local oral health plan - final version oral...in-depth analysis of dental care (excluding...

Public Health Wales & Hywel Dda Health Board Oral Health Plan for Hywel Dda Health Board

Local Oral Health Plan

Hywel Dda Health Board

Authors: Bryan Beardsworth, Asst Head of Primary Care & Dental Services, HDHB

Dr Hugh Bennett, Consultant in Dental Public Health, Public Health Wales

Date: December 2013 Version: 1

Publication/ Distribution:

Final Version to be sent to Welsh Government

Review Date: Continual

Purpose and Summary of Document:

Provide a framework to improve :-

a. the oral health of the population of Hywel Dda

b. access to dental services

c. quality assurance of dental services

Work Plan Reference:

Service Development / Health Improvement / Quality and Safety


Date: Dec 2013 Version: 1 Page: 2 of 58

Delivering Good

Oral Health Together

An Oral Health and Dental

Service Improvement Plan for

Hywel Dda Health Board Reducing Inn Oral Reduced inequities

A Three Year Vision



Foreword

On 18th March 2013, Welsh Government (WG) released a national Oral Health Delivery plan. In response to Hywel Dda Health Board must develop a local plan, indicating how it will achieve the aims and objectives set out by WG. This Local Oral Health Plan (LOHP) outlines an agenda for improving oral health and reducing oral health inequalities in Hywel Dda over the next three years and beyond. The LOHP raises some significant long term aims and objectives, However, it is vital that it also has a strong shorter term focus in order to begin the developments, The LOHP will be a evolving plan and subject to regular review and revision, to ensure the plan is reactive to changes in service need. To achieve our aims change is required. The skills, experience and dedication of the dental workforce are, and will remain, a vital resource upon which we will need to draw to achieve that change. Oral health is an intrinsic part of general health, and it is the responsibility of everyone involved in delivering health services to play a role in helping to deliver the oral health improvement we need to see. There remain significant differences between individuals with the best and worst oral health in Hywel Dda. We must improve the health of everyone in our area and pay particular attention to the young, and reduce inequalities. Services must be encouraged to deliver modern prevention orientated NHS dental services resulting in high quality care. Prevention is at the core of this plan. Reducing the risk factors that lead to oral disease is only possible if the delivery of dental services and oral health improvement programmes are orientated towards primary health care and prevention. One of our major goals must be to help people take responsibility for ensuring their own good oral health.



Our Vision

Our vision is to improve the oral health of the people of Hywel Dda, and access to dental

services by delivering high quality services in an efficient & effective manner. The aim will

be to deliver services locally and from a Primary / Community Care setting wherever

possible.

To achieve this, the approach will be to focus on supporting the Designed to Smile

program and other oral health promotion programmes, clinical engagement, partnership

working and developing integrated care pathways.

Action Required

Adoption of this Local Oral Health Plan in order to provide a framework and to strategically

underpin improvements to oral health and the provision of dental services.

Due to current levels of funding, investment and geographical challenges, improvements in services will require the Health Board to work closely with neighbouring Health Boards, to take a regional approach to planning, commissioning and provision of services.

Delivering the Vision

The purpose of this document is to set a way forward for improving oral health and delivering on the actions set out the National Oral Health Plan 2013. Poor oral health blights the quality of life of those affected, failure to improve Oral Health will result in future generations suffering with its associated problems. Good oral health is to be valued; it is a major contributor to good general health.

Our key aims are to:-

• prevent poor oral health and reduce oral health inequalities.

• improve access to dentistry so that patients have timely access to emergency, urgent, routine and specialist dental services.

• address the inequalities in geographical distribution and numbers of the dental workforce in all three dental services.

Key Strategic Documents

• Together for Health - A National Oral Health Plan

• Together for Health - A 5-year vision for the NHS in Wales, sets out WG`s collective aim

• Our Health Future & Fairer Health Outcomes



• Doing Well Doing Better: Standards for Health Services in Wales, sets out the standards for health services in Wales, including dental services.

To help deliver this Local Oral Health Plan (LOHP) the Health Board will need to work with

a wide range of dental service users, the dental workforce, other Local Health Boards

(LHBs), Public Health Wales (PHW), the Department of Dental Postgraduate Education,

the NHS Business Services Authority Dental Services Division and other partners,

including Education and Local Authority Social Services.



Chapter 1

Oral Health Improvement

Our key aims are to:

• Reduce the prevalence of dental disease, especially in young children and other vulnerable groups.

• Reduce inequalities in the prevalence of oral disease.

• Increase the awareness of self-care through increasing the range of measures people can follow at home to improve and protect their oral health.

• Ensure that oral health improvement actions are evidence based. The LOHP has been informed by A Picture for Oral Health in Hywel Dda which provides an overview of oral health status (see appendix 1). In addition, the report NHS Primary Dental Care Provision in Wales, Exploring current service use and the distribution of services in relation to need Clinical and Applied Public Health Research, Cardiff University Dental School June 2011, presents the results of an in-depth analysis of dental care (excluding orthodontics) undertaken by general dental practitioners in Hywel Dda Health Board (HDHB). It expands on the Health Equity Audit reported in September 2010, with an emphasis on how current dental care relates to demographics within the Health Board area.

Demographics - What is happening to the population of Wales?

The population of Wales has gradually increased between 1999 and 2009 and now stands at nearly three million. During this time the number of people aged under 35 decreased by 2.6 percent while the number aged 65 and over increased by 9.1 percent. The number of live births in Wales increased from 32,325 in 2004 to 34,937 in 2009. The population is projected to increase further reaching 3.2 million by 2023, and continue to become gradually older. These demographic changes will have a major effect on service planning, development and delivery.

Approximately 10% of the population of Hywel Dda Health Board is aged over 75 and

this age group is predicted to double to 70,000 over the next 20 years

As patients retain teeth into older age there is likely to be a related increase in complex

dental problems, with increasingly complex medical co-morbidities and polypharmacy. This

will probably result in increasing demand for skilled general dentists and specialist

services.

Tooth Decay in Childhood



The most common oral disease of childhood is dental caries, often called tooth decay. Children in Wales have the poorest dental health in Great Britain. Tooth decay is found in deprived and affluent communities but is more common and likely to affect more teeth per child in deprived communities. Therefore, while half of the 5 year old children across Wales have no decayed teeth, the other half experience a high disease burden and have on average four teeth decayed or filled or extracted. The trend in prevalence of child dental decay in Wales is generally static; this suggests that Wales is likely to have the poorest child dental health in Great Britain for some time. The dental health of Welsh 12 year olds has improved. There have been dramatic improvements in decay levels in permanent teeth since fluoridated toothpaste became widely available in the 1970s. However, despite this improved situation, Wales still lags behind the rest of the UK.

The Consequences of Poor Child Dental Health

The consequences are multiple, and all the more concerning because they affect the youngest in our society. Tooth decay commonly results in pain and infection, often resulting in sleepless nights, time off school and possible need for general anaesthesia to treat effectively. There is an impact on children`s general wellbeing, disruption of schooling, with parents and other family members having to cope with a child in pain. On average across Wales in a class of thirty 5-year-olds,four children would have experienced dental pain in the last 12 months. Table 1 gives an indication of the Health Board’s position in relation to the 2020 target.

Welsh Government Targets

Dental health targets were set for Wales in Eradicating Child Poverty in Wales - Measuring Success In summary:-

• By 2020 to reduce the levels and burden of decay at age 5 among the most deprived quintile of the population to that recorded for the middle deprived quintile.

• By 2020 to reduce the levels and burden of decay at age 12 among the most deprived quintile of the population to that recorded for the middle deprived quintile.

We intend to vigorously address this inequality in experience of child tooth decay over the next 5 years. For the most deprived fifth of 5 year old children in Wales, the average dmft (decayed, missing due to caries and filled index) was 2.7 in 2007-8 when the baseline was set. The national child poverty target is to bring this average down to 1.77 by 2020. The percentage with caries (%dmft>0) was 57.6% for the most deprived fifth of 5 year olds in 2007-08 and the national target for 2020 is 44.1% (Table 1).



