Part one

Edited transcript of BOS PCT Day, 15 September 2009 in Edinburgh1

Part 1

Dr Nigel Harradine, Chairman of the British Orthodontic Society

NIGEL HARRADINE: Good morning ladies and gentlemen. Welcome. My name’s Nigel Harradine, I’m Chairman of the British Orthodontic Society, so it’s my formal pleasure to welcome you all here for a new venture for this Society. There are three things I want to say in a couple of minutes before we start; to describe what I hope we will get out of the day; The first is that we hope you get quite a bit of information