Commissioning and Delivering Minor Oral Surgery Services in the primary care setting

1
Commissioning and Delivering Minor Oral Surgery
Services in the primary care setting

• Ken Wragg Consultant in Dental Public Health
  Derbyshire
• Dental Lead Trent Strategic HA

2
Objectives

• The South Derbyshire Minor Oral Surgery Service
• Set the scene - context
• Dental public health / commissioning perspective
• What might the future hold?

3
Oral surgery services

• Primary Care
• GDS SDR
• PDS
• Secondary Care
• Broad spectrum of complexity
• Training location
• Mixed economy
• Independent sector NHS Private
• Directly delivered services CDS / PDS / HDS
• Effective use of the total public resource
  skill mix
• Local solutions for local problems

4
Issues in oral surgery

• Oral surgery skills of new graduates.
• Willingness to carry procedures out in practice
  not a practice builder
• Management of waiting lists
• Cost - Tariff
• Optimal use of work force
• Doubly qualified OMFS consultants
• Specialists in minor oral surgery
• Dentists with a special interest in MOS
• Dental practitioners
• Local solutions for local problems

5
Southern Derbyshire Minor Oral Surgery Pilot

• To assess feasibility of delivering MOS via a PDS
  pilot
• To assess acceptability of this service to
  patients, providers, performers, referring
  dentists commissioners
• To aid development of clinical criteria
• To help develop appropriate skill mix for MOS
• To investigate impact of this pattern of service
  delivery on cost quality of treatment provided

6
MOS pre-pilot

• Began 1996
• Persuaded HA to invest 20k non-recurrently
• Cost per case no patient charges
• Major issue - vicarious liability clinical
  standards
• Budget spent after 9 months

7
PDS Minor Oral Surgery Pilot

• Commenced November 1998 (after pre-pilot)
• Recurrent funding patient charge
• Long waiting lists/times for MOS esp 3rd molars
• Unattractive GDS fee scale / MOS not a practice
  builder
• Initially 2 (later 3) GDPs with specialist
  skills in MOS
• Admission to specialist list a defined surgical
  standard
• SAAD independent audit used to define sedation
  standards
• Worked closely with specialists to develop and
  refine process that reflects NICE guidance

8
PDS Minor Oral Surgery Pilot (2)

• Initially patients aged 18 to 45 only (upper age
  limit now removed)
• Referral made directly to PDS practice by GDP
• 3rd molar surgery apicectomies on previously
  root filled canines and incisors
• Treatment under LA with or without sedation
• Medically compromised patients - ASA categories 1
  2 only

9
PDS Minor Oral Surgery Pilot (3)

• Variation sought and granted range of
  procedures increased in 2002 to reflect SDR
• Locally administered system
• Protocol
• Case audit form / invoice for each patient
• 100 response rate.
• Patient satisfaction questionnaire (70 response)

10
PDS Minor Oral Surgery Pilot (4)

• Simple cost per case used initially for pre-pilot
• 1998 - Simple fee scale in place
• Core fee
• Sedation fee
• Supplementary fee
• Made more complex by having to use the SDR to
  calculate the patients charge
• Cost per case to the pilot budget, depends on
  patients contribution sedation rate.

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Patients Treated 1998 to 2003
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Cases Treated 2002 - 2005
13
Costs
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Cost per case
15

• 05/06 national tariff costs

• Inpatient
• 730 Planned procedure
• 1271 Emergency procedure
• Outpatient
• 1st visit
• Adult - 116
• Child lt17 - 156
• Follow up visits
• Adult - 60
• Child lt17 - 81

16
Improved service for patients referrers

• Geographical access
• Waiting times
• Known operator continuity from assessment to
  surgery

17
Personal Dental Services

• Has added the vital ingredient of flexibility
• Provided a tool for creating local solutions for
  local problems
• BUT .
• How will this pilot be contracted for in the
  future?
• Are nPDS Regulations the appropriate mechanism?

18

• Issues

• Patient charge will be collected by referring
  dentist loss of PCR to service?
• How does the provision of sedation affect this?
• Will PCTs be willing to invest their local
  resources in a referral service that can be
  accessed by any patient regardless of where they
  live?
• Will PCTs collaborate over the commissioning of
  primary care based specialist services?

19
Lost cases
20
Potential alternatives

• Local service level agreement
• Each PCT invests as it sees fit
• Applies to all primary care based specialist
  dental services that provide treatment on
  referral?

21
Conclusions

• PDS MOS service is a success!
• Is in the public interest.
• Provides a tool that can be used elsewhere in the
  right circumstances
• Needs to be taken forward in a spirit of
  partnership
• 10 and 20 care are different parts of spectrum of
  services funded by the public for the public
  need to look at total resource
• CPD of the primary care dental workforce role
  for specialist practices?
• PCTs need to consider the best framework locally
  for delivering services on referral in primary
  care