There are no specific local health board targets, but we can use the Welsh targets as a bench mark. There has been an improvement in both average dmft and the %dmft>0 for children in Hywel Dda between 2007-08 and 2011-12 across all deprivation quintiles. Furthermore, the children living in the most deprived areas have an average dmft of 1.50 and a %dmft>0 of 34.9%, which are below the Wales targets for this group. But, when considering the ratio of the most deprived: middle deprived for average dmft it can be seen that Hywel Dda has experienced a widening of inequalities as the ratio has increased from 1.2 to 1.40 (Table 1). Table 1: Average dmft & %dmft>0 for 5 year olds by quintiles of deprivation index, for Wales and Hywel Dda Health Board

5 year olds 2011-12 5 year olds 2007- 08

WALES Hywel Dda Wales Hywel Dda

Mean DMFT

%DMFT>0 Mean DMFT

%DMFT>0

Mean DMFT

%DMFT>0 Mean DMFT

%DMFT>0

Least deprived 1.00 31.3 0.80 22.5 1.2 34.5 1.50 34.6

Second least deprived 1.2 32.8 1.2 33.0 1.6 41.3 1.9 48.2

Middle deprived 1.5 41.4 1.1 31.9 1.8 44.1 2.1 47.2

Second most deprived 1.9 48.3 1.6 42.9 2.0 49.2 1.9 47.2

Most deprived 2.2 51.5 1.5 34.9 2.7 57.6 2.5 52.9

All within area 1.6 41.4 1.2 33.1 2.0 47.6 2.0 47.4

Ratio – most deprived : middle deprived

1.4 1.2 1.4 1.1 1.5 1.3 1.2 1.1

Table 2: Average dmft & %dmft>0 for 5 year olds in Hywel Dda Health Board unitary authority areas, 2007-08 and 2011-12.

mean dmft %dmft>0

2011-12 2007-08 2011-12 2007-08

Carmarthenshire 1.0 2.2 30.6 53.2

Ceredigion 1.2 1.6 28.7 35.7

Pembrokeshire 1.6 1.8 38.8 44.9

Unitary authority breakdowns of average dmft and %dmft>0 are presented in Table 2, highlighting improvements in the oral health of 5 year olds, but it remains that approximately one third of 5 year olds experience decay. In 2008-9 the average DMFT for 12 year olds for Hywel Dda was 0.80 and for the most deprived group it was 1.18 (Table 3); the LHB needs to ensure that this reduces to 1.12 by 2020 to meet national targets.



Table 3: Mean DMFT & %DMFT>0 for 12 year olds by quintiles of deprivation index, Wales and Hywel Dda Health Board

For Hywel Dda approximately 1330 children annually undergo a general anaesthetic for tooth extractions. This is unacceptable for what is an almost totally preventable disease. It is a risk to child health and wellbeing that would not be tolerated in other diseases, and this is one reason why we will continue to support Designed to Smile.

Common Risk Factor Approach

The most effective and efficient model for promoting oral health in the community is through the Common Risk Factor Approach. This involves partnership working to address the risk factors shared by common chronic diseases, such as tobacco smoking, poor diet, high alcohol consumption, injuries and a sedentary lifestyle. Coordinated targeting of such risk factors is likely to have an impact on reducing poor health associated with a range of conditions, including obesity, heart disease, stroke, cancers, diabetes and mental illness, as well as oral diseases. In oral health improvement our common risk factor approach is complemented with maximising fluoride delivery in community settings. The evidence supporting fluoride in reducing dental decay is well established. The fluoride interventions that are local priorities for action at a community level are fluoride toothpaste and fluoride varnish. Children who start brushing with fluoride toothpastes in infancy are less likely to develop tooth decay than those who start brushing later. In addition evidence supports the effectiveness of fluoride varnish in both permanent and primary (baby) teeth. Fluoride varnish as a topical treatment has a number of practical advantages as it is well received and considered safe, the application of fluoride varnish is simple, cheap to deliver and requires relatively little training.

mean

n

DMFT

T

%DMFT>0

0

mean

n

DMFT

T

%DMFT>0

0

mean

n

DMFT

T

%DMFT>0

0

mean

n

DMFT

T

%DMFT>

>

0

Least deprived

deprived

0.58

8

30.5

5

0.56

6

31.7

7

0.78

8

35.5

5

0.77

7

40.3

3

Second least deprived

deprived

0.74

4

35

5

0.59

9

27.8

8

0.96

6

41.4

4

1.06

6

44.4

4

Middle deprived

deprived

0.95

5

42.1

1

0.81

1

38.2

2

1.12

2

45.5

5

0.91

1

40.3

3

second most deprived

deprived

1.11

1

45.5

5

0.83

3

34.7

7

1.18

8

48.5

5

1.04

4

40.5

5

Most deprived

deprived

1.31

1

52.4

4

1.18

8

48.2

2

1.35

5

53.8

8

1.08

8

48.0

0 All within area

area

0.98

8

42.5

5

0.80

0

35.6

6

1.09

9

45.1

1

Ratio - most deprived:

deprived:

middle deprived

deprived

1.38

8

1.24

4

1.45

5

1.26

6

1.21

1

1.18

8

1.19

9

1.19

9

WALES

S

Hywel Dda

Dda

WALES

S

Hywel Dda

Dda

12 year olds 2004-05

05

12 year olds 2008-09

09



Welsh Government is current piloting a new style of Dental Contract which may allow a greater emphasis on health promotion, preventative care and integration with other health services.

Designed to Smile

For several decades Scotland has put great effort into preventing decay in children. Lately through its Childsmile programme, Scotland has been rewarded with significant improvements in child dental health achieving its 2010 targets, and confirming that a sustained national oral health programme can deliver significant improvement in a nation`s oral health. The Welsh Government has no current plans to fluoridate water supplies in Wales. The Welsh Government acknowledges that in view of the poor dental health in Wales, the introduction of water fluoridation has the potential to deliver significant health gains and address health inequalities. It is sensitive to the fact that there are some small groups of people opposed to it. In 2009, in the absence of water fluoridation, the Welsh Government launched the

Expansion of Designed to Smile – A National Oral Health Improvement Programme,

Wales’ national child oral health improvement programme. The programme sets out to

improve oral health in children by targeting preventative care in areas of greatest need.

These areas are identified according to the highest need as shown by Townsend scores,

the Welsh Index of Multiple Deprivation, dmft dental planning areas (DPA), Communities

First, Flying Start and local knowledge.

The program is underpinned by an evidence based review carried out by Dental Public Health at Cardiff University, the D2S website http://www.designedtosmile.co.uk provides a useful national resource for dentists, parents, teachers and other health professionals. It also provides information on local programmes. Significant progress has been made across Hywel Dda. There have been substantial

increases in the numbers of settings taking part in the supervised toothbrushing element of

the programme.

The programme is overseen by the Designed to Smile Steering Group, whose role it is to

manage the overall work programme and the effective use of the budget to deliver on the

service objectives.



Action Required Continue to support the D2S programme. Production of an annual costed development and delivery plan. Ongoing monitoring of the D2S budget to ensure effective expenditure against the annual financial plan. Regular reporting to the Dental Planning, Performance & Delivery Board, on the roll-out of the scheme to new areas.

Practice Based Prevention

Dentists have a duty to provide preventive advice for patients who attend for dental treatment and are referred to;

Delivering Better Oral Health: An evidence based toolkit for prevention.

Prevention and Management of Dental Caries in Children, Scottish Dental Clinical Effectiveness programme.

Oral Cancer

Many cases of oral cancer could be prevented, the most important aetiological factors in the cause of oral cancer have long been known as tobacco usage and excess consumption of alcohol. These factors together are thought to account for up to three-quarters of oral cancer cases in Europe.

