Special Care Dentistry - Implementation Plan

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Development of the Speciality of Special Care Dentistry
Special Care Dentistry was recognised as a speciality by the General Dental
Council in 2008 and the specialist list was established. The speciality is defined
as the improvement of oral health of individuals and groups in society with
impairment or disability by providing and enabling the delivery of oral care for
people with for example physical, sensory, intellectual, mental, medical,
emotional or social impairments or disability or, more often, a combination of
these factors.
Welsh context
There are many factors that are likely to add to both the need and demand for
Special Care Dentistry. These principally relate to changes in the demography of
the population, public values and expectations, reconfiguration of health services
delivery and dental service developments (British Society for Disability and
Oral Health: “Commissioning Tool for Special Care Dentistry 2006”). The
implementation process of the review of the speciality in Wales provides an
important opportunity to lay down strong foundations for the speciality. This has
delivered a strategic all-Wales development plan to address the inequalities in
provision of special care dentistry to highly vulnerable groups across Wales. It
highlights the need to develop specific training positions and publicises to Local
Health Boards (LHBs) the importance of developing robust service frameworks to
deliver specialist care.
A strategic approach is required to develop effective special care dentistry
services for vulnerable adults in Wales and to ensure the current inequalities in
access to, and uptake of, services can be addressed and monitored. This would
be best achieved by regional joint working through formal clinical networks,
advised by representatives of stakeholders, co-ordinated by the Welsh
Government (WG).
Providers of dental services in primary and secondary care, clinicians, managers,
local authorities, public health teams, social care teams, patients themselves and
their carers all play an important part in delivering oral health promotion and
preventive care and should be represented in the governance of these clinical
Referral and care pathways need to be as simple and unambiguous as possible
to ensure that the clinical needs of patients are dealt with promptly and
effectively. The development of all-Wales referral and acceptance guidelines,
which could accommodate local variation, would assist this objective.
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A common approach to data collection and defined processes to enable the
transfer of essential information between organisations should be established to
ensure patient needs are met.
When special care dentistry is provided across different health services, clear
lines of responsibility and accountability are required. This is particularly
important for patients referred for dental procedures under general anaesthesia
or sedation.
Better co-ordination, information and access to patient transport services are
needed to allow vulnerable adults to use appropriate special care dental
services. This is a particular challenge for people in rural communities.
Indicators for special care dentistry and data sets for recording special care
dentistry activity need to be agreed.
Methods to use technology to improve access to Special Care Dentistry expertise
and the effectiveness of care delivery need to be considered.
The need for an all Wales approach to the planning and delivery of
Special Care Dentistry services
There are inequalities in access to and uptake of dental services for
vulnerable adults in Wales; these inequalities are greater for older people.
Some people who need special care dentistry may not be identified as
needing help and others may not receive care because of lack of
appropriate accessible services and lack of information about how to
access services.
In some areas, there are no dedicated special care general anaesthetic
lists, and special care patients can face unacceptable waiting times. The
same situation exists for sedation services in some areas, where no
intravenous and limited inhalation sedation services for special care
patients is leading to unacceptable waiting times in the Hospital Dental
Consultant expertise and specialist training are presently concentrated in
the South East of Wales and the specialty should be developed in this way
throughout Wales.
The funding for, availability and uptake of additional postgraduate training
in special care dentistry by dentists and dental care professionals is not
related to population needs.
Data relating to special care dentistry are variable, and are insufficient for
robust planning and monitoring.
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Service Development for Special Care Dentistry
Managed clinical networks (MCNs) should be enabled and developed for special
care dentistry. Strategically placed “Networks of Special Care Dentistry
Excellence” with leadership from a consultant or specialist in special care
dentistry should be set up across Wales. The networks should work across Local
Health Board boundaries and provider organisations.
Networks of clinicians are in a unique position to lead the development of an
integrated service approach to special care dentistry. Workforce capacity and
capability needs to be developed in all three areas of dental services delivery
(general dental practice, community and hospitals).
