Access to care: waiting times for special care patients accessing specialist services in a dental hospital

Journal of Disability and Oral Health (2012) 13/1 27-34 Access to care: waiting times for special care patients accessing specialist services in a dental hospital Grace Kelly BDS MFDS RCSI 1 and June Nunn 2 1 SHO Special Care Dentistry; 2 Dean/Professor of Special Care Dentistry: Public and Child Dental Health, Dublin Dental University Hospital, Lincoln Place, Dublin 2, Ireland Abstract Aim and Objectives: To measure the waiting times experienced by Special Care dental patients at Dublin Dental University Hospital; to compare 2006 and 2007 data with similar lists for advanced restorative dental assessment; and check compliance with a proposed standard of 18 weeks. Also to determine: waiting times for dental treatment in SCD clinics (2006 and 2007) depending on choice of local anaesthesia alone, conscious sedation or general anaesthesia; the care pathway of patients after assessment in SCD clinics. Methodology: Review of referral letters and computer records, hospital monthly waiting times and the type of adjunct required for dental treatment. Results: In 2006, 70% of patients were waiting less than 18 weeks for dental assessment in the SCD clinic (60%, 2007) meaning the standard was not met in either year. SC assessment waiting lists times compared similarly in 2006 to advanced restorative assessment. There was no substantial difference in the waiting times for dental treatment in SCD clinics between 2006 and 2007. Average dental treatment waiting times increased in 2007 by almost 12 weeks for those awaiting treatment under general anaesthesia, compared to 2006. Conclusions: Increasing the number of clinics available and/or increasing the staffing numbers would reduce the waiting times for both assessment and dental treatment in SCD consultant clinics. This particular group of patients has a number of concurrent medical and physical problems, compared to the general population, which make it difficult for them to attend dental services and thus the number of patients who fail-to-attend or have to cancel at short notice is substantial, making the clinics more difficult to run efficiently. Key words: Special care dentistry, waiting times, dental treatment Received - 07 September 2011. Accepted - 22 February 2012. DOI: 10.4483/JDOH_004Kelly08 Introduction Special Care Dentistry (SCD) provides dental care for people with special needs. This involves the improvement of oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of a number of these factors (BSDH, 2003). The 2006 Irish Census of Population found that 9.3% of the population, or 393,800 persons, reported a disability (National Disability Survey, 2006). The majority of these patients are successfully treated in primary dental care settings (Department of Health (Dublin), 2003). However, it is essential that there are secondary/tertiary care centres for general dental practitioners to refer special care patients for complex dental treatment with or without adjuncts like sedation and general anaesthesia. A set of referral criteria for the Dublin Dental University Hospital s (DDUH) Special Care Clinic was established in 2002 to provide for people: 1. With a disability where: Communication and/or cooperation is insufficient to allow routine dental care (examination / operative / surgical procedures with / without local anaesthesia) Where appropriate sedation facilities are not available from the referral source at present 2. With a physical disability, whose impairment does not permit the safe delivery of dental care in the conventional way 3. Where there is unstable organic disease and where the consultant physician requires the patient to be treated in a hospital (secondary or tertiary) setting

