Enclosure 7
A Collaboration between Portsmouth City, Southampton City and Hampshire Primary Care Trusts
(PCTs)
The Provision of NHS Orthodontic Care across Hampshire
Questions and Answers
Portsmouth City, Southampton City and Hampshire PCTs recently contacted all Hampshire NHS
Orthodontic Providers inviting comments on the proposed new care pathway for the provision of NHS
Orthodontic care across Hampshire.
In summarising the feedback received it was evident that the information provided by PCTs to GDPs
which aimed to introduce the draft proposals was not sufficiently detailed and resulted in many
questions being raised. On this basis, the PCTs have taken the comments received on board and
pulled together a questions and answers sheet to address some of the comments raised. Please see
below.
1. Do all patients that access the service have to live in Hampshire? What happens to
patients being referred or treated in my practice that live outside of Hampshire?
The proposed new care pathway to access NHS orthodontic treatment within Hampshire is open
to patient’s resident within Hampshire and those outside of Hampshire, subject to historical flows.
For those patients who are resident outside of the Hampshire borders, they will need to be
referred on the standard referral form to the Central Referral Centre. Based on the analysis of
patient flow data (which identifies the historical flow of patient seeking NHS orthodontic care within
Hampshire), should the historical flow of patients remain and bordering PCTs have reciprocal
arrangements in place, patients resident outside of Hampshire can continue to be seen by
Hampshire NHS Orthodontic Providers. This process is not new to the proposed pathway and has
been in place since the introduction of the new contract from 1st April 2006.
Referrals for residents outside of Hampshire, Portsmouth and Southampton PCT areas for
secondary care orthodontics are to be forwarded direct to the secondary care provider and should
not form part of the referral management centre process. These referrals should be managed by
secondary care under Payment by Results. This does not apply for primary care referrals for
Hampshire registered patients which should be managed by the Central Referral Centre.
2. Will dentists have to go on a calibrating course for IOTN? I have some concerns
regarding GDPs capability to assess IOTN.
All General Dental Practitioners within Hampshire will be provided with the opportunity to attend
an IOTN training course prior to implementation of the new care pathway.
Post implementation, the quality of referrals will be monitored closely to identify any issues for
action.
3. Will dentists be funded for the extra time required to fill in the referral form?
Within the Personal Dental Services and General Dental Services contracts for the provision of
primary care dental services, there are clauses which specify all providers should use referral
templates provided by the PCTs where available.
General Dental Practitioners will be expected to complete the referral form template within their
existing contracting arrangements. The information contained within the referral form template
should not differ substantially from the information provided within previous written referrals.
4. Where is the Central Referral Centre as it makes another trip for patients?
Are you expecting most referrals to the Central Referral Centre to be seen in the flesh
and who is going to do it?
The Central Referral Centre is purely an administration function. Patients will not be seen on a
face to face basis for assessment at the Central Referral Centre.
The purpose of the Central Referral Centre is to log and process all NHS orthodontic referrals
received. The Centre will review all referrals to ensure the referral form is complete and all
necessary information has been provided. If this is not the case, the Centre will contact the
referrer to ensure the relevant information is complete.
Should a referrer/patient have specified a choice of provider the Central Referral Centre will
facilitate this request and provide the patient with further information where appropriate.
5. Why is it deemed necessary to refer my patients to a Central Referral Centre for
assessment?
As we are sure you are aware, the provision of NHS orthodontic care across Hampshire has been
in high demand resulting in increasing waiting lists for many providers.
The purpose of this project was to understand the current and future demand for NHS orthodontic
services, to ensure the future commissioning of NHS orthodontic services was in line with local
need. This is why the PCTs are now in contact to discuss the management of your existing waiting
lists and why there is now an opportunity to tender for additional NHS orthodontic services across
Hampshire.
As part of this process, an initial workshop was held from which a Steering Group was formed
including representatives from primary and secondary care orthodontics across Hampshire.
The purpose of the Central Referral Centre is to process all NHS orthodontic referrals working to
ensure the following:
- Only appropriate and necessary cases are seen within secondary care
- Manage demand for NHS orthodontic services, ensuring referrals are distributed evenly and
appropriately across Hampshire providers of care.
- To manage a central waiting list for NHS orthodontic treatment should this arise – to alert
PCTs when this occurs so that immediate action can be taken (where appropriate).
- To manage waiting times appropriately
- To monitor the quality of referrals received by referrers, identify issues and action as
appropriate
- To facilitate improved communication for all parties.
- To facilitate patient choice and support implementation of choose and book in the future.
6. Providers would like feedback from the patients lists sent last year
All NHS Orthodontic Providers contracted to provide activity with Portsmouth City, Southampton
City or Hampshire PCT should have recently received correspondence from their PCT Dental lead
regarding the above.
Should you have any queries concerning the above please contact your PCT Dental Lead.
7. What about patients already seen and on recalls?
Patients that have already been seen by an orthodontic provider and are currently under review
awaiting treatment should remain the responsibility of the provider concerned.
Providers should consider these cases when informing the Central Referral Centre of their
capacity to accept further referrals.
In the new process, if a provider was to see a patient for an assessment and the patient is not
ready for treatment; a long term review means the patient should be referred back to the GDP and
that patient can request to return back to the provider concerned; a short term review should be
managed by the provider concerned (as is currently the case).
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8. Will I be expected to accept a limited number of patients from outside my practice to
fulfil by orthodontic contract?
As has always been the case, all Providers should work to ensure they achieve their contracted
activity. All orthodontic activity contracted for is for treatment on referral, therefore in order to
deliver the terms of the contract orthodontic providers should be sourcing patients from outside of
the practice in order to manage their contracted activity.