WG recently published Together Against Cancer: A Cancer Delivery Plan for Wales.

The risk of developing oral cancer increases with age and in the UK the majority of cases (87%) occur in people aged 50 or over. In the UK the gender ratio, male to female cases, has decreased from around 5:1 fifty years ago to less than 2:1 today. Many oral cancer patients are diagnosed at a late stage in their disease. The overall prognosis would be considerably improved if patients could be diagnosed earlier. Like most cancers, survival is better for younger than older patients. After the improvement in survival over time was analysed by deprivation group, it became clear that most of the improvement had occurred in the affluent group (Coleman et al 1999).



Preventing Oral Cancer

Cancer Research UK states, “at least three-quarters of oral cancers could be prevented by

the elimination of tobacco smoking and a reduction in alcohol consumption”. The removal

of these two risk factors also reduces the risk of secondary tumours in people with oral

cancer. The debate on screening is ongoing but better still would be the primary

prevention of at least three quarters of cases through the elimination of tobacco

consumption and the moderation of alcohol-intake, further information can be found at

http://info.cancerresearchuk.org/cancerstats/types/oral/prevention/.

Smoking cessation is associated with a rapid reduction in the risk of oral cancers, with a 50% reduction in risk within 3 to 5 years. Ten years after smoking cessation, the risk for ex-smokers approaches that for life-long non-smokers. Protection against solar irradiation would further reduce the incidence of lip cancers. Patient delay has been cited as the main reason for late presentation and it seems probable that in both high-risk groups and the general population, neither the symptoms of oral cancer nor the main risk factors are well understood. With rising incidence rates, in younger age groups whose expectation of cancer is low, public education is urgently needed, including the increasing evidence of the role of papiloma viruses in cancer aetiology.

Action Required The Health Board will work with Dental Practices in order to support local and national smoking cessation initiatives. Ensure Practitioners have access to high quality post graduate training & high risk groups are targeted by national campaigns.

Oral Cancer patients require specialist dental assessment, treatment and post operative

rehabilitation. We will create efficient care pathways and commission appropriate specialist

dental services to meet the need of these patients.

Adult Dental Health

Successive Adult Dental Health surveys have shown that the percentage of adults in Wales who are without their own teeth has fallen from 37% (1978) to 10% (2009). Complete tooth loss is now more or less confined to those aged 55 years and older, it can be reasonably predicted that the improvements in adult dental health will continue, however of greater concern is the inequality of dental health in adults.



The impact of socio-economic inequalities on children’s oral health has been discussed earlier, and they also impact on adult oral health. The percentage of individual adults with at least one carious tooth at the time of the 2009 Adult Dental Health Survey varied from 26% of those in professional and managerial positions rising to 37% of those with routine or manual occupations. The percentage of individuals with bleeding gums (an indicator of poor periodontal health) rose from 49% to 59% across the same social-economic spectrum. Overall the data shows that those from manual occupations were judged to be 43% less likely to have excellent oral health compared with professional and managerial groups. In this context the Health Board remains committed to ensuring all dental commissioning, targets resource to areas of need.

Vulnerable Groups

The Welsh Government set out a requirement for Health Boards to provide for the oral health improvement needs of the most vulnerable groups in the population in Ministerial Letter EH/ML/014/08: Dental Services for Vulnerable People and the Role of the Community Dental Service. The description of an individual as vulnerable will vary from time to time, but there are some groups of people for whom there is evidence of health inequality and thus vulnerability. For example, the frail and elderly, people with impairment and disability, people with mental health and medical problems, those with anxiety and phobia, prisoners and the homeless. A strategic approach is required to develop effective services for vulnerable adults and to ensure the current inequalities in access to, and uptake of, services can be addressed and monitored. WG recently published a Special Care Dentistry Implementation Plan.

Action Required The Health Board will seek to implement the national SCD Implementation Plan within their future planning of dental services, to ensure oral care is integrated into the general health and social care plans and pathways. Continue to work with colleagues in ABMU in the development of the South West Wales Managed Clinical Network for Special Care Dentistry.



Nursing and Residential Homes

WG commissioned two surveys of nursing and residential homes to investigate how their residents access dental care, and to help us get a better understanding of their oral health status and needs of those residents. The surveys showed that many homes do not have written procedures in place to highlight whether individuals have teeth or dentures, dental problems or a desire to see a dentist or are in fact already receiving care from a GDP.

As a direct result of the survey WG published an advice leaflet for residential and nursing homes in Wales, Accessing Dental Care for older people in care homes in Wales June 2011. This leaflet provides information on the importance of oral health care for older people and how they can access dentistry in Wales.

Domiciliary care is currently provided by the Community Dental Service to patients in both nursing and residential homes as well as people who are housebound within their own homes. Robust acceptance criteria is in place for the service.

Action Required In light of the likely demographic changes, it is essential that the need for this service continues to be monitored and integrated into future service planning.



Chapter 2

The Planning, Development and Delivery of Dental Services

Developing a Strategic Delivery Programme for Dental

Services

Welsh Government have set out Dental Access and addressing Oral Health Inequalities amongst its priorities in its Programme for Government 2011, the planning of services based on need and not demand is vital. Currently Hywel Dda Health Board;

• Provides Community Dental Services.

• Commissions General Dental Services (GDS) from external contractors.

• Commissions Consultant lead Hospital Dental Services (HDS) from ABMU

• Commissions Oral Surgery from external contractors. Ensuring integration between the above and clear care pathways are essential in order to improve delivery of dental services and improve oral health outcomes. The Health Board’s Dental Planning Performance & Delivery Board (DPPDB) has a vital role in setting and overseeing the strategic development agenda for dentistry. It is also important that there is clear Executive Director responsibility for dentistry.

Action Required Ensure the Dental Planning Performance & Delivery Board is led by an Executive Director.

The aim of the DPPDB is to ensure the provision of effective and efficient dental services for the population served by the Health Board within available resources and meeting required targets set by the Welsh Government. In summary, the objectives of the group are to:

• Develop channels for communication and partnership working.

• Develop integration of service through the planning process.

• Encourage a patient journey/pathway approach, breaking down Primary/Secondary distinctions.

• Ensure clinical work is carried out in the most appropriate environment by the most appropriate service.

• Ensure a system-wide approach is taken to implement service plans.

• Ensure all operational targets are met.

• Manage financial resources within the allocated funding envelope.



Integrating Dental Services

To achieve maximum oral heath gain and efficiency in the delivery of services, primary, community and hospital dental services must be viewed as complementary. We believe that robust local planning of dental services in this context will allow the NHS to develop the most appropriate services and target resources to where they are most needed. We wish to work with our dental service providers, in all sectors, in the development of our clinical services strategy. Aligning planning across all three dental services as described above has the advantage of integrating service provision. Continuing to develop a more robust management structure, supported by the DPPDB will help to facilitate this work. Figure 1. Structure of General Management and Administration of Dental Services

We need to ensure that the right patient is seen by the right service, our vision of how the level of complexity of care is catered for within the role of each service, is set out in figure 2.

Dental Planning, Performance &

Delivery Board

Community Dental

Services Management

Group

Designed to

Smile Steering

Group

Managed

Clinical

Networks

Dental

Services

Team

Dental Operational Group



Figure 2

*Care that is technically and or medically complex and / or requiring multi disciplinary care

Hospital

Dental

Services*

Specialist Dental Services in

Primary and/or Community Care

(including DWSIs)

General Dental Practice

Routine care, emergency dental care, primary care

orthodontics, intravenous sedation, oral health education.