28 Journal of Disability and Oral Health (2012) 13/1 4. With organic disease for whom routine management of their impairment puts them at risk from dental procedures (example: need for complex antibiotic cover, steroid cover, INR management) 5. With a general and dental impairment that requires interdisciplinary care, for example, a person with a combination of ectodermal dysplasia, cleft palate and mild learning disability 6. With any combination of the above. The 2004 United Kingdom s NHS Improvement Plan set out a plan for reform: By 2008, no one will have to wait longer than 18 weeks from GP referral to hospital treatment (Department of Health (UK), 2006). The 18- weeks applies to pathways that do or might involve consultant-led care, setting a maximum time of 18 weeks from the point of initial referral up to the start of any treatment necessary for all patients where it is clinically appropriate and where patients want it. No such established standard is available in Ireland in regard to the length of assessment or treatment waiting lists following on specialist referral. Using the guide of the NHS 18-week standard, this study set out to determine the waiting times from the date of initial referral to the date of assessment instead of the start of treatment, as per the NHS 18-week rule, to the Special Care Dentistry (SCD) consultant clinic for two separate years using another consultant-provided clinic for comparison. The aim of this study was to investigate waiting times for dental assessment and treatment and the determinants of such waits for two cohorts of patients referred to secondary/tertiary clinics in a dental hospital. The objectives of this study were to: Compare Special Care dental assessment waiting lists to similar lists for Advanced Restorative Dentistry (ARD) in the DDUH for 2006 and 2007 Audit and compare waiting times for dental treatment in SCD clinics for patients referred to a SCD clinic in 2006 and 2007 Determine how the waiting times for SCD assessment relate to the NHS 18- week standard for specialist referral (UK standard) Observe differences in waiting times, depending on choice of adjunct: local anaesthetic, conscious sedation or general anaesthesia, for those patients referred to SCD clinics in 2006 and 2007 Determine the dental care pathway of the patients after assessment in SCD Clinics in 2006 and 2007. Materials and methods The referral letters to the SCD department in 2006 and 2007 were individually triaged and the date of receipt of the referral was recorded. From the information in the letter, the patient s disability was determined, to ensure they fulfilled the referral criteria. If there was a doubt about this due to the brevity of the letter, the referring clinician was consulted. If they did not fulfil the criteria or no specific disability was stated, the patient was excluded from the study.the patient s age and address were also noted. The charts of 100 and 145 SCD patients, from 2006 and 2007 respectively, were reviewed. Using the Salud Dental computer system, the date the patient was called for assessment in the SCD consultant clinic was recorded. Any cancellations or failures to attend were noted, since this would have affected the calculation of the waiting time between the date of referral and the dental assessment. From the patient s record, the waiting time between assessment and start of dental treatment was calculated and the treatment pathway of the patient, after initial assessment, was identified, if dental treatment was necessary. This allowed for waiting times to be calculated for dental treatment, involving local anaesthetic, conscious sedation or general anaesthesia. As this was an audit project, following advice from a statistician, no statistical testing of the data was indicated. Data from the hospital monthly waiting times for dental assessments in consultant clinics in the DDUH were obtained, noting the SCD clinic and, for comparison, the ARD clinic waiting times for dental assessment. Results In 2006, 100 patients were referred to the SCD consultant clinic, with an age range of 5 years to 86 years (53 female and 47 male patients). These patients were referred from a number of sources: senior dental surgeons in SCD, general dental practitioners, general medical practitioners, medical/surgical consultants and from the patients themselves or their parents. There were three consultant sessions per week in 2006 and 2007, with a Senior House Officer or Postgraduate student assisting on one of these sessions. New patient referrals were seen once a month, on one session. Referrals for assessment in 2006 Each patient fulfilled the SCD referral criteria. Of those referred, 74 patients came from Dublin City and County and 26 patients from outside Dublin. The waiting time to assessment varied from one to sixty weeks. Of those waiting, 70 (70%) were seen within the 18-week limit. The number of referrals varied considerably over the 12 months (range: 16 patients /month- 36 patients /month).

