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«1 NHS dental contract pilots – Clinical pathway review after one year DH INFORMATION READER BOX Policy Clinical Estates HR / Workforce Commissioner ...»

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NHS dental contract pilots ­

Care Pathway Review

A report by the dental contract pilots clinical

pathway review group


NHS dental contract pilots – Clinical pathway review after one year


Policy Clinical Estates

HR / Workforce Commissioner Development IM & T

Management Provider Development Finance

Planning / Performance Improvement and Efficiency Social Care / Partnership Working Document Purpose For Information Gateway Reference 18301 Title NHS dental contract pilots - Care Pathway Review Author Department of Health Dental & Eye Care Services 10 December 2012 Publication Date Target Audience PCT Cluster CEs, SHA Cluster CEs, Directors of PH, Local Authority CEs, PCT Cluster Chairs, Directors of Finance, Primary care dentists & allied dental professionals Circulation List #VALUE!

Description The report details the review of the clinical pathway currently being used in the piloting of elements of a new national contract for primary dental care services.

Cross Ref N/A Superseded Docs N/A Action Required N/A N/A Timing Contact Details Elizabeth Lynam Dental & Eye Care Services Skipton House 80 London Road London SE1 6LH 020 7972 1406 0 For Recipient's Use You may re-use the text of this document (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit www.nationalarchives.gov.uk/doc/open-government-licence/ © Crown copyright 2011 First published [Month Year] Published to DH website, in electronic PDF format only.

www.dh.gov.uk/publications 2 NHS dental contract pilots – Clinical pathway review after one year NHS dental contract pilots – Clinical pathway review after one year A report by the dental contract pilots clinical pathway review group Prepared by Eric Rooney, Consultant in Dental Public Health

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Contents Contents



The clinical pathway

Reviewing the clinical pathway


Other issues

Appendix 1: Members of the clinical pathway review group

Membership of Clinical Pathway Review Reference Group

Membership of Clinical Pathway Review Working Group

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Foreword Over the last year there has been much interest and discussion within the profession about the new contract pilots and the clinical model which is being used.

The report of the Evidence and Learning group published in October 2012 showed widespread support amongst pilot practices and patients for the general approach- a clinical pathway which promotes a standard oral health assessment, identification of need and disease risk and evidence based prevention for patients. Although the concept is well supported, the report highlighted the need to review this clinical pathway approach with a view to improving the efficiency of the process whilst maintaining the underlying principles.

This report covers the detailed work, predominantly undertaken by clinical colleagues from pilot practices, to review the current clinical pathway. It makes recommendations for changes to be implemented as the pilot program rolls forward into 2013.

The recommendations come from the practical experience of pilot practitioners in the first year and the majority are straightforward, pragmatic and can be implemented quickly. Work is already underway to amend the pilot software to achieve this. The outcome should be a more personally focussed approach to patients focussing only on their personal risks and the way in which they wish to manage them. This in turn should lead to fewer interim care management (ICM) appointments booked, and fewer broken appointments increasing the efficiency of the pathway approach.

Recommendations in relation to the appropriate intervals for disease specific reviews and full oral health reviews challenge current custom and practice and require further development and wider stakeholder discussion.

In the spirit of continuous improvement and development, the impact of the recommendations and the revised clinical pathway should be reassessed as part of the ongoing pilot programme.

I am grateful for the enthusiastic participation of the practitioners and others involved in the clinical pathway review and hope you will find this report of our work informative, leading to greater insight into the clinical aspects of the pilot programme Eric Rooney Chair of Pathway Review Group

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Background The Clinical Pathway Review was established as part of the ongoing development and refinement of the ideas being tested in the Dental Contract Pilot Programme.

The pilot programme is testing ideas for a new contract based on registration, capitation and quality and although there are three different approaches to the capitation aspects being tested, the clinical service offered to patients is common to the three pilot types.

The clinical service aims to provide high quality clinical care appropriate to the needs of individual patients. As the most common dental conditions (tooth decay and gum disease) are largely preventable, there is an emphasis on prevention and patient self care within the clinical model.

There is considerable evidence1 to support specific preventive interventions, either by dentists and their teams or by patients themselves. Additionally, guidance also exists regarding appropriate periods for routine recall of patients based on risk2. Given this background, a clinical pathway approach is being used to guide pilot clinicians in the delivery of needs led, outcome focussed primary dental care.

The clinical pathway currently being used in the pilots was developed using a consensus methodology over two workshops. These took place in October 2009 and February 2010. The approach adopted built upon on the innovative work of clinicians and commissioners who had been independently developing need/risk based pathways in different parts of the country.

Workshop participants included primary care clinicians – some with clinical pathway experience – specialists and consultants, clinical academics, representatives of the British Dental Association, patients and NHS commissioners.

Prior to starting the pilots, clinical training supported by those dentists with experience of working with clinical pathways was provided to all pilot practices.

Going forward any progress on information systems for a new contract that will include the underpinning clinical pathway software will take into account the Government’s May 2012 overall information strategy for health and care in England – The power of information.