There is a need to utilise skill mix to optimise effective team working and
resources. Shared care between and within dental teams can allow nonspecialists to contribute effectively to the delivery of specialist care. Routine care
will normally be delivered in a primary care setting.
Dental Care Professionals (DCPs) with additional skills can provide support to
dentists in all sectors, enabling better quality care and greater access and
Workforce Development
Formal training programmes and continuing professional development courses
should be provided to address population needs. As part of the national
workforce review a specific workforce development process should be developed
for special care dentistry in Wales to ensure sufficient specialists (including
academic specialists), Community dentists and GDPs, Dentists with a Special
Interest (DwSIs) and DCPs should be trained to meet patient needs in Wales.
The Special Care Dentistry Workforce needs ongoing development and support
to meet the changing needs of the populations they serve and to ensure
appropriate succession planning. Teams from Networks of Special Care
Dentistry Excellence will need to support the planning, ongoing development and
delivery of knowledge, training and experience to the dental workforce. Note:
there will be teams who have skills perhaps not possessed by
consultants/specialists who will need to be involved e.g. GA teams and sedation
teams which may not be located in these centres.
Many patients with special care needs may have some or all of their dental
treatment in general practice and it is estimated that around three quarters of
patients with less complex special care needs who do see a dentist, are seen in
general dental practice for at least part of their care. Special Care Dentistry
courses, training and placements should be planned and implemented to meet
the needs of the general dental teams and the communities they serve.
Participation should be supported and encouraged.
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A consultant or specialist with the necessary management skills will be needed
for each Network of Special Care Expertise. This will enable specialist training
and the development of Dentists with Special Interests to meet oral health needs
across Wales. Specialist training and the development of dentists with Special
Interests will also need to be planned to replace outgoing staff with special care
expertise and to meet patient care needs.
Proposed Implementation Action Plan
Establishment of a Strategic Advisory Group for SCD
Group membership would evolve from the current SCD working group. The
Group’s remit would be to monitor progress and outcomes and identify
operational issues managed and implemented by regional managed clinical
networks. This group would report on an annual basis to the Chief Dental Officer
for Wales. Specific tasks will include:
6.1.1 Identify core data collection requirements for special care dentistry.
The Group in consultation with MCNs will identify a core data set. Clinical IT
systems that are capable of collecting and transferring core data should be
introduced to all services. All dental services should be required to routinely
collect and share data in a transferable format relating to the oral health care
needs and treatment of vulnerable adults. Where feasible this data should be
capable of being shared with medical, nursing and social care systems.
Target Date: April 2013
Responsibility - Strategic Group/MCNs
6.1.2 Develop a national communication plan regarding Special Care Dentistry
The Strategic Advisory group in consultation with MCNs will advise and facilitate
the development of guidance by Welsh Government. This will include both
interim and substantial guidance regarding network and speciality development.
It is expected that the process used could mirror that used recently by the WG to
implement the findings of a national review into Orthodontics.
Target Date: December 2012
Responsibility - WG/Strategic Group/MCNs
Establish Regional Managed Clinical Networks (MCNs) for Special
Care Dentistry
Proposed networks would cover:
 North and Mid Wales (Betsi Cadwaladr and Powys)
 South West Wales (ABMU and Hwyel Dda)
 South East Wales (Cardiff and Vale, Cwm Taf and Aneurin Bevan)
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The networks will be developed with common defined membership, remit
and accountabilities and clearly defined boundaries.
Target Date: June 2012
Responsibility - All LHBs
Establish MCN work programmes
6.3.1 Each MCN will review/develop a pragmatic dental referral and treatment
pathway for adults requiring special care dental service in their area.