Kelly and Nunn: Access to care 29 This variability was repeated for the weekly ARD assessment clinic (range: 92/month to 239/month). Referrals for assessment in 2007 In 2007, 145 patients were referred to the SCD consultant clinic, with an age range of 2 years to 84 years (65 females and 79 males). These patients were referred from a number of sources: senior dental surgeons in SCD, general dental practitioners, general medical practitioners, medical/surgical consultants and from parents. Again, each patient fulfilled the SCD referral criteria. Of these, 105 were referred from Dublin City and County and 40 patients from outside Dublin. These people waited from one to 51 weeks. Of this cohort, 87 (60%) waited less than the 18-week limit and 58 (40%) waited longer to be seen. As in the previous year, the monthly referrals varied from 16 to 44 people for SCD clinics and from 222 to 412 people referred to ARD clinics. The monthly figures of patients waiting for Special Care Dentistry assessment and ARD assessment were obtained. Table 1 shows the percentages plotted for 2006 and in Table 2 for 2007, to compare the waiting times for patients waiting less than 3 months, 3-6 months, 6-9 months, 9-12 months and greater than 12 months, for both assessment clinics. Individual s data were unavailable as the monthly figures were obtained from administrative records, with overlapping summary data, so statistical analysis was not possible. The range of patients waiting less than 3 months for assessments on the SCD waiting list in 2006 was between 55.5-96.0% and 43.0-96.5% in 2007, compared to those on the ARD waiting list, which was between 18.5-85.0% in 2006 and 26.0-88.5% in 2007. However, the summary of monthly percentages are seen in Tables 1 and 2, with comparative percentages for both clinics, demonstrating the percentage of patients waiting for assessments for both clinics, for less than 3 months, 3-6 months, 6-9 months, 9-12 months and greater than 12 months. The SCD assessment waiting lists times compared similarly in 2006 to the ADR assessment waiting lists but were more efficient in 2007, with a lower percentage of patients, on average, waiting more than three months to be seen from receipt of the referral. Waiting times for dental treatment in Special Care clinics in 2006 and 2007 The waiting times to treatment in these two years includes patients who were assessed in SCD clinics prior to 2006, as well as patients from 2006 and 2007. The results for the two years can be seen in Table 3. In 2006, on average, there were 19 patients waiting each month (Range: 10-29). These waiting times include waiting times for treatment under general anaesthesia. Patients who waited in excess of 12 months often had concurrent medical problems and/ or required in-patient management that prevented them for accessing dental care. In 2007, there was an average of 35 patients per month waiting for dental care (Range: 25 to 60 patients). There was no substantial difference in the waiting times for dental treatment in SCD clinics between 2006 and 2007 with 35% patients being seen for dental treatment within 12 weeks in 2006 and 36% in 2007. Outcome for the patients referred in 2006-07 after assessment in SCD clinics The outcome for patients referred for assessment to the SCD clinic in the Dublin Dental University Hospital in 2006 and 2007, is given in Table 4, with confidence intervals of the results recorded. Waiting times for dental treatment in 2006 and 2007 depending on choice of anaesthesia In 2006, of the 100 patients referred, 46 received dental treatment in SCD clinics compared with 74 patients, who received treatment, of the 145 referrals in 2007. The distribution across the different adjuncts is given in Table 5. The average SCD treatment waiting times reduced substantially in two of the three adjuncts for dental treatment, between 2006 and 2007. There was a reduction by 5 weeks for those awaiting treatment under local anaesthesia, and a reduction of 21 weeks for those awaiting treatment under conscious sedation, both intravenous sedation and inhalation sedation, in 2007 compared to 2006. However, the average waiting times increased in 2007 by almost 12 weeks for those awaiting treatment under general