Abstract
Historically, specialist dental services in Northern Ireland have mainly been provided in the hospital setting, however, in the 1990s a number of specialist oral surgery practices were established in primary care. The dentists working within these practices were paid using the fee structure that was applied to general dentists even though their work was of a specialist nature. NHS primary care oral surgery treatment activity levels peaked in 2013/14 but saw a 35% decline by 2015/16. This was due to perceived unattractive NHS payment rates and a cumbersome claiming system. Improved access for NHS patients was essential to reduce risks of prolonged pain or discomfort while on long waiting lists, delayed orthodontic treatment and worsening oral health.
In 2017, an Oral Surgery Pilot Scheme was implemented within primary care to stabilise the declining service and reduce inappropriate referrals to secondary care where cost per case levels were much higher than in primary care.
The service delivers specialist oral surgery treatment that is beyond the competency levels of a general dentist but not sufficiently complex as to require hospital consultant care. Patients include those with modifying factors such as co-morbidities as well as children requiring pre-orthodontic treatment. Patients are often from deprived communities with the worst oral health and who are least likely to be able to afford private treatment.
The service model was designed in-house. It was informed by learning from a 2013 Oral Surgery Pilot and also by the 2015 NHS England Guide for Commissioning Oral Surgery and Oral Medicine Specialties. Personal Dental Services (PDS) legislation provided the contractual framework and, in line with PDS pilot Directions, there was formal consultation of major stakeholders including the Patient and Client Council, the British Dental Association (BDA), dental practitioners and NHS Trusts.
The pilot offered providers a new contract which awarded enhanced remuneration subject to attainment of agreed volumes of patient numbers whose treatment needs were of at least moderate complexity. Volumes targets are reviewed annually to ensure they are realistic and achievable. Some discretionary item of service fees were replaced by set rates.
From the outset the pilot demonstrated a range of positive outcomes including:
- Increased oral surgery activity within primary care in participating practices.
- Delivery of a wider and more consistent range of moderate complexity treatments.
- A reduction in general dentist referrals to secondary care.
- Positive feedback from patients, general dentists, the BDA and from secondary care providers.
Since the Covid pandemic longer NHS waiting times have led to more patients opting for private treatment and as a result providers are focusing more on lucrative private provision. However, ongoing negotiation with providers including a three-year contract term has ensured a sustainable service.
By operating a model that recognises the needs of all stakeholders and is able to adapt flexibly to changing circumstances it has been possible to ensure a sustainable service. The service not only benefits patients and providers but also the commissioner through financial efficiency, accurate prediction of expenditure and greater budgetary control.