Experiences of an early achiever a PCTs perspective Roger Anderson Dental Lead, Torbay Care Trust

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Experiences of an early achiever a PCTs
perspective Roger Anderson Dental Lead,
Torbay Care Trust
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Experience of an early achiever - a Primary Care
Trusts perspective

• Roger Anderson Dental Lead,
• Primary Care Team of the Commissioning
  Directorate.
• Torbay Care Trust

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Why am I presenting this today!

• Because I have difficulty saying no.
• I think we have learning to share as an early
  achiever. What has worked, what is still to be
  done. Recognising that all our areas are
  different, what are the principles we can share.
• Please note, I am not an expert on 18 weeks wait.
• And of course who wouldn't want to see
  Manchester?

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What do you think about an 18weeks wait target?

• Not another target being imposed!
• Is it really necessary in Dental specialties,
  especially Orthodontics?
• I am working as hard as I can, how do we achieve
  this?

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Who owns the 18 week wait target? Secondary Care?

• Yes it is, but it is also a Primary Care Trust
  target-
• Is it just a quick fix approach to meet a target.
  Just employ extra staff in the Hospital.
• Referrals from Primary Care practitioners (GDPs)
  affect the waiting list.
• Where is work done, by whom and why, at what
  cost?
• Where would patients choose to be treated?
• Whole systems examination. Develop a
  comprehensive commissioning strategy, across
  primary and secondary care. Since April 2006
  PCTs have the budget for Primary Dental Care!

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Removing Unnecessary Waiting
South Devon Community

• Delivering 18 Weeks in Orthodontics

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End waiting, change lives

• South Devon Health and Social Care Community

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• South Devon
• Population 275k
• Coast, rural, urban
• One Foundation Trust Acute Provider
• 9 community hospitals and intermediate care units
• 2 commissioners
• Largest employer

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What happened in South Devon?

• Sign up by the whole South Devon Health Community
  to early achiever status by December 2007,
  ahead of national timetable of Dec 2008.
• Local community main referrers from Torbay CT
  and Devon PCT
• Commitment to deliver this in support of Torbay
  Hospital.

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No Delays Project
Phase 1 - Community Engagement Model
Phase 2 - Strategy to deliver No Delays
Phase 3 Identification of High Risk service
areas
Phase 4 Service Improvement Events
Phase 5 - Action Plans Delivery
Phase 6 Benefits Realisation Right TRaC
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Phase 3 Identification of clinical areas
Backlogs
Benchmarking High Impact Change
Waiting times
New to follow up rates
Diagnostics
Referral rates
No delays achiever
Discussions with clinical teams
Relatively unscientific but a reasonable basis
none the less.
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Areas highlighted for service improvement events

• Trauma and Orthopaedics
• ENT
• Gynaecology
• MXFS
• Orthodontics
• Neurology
• Gastroenterology
• Generic admin and systems

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The system
South Devon Community

• Service Improvement Group
• Executive Director Sponsorship
• Programme Management Team No Delays
• National ISIP input
• Identification of highest risk specialties
• Commitment

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The programme
South Devon Community

• is available to you
• Critical components
• Definition of the scale of problem
• Vision
• Value stream mapping
• Action plan linked to ISIP
• Task group with clear accountability and freedom
  to act
• Follow up

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What we did in May
South Devon Community

• What? - lock in aka an improvement summit
• Who? everyone with an interest
• Where? nice venue
• When? 6 weeks in advance for scheduling
• How? using rapid cycle improvement methodology

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The process
South Devon Community

• Pre-meets with the clinical teams
• Data preparation
• Focus on issues key pathways to map and
  objectives to meet
• Whole community
• Clinical and managerial leadership

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18 weeks wait and Orthodontics.

• Orthodontics not an urgent service, initial
  disbelief that Orthodontics would be included.
  But it is!
• Treatment Waiting list in Torbay Hospital over a
  year.
• In Primary care orthodontic treatment waits are
  mixed, can be greater or less than a year down to
  6 months.

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Where are orthodontic treatments carried out?

• In Hospital with a Consultant led service.
• In independent dental practices by specialist
  practitioners.
• In Independent dental practitioners by dentists
  with an interest, who may have a mixed contract
  for orthodontics and general dental care.