1 Delivering Better Oral Health An evidence-based toolkit for prevention - second edition, July 2009 (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_102331) 2 Dental recall - Recall interval between routine dental examinations, October 2004 (http://guidance.nice.org.uk/CG19)

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The clinical pathway The clinical pathway begins with a comprehensive oral health assessment which includes • Gathering key clinical findings and personal information related to the following four

main causes of poor oral health:

o dental caries (tooth decay) o periodontal disease (gum disease) o tooth surface loss (worn down teeth) o conditions affecting the soft tissues of the mouth, for example oral cancer • Identifying the degree of risk of these conditions occurring, or of the conditions


Based on this information, the pathway guides clinicians to provide patients with a preventive care plan indicating their risk using a red amber green (RAG) traffic light system. The care plan provides a platform for communication with patients and assists in the transfer of responsibility for patient self care. It includes • personally tailored advice to patients on their oral health status and the preventive actions they need to take to improve their own oral health • information about preventive actions recommended by the dental team - for example, fluoride varnish applications every three months, referred to as interim care management (ICM) • suggested timing for the next oral health review (recall interval)

Figure 1 – The clinical pathway

The clinical pathway acts as a decision support system to help clinicians to offer and deliver the most effective evidence based care. Clinicians are expected to use their clinical skills and judgement in matters of diagnosis and treatment planning to deal with the four conditions, as previously listed, and any others.

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Within the pilot programme, there are several advanced care pathways that use information from the oral health assessment to help guide clinicians take decisions on the appropriateness of treatment in the following areas

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These advanced care pathways were not covered within the review, and consequently no comments or recommendations relating to them appear in this report.

To support the delivery of the pathway, all pilot practices use software provided by one of three dental software companies.

A separate software review has taken place and, as a result, the majority of the recommendations in this report will require IT adaptations.

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Reviewing the clinical pathway The review of the clinical pathway took place during July and August 2012. It was chaired and facilitated jointly by Eric Rooney – Consultant in Dental Public Health and facilitator of the original Clinical Pathway development workshops – and Rob Haley, a senior manager with Primary Care Commissioning (PCC) who previously worked in the capacity of commissioner in the early innovative pathway work that took place in the North West A reference group was established to guide the review and to ensure that inter- dependencies with other aspects of reviewing the pilot programme could be identified. At the same time a working group comprising of 17 pilot clinicians from 14 practices was also established.

A full list of participants can be found at Appendix 1 of this report.

Terms of reference The purpose of the review was to develop recommendations for consideration by the National

Pilot Steering Group with the aim of:

• reviewing the utility of the pathway with clinicians involved in the pilots • improving and simplifying the clinical pathway approach whilst maintaining the concept of identifying need and risk, and delivering personalised evidence based care • increasing the efficiency of the pathway approach to help deal with the impact on the availability of patient appointments seen in the first year of the pilots Method During the review, the reference group met three times and the working group met twice, in the form of two one-day workshops. At the first workshop, and following initial background briefing on the development of the clinical pathways, the working group members were asked to look at

the following three areas:

• the overall pathway and its applicability • the four key conditions and their assessment of need and risk • the actions advised for the patient and the dental teams Participants were asked to identify what works well, what does not, and what could be changed to make the pathway more effective and efficient.

On the basis of the outputs from the first workshop – plus further information gained from two subsequent regional engagement events – the Reference Group formulated some initial suggestions for amending the pathway in each of the three areas.

These suggestions were then used as the basis for discussions in the second workshop to develop and agree final recommendations for inclusion in this report.

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Results The following figures highlight the main conclusions from the first workshop. Figure 2 shows the agreed views on the overall pathway and its applicability.

Figures 3-6 show the agreed conclusions reached on each of the clinical conditions (clinical domains) covered in the pathway.

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Following workshop 1, some of the ideas generated for change were tested at the North West and North East Regional engagement events, where additional comment on the current pathway was also sought.

Revision of the overall pathway and changes proposed to risk assignment were generally welcomed. Wider comments from these sessions along with comments from the review group are included in “other issues” section later in report.

During the second workshop, participants reviewed the changes proposed at the first session and achieved consensus on the following recommendations.

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Recommendations • Agreeing the approach with patients - revise the pathway to provide an option for patients who are currently unwilling or unable to accept the offer of professional preventive activity The group identified that a considerable amount of appointment time is currently being lost as a result of failure to attend by patients who have not bought into the concept of prevention.

Whilst offering and encouraging patients to develop preventive behaviours, it was felt important to accept that some patients may not want to take up this offer and that this view should be accommodated within the pathway. Figure 7 shows the additional branch recommended within the pathway, recognising that at any time patients may change their position. It is expected that the clinical record will reflect the agreed approach to be taken. The green coloured background to this recommendation shows that this is expected to increase the efficiency of the pathway and make it more acceptable both to patients and professionals.

• Software improvements to allow flexibility It became clear during the workshops that the way in which the pilot software currently works makes it difficult to see a patient for unscheduled activity – either during a course of treatment, or in the period between the end of a course of treatment and the next planned oral health review – without undertaking a full oral health assessment. As this is not always required,

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