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PRIMARY DENTAL CARE ORAL SURGERY PILOT MODEL
BACKGROUND
Trust Oral Surgery (OS) waiting lists have grown significantly over the last 3 years.
One potential solution is to utilise increased provision by High Street Oral Surgeons
who, background research suggests, would be able to see approximately 75% of
patients referred to Trust OS services.
CONTEXT
Minister McGimpsey directed the Service to pilot three new dental contracts, oral
surgery, General Dental Services and orthodontics. A new OS primary care contract
is needed to secure sufficient OS capacity from High Street Specialists. As OS is, in
contractual terms, less complex and diffuse than general dentistry, a pilot OS
contract could lead to resolution of the OS waiting list problems and also act as a
pathfinder project for the wider new GDS contract.
SUMMARY
A pilot model is proposed that at its heart has a Referral Management Centre (RMC).
All referrals from Southern Area practitioners will come through the RMC which, in
turn, will determine if the patient is best seen in primary or secondary care. The pilot
will run for 6 months before being evaluated. If successful, the model could be rolled
out across Northern Ireland. However, a new approach such as this is only feasible
in the long term if a proportion of funding currently used for secondary care OS
services is redeployed to follow the movement of patients. This proposal will only
proceed on the basis that it meets value for money criteria.
EQUALITY AND HUMAN RIGHTS
Screening has excluded equality and human rights issues.
RECOMMENDATION
SMT is asked to approve the proposed pilot model and project support
requirements. In particular, SMT support is sought for the use of a RMC which
will, almost certainly, result in a greater proportion of OS patients being seen
in primary care.
Dr S Harper
Director of Integrated Care
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PRIMARY DENTAL CARE ORAL SURGERY PILOT MODEL
EXECUTIVE SUMMARY
Northern Ireland has a small but potentially productive group of High Street Oral
Surgery practices. Research shows that many of the patients currently seen by
hospital-based Oral Surgeons could appropriately be treated in primary care. The
main barrier to moving oral surgery patients from secondary to primary care is the
current level of remuneration payable to High Street specialists under the GDS
contract. An OS pilot is proposed with (yet to be agreed) more attractive levels of
remuneration that will fully engage primary care specialists. This will reduce
secondary costs but increase primary care costs. If the pilot proves successful a
mechanism needs to be developed to allow some of the current baseline secondary
care OS funding to be moved to primary care.
1.0 BACKGROUND – ORAL SURGERY SERVICES
1.1 The General Dental Council defines the specialty of Oral Surgery as, “the
treatment and ongoing management of irregularities and pathology of the jaw and
mouth that require surgical intervention.” Oral Surgery services in Northern Ireland
are currently provided in primary and secondary care settings.
1.2 Specialist Oral Surgery Services are provided in four main ways:
1) Hub and spoke Hospital Dental Services (HDS) – In Local Hospitals
delivered by teams that have evolved to be Consultant-led, but by the
medical specialty of Oral and Maxillofacial Surgery (OMFS). The
service hubs are based at Altnagelvin Hospital and the Ulster Hospital
with spokes for outreach services both within and outwith these Trust
areas.
2) BHSCT HDS - In the Dental Hospital by a small team led by an
Academic Consultant in Oral Surgery who is in a joint appointment post
between QUB and BHSCT.
3) Primary care-based specialists - In High Street Oral Surgery practices
led by Specialist Oral Surgeons who have completed a training
programme in Hospital units and are on the GDC specialist list. There
are six practices (Ballymena, Ballymoney, Belfast x 2, L’derry and
Newry) with a workforce of approximately nine WTE dentists in total.
Most of the dentists are Specialist Oral Surgeons but some are not.
They all work under the same GDS contract and remuneration model
as General Dental Practitioners (GDPs).
4) NHSCT Community Dental Service (CDS) - There is also a very small
Community Dental Service Oral Surgery Service which is essentially
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for internal referrals in NHSCT and is led by one part-time Oral Surgery
Specialist who previously owned a High Street Oral Surgery practice.
1.3 Those who are allowed to carry out oral surgery procedures are:




General Dental Practitioners (GDPs), if the procedure is within their
competence (GDC expected competencies include relatively simple
procedures such as removal of roots, biopsies and dentoalveolar trauma).
Specialist Oral Surgeons in ‘High Street’ practices – (wisdom teeth and
exposure of canines for orthodontic treatment).
Specialist Oral Surgeons working in Hospitals – (cysts of the jaw and
medically compromised patients).
OMFS Consultants – (cleft lip and palate, road traffic accidents).
1.4 There is therefore a hierarchy of increasing specialisation with the most difficult
cases being seen by the OMFS Consultants. This system operates efficiently when
case complexity is matched to level of specialisation. However, at the moment it
appears that many cases that could be seen by High Street Oral Surgeons are
making their way to the HDS. This is the key issue that the proposed Oral Surgery
Pilot seeks to address and is discussed in more detail below.
1.5 The OMFS service model is somewhat complicated by the fact that Specialist
Oral Surgeons work under the supervision of OMFS Consultants but their activity is
credited to the OMFS Consultant.
1.6 It should be noted the provision of Oral Surgery services in Hospital-based
secondary care forms part of the wider Review of Consultant-led Hospital Dental
Services currently underway at DHSSPSNI. This pilot will help inform that review.
2.0 BACKGROUND – CURRENT WAITING LISTS FOR HOSPITAL-BASED ORAL
SURGERY SERVICES
2.1 There is a rising number of Oral Surgery referrals and there are believed to be
several reasons for this:
(1). Younger dentists have received less practical oral surgery experience
during training.
(2). Oral Surgery can be somewhat traumatic and complications can occur so it
is not viewed as a ‘Practice Builder’ and is often referred out.
(3). Patients may seek free treatment in secondary care rather than paying for it
in primary care under the GDS scale of patient charges.
(4). Demographic changes – Northern Ireland’s population has a growing
proportion of older people and elders have more complex medical and
dental needs.
2.2 There are significant numbers of patients waiting (circa 1000) and waiting times
(approximately 1 year) in all Trusts (see Appendix 1) except WHSCT and
consideration is currently being given for a regional tender approach to the
Independent Sector to clear the current backlog.
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2.3 The situation in SHSCT appears to be particularly challenging and seems to be
associated with difficulties with the contracting and cost of the provision of Oral
Surgery (OS) services, as delivered through the OMFS team by SEHSCT. Services
are provided at Craigavon Area Hospital and Daisy Hill Hospital. Recent data shows
that approximately 2400 OS cases are referred to the HDS each year from GDPs in
the Southern Area and there are approximately 1000 cases on waiting lists (2:1,
Craigavon:Daisy Hill). SHSCT has expressed interest in a longer term solution for
their service needs, but is likely to use an Independent Sector tender to clear the
current backlog which will not form part of the pilot).
3.0 BACKGROUND-remuneration of Oral Surgeons
3.1 High Street Oral Surgeons feel that they are not well remunerated under the
GDS system. They complain that the Item of Service fees do not recognise that they
are specialists and that they receive the same fees per procedure as GDPs. It could
be argued, however, that as specialists they are highly skilled and can carry out such
treatments at a faster pace than GDPs and are remunerated appropriately. They are
also able to carry out private treatment (subject to market demand) for higher levels
of remuneration. The practices have varying levels of GDS commitment with more
health service provision tending to come from associates. One practice owner has
very publicly withdrawn from the GDS on two occasions but has ultimately returned.
4.0 BACKGROUND – new primary care dental contracts
4.1 Negotiations have been ongoing between the DHSSPSNI and the Northern
Ireland Branch of the BDA since 2006 and latterly the HSCB have been involved in
the process. The basic model of the general contract has been developed but the
key issues of fees and remuneration system have not been addressed. Separate
contracts have been proposed for specialist Orthodontics and Oral Surgery services
provided in primary care.
4.2 A considerable amount of work was undertaken in 09/10 to develop an Oral
Surgery contract model. OS was seen as a manageable way to begin piloting the
new contractual arrangements (the aging BSO dental payment system makes
piloting of the general contract difficult). A simplified, banded model was developed
and it was hoped to pilot this across all OS sites. However, progress stalled when
the BDA sought a fee increase of 100% on the extant SDR.
4.3 A new pilot model has been in development since April this year when we
essentially started over again. A key challenge has been to reconcile a demand-led
service model with a capped budget. Added value services and an interface with the
CDS were explored before it became apparent that some local service difficulties in
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the SHSCT may present an opportunity for a discrete pilot model to be tried. The
model that has now been proposed is outlined in section 5.
4.4 A formal consultation process has been carried out on the use of Personal
Dental Services (PDS) legislation for the pilots for the new contracts. This
consultation ended on 31/1/11 and a summary paper was presented at the HSCB
public Board meeting of 31/3/11. As the consultation had a positive outcome pilot
models can now be run under the PDS legislation.
4.5 The next formal procedural steps required to establish a PDS pilot are:
1. HSCB to seek Expressions of Interest.
2. Replies will inform an HSCB Proposals paper on the pilot for submission to
DHSSPS.
3. DHSSPS will then issue Implementation Directions to the HSCB to commence
the pilot.
4. HSCB draws up Agreement(s) i.e. legal contract(s) with pilot participant(s) in
line with Directions.
5. HSCB to publish details of pilot scheme.
5.0 THE PROPOSED OS PILOT MODEL
5.1 The model can be briefly outlined as follows:

Remuneration System – A banded model where cases are classified into four
groups based on treatment complexity is proposed. The fees practitioners will
receive for each band is still to be negotiated. Further negotiation is also
required to determine whether the pilot contract will be with practitioners or
practices. There are advantages and disadvantages of each:
o Practitioner based contracts. This has been the preferred model from
the beginning of negotiations. Each practitioner in the contracted
practice would be paid as per the agreed bands. Consideration may
need to be given to different levels of payment for specialists and non
specialists working in OS practices if this model is used. The levels
could reflect years of experience and degree of competence of the
practitioners which may in turn reflect the types of treatment that they
are able to successfully undertake.
o Practice based contracts. To date this system has not been discussed
with the BDA / Practitioners. Under this system the practice owner
enters into a contract with HSCB to provide OS services for the
duration of the pilot. The Board may want to stipulate the criteria that
must be met by each performer within the pilot practices (e.g. must
have worked in a specialist practice for x of the last y years, be on the
GDC specialist list or have carried out xxx types of procedures in the
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bandings). The payments to each practitioner would then be the
internal business of the practice. This would be easier for the Board to
administer although there may be regulatory issues to deal with as
those with associate status effectively become employees of the
practice. Issues such as superannuation also become problematic.



Claiming options - The practitioners claim fees for work done as per the bands
described above. This could be carried out in a number of ways:
o Claims could be transmitted electronically to the BSO with the relevant
patient details. Patients seen in the pilot must pay the same fee as
those who receive the same treatment under the standard GDS
contract so within practices patient contributions need to be calculated
under the old system. When the claim is submitted to BSO it can also
be under the old codes and then converted to the relevant band at the
BSO for payment. Alternatively the practice can convert to appropriate
band and submit the claim for payment to the BSO. Either way there
will need to be discussions with the BSO on the processes to be used
to ensure maximum governance and minimum risk. There may also
need to be an offline system developed at the BSO to cope with this
pilot as the current dental payment system is over 20 years old and
rather inflexible.
o The claims could also be processed by integrated care business
support staff at the local offices of the LCG where the practice is
based. There is currently a model to pay practitioners who make
claims for the NIC-PIP trial activity and this could be used as the basis
for an OS pilot claims system. If this is the preferred approach for the
pilot, discussions with the local office staff will need to commence as
soon as possible. There will also need to be communications with the
BSO as consideration need to be given to other payments that are
related to the payment of treatments such as maternity leave,
superannuation, practice allowance etc. With either process new forms
need to be designed and a database/spreadsheet developed to collect
the information for payment and evaluation.
Location – The patients to be seen during the pilot period will be those
referred from GDPs working in the Southern Area. Referring
practitioners/patients will be offered a choice of High Street OS if it is decided
that they are suitable for care by a Specialist OS based in primary care.
Providers – Currently, patients referred from GDPs in the Southern Area may
be seen by a range of High Street OS (often depending on where the patient
works). It is intended to retain the same levels of patient choice in the pilot.
Therefore all OS practices will have the opportunity to take part in the pilot.
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
Patients o Case Numbers - proportionate to circa 4800 cases per year. (2400
referred to secondary care and identified from SHSCT data + 2400
estimated to be currently treated in High St OS practices).
o Case mix – clear list of routine treatments that can be referred. For
High Street providers the complexity of treatment and/or patient
management determine case fee as per a banding system.
o Duration – 6 month pilot only.