9. Patients who request and come to me specifically, will they have to be referred?
Yes, they will still have to be referred via the Central Referral Centre. However, the referral form
provides both the patient and referrer with an opportunity to specify a particular provider for NHS
orthodontic care.
It is the role of the Central Referral Centre to facilitate such requests for a specific provider of care.
10. My main concern is that because treatment takes at least 18 months to complete, I
cannot see how it is possible to maintain an 18 week timeframe for referral and
treatment.
The 18 week timeframe is measured from the point of referral to the point at which treatment
starts. The guidance states that there are a number of instances where the clock can be stopped
to accurately measure the 18 week timeframe including when patients are under review awaiting
the right time to start treatment.
Further details can be found at www.18weeks.nhs.uk
11. With the use of the Central Referral Centre, as a Provider am I likely to receive more
difficult cases than other less experienced Providers in my area?
The Central Referral Centre will work to identify any cases which are most likely to be seen within
secondary care. The distribution of all other cases will be subject to a number of factors such as a
patient or referrer requesting a provider, a patient’s residence, capacity of providers concerned
etc. The Central Referral Centre will refer patients to each provider for assessment.
It is the provider’s responsibility to assess the patient to determine whether the case is within their
capabilities. Should the case be outside of their capabilities the patient will be re-referred to an
alternative provider. This is the process in place currently and will continue via the Central Referral
Centre for the future. Re-referrals will be monitored closely by PCTs to identify any issues for
action.
12. We need to convene a meeting/workshop to discuss the proposal in more detail.
The PCTs in an effort to communicate the development of the project further, have compiled this
question and answers sheet. However, as stated in the covering letter if you feel that this
information is not sufficient and a workshop would still be helpful please complete the template
provided requesting a workshop and detail the questions which you would like to be addressed at
the workshop. The PCTs will review the responses received to ensure a workshop will be both
well attended and the questions raised are appropriate for discussion within a workshop forum.
13. Does this process not add another unnecessary and expensive level of complexity?
This process does not require any additional substantial funding. The funding that has been
secured for the proposed new process is additional funding. The new process has not reduced the
current capacity within NHS orthodontic provision and this project has actually resulted in a
substantial increase in the provision of NHS orthodontic care being commissioned across
Hampshire.
The PCTs do not consider this process to be unnecessary and see the Central Referral Centre as
having a significant role in the future management of NHS orthodontic care. Please see questions
4 and 5.
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14. Does this process not limit patient choice?
No. The process is designed to support patient choice and actually may facilitate greater patient
choice in some instances.
The referral form provides all patients with an opportunity to request a specific NHS orthodontic
provider. Subject to the case concerned being within the capability of the provider concerned, it is
the role of the Central Referral Centre to facilitate this request.
Certainly in some instances where a specific provider may have a long waiting list, the Central
Referral Centre can advise of alternative providers and the patient will always have a choice of
which provider to see for assessment and treatment as appropriate.
15. Hampshire is a very large area to have to agree to travel across to get treatment.
Yes. The PCTs have considered the feedback received on this issue and as a result the referral
form template has been amended to remove the request for patients to sign to this agreement.
The PCTs have a completed a number of semi-structured interviews with patients currently within
the NHS orthodontic care pathway to discuss the proposals concerned. This process has
identified the average distance patients wish to travel. This information has now formed part of the
Central Referral Centre standards which they must work to when managing NHS orthodontic
referrals.
16. It is not clear how potential orthognathic cases should be handled if they are already an
adult.
Guidance states that patients aged 18 years or over at the point of orthodontic referral are not
eligible for NHS orthodontic treatment. However, the process has worked to incorporate a pathway
for exceptional cases as follows.
If as a clinician seeking to refer a patient for NHS orthodontic treatment, you believe that the case
of an individual patient is so singular as to justify an exception to the acceptance criteria for NHS
orthodontic care, you may apply for the case to be considered individually by the PCT. All
requests should be provided by the patients General Dental Practitioner or Orthodontist (where
appropriate), in writing and supported by a clear description of the exceptional circumstances with
copies of any relevant correspondence and other supporting documentation e.g. robust evidence
of clinical effectiveness, consultant and other specialist assessments etc.
The PCT will only approve a request for an exception if there is robust evidence that the patient
would be likely to derive significant clinical benefit from the therapy in question. It is important
therefore that you provide all the information that you wish to be taken into account in reaching a
decision, specifically how a condition effects the day to day functioning of the patient concerned.
In order for the PCT to consider an application, the patient must be registered with a GP practice
belonging to the PCT or, if not registered with any GP, lives within the geographical responsibility
of the PCT. Please note that only a GP, General Dental Practitioner or orthodontist (where
appropriate) can make a referral to the panel for consideration
It is expected that General Dental Practitioners should submit referrals on the template provided
together with all supporting documentation such as relevant clinical history, orthodontic referral
form etc. In most instances the form alone will not be sufficient for the PCT to make a decision.
The completed referral should be sent to the Central Referral Centre to action. An orthodontic
provider will assess the patient concerned and the findings will be sent to the PCT to action as
appropriate. All referrals received by the PCT will be considered reference a written report from an
appropriate dental professional within the Hampshire locality (i.e. General Dental Practice Advisor
or a Consultant in Dental Public Health); on the basis of these findings appropriate referrals will be
considered by the PCT Referrals Panel within the relevant PCT on a monthly basis.
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17. The system makes no allowance for such things as early interceptive treatments before
definitive treatments can be commenced.
The PCTs have considered these comments and the referral form have been amended to enable
interceptive treatment to be referred via the same process. Further details can be found in the
Service Description provided.
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