In consultation with relevant stakeholders, identify levels of need and appropriate
limits of complexity to be delivered by:
 DCPs
 Specialists and Consultants in Special Care Dentistry
 Joint multi-professional specialist teams
Initially, exact arrangements are likely to vary across Wales, depending on
available and accessible facilities and workforce skills. Existing specialist
services (e.g. restorative dentistry, oral and maxillofacial surgery (OMFS)) may
already provide some elements of special care dentistry in some areas and will
need to be embraced in the future development of services, both for workforce
training and supervision and on going service delivery. The pathways should be
reviewed frequently and as the workforce and facilities are developed and
improved, a common approach should be introduced in all MCNs.
Target Date: December 2012
Responsibility - LHBs/MCNs
6.3.2 Provision of regional and relevant local information for patients and
MCNs working with all relevant local stakeholders will publish specific information
to allow clinicians to ensure that patients receive care at the most appropriate
time and place. In addition information will be made available to patients and
carers about facilities, resources and infrastructure to enable and facilitate easy
access to services. MCNs will ensure that the information is provided using
reliable and appropriate communication methods and media.
Target Date: December 2012
Responsibility - LHBs/MCNs
Development of a Workforce Strategy for Special Care Dentistry in
6.4.1 Speciality development.
Working with the Welsh Government, Postgraduate Deanery and those
responsible for commissioning and delivering multi professional health care
education and training The Strategic Advisory Group should ensure that the
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national dental workforce review (currently being carried out by NLIAH) contains
robust information about the speciality, and, the group works to implement any
relevant finding. North Wales will naturally look to North West England in relation
to links for SCD and education providers, as well as to those in Wales. The
implementation group recommends that the Workforce strategy must consider
how to establish and fund additional SCD speciality training programmes based
in North and South West Wales. The Implementation group supports the
retention of existing training posts in South East Wales.
Target Date: March 2013 Responsibility - WG/LHBs/Postgraduate deanery
6.4.2 Continuing Training and Education.
Training programmes for Dental Nurses leading to the award of
Certificates in Special Care Dentistry and in Conscious Sedation should
be regularly provided in all areas of Wales.
Annual CPD programmes for the dental team should regularly include
special care dentistry, care of older patients and domiciliary care in a
format that is acceptable and accessible to participants.
Training programmes and continuing professional development courses
for trainee and practising general nurses (both in hospitals and primary
care) in Wales should include a module on oral health care for vulnerable
adults.1 There should be a particular focus on those caring for vulnerable
and older people in hospitals, care homes and in their own home.
Development of distance and blended learning packages for special care
dentistry, especially using web based and IT packages should be
Target Date: April 2012
Responsibility - WG/LHBs/Postgraduate deanery
See also the work of the All Wales Oral Health Assessment and Care Group.
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Annex1: Implementation Working Group membership
Mrs Helen Falcon (Chair)
Postgraduate Dental Dean, Oxford
Deanery.(Lead Dean Special Care Dentistry
Dr Shelagh Thompson
Reader in Conscious Sedation and Special
Care Dentistry, Honorary Consultant in Special
Care Dentistry, Cardiff University.
Dr Sandra Sandham
Specialist in Dental Public Health (Public Health
Wales)/Clinical Director, North Wales
Community Dental Service (BCULHB).
Mrs Ilona Johnson
Walport Research Fellow and Honorary
Specialist Registrar Cardiff University.
Mrs Rhian Bond
Head of Primary Care, Abertawe Bro
Morgannwg UHB.
Mr David Davies
Clinical Service Manager, Community Dental
Services Abertawe Bro Morgannwg University
Local Health Board.
Mrs Catherine O’Sullivan
Chief Officer, Aneurin Bevan Community Health
Dr Sue Greening
Consultant in Special Care Dentistry, Clinical
Director, Community Dental Service Aneurin
Bevan HB.
Mr James Owens
Consultant in Restorative Dentistry and Oral
Rehabilitation .Abertawe Bro Morgannwg UHB
Professor Barbara
Associate Dean for Postgraduate Studies,
Professor of Paediatric Dentistry, Cardiff
Mr Robert Davies
General Dental Practitioner and Dental Practice
Advisor. Public Health Wales.
Mr Neil James (in
Dental Division, Welsh Government.
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