anaesthesia, (GA), compared to 2006, due to restricted bed availability in the GA facility. Discussion As SCD is a relatively new dental specialty, even in the UK, it will take time to establish itself as its own entity in Ireland. The UK s General Dental Council agreed to the setting up of a Specialist List in SCD in the summer of 2008 and this list opened for a transitional two-year period from 1 October 2008 (GDC, 2008). Although the Dental Council in Ireland has recognised the specialty of SCD, it is still not recognised as such by the Department of Health (Dublin) and thus no specialists in SCD are recognised in Ireland. This may have a negative impact on the dental needs of special care patients and hinder appropriate allocation of resources to oral health initiatives for this patient group. Many primary care dentists are unsure of how to refer a special care patient to secondary/tertiary services in Ireland. Many referrals received had been sent to different departments in the dental hospital prior to being received in the Special Care clinic. In order to investigate the time that patients waited to be seen in the Dental Hospital, the study design had to

30 Journal of Disability and Oral Health (2012) 13/1 Table 1: Relative waiting times for assessment for Special Care Dentistry (SCD) and Advanced Restorative Dentistry (AR) clinics in 2006. incorporate a benchmark from another jurisdiction since there is no established standard for waiting times for consultant dental clinics in Ireland. The standard selected was modelled on the 18-weeks limit used in the National Health Service in the UK (Department of Health (UK), 2006). However, in this audit, the proposed standard was not achieved in either year audited, despite the fact that the UK standard is more stringent, in that the 18-week rule is the time from referral to treatment and this audit had used the 18 week guide as the time from referral to being seen on the first occasion. The capacity of consultant clinics may be limiting factor. When reviewing the waiting lists, SCD assessment waiting lists compared similarly in 2006 to the ARD assessment waiting lists, but were more efficient in 2007. On average, in both 2006-07, over 92% of SCD patients were waiting less than 3-6 months for assessments. It should be noted that referrals to this specialist area also increased each year. Care needs to be taken in interpreting these results as this group of patients can have either a disability or impairment that can result in cancellations, often at short notice. There was a large failure-to-attend rate of 22% in 2006 but this reduced to 13% in 2007. Appropriate referral of special care patients to secondary/tertiary services is required. It may be easier for patients and their families and more clinically appropriate for them to be seen in primary dental care. In this study, the majority of patients referred to the SCD department were subsequently treated in the Dental Hospital, indicating appropriate referrals. The average SCD treatment waiting times reduced, depending on the adjuncts used for dental treatment, between 2006 and 2007. There was a reduction by 5 weeks for those awaiting treatment under local anaesthesia alone, and a reduction of 21 weeks for those awaiting treatment under conscious sedation, both intravenous sedation and inhalation sedation. For those awaiting treatment under GA, the average dental treatment waiting time increased in 2007 by comparison with the data from 2006, by almost 12 weeks. More patients were seen for dental treatment either with local anaesthesia alone or sedation, rather than a GA in both years, which is more appropriate.

Kelly and Nunn: Access to care 31 Table 2: Relative waiting times for assessment for Special Care Dentistry (SCD) and Advanced Restorative Dentistry (AR) clinics in 2007. Table 3: Treatment waiting times for Special Care Dentistry treatment including general anaesthesia for 2006 and 2007. <3 months 3-6 months 6-9 months 9-12 months >12 months SCD Treatment Waiting List 2006 SCD Treatment Waiting List 2007 35% 25% 17.5% 9% 13.5% 36% 18.5% 14% 10% 21.5% >12 months in 2007: waiting times due to restricted bed availability From Oct 2007: waiting lists included IV sedation restorative waiting times also.

