Current Issues in Prison Dentistry

Sue Gregory Deputy Chief Dental

Officer

DH Update on Prison Dentistry and DwSI Accreditation

“The DwSI and PCTs – how it will work”

5th February 2010Sue Gregory OBEDeputy Chief Dental Officer (England)

NAPDUK Conference 2010Botanical Gardens, Birmingham

April 1st 2006 Primary Care Trusts (PCTs) responsible for reviewing the oral health needs of their population and commissioning services to meet these needs.

Dentist with Special Interest (DwSIs) schemes, give PCTs additional flexibility to commission NHS dental services of a more specialist nature within a primary care setting that are directly in line with the needs of their local communities.

Why would PCTs use DwSIs?

Definition“A dentist working in the primary care setting who provides services which are in addition to their usual and important generalist role. The DwSI provides a service which is complementary to the secondary services but does not replace that provided by a dentist who has undergone the training required for entry to a specialist list. The DwSI is an independent practitioner who works within the limits of their competency in providing a special interest service, and who refers on where necessary.”

Department of Health, FGDP (UK) 2004http://www.dh.gov.uk/cdo; http://www.fgdp.org.uk

Definition (contd)“The DwSI may deliver a clinical service beyond that normally provided by a primary dental care practitioner or may deliver a particular type of treatment. Individual DwSIs will be able to demonstrate their competencies in their special interest areas. Special interests may be demonstrated by dentists through the completion of formal training programmes and/or experience based evidence.”

Department of Health, FGDP (UK) 2004http://www.dh.gov.uk/cdo; http://www.fgdp.org.uk

Why Now?

Steele Review- NHS Dental Services in England22nd June 2009

Commissioners should find ways to support dentists to make best and most cost-effective use of the available dental workforce

Steele June 2009

Contractual schedules are introduced through which the more complex and demanding treatments are provided appropriately by dentists skilled and equipped to provide them to a high quality

Steele June 2009

The Faculty of General Dental Practice (UK) and DH have set out guidelines and competencies for dentists with a special interest, and these can support commissioners and providers in developing advanced and complex services.

Primary dental care can be provided by: ‘Independent contractor’ dentists or corporate bodies holding contracts with PCTs Dentists with special interests PCT provider arms and other NHS organisations

DH January 2009

Who provides primary dental services?

The World Class Commissioning Cycle

How?

Four initial sets of guidance:- Endodontics- Periodontics- Orthodontics- Oral Surgery

Subsequent Guidance

- A step by step guide to setting up a DwSI Service

- Prison Dentistry- Conscious Sedation

DH 2007

Model for commissioning prison and detention centre oral health services

1. Oral health needs assessment

Understand the establishment- Types and numbers

- Turnover

- Future plans

- Demography

Existing Research & Epidemiology- national eg untreated disease 4X greater

- local

Input from prison service Rigorous analytical approaches

2. Develop Service Specification Define scope of the service

- Prevention & oral health improvement- High quality, safe clinical care- Urgent/routine/specialist

Demand management and referrals

Links to other services

Quality and risk management

Prison health support

Research

2. Develop Service Specification

Prison health support- Security

- Ethical issues and safe practice in prison

- The prison dental environment

- Prison dentistry in the wider context

3. Review the current serviceprovision

Assess against service specification

Multidisciplinary working group

Process map the service, analysing

demand and capacity

4. Strategic Decision

Reflect strategic direction of PCT

Impact assessment:

- part of integrated commissioning

strategy and Local Delivery Plan

Identify and agree approach to:

- potential new providers and

improving care

5. Shape supply/Market testing

Work with all existing and potential

providers to develop new services and

competent practitioners Accreditation of DwSIs Pay, contracting, appointing and

practicalities Procurement process through “Supply to

Health” or local process

Competent practitioners

The workforce to deliver such services should have a range of different skill mix and adopt a team approach. It could be primary dentists, DwSI in Prison Dentistry, DCPs and finally specialists-mostly in Special Care Dentistry. They should be well trained, resourced, supported and work within and between the prison and the community

Competent practitioners

Oral health

Promotion Unit

GDP DwSI in Prison

Dentistry

Specialist service

providers e.g. Specialists in Special Care, Restorative, Oral Surgery

Oral Health Improvement

v v v v

Needs assessment v v v

Routine dental care v v

Secondary care and referrals

v v

Emergency dental care v v v

DWsI Accreditation

Formal process of accreditation by commissioning/employing organisation

National clinical competency framework for each special interest area as basis

Local appraisers of practitioner’s portfolio of evidence (consultant/specialist, FGDP rep, PCT rep)

(Administrative support and premises fit for purpose)

Accreditation (contd) Competent and experienced in delivery of primary dental care

- minimum 3yrs experience+ ?postgrad qualification

- portfolio approach- audit and peer review

Special interest competencies- Recent, relevant diplomas, provide set hours of

learning and supervision- Portfolio:

clinical attachments activity/procedure records relevant courses/training and PDPpatient feedback

Prison Specific CompetenciesEnvironmental domain

- Security- Ethical issues and safe practice in prison- The prison environment

Clinical domainHistory and Diagnosis

- Early diagnosis of oral cancer- Management of localised oral infections- Management of trauma/self harm- Range of special needs skills- Knowledge of medication- Knowledge of prison medical records

Practicalities

Independent contractorGDSPDS- cost and volume- cost per case- identified sessions- support with premises and equipment

Directly employed

The contract for a DwSI will need to specify: The core activities and the competencies required The types of patients and clinical problems suitable for the service including age range, minimum caseload, medical status and reasons for referral The facilities and staffing that must be present to deliver that service The clinical governance, accountability and monitoring arrangements, including links with other practitioners working in primary care, at PCT level and specialists in Acute Trusts

6. Manage demand and ensure appropriate access to care

Address best value Monitor resource utilisation Check that appropriate access

available Development of a managed local

clinical network

NetworksDental Clinical NetworkA group of practitioners providing treatment in the relevant special interest area, including consultants, specialist practitioners, 1ary care dentists with a special interest and rep of referring practitioners (+academic). Make up will vary depending on pattern of local workforce.

Prison professional networksPrison dentists needs to understand and work with the extended inter-professional prison teams, including other agencies and support groups outside the prison

NetworksPCT needs to work closely with networks on needs assessment, development of the service and monitoring standards of delivery and outcomes of care.

7. Clinical decision making

Individual needs assessments Patient information and choice

- a real challenge Maintaining records Competencies in prison dentistry

8. Managing performance(quality, performance, outcomes)

Define lines of accountability Risk assessment Review the service and assess the

impact Measure performance and outcomes Plans for the future Re-accreditation of DwSIs

Performance and outcomesActivity

- ? need for case-mix data to reflect complexity

Outcomes- Exit questionnaires- Oral assessment on departure- Assessment of oral habits- Views of the dental team- Prison environment

ReaccreditationContinuing Professional Development

Consultant/Specialist practitioner mentor

50 hours of verifiable CPD in the special interest area in 5 year cycle, in addition to general & verifiable laid down by GDC

Clinical sessions with consultant/specialist practitioner

Appraisal, PDP

Clinical Network Support- Audit

9. Patient and public feedback

Agree mechanism for collating feedbackeg exit questionnaires

Ensure patient voice heard

Going Forward

• Medical Education England - Dental Programme Board

Supply side model workstream Demand for dental treatment workstream Skill mix workstream Specialty review workstream Review of oral surgery workstream Foundation Training workstream

• “Modular credentialling”