Referral Management Centre (RMC) – There are a number of OS RMCs in
England. It is proposed to issue a tender for a RMC to triage the 2400 patients
expected to be referred from Southern Area GDPs during the 6 months of the
pilot. Discussions with English RMCs have taken place and it is feasible to
submit referrals to an external RMC either electronically or via Royal Mail. The
anticipated cost per referral is £10 (triage undertaken by an OS specialist).

Funding – The treatment costs element of the pilot would be funded by the
primary care GDS budget but in the longer term movement of funds from
secondary to primary care would be required if the pilot proved successful and
was rolled out across Northern Ireland.

Monitoring - Monitoring of the pilot will take place through data that is
collected by the RMC, by SEHSCT and through the system used to pay
participating practitioners. Probity and quality monitoring will take place in the
usual way. Practitioner-based monitoring would give more accurate
information for evaluation of the pilot, and having this based at the BSO would
allow for comparison with the previous system of remuneration.
6.0 EVALUATION OF THE PILOT
6.1 The pilot will need to be robustly evaluated both in terms of process and
outcome. Process can be evaluated through the information received from the
RMC. This could be bolstered by a short piece of work in relation to how this pilot
RMC compared with other work the RMC team have previously been, or are
currently are, involved in. Other elements of the process evaluation include
numbers of inappropriate referrals, numbers of referrals that attempt to
circumvent the RMC and number of patients seen in primary care OS that end up
needing seen in secondary care OS due to complications.
6.2 A focus group discussion with the pilot participants and a separate discussion
with the referring GDPs would help to qualitatively capture different perspectives
on the pilot. It is vitally important to get feedback from patients who go through
the system This could be done through both a patient satisfaction questionnaire
and a small number of focus groups.
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6.3 The outcome also needs to be evaluated in terms of the treatments carried
out and the money spent, all in relation to what was spent previously both in the
primary and secondary care sites. Waiting lists in secondary care also need to
be monitored and viewed as an outcome in the evaluation. Data returned to the
BSO from practices and data only captured at practice level on their own IT
systems also needs to be considered.
6.4 A clear plan of evaluation needs to be developed and costed prior to the
beginning of the pilot so that appropriate data are collected at baseline and at the
end of the exercise as well as at specified points in between.
7.0 RISKS
7.1 The High St OSs collectively decide not to participate and even withdraw service
from current legacy arrangements. This is perhaps unlikely because they can
currently generate reasonable practice income through the GDS model.
7.2 Some individual High St OS may feel that they are losing out with the pilot
because their premises are remote from the SHSCT so they will not receive pilot
patients. Discussions with the BDA will address this matter.
7.3 Some of those working in the OS practices are not specialists. If the HSCB is
commissioning specialist services through a specialist OS contract then it could be
argued that the pilot agreement (contract) should specify specialists only.
7.4 Oral Medicine (OM). There have already been well-publicised issues with the
diagnosis and treatment of some OM cases. Ideally, OM cases should be seen
within the more controlled Hospital Environment, where senior specialists and
Consultants are more skilled/experienced. Also this is where the laboratory and
other support services are directly available. It is proposed that referral pathways
and criteria will be closely defined in the pilot and reviewed as it progresses.
7.5 The governance structures and processes (protocols, audits, etc) in primary care
may not be as robust as those in the HDS and will be variable across the OS
practices. This will be addressed through the pilot.
7.6 There may be a longer-term impact on the OS HDS workforce, especially OMFS
Consultants, with Trusts having to divest themselves of experienced specialist staff.
There may then be a lack of cover in secondary care when complications arise
unpredictably in primary care or there may not be adequate numbers to staff oncall
rotas. These issues will raised with the SEHSC Trust.
8.0 BENEFITS
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8.1 This pilot may be act as a test of key principles set out in the ‘McKinsey Report’
i.e. to reduce the HSCB costs for oral health services by shifting care to lower-cost
settings. There are several potential benefits in doing this:

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

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More efficient delivery of some routine Oral Surgery services in primary care
setting.
More efficient use of secondary care Oral Surgery and OMFS services.
Should reduce current Waiting List difficulties.
Potential to use the RMC model for other dental specialties.
Potential to extend to other aspects of primary care health services.
9.0 COMMUNICATIONS
9.1 Discussions have already taken place between HSCB Dental representatives
and key commissioning personnel from SHSCT who are interested in this proposal
but it will require the support and involvement of their LCG. As the pilot is a
significant departure from previous service arrangements, the support of SMT will be
key to reassuring SHSCT of the value of exploring this potential new service model.
9.2 In the short term there will be added pressure on the GDS primary care dental
budget which has already been overspent in 10/11 and will be challenged again in
11/12. Lower-cost settings will lead to efficiency savings in the global HSCB budget.
If the pilot model is to be rolled out it will require transfer of the necessary funding
from secondary care dental services into primary care dental services. Without such
a transfer of funds this new model would not be sustainable.
10.0 PROJECT SUPPORT
10.1 DoIC has submitted a bid (under ‘Devolved Functions’) to DHSSPS for
additional funds to support the piloting and implementation of new contracts and
awaits the outcome of DHSSPS’ considerations. The following requirements will be
sought on a temporary basis to support the project arrangements for this and
subsequent dental contracts:

Band 7 Project Manager 1.0wte

Dental advisor 0.5wte
10.0 RECOMMENDATION
10.1 SMT is asked to approve the proposed pilot model and project support
requirements. In particular, SMT support is sought for the use of a RMC which will,
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almost certainly, result in a greater proportion of OS patients being seen in primary
care.
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APPENDIX 1
NUMBERS WAITING FOR A FIRST OUTPATIENT APPOINTMENTT AS OF 16 SEPTEMBER 2011
Hospital Name
CAUSEWAY HOSPITAL
DOWNE HOSPITAL
ULSTER HOSPITAL
CRAIGAVON AREA
HOSPITAL
DAISY HILL HOSPITAL
ALTNAGELVIN HOSPITAL
ERNE HOSPITAL
TOTAL
Specialty
Description
(R)
Oral
Surgery
Oral
Surgery
Oral
Surgery
Oral
Surgery
Oral
Surgery
Oral
Surgery
Oral
Surgery
Totals
Waiting
Totals
Waiting
more
than 9
weeks
Totals
Waiting
more
than 13
weeks
Totals
Waiting
more
than 22
weeks
Totals
Waiting
more
than 23
weeks
Totals
Waiting
more
than 24
weeks
Totals
Waiting
more
than 26
weeks
Totals
Waiting
more
than 39
weeks
Longest
Wait
(Days)
170
73
43
0
0
0
0
0
130
539
373
287
77
54
40
12
0
198
592
341
286
117
98
85
38
0
268
788
635
572
437
417
405
358
180
395
393
289
250
152
131
124
98
0
239
958
453
286
12
9
2
0
0
179
225
105
69
0
0
0
0
0
152
3665
2269
1793
795
709
656
506
180
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