.e. approaching normative need. If this figure is used as the level for commissioning orthodontic services commissioners must ensure this does not perpetuate pressure on waiting lists by stimulating increased demand that does not impact on work to address contract inefficiencies and a whole system approach to care pathway design. 24 P a g e

25 11. Considerations Overall the population in the Peninsula is increasing; however the population of year olds has been decreasing since the implementation of the new contract in By 2017 the population of year olds in the Peninsula will have recovered back to the 2006 level. However from 2017, there will be a need to commission more orthodontic treatment due to a steady increase in year old population (see Appendix 2) The overall oral health of the population and their requirements should be considered alongside this report There has been no public and/or the professions view of waiting lists included in this report We would like to thank NHS England (Area Team), the Managed Clinical Network for Orthodontics (Devon), Mr Nick Wenger in Cornwall, the NHS Business Services Authority and all the secondary care orthodontic departments for providing data and supporting this service review. 25 P a g e

26 Appendix one Population changes across Cornwall and Devon Overall the population in the Peninsula has been increasing; however the year old population has been on a steady decline since the introduction of the new contract. From 2017, the year old population will reach the level of 2006 when the contract was introduced. The table and charts below contain this data. Figures in red denote a decrease in the population. (the y axis values are per 100,000 / years) Cornwall Plymouth Cornwall Percentage increase Plymouth Percentage increase Increase in year old population (Actual numbers) Increase in the year old population (actual numbers) 26 P a g e

27 Devon Devon Percentage increase Increase in the year old population (actual numbers) Torbay Torbay Percentage increase Increase in the year old population (actual numbers) 27 P a g e

28 Appendix two Cornwall and Devon is a geographically rural area with a scattering of small population centres/ settlements. The map of Cornwall and Devon below demonstrates the location of Primary Care orthodontic practices. The larger legends depict a higher contract value. As expected the larger contracts are located in areas of higher population/ need. Figure One. Demonstrating the location of current primary care orthodontic providers 28 P a g e

29 Figure 2 Figure 2 demonstrates the spread of Orthodontic providers across Cornwall and Devon with most areas being within a 15 kilometre distance of a provider. Also depicted on the map is the year old population in localities. As per legend, the lighter shaded areas indicate a lower resident population of this age group. Residents in Salcombe and Okehampton have to travel over 15 Kilometres to access Orthodontic Services. 29 P a g e

30 Appendix Three The Business Service Authority produces quarterly performance reports across the region for orthodontic contract providers. This framework measures a number of quality indicators. These reports contain data about the patterns of FP17 submissions and the Area Team/National averages for these submissions. For example, the Area Team s average for Assessment and Review for under 9 years old is 12.8%. Therefore it s anticipated that approximately 12.8% of all FP17 submissions will fall into this category. There will be a number of clinical reasons that might explain these claiming patterns. However, a child with poor oral hygiene, untreated dental decay, an inappropriate referral, or a child not clinically ready for an appliance will generate appropriate claims and this is accounted for in the Area Team s averages. The table below contains information about the Area Team s average compared with England s average. This is for the period of October 2013 to September Delivery England AT UOA Delivered % of Contracted UOA Delivered ( Yr to Date) Assessment England AT Assessments by category % of assessments that are Assess and fit appliance Assessments by category % of assessments that are Assess and refuse Assessments by category % of assessments that are Assess and review Age at assessment % of reported assessments and review where patient is 9 years old or under Treatment England AT Cases reported complete as a Ratio of reported concluded function assess and fit appliance (completed, abandoned or discontinued) courses of treatment to reported assess and fit appliance. Type of appliance used % of concluded* (completed, abandoned or discontinued) courses of treatment reported as using removable appliances only. * currently only using completed Outcomes England AT UOAs reported per completed case Ratio of the number of UOAs reported per reported completed case (not including abandoned or Reported PAR Scoring: actual versus expected discontinued cases) % of contracts meeting their expected reporting of PAR scores P a g e

31 Abandoned or discontinued care % of concluded (completed, abandoned or discontinued) courses of treatment where treatment is reported as abandoned or discontinued 8.8 The table demonstrates that the area team is broadly in line with the England average with the majority of providers below or at the area team average. However when this data is investigated further it does reveal a number of providers above these levels. There may be valid reasons for this which needs to be investigated further by the provider and commissioner. However, it should be acknowledged that this contract inefficiency if reduced would provide additional orthodontic capacity in the region. 31 P a g e