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Costs of Hospital Ortho treatment

• Based on PBR-

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Cost of Ortho treatment in Primary Care setting.

• Based on a national UOA value of 55

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Recent changes in Primary Care Orthodontic
treatment provision in S. Devon.

• Introduction of nGDS / nPDS contracts-
• Existing activity and payments transferred to a
  new currency.
• Separation of Orthodontic and General dental
  care. No immediate transferability.
• Activity limited by the value of the contract in
  s and UOAs expectations.
• Take out the dabblers!
• Changing workforce, new GDPs now working.

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Other possible factors affecting Orthodontic
treatment demand.

• Has the demand for treatment increased? Are we
  seeing a temporary blip?
• Overall since April 06 an increasing number of
  patients accessing a Primary Care dentist?
  Private and NHS.
• Patients on a waiting list gaining access to a
  dentist after many years of no dental access.
  Anecdotal. No GDP no treatment!
• Both likely to increase referrals.

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Is there a more objective measure of demand?

• What is the overall need for orthodontic
  treatment in South Devon?
• DH Gateway Ref No 7105 Advises on calculating a
  need for orthodontic treatment, based on 35 of
  12 year olds. (Evidence based on 2003 National
  Child Dental survey)
• Numbers of 12 year olds in Torbay, South Hams and
  Teignbridge districts used as crude baseline.
• Calculate the numbers of treatments per year.

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Are there risks in reducing the waiting times in
Hospital?

• We could produce instability in that-
• GDPs refer in expecting a 1 year wait, system
  could clog with patients not ready.
• Patient choice through Choose and Book could
  increase demand from outside S. Devon. Plans
  blown out of the water!
• An 18 week wait for treatment in Hospital, but
  still a year or over in primary care! Not
  sustainable, and could see a shift to Hospital
  referrals.

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The action plan
South Devon Community

• Information for GDPs and Patients
• Review information available for GDPs and
  Patients / Parents or guardians
• Review existing referral template
• Develop Induction Pack for new (individual) GDPs
• Improve the referral process
• Develop proposal for the supporting nurse role

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The action plan
South Devon Community

• Improve quality of information received on and
  compliance with the use of the referral form
• Discharge criteria
• Education and training for GDPs
• Improve productivity to deal with volume of
  referrals
• Manage the expectation of the parents
• Accommodation for Orthodontists

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And since May?
South Devon Community

• Primary Care practitioners with UOA contracts for
  additional orthodontic treatments to reduce
  backlog
• Contract with Specialist Practitioner to take 120
  treatments off the hospital treatment waiting
  list
• Additional Specialist Practitioner into hospital
• Maxed clinic and treatment sessions
• Work begun with independent contractors to reduce
  their waiting time to 18 weeks

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What since May?
South Devon Community

• Analysing referrals to all orthodontic providers
  trends, completed treatments compared with
  expected demand based on population figures
• Local Clinical Network agreement to develop
  information packs for patients and GDPs to
  improve referrals and patient expectations as
  patients are referred on
• Clinician to clinician process, C2C.

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Suggestions to consider in delivering 18 weeks.

• You must have sign up between Hospital and local
  PCTs at Chief Executive level as to achieving
  this together.
• This local health community sign up must
  translate into commitment at all levels. Who
  drives it, who manages the process.
• Involve the right people. Hospital Clinicians,
  GDPs, Managers, PCT Commissioners. Patients?
• Is there a Local Clinical Network where
  clinicians can engage with each other.

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Suggestions to consider in delivering 18 weeks.

• This is an opportunity to look at the whole
  system, not just secondary care. Clear overall
  commissioning strategy.
• Who monitors progress? What alerts will you
  build in? What happens if one part of the system
  goes down?
• Once initial changes made, how is this sustained?
  What ongoing structures and processes have you
  in place?

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Acknowledgment.

• I want to record that in pulling this
  presentation together, this represents the work
  done by many people-
• Commissioning Directorate, Choose and Book Team
  of Torbay Care Trust.
• South Devon Healthcare Foundation Trust.
• Primary Care Contract Managers of Devon PCT
• Orthodontic Consultants, Orthodontic Specialists
  and General Dental Practitioners in South Devon.

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Thank you.

• If you want further information, I can be
  contacted in the following ways-
• By telephone [phone]
• By e mail rogeri.anderson_at_nhs.net