Community Dental Services

Clinical services including paediatrics, inhalation sedation,

special needs, epidemiology, screening, oral health promotion

Self Care

Advice from professionals, toothbrush and paste for infants, health snacks and drinks in

early years and school, community oral health promoters, links to Designed to Smile

Increasing cost of

care

Increasing

number of

patients



Health Board Dental Advisory Structures

The Strategic Dental Services Planning Group will be a key mechanism for focusing advice. In addition, we need to have in place a structure to fulfil the statutory requirement for us to consult with the Local Dental Committee (LDC).

Action Required

We will ensure that the Health Board has adequate measures in place to ensure dental

professional advice, including access to that of Consultant in Dental Public Health and

Dental Practice Advice from Public Health Wales.

Work with Dyfed Powys LDC in order to fulfil the statutory requirement for us to consult

with a Local Dental Committee.

Managing the GDS

The Health Board will continue to develop a Performance Management Framework for the management of dental contracts. This will facilitate a consistent application of contracting arrangements and management policy.

Action Required Continue to engage with stakeholders in order to continually improve and implement a performance management framework.

Access to General Dental Services

The following map shows the location and number of GDS & PDS contracts. Implementation of the Performance Management Framework will help identify inefficiencies ensuring maximum resource is directed to patient care, by way of ;

• compliance with NICE guidelines on recall intervals.

• robust monitoring of inappropriate claiming.

• application of Guidance on Management of NHS Orthodontics in Primary Care.

• Improved integration of GDS with other dental services.

• that one off funding initiatives are based upon need and not demand, and have a high probability of health gain outcome.

We will also do our best to encourage incentives to assist the setting up / longer term support of practices in areas of low access and high need.



Urgent Access (Midweek & Weekend)

For patients who do not have access to regular NHS dental care, the Health Board

provides a number of access sessions across 7 days in multiple locations throughout the

Health Board area.



General Dental Practices in Hywel Dda

CARMARTHENSHIRE

PEMBROKESHIRE

HAVERFORDWEST

x5

FISHGUARD

x2

ST DAVIDS

x1

MILFORD HAVEN

x4

NARBERTH

x2

WHITLAND

x2

CARMARTHEN x7

(1)

BURRY PORT

x1

LLANELLI x5

LLWYNHENDY

x1

LLANDEILO

x3

CROSSHANDS

x1

TUMBLE

x1

AMMANFORD

x2

LLANDOVERY

x1

BRYNAMMAN x1

CEREDIGION

LAMPETER

x1

ABERYSTWYTH

x 5

CARDIGAN

x2

PEMBROKE

x1

PEMB D

x1

ABERYSTWYTH x5

NEWCASTLE EMLYN

x1

CARMARTHENSHIRE PRACTICES x23:

AMMANFORD

1. Brynteg Dental Practice

2. IDH, Margaret Street Dental Practice

BRYNAMMAN


BURRY PORT

1. Achddu Villa Dental Practice

CARMARTHEN

1. AJ Bhattacherjee


3. Capel Dental Practice

4. Old Oak Dental Practice

5. SJ Lewis

6. The Parade (orthodontics)

CROSSHANDS

1. Llandeilo Road Dental Practice

LLANDEILO

1. Celtic Dental Practice

2. RAD Phillips

3. Tywi Dental Practice

LLANDOVERY

1. RAD Phillips

LLANELLI

1. Avenue Villa Dental Practice

2. Berwen Dental Practice

3. IDH, Mill Lane Dental Practice

4. Murray Street Dental Practice

LLWYNHENDY

1. Warren Davies Ltd,

TUMBLE

1. Llannon Road Dental Practice

WHITLAND

1. IDH, Hendy Gwyn Dental Practice

2. King Edward Street Dental Practice

PEMBROKESHIRE PRACTICES x16:

FISHGUARD

1. Vergam Terrace Dental Practice

2. West Street Dental Practice

HAVERFORDWEST

1. Dew Street Dental Practice

2. DM Snape

3. Portfield Dental Practice

4. Rhos Cottage Dental Practice

5. Whitecross, The Candle Stores Practice

MILFORD HAVEN

1. Charles Street Dental Practice

2. Haven Dental Practice

3. My Smile Centre

4. Whitecross, Robert Street Practice

NARBERTH

1. HW Jones

2. Winchester House Dental Practice

PEMBROKE

1. Westgate House Dental Practice

PEMBROKE DOCK

1. DB Mothibi

ST DAVIDS

St David’s Dental Practice

CEREDIGION PRACTICES x9:

ABERYSTWYTH

1. Denticare Ltd, Friar’s Park

2. Denticare Ltd, North Parade

3. Eastgate Dental Practice

4. MR Saddington

5. Portland Street Dental Practice

CARDIGAN

1. IDH, Feidr Fair Dental Practice

2. The Charlsfield Dental Practice

LAMPETER

1. Denticare Ltd, The Barn

NEWCASTLE EMLYN

1. Deintyddfa Emlyn



Primary Care Orthodontic Services

Demand for orthodontic services has been rising for many years, however the service

must be provided in terms of need, a point strongly made in both national and local

reviews of orthodontic services and reiterated in the National Oral Health Plan. Orthodontic

provision must be placed in context with other dental health priorities. In general terms the

dental health of 5 year olds in Wales is the worst in Great Britain. As mentioned earlier in

the document, within Hywel Dda approximately 1330 children annually undergo a general

anaesthetic for removal of decayed teeth, which is almost a preventable disease.

Orthodontic spend within the general dental services currently makes up a significant

percentage of the total funding of primary dental services, it is vital that continued funding

is based upon sound needs assessment, prioritisation and an integrated approach

between the orthodontic dental service providers. A balance in the prioritisation of NHS

dental resources has to be determined.

The current NHS primary care orthodontic contract, pays providers up front, theoretically a

provider of orthodontics might never complete a case and yet still get paid in full. Ideally,

future orthodontic contracts will have an improved outcome based structure.

Key Strategic Documents

National Assembly for Wales – Orthodontic Services in Wales WG Response PHW Orthodontic Needs Assessment in Mid and West Wales



Summary of orthodontic service provision in Hywel Dda

Figure 5 – Orthodontic Referrals received April 12 – March 13

National clinical criteria determine eligibility for Orthodontic Services, patients must meet the requirements of the Index of Treatment Need (IOTN) to be eligible for NHS treatment. This helps ensure Orthodontic resources are targeted toward need, not demand. Welsh Government published guidance on the management on Orthodontics in Primary Care. In general this called for improvement in the efficiency and effectiveness of the orthodontic services delivered in Wales. Local and National reviews suggest current levels of Orthodontic funding meet the need of the population, but this will only be realised with effective procurement and contracting, appropriate referral behaviour and performance management. Progress has been made with Hywel Dda and ABMU by the development of an Orthodontic Managed Clinical Network for South West Wales.

Action Required Continue to implement the Welsh Government`s Guidance on Management of NHS Orthodontics in Primary Care.

Pembrokeshire Ceredigion Carmarthenshire Other

Orthodontic Referrals

0

200

400

600

800

1000

1200

1400



Community Dental Services

We remain committed to the provision of a Community Dental Services (CDS). Patients should be treated in GDS unless there are clear reasons for them to be treated in CDS or Hospital Dental Services. WG issued guidance on the role of the Community Dental Services in Ministerial Letter EH/ML/014/08: Dental Services for Vulnerable People and the Role of the Community Dental

Service and was reiterated in further Ministerial Letter in March 2012.

The Community Dental Service should include:

• provision of facilities for a full range of treatment to children who have experienced difficulty in obtaining treatment in the GDS, or for whom there is evidence that they would not otherwise seek treatment from the GDS.

• provision of facilities for a full range of treatment to children and adults who due to their special circumstances require special care dentistry, and/or have experienced difficulty in obtaining treatment from other services or would not have otherwise sought treatment from other services.

In addition the CDS performs other important roles, e.g. screening, providing the field workers of epidemiology surveys and health promotion. A review of the CDS Estate is currently being carried out by Public Health Wales, to identify if the estate is fit for purpose and ensure all sites are used effectively and efficiently. The review will look at all opportunities to ensure wherever possible that sites are multi chair and able to support a range of treatment services.

Action Required

Review the current status of the Hywel Dda CDS in the context of Welsh Government

(WG) guidance and the review of the CDS conducted 3 years ago. In particular to;

Implement the recommendation & ensure the Estate is fit for purpose.

Ensure the skills and skill mix within the service are being used to maximum effect, to

further ensure equitable service provision across the health board.

Develop the focus toward caring for vulnerable groups.

Establish a CDS management group to manage workload and develop the service

equitably across the Health Board & produce a 3 year Service Development Plan.



Dental General Anaesthetic Services

It is imperative that where possible we must seek to reduce the GA need by ensuring the continued development of community based programmes promoting better oral health using initiatives, e.g. the D2S and Healthy Schools programme. In addition, development of alternative patterns of care e.g. developing the Specialist Dental Paediatric services and workforce and building the capacity of alternative treatments such as sedation.

Action Required

Develop a strategy which seeks to reduce the number of GAs, e.g. where appropriate provide services such as conscious sedation.

Hospital Dental Services The Health board will work with ABMU in order to take a regional approach to service delivery. We need to further develop integrated care pathways and establishment systems for managing referrals into Specialist Services in Primary and Secondary Care, including the introduction of a universal referral proformas, monitoring and evaluation of referral processes in a transparent and equitable manner.

Action Required

Build upon the current working links between Hywel Dda and ABMU Health Boards to

foster a “regional” perspective to planning and delivery of Specialist Dental Services.

Move any dental treatment that is inappropriate for Secondary Care into the Primary, Community and Independent services. Develop robust referral criteria within simplified and integrated care pathways to assist referrers in making the most appropriate choice of care for their patients. Support the further development of referral management systems.



Oral Surgery

Currently all Oral Surgery is commissioned outside the boundaries of Hywel Dda, resulting in significant travel for patients.

Action Required Develop a commissioning framework for Oral Surgery that seeks to provide services locally wherever possible utilizing a mix of service providers.

The Welsh Dental Committee (WDC) is considering the Review of Oral Surgery conducted

by the Dental Programme Board of NHS Medical Education England and how this may be

applied in Wales. The WDC will report findings to the WG.

Restorative Dentistry

The majority of patients will receive their restorative dental care in the GDS. Hospital based restorative dentistry provides services to those patients with conditions such as cancer, some congenital conditions and trauma. In addition, it provides GDPs with specialist treatment planning allowing them to treat more cases within primary care. This demand is likely to increase as a result of demographic changes.

Action Required Support the regional Operative Dentistry working group in its development toward a Managed Clinical Network for Restorative Dentistry.

Orthodontics

Complex cases that are unable to be treated within Primary Care, are referred into Secondary Care, the service is currently provided by ABMU from Morriston Hospital, Swansea.



Action Required Continue to support the South West Wales Orthodontic Managed Clinical Network developing improved referral guidelines, agreed monitoring arrangements, and addressing the following issues:- i) Inappropriate referrals where dentists refer children too early, thus inflating waiting lists and causing patients and parents undue concern. ii) Multiple referrals to the limited number of providers available, which again artificially inflate waiting lists. iii) Assessment to treatment ratios – ensuring that patients assessed for treatment receive the treatment in line with timescales set out in Welsh Government guidance, rather than a frequent assessment process without progression to treatment. iv) Identification and appropriate management of urgent referrals.

Specialist Paediatric Dentistry

The Specialist Paediatric Dental service is currently limited to a Consultant who is

dedicated to supporting Cleft Lip and Palate (CLP) services within the Maxillofacial Unit at

Morriston.

There is no other Specialist Paediatric Dental provision in any of the dental services

across Hywel Dda or ABMU Health Board areas. The nearest centre for Specialist

Paediatric Dental Services is at the Cardiff Dental Hospital, however it is not currently

accepting referrals from practices west of Bridgend.

Action Required

Request PHW undertake a review of access to specialist dental paediatric for Hywel Dda

children.



Chapter 3

Quality and Safety

Assuring Quality and Safe Dental Services

‘Doing Well, Doing Better – Standards for Health Services in Wales’, sets out the Welsh Assembly Government's common framework of standards to support the NHS and partner organisations in providing effective, timely and quality services across all healthcare settings. The revised standards came into force the 1st April 2010. The updated framework of standards presents the requirements of what is expected of all health services in all settings.

Standards provide a consistent framework that enables health services to look across the range of their services in an integrated way to ensure that all that they do is of the highest quality and that they are, “doing the right thing, at the right time, for the right patient in the right place and with the right staff”. The standards are used by all NHS organisations at all levels and across all activities as a key source of assurance to enable them to determine what areas of healthcare are doing well and those that may need to do better.

The Standards are incorporated into a number of key assurance systems in dental care, including the Self Assessment Quality Assurance system in GDS and Dental Reference Service practice visits and reporting. The Health Board will ensure all dental staff are appropriately trained and knowledgeable to enable them to have the skills and competencies to deliver the care needed. In addition, dental staff need clinical and service environments which support the delivery of high quality dental care. The care provided should be evidence based with clinical audit and significant event analysis in place to monitor and improve existing dental practice. It is vital that as a Health Board we have systems in place which recognise and act upon poor performance.

The Wider Picture in Quality and Safety Improvement in

Dentistry

In Wales we are fortunate to benefit from strong working links between the office of the Chief Dental Officer for Wales, Public Health Wales Dental Team, Health Boards, the NHS Wales Shared Services Partnership, the Department of Postgraduate Dental Education and the Dental Reference Service. This is particularly beneficial to how, in Wales, we support and deal with practices and practitioners whose performance gives rise to concern.

It will be important to retain and build on the processes and systems in the future to ensure that the dental team can continue to deliver a high quality, safe and effective service. One



specific area we need to focus on as a Health Board is the support provided for non UK qualified dentists commencing work with the NHS GDS in Wales. Performance measures in dentistry should improve the ability to measure effectiveness of care and use of service. As we have indicated above we will begin to standardise high level reporting and have requested Public Health Wales to develop a GDS Governance Framework and an annual Reporting Matrix. This reporting will embrace Quality and Safety. In Hywel Dda / Wales the Dental Reference Service (DRS) visiting programme, inspecting and reporting on every practice with a GDS/PDS contract on a three year cycle effectively ceased 31 March 2013. In the interim arrangements have been made nationally for the DRS to retain visiting to those practices deemed of presenting a higher risk, while the PHW Dental team will visit new and refurbished practices. The dental public health team of Public Health Wales also manages the annual Quality Assurance Self-Assessment process on behalf of the Health Board, whereby every contracted practice is requested to make a QAS return. The returns are collated, scrutinised and reported to the Health Board. The Private Dentistry (Wales) Regulations 2008 came into force on 1 January 2009. These regulations require all dentists that practice any private dentistry in Hywel Dda / Wales to be registered with Healthcare Inspectorate Wales (HIW). HIW have an arrangement with the DRS to visit and report on private practices to the same standards as applied to NHS practices across all of Wales.

Information and Communication Technology in Dentistry

General Dental Services – the WG primary dental care strategy, Routes to Reform 2002, stated that, “The needs assessment identified that general dental practitioners consider they have fared badly in IT developments when compared with their colleagues in the General Medical Services and perceive this as further evidence that they are not embraced fully within the NHS Family. It is of concern that this statement still holds credence some 10 years later and we are determined to address this. The extent to which Hywel Dda practices utilise information technology varies widely. At one end of the spectrum some practices are fully computerised and utilise complex patient management systems, which are capable of maintaining clinical records (including digital radiographs); organising appointment scheduling and patient recall systems. They can also transmit claims directly by electronic transfer to the Dental Practice Board. On the other hand, some practices barely make use of information technology, if at all. However, since 2002 the percentage of practices transmitting claims by electronic transfer has increased but some practices still submit paper claims.



Community Dental Services - Since 2002 there has been development of IT infrastructure within many of the CDS services across Wales. This has not been mirrored in Hywel Dda. It is of concern that the Hywel Dda CDS still does not have an integrated IT infrastructure which is a reasonable expectation of any modern NHS dental service provider. Developing and enhancing the information and technology infrastructure within community and primary care dentistry is important for the future effectiveness and efficiency of these services. It is also vital if they are to function in an integrated way with the wider "NHS family”.

Occupational Health for General Dental Practitioners and their

Teams

The Health Board will look to implement a service that supports Primary Care Dental Teams by funding Occupation Health Support.

Action Required Implement an OH service for all dental contractors.



Chapter 4

Delivering the Plan

This Local Oral Health Plan sets out to strengthen delivery of dental care and improve oral health in our communities, it outlines a co-ordinated approach and maps out a vision. We must have a robust mechanism in place to take forward the actions we have set out above and deliver the Plan. This will provide a means whereby planners and providers will be held accountable for assessing oral health needs, proposing actions to improve oral health and the contracting of and direct provision of services in their locality. Improving oral health and integrating dental services should become an integral part of the Health Board`s delivery plans. The implementation plan will be fluid and respond to service demands as they arise. It will be led by an Executive Director with a supporting management structure. Key support into this structure will be provided from estates, HR and finance. In this way dental services will be enabled to develop across the Health Board.

Summary of Actions

Oral Health Improvement

Designed to Smile Continue to support and monitor the D2S programme to ensure it delivers the programmes aims.

Implement the reporting framework, currently under production at WG.

Continue to ensure the programme further integrates

with the GDS.

Oral Cancer Work with WG & PHW to ensure high risk groups are targeted by national campaigns.

Work to extend the Tobacco Control Action plan into dental services.

Ensure service providers have access to high quality

postgraduate training to address educational needs.

Encourage dentists and their teams to discuss the risks

with their patients of smoking and alcohol.



Service Planning, Development and Delivery

Integrated Planning Establish clear Executive Director leadership through the Dental Planning, Performance and Delivery Board.

Embed oral health and dental services into strategic planning across the Health Board. It is essential strong links exist across Primary Dental Care and Specialist services in order to ensure clear patient pathways are developed and services are easily accessible.

Ensure adequate measures are in place in order to obtain professional advice. Continue to engage with the Consultant in Dental Public Health & the Dental Practice Advisor (Public Health Wales),

Continue to respond to WG dental policy, e.g. Special Care Dentistry Implementation Plan, by way of taking a regional approach and development of a Managed Clinical Networks.

In partnership with the Local Authority and voluntary

sector, ensure that oral care is integrated into general

health and social care plans/pathways of patients with

complex medical and social problems.

Workforce Seek to develop a functioning relationship Local Dental Committee (LDC) for Hywel Dda (and Powys). The Health Board has a statutory obligation to consult the LDC for all future proposals.

Develop occupation health support for all dental teams

within Hywel Dda.

General Dental Services Continual assessment & monitoring of dental services to evidence whether commissioned services meet the needs of the population and ensure services are based on need from within the ring-fenced budget.

Implement patient pathways to ensure patients are sign posted to appropriate services in appropriate settings.

Investigate the opportunity to commission further dental

services in the GDS, for example an Emergency,

Urgent & Routine Dental Service for patients that do not

currently have access to routine dental services.



Specialist Dental Services Build upon the current links between Hywel Dda and ABMU Health Boards to foster a “regional” approach to the planning and delivery of Specialist Dental Services.

Investigate opportunities to develop specialist services locally within Hywel Dda to improve local access & achieve cost savings / increased capacity.

Seek to develop complementary provision by Dentists

with Enhanced Skills (DwES), wherever appropriate.

Orthodontics Ensure that funding for orthodontics is based on need

and not demand. Develop an assessment service in

order to quantify current levels of need and ensure any

future investment in orthodontics is justified, specifically

in relation to other oral health improvement and dental

service priorities.

Oral Surgery Explore the opportunity to develop a Minor Oral

Surgery Service to be delivered locally from within a

Primary / Community Care setting.

Build upon the current working links between Hywel

Dda and ABMU Health Boards & explore the

possibilities of joint commissioning of services.

Review referral management systems, develop robust

referral criteria, simplify care pathways in order to assist

referrers in making the most appropriate choice for care

and ensure timely clinical care.

Restorative Dentistry Incorporate the specialties of Special Care and

Restorative Dentistry into clinical networks across

Hywel Dda and ABMU.

Use these groups to develop a regional approach to

improving services and local delivery where possible.



Community Dental Service To develop a truly unified service, ensuring a standardised service is provided across the three counties.

Produce a service development plan to identify potential areas of growth & opportunities to integrate with all other dental services.

Review the service specification to ensure it meets the needs of the population and is delivered locally where possible.

Special Care Dentistry Strengthen the provision through CDS care by recruitment of clinical staff with appropriate skills. Where possible reintroduce a local service for assessment and treatment for adults and children with special needs, that require access to sedation and general anaesthetic services and direct them to the most appropriate provider.

Paediatric Dentistry Regionally there is a lack of a Consultant lead

Paediatric Dental services. In the context of the high

demand for child dental GAs and some emerging

evidence of repeat GAs – to work with ABMU to

investigate any opportunities to develop this speciality.

Request that PHW carries out a review of access to

specialist dental paediatric care for Hywel Dda children.

General Anaesthetic &

Sedation Services

In context of the above, consider ways to reduce the

numbers of General Anaesthetics (especially for

children) and consider ways to advocate the need for

continuity of care in accordance with the National Oral

Health Plan.

Domiciliary Services Review Domiciliary services and establish a single Domiciliary Policy for Hywel Dda with common standards.

Investigate the possibility of a dual approach to service

delivery, combining the GDS and CDS.



Quality & Safety

Clinical Governance Support national dental practice based audits.

Ensure all primary and community dental settings meet the essential requirements of HTM01-05 and continue to work towards best practice.

Continue to take part in national dental practice visits programmes and the annual self-assessment of practice QAS.

Integrate clinical governance management issues into a

performance management framework, to create a high

level Reporting Matrix, covering service activity and

quality and safety.



Appendix 1



Actions for Health

Boards

WG expected outcome HB expected outcome The defined process to deliver

the action in stages

Measurable

outcomes

Timeline

1. Develop a Local

Oral Health Plan to

address the oral

health needs of their

residents, and clearly

describe how they

will ensure good

governance in

commissioning and

delivery of all dental

services (p17)

Local Oral Health Plans to

be in place by 31

December 2013

Board approved LOHP by

31st

December 2013

Draft consultation with all

contract holders.

Prepare find draft, formally

consult LDC.

Engage with ABMU as

neighbouring health board and

HDS provider.

Present to Board on 23rd

November

Submission to WG

Production of an

agreed plan for the

Health Board

Dec 2013

2. Health Boards will

be expected to work

with dentists and

their teams, and all

other relevant

stakeholders to

develop and support

delivery of Local Oral

Health Plans (p 36)

WG will seek assurance

that this action point is

being addressed, how it is

being achieved, and

specifically that

structures are in place to

receive multi-professional

dental advice, including

that of a consultant

specialist in Dental Public

Health

For all stakeholder to

have the opportunity to

contribute to the

document.

Document co-authored

by the Consultant in

Dental Public Health.

Consultation with all Contract

Holders & the LDC.

Engagement with CDS & D2S

Engagement with ABMU

Submitted LOHP to

WG.

Detailed annual

review of the LOHP

with the CDO.

Dec 2013

and on

going.

Appendix 2 – National Oral Health Plan – Action Matrix



Actions for Health

Boards



Measurable

outcomes

Timeline

3. Ensure the

continued

participation in

evidence based

community oral

health promotion

programmes

particularly the

Designed to Smile

and Healthy Schools

programmes (p 28).

Evidence that CDS

Designed to Smile Teams

are fulfilling the

standards in the Designed

to Smile quality

framework. WG will seek

assurance from HBs,

including the CDS, of

participation in evidence

based community health

promotion initiatives

which may include

smoking cessation,

alcohol and nutrition.

Local D2S team involved

in drafting the LOHP

Local D2S program

fulfilling the standards in

the D2S quality

framework

CDS participation in

community HP initiatives

which may include

smoking cessation,

alcohol and nutrition

Improved CDS links with

the GDS.

Development of robust

and comprehensive

Service Specification,

including a annual plan

and measurable

outcomes.

CDS Organisational

Review .

Ensure the D2S steering group

provides strategic management

for the programme.

D2S team to support schools

and nurseries to continue

participating in the programme

and to encourage daily

brushing. Recruitment of

additional schools and

nurseries.

Increase provision of clinical

interventions e.g. fissure

sealant and fluoride varnish

through mobile dental unit and

domiciliary kit.

Delivery of priorities in annual

plan.

Achievement of

the 11 standards.

Number of

locations

participating in the

programme

Number of children

receiving FS & FV.

Reporting-

Annual financial

report to WG

Activity/workforce

etc to WOHIU as

required.

Compliance with

WG D2S Quality

Framework

D2S Steering Grp –

annual costed

development plan

2014

ongoing

July every

year

ongoing




Actions for Health

Boards



Measurable

outcomes

Timeline

Creation and

delivery of

measurable

outcomes tool /

reporting

mechanism.

4. Liaise with the

Cancer Networks and

the Head and Neck

Cancer National

Specialist Advisory

Group to ensure that

the Welsh Cancer

standards (2005) are

implemented. Health

Boards to work

together to ensure

evidence based,

multi-disciplinary

care is available to all

their patients

diagnosed with oral

cancer. We will seek

assurance that any

identified variation in

Evidence of (i) cross

border discussions on

oral cancer services and

(ii) liaison with Head and

Neck Cancer National

Steering Group.

Cancer Delivery Plans

include details on

addressing oral cancer.

Full participation in

National Head and Neck

Cancer Audit as required

under the NCAORP.

Long term outcome:

reduction in the

percentage of oral cancer

Continue to deliver

effective, evidence based

audited services with

links where necessary to

other Health Boards.

Local reporting and

benchmarking against the

national audit

Collate data on oral cancer

cases including staging of

cancer in HDHB / Review

referral systems for oral

cancers with Maxillofacial Unit

at Morriston Hospital and with

any other relevant secondary

provider.

Status reports

March 2014

March 2015

ongoing




Actions for Health

Boards



Measurable

outcomes

Timeline

treatment outcomes

is addressed by the

Cancer Networks

(page 14).

patients presenting at

stage 3 or 4 and an

increase in the

percentage of patients

presenting with Stage 1

or 2.

5. Use the

recommendations

from the Special Care

Dentistry

Implementation Plan

in ensuring that the

needs of all

vulnerable groups

are addressed (page

15).

Regionally agreed referral

and care pathways are in

place for patients who

require advice from, or

treatment in, specialist

dental services.

WG will review LOHPs to

ensure the

recommendations have

been taken into account

in developing services for

people with special

needs.

Development of

regionally agreed referral

and care pathways

through joint Special Care

Dentistry Managed

Clinical Network (HD &

ABMU).

Increased joint working

with ABMU.

Development of

workforce skill mix.

Participate in regional SCD

MCN.

Determine SCD provision in

ABMU and HD HB’s and

available workforce.

Establish clear referral and

acceptance criteria for SCD.

Establish referral and care

pathways and publish

pathways.

Improved SCD GA list facility at

WGH.

Improved availability of

conscious sedation.

Annual Plans for

the delivery and

Planning of

services.

Specific section in

the CDS service

specification,

detailing referral

and acceptance

criteria.

Sedation referrals.

Transmucosal

techniques used.

Enhanced clinical

support available.

2013-14




Actions for Health

Boards



Measurable

outcomes

Timeline

Support for Mouth care for

Adults in Hospital Programme.

Development of SCD data

collection to allow informed

future service planning.

CD workforce development.

Improved links with SCD patient

support groups.

Data collection for

SCD referrals and

patients seen.

Improved training

in SCD available.

Involvement in

MCN

6. Following

recommendations by

the National

Assembly Children

and Young People

Committee collect

annual data on the

number of children

who receive dental

treatment under GA

(p 36).

Data collated and

reported on a quarterly

basis to the Board /

responsible Committee

on numbers of children

receiving dental

treatment under GA.

Each HB will be required

to complete an annual

return to WG for this

issue.

Referral management

process in place for child

GA referrals and new

service model in place

Quarterly submission to

DSPG of referral and

outcome activity

Annual review of service

including clinical audit

Annual report to Board

Annual submission to WG

Create a Service Specification of

a Child GA service, including a

reporting mechanism.

Establish regular data collection

for consideration at DSPG &

DCGC

Implementation of a service as

per specification, and annual

review.

Reporting of

Service usage to

DPPDB.

April 2014.




Actions for Health

Boards



Measurable

outcomes

Timeline

delivered

7. Keep up to date

information on

waiting lists for

vulnerable people

who require dental

treatment under GA,

and ensure that

patients do not wait

longer than Welsh

Government

guidelines (page 28).

Data collated and

reported on a quarterly

basis to the Board /

responsible Committee

on waiting lists and times

for vulnerable people

who require dental

treatment under GA.

Patients do not wait

longer than WG waiting

time guidelines.

Implementation of data

collection and waiting list

management.

Improvement plans to

ensure compliance with

WG guidance on waiting

times.

Identification of patients

waiting more than the

advised waiting times.

Implementation of data

collection system.

Reporting system developed.

SCD GA waiting list down to 6

months over 5 years

Continued

reduction in

waiting times.

Annual report and

service plan

detailing

achievements and

aims.

2013-2016

8. Work together to

develop regionally

agreed referral and

care pathways which

will promote efficient

patient care and

better working across

GDS, CDS and HDS

(page 30).

Action is taken to identify

areas where there is

limited access to both

primary and secondary

NHS dental services and

to improve access where

there are localised

problems (access includes

geographical / specialist

services / provision for

children and vulnerable

groups). There is effective

Enable a combination of

the Referral Management

Centre and direct referral

pathways to ensure

patients can access

services in a safe and

timely manner.

Engage with all service

providers to ensure most

appropriate methods are

implemented.

Development of a Dental

Service Handbook for all

Stakeholders. To include

comprehensive details on all

services.

Development of a Website for

both service users and service

providers.

Continual reviews of all services

and pathways & engagement

Reduction in

episode s of

patients not

following the

correct pathway.

Creation,

documentation &

implementation of

effective patient

pathways that

promote quick




Actions for Health

Boards



Measurable

outcomes

Timeline

and proper use of ring-

fenced dental budgets

against the specific

services to which they are

allocated.

with stakeholders on service

development.

Build on relationship with all

Dental Service providers to

continually shape the service to

meet the needs of patients.

access to services

in an appropriate

care setting.

Annual reporting

of Dental Budget

to WG at annual

review meeting.

9. Work with PGMDE

to ensure dental

teams have access to

high quality

postgraduate training

to address

educational needs in

oral cancer, including

information on

appropriate Third

Sector organisations

and websites which

patients can access

for evidence based

advice and support

(page 13).

Collect the number and

percentage of primary

care dental team

members who have

received training in risks

for patients associated

with smoking and

alcohol.

Identify the number and

percentage of primary

care dental team

members who have

received core training in

recognition of oral

cancer, understanding

associated risks factors

and local referral

To have developed

robust links with PGDME

and to ensure that CPD is

supported appropriately.

Data collected from PGMDE

and included in annual plans.

Implementation of local CPD

events.

At GDS contractual reviews

discuss oral cancer issues with

contractors.

Work with CDS/PHW and

LDC/GDS to raise oral cancer

awareness with patients

Increased levels of

training on a local

level for dentists

and their teams to

participate in.

Dental services

participation in

national and local

promotional

initiatives

October

2014 and

ongoing.




Actions for Health

Boards



Measurable

outcomes

Timeline

pathways.

10. Work with

PGMDE to ensure

that the dental

actions contained

within the Tobacco

Control Action Plan

(TCAP) are taken

forward (page 13).


that this is being

achieved.

To have an increased

number of dentists who

have undertaken brief

intervention training.

Provide Health Board

wide support to the Lead

agencies.

Ensure promotion of plan to

Dental Practices & include

during annual visits.

Increase in the

numbers of

patients who stop

smoking and

remain smoke free.

2013 - 2016

11. Take account of

and participate in the

1000 Lives Plus

programme to

Improve Mouth Care

for Adult Patients in

Hospital (page 16).

Participation in 1000

Lives Plus programme to

Improve Mouth Care for

Adult Patients in Hospital

as evidenced by active

mini collaborative in

place, and data reported

to dental programme

manager.

Full implementation of

1000 Lives Plus

Programme ‘Improving

Mouth Care for Adult

Patients in Hospital’ into

identified priority areas.

Identification of priority area &

Oral Health Champions.

Delivery of training for Oral

Champions & mouth care

processes implemented in

nurse care metrics.

Annual review

detailing

outcomes.

CDS Annual Review

2013 – 2014

12. Include issues

relating to primary

dental care as part of

their annual primary

care reporting

process, and include

them in their Annual

Quality Statement


that actions in the Quality

Delivery Plan (QDP) are

being addressed in

relation to dentistry and

dental patients, including

Action 5 of the QDP on

measuring patient

Undertake Board

development sessions

and provide briefing

papers to ensure

awareness of issues

relating to primary care

dental services and their

interface with community

Board approval of the LOHP.

Regular update reports.

Review of the actions within

the QDP to ensure that dental

services are included.

Joined up plans

and

communication

across the Health

Board on the

delivery of

effective and

efficient dental

October

2014




Actions for Health

Boards



Measurable

outcomes

Timeline

(page 21). satisfaction.

and secondary care, and

that these are included in

the Annual Quality

Statement where

appropriate.

services.

13. Work with LDC to

review the

occupational support

they provide, and

develop an

occupational health

programme for all

members of the

dental team in

general dental

practice (page 34).

An NHS GDS dental team

occupational health

service is in place, has

been agreed with the LDC

and publicised to GDS

dental teams.

To implemented a OHS

for all GDPs and their

associated clinical staff

Agreement of a Service

Specification with LDC.

Agreement of a Service Level

Agreement within the Health

Board for the delivery of the

service

Advising GDPs of the service

availability and of the Well

Being at Work service

Implementation of

service

Dec2013

14. Support the CDS

to work with

educational providers

to ensure consistent

evidence based oral

health input to all

pre-registration

nurse courses in

Wales, and to

address training for


from CDS services that

they are working

appropriately with local

nurse education

providers, and that the

training requirements of

Health Care Support

Workers have been

identified and addressed.

Development and use of

an evidenced based oral

health education

framework for Pre –

registration nurses &

Health Care Support

Workers.

Define the service within the

CDS Service Specification.

Identify outcomes

in annual report.

April 2014




Actions for Health

Boards



Measurable

outcomes

Timeline

Health Care Support

Workers (page 31).

15. Ensure that high

risk groups are

targeted by national

campaigns (e.g.

Mouth Cancer

Awareness and

National Smile

months (page 13).


that LHBs take a

proactive approach to

target local high risk

groups in suitable

national campaigns e.g.

clarification of plans to

link National Smile Month

(May/June) with delivery

of Designed to Smile and

Oral Cancer Awareness

month (October).

A multidisciplinary

approach is taken to

raising the awareness of

national campaigns.

Ensuring that national

campaigns are publicised via

the Health Board

Communications Team

That links are made between

national campaigns and local

awareness raising

Identify resources to ensure a

multidisciplinary approach.

Report outcomes

in annual report.

Greater public

awareness of oral

health campaigns

and how they link

to local initiatives

and dental

services.

2013-2016

16. In partnership

with the Local

Authority and the

Third Sector, ensure

oral care is

integrated into the

general health and

social care plans/

pathways of patients

with complex

medical and social

problems (page 15).


that this is being taken

forward and evidence as

to how partnership

arrangements are

being/will be developed,

together with the

relevant timeframes.

Develop links with the

Third Sector to increase

the

Convene a meeting with key

Local Authority Stakeholders to

scope issues

Second Step Action

Establish a LHB / LA oral health

liaison group

Oral care is

integrated into the

general health and

social care plans

2014




Actions for Health

Boards



Measurable

outcomes

Timeline

17. Plans must

contain specific

actions regarding the

management of the

current GDS contract:

- enhance contract

monitoring and

reviews on GDS/PDS

contracts with high

value Units of Dental

Activity (UDA);

- ensure better

compliance with NICE

guidelines on recall

intervals;

- monitor “splitting”

courses of treatment;

- work to the interim

Guidance of NHS

Orthodontics in

Primary Care,

particularly during

contract renewal

(pages 41 and 27).


that LOHP commitments

are progressed and

achieved.

HBs to ensure that

providers of NHS

orthodontic services have

separate PDS agreements

and established that staff

are appropriately skilled

and qualified. HBs should

be mindful of advice of

their local orthodontic

Managed Clinical

Network.

Implementation of a

Contract Management

Framework (CMF).

Develop policies for the

management of

contractual issues

Agree CMF with LDC.

Implement CMF and continually

review to ensure it provides a

framework for robust contract

management across all dental

services.

Report outcomes

in annual report.

April 2014

and on

going




Actions for Health

Boards



Measurable

outcomes

Timeline

18. Use BSDH

guidelines in

developing plans for

the delivery of

domiciliary care

(page 26).


that the guidelines are

used and a monitoring

process is in place.

Domiciliary Services to be

provided using BSDH

guidelines.

Integrate guidance into the

service specification for CDS.

Develop a data collection tool,

to inform future service

planning.

Implementation of

service

specification for

CDS.

April 2014

19. Develop

alternative patterns

of care e.g.

increasing the

specialist dental

paediatric services

and dental paediatric

DwES workforce, and

building the capacity

of alternative

treatments such as

sedation where

feasible (page 28).

This action links with No’s

5, 8 and 16 in terms of

developing regionally

agreed referral care

pathways. Recognising

that this action will

require longer term

planning, WG will seek

assurance that plans are

in place to identify and

address local needs.

To investigate alternative

models of service delivery

that include the use of

DwES’s within the CDS.

Undertake a review of CDS

organisational structure and

identify key priorities of the

service.

Questionnaire to GDS to assess

interest of performers and

providers in providing ot

training towards

Enhanced status

Detail outcome of

CDS service

planning within

annual report.

Report

April 2015

April 2014

20. Develop clear

plans on how

residents will access

specialist dental

services in Primary

Care (specialists/

This action links with No’s

5, 8 and 16 in terms of

developing regionally

agreed referral care

pathways. Recognising

that this action will

Review Dental budget to

inform future planning of

service, to enable an

integrated approach to

the delivery of a wide

range of dental services.

Operate services under robust

frameworks, with appropriate

reviews.

Detail plans in

annual reports and

service planning.

April 2014

and on

going




Actions for Health

Boards



Measurable

outcomes

Timeline

DwES), the CDS and /

or secondary care,

and ensure an

integrated approach

to the delivery of

these services (page

30).

require longer term

planning, WG will seek

assurance that plans are

in place to identify and

address local needs

Enable a combination of

the Referral Management

Centre and direct referral

pathways to ensure

patients can access

services in a safe and

timely manner.