32 Journal of Disability and Oral Health (2012) 13/1 Table 4: Outcomes from an assessment clinic for special care patient referrals in 2006 and 2007

Kelly and Nunn: Access to care 33 Table 5: Adjuncts used and waiting times for dental care for patients referred in 2006 and 2007 to a Special Care Dentistry clinic in a dental hospital. Conclusion There are several changes that may need to be implemented to improve the efficiency of the SCD clinics: increasing the number of clinics available and also increasing the staffing numbers would reduce the waiting times for both assessment and dental treatment. Further training of dental students, senior dental surgeons in SCD and general dental practitioners, as well as other educational and training courses in SCD would allow more special care patients to be seen in primary care settings. The British Society for Disability and Oral Health established a guideline for developing the undergraduate curriculum in SCD in 2004 and adoption of some of the principles outlined in this document would enable more graduates to be confident and competent in the management of special care patients (British Society for Disability and Oral Health, 2004). In 2009, the GDC approved and the Royal College of Surgeons of England s Specialist Advisory Committee subsequently oversees a specialty training programme, encouraging qualified general dental practitioners to specialise in this area and underpinning a career pathway for dentists with an interest in SCD (Royal College of Surgeons of England: Specialist Advisory Committee, 2009). Both of these developments will increase the number of dentists experienced in treating this group of patients, who have a number of concurrent medical and physical problems, compared to the general population. This makes it difficult for patients to access dental services and thus the number who fail-to-attend or have to cancel at short notice is substantial, making the clinics more difficult to run efficiently. Further research needs to be undertaken to: Correlate the degree of disability, patient s home area, as well as other supports, with failure to attend or cancellation Establish criteria for prioritisation, according to degree of disability/need, and thus reduce the waiting times for assessment and treatment for those patients in greatest need Correlate the number of cancellations with any perceived delay in assessment and treatment and address any deficit so identified Design a questionnaire to ascertain reasons why patients cancel or fail to attend appointments in order to improve the efficiency of clinics Establish a short notice cancellation protocol. These data would enable us to greater understand the needs of special care patients and adapt our dental services appropriately to offer them optimal dental care, with the minimum time. Following this audit, as a consequence of these results, the DDUH has published acceptance criteria on their website: www.dentalhospital.ie/clinical-services/clinics and instituted more active, timely reviews of the SCD waiting lists. There are now two new diplomas being taught in the DDUH, in Conscious Sedation and SCD, as well as the development of formal continuing dental education courses in SCD, which has reduced the treatment waiting times, especially for inhalation sedation. The intravenous sedation waiting list is being reorganised and will be reaudited when this list has been established. A text messaging system has been introduced in DDUH to help reduce failure rates, whereby patients are sent a text message three days prior to their appointment as a reminder, provided the patient/support staff have a mobile phone number. Further dental training of SCD dental surgeons and general dental practitioners in the primary

34 Journal of Disability and Oral Health (2012) 13/1 care setting would facilitate treatment for these patients and reduce the number of referrals to secondary/tertiary care. This would result in easier access for Special Care patients to primary dental care and reduce their waiting times for dental treatment. Acknowledgements We would like to thank Ms. Susanne Bushe and Dr. Rebecca Playle for all their help during this study. References British Society for Disability and Oral Health (BSDH, 2003). Joint Advisory Committee for Special Care Dentistry: A case for need: proposal for a specialty in special care dentistry. www.bsdh.org.uk/ misc/acase4need.pdf British Society for Disability and Oral Health (BSDH, 2004). Developing an undergraduate curriculum in Special Care Dentistry. Available at: http://www.bsdh.org.uk/misc/teaching_doc_06july04.pdf Department of Health, (Dublin, 2003). Oral Health of Adults with an Intellectual Disability in Residential Care in Ireland. Available at: http://www.dohc.ie/publications/oral_health_residential_care.html. Department of Health, (UK, 2006). Tackling hospital waiting: the 18 week patient pathway - an implementation framework and delivery resource pack. Available at: www.dh.gov.uk/en/publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_4134668 General Dental Council (Specialist List) Regulations, (GDC, 2008). Available at: http://www.gdc-uk.org/governanceandcorporate/gov- ernancemanual/documents/thegeneraldentalcouncilspecialistlist- Regulations20.pdf National Disability Survey, (Ireland) (2006). Available at: http:// www.cso.ie/releasespublications/documents/other_releases/nationaldisability/acknowledgements,%20introduction,%20executive,%20 Commentary.pdf Specialist Advisory Committee for Special Care Dentistry Specialty Training Curriculum: Special Care Dentistry, (2009). Available at: http://www.gdc-uk.org/dentalprofessionals/specialistlist/documents/ SCDCurriculum.pdf Address for correspondence: Dr. Grace Kelly Special Care and Sedation Unit, School of Dentistry Cardiff University, Heath Park Cardiff, CF14 4XY, Wales Email: KellyG6@cardiff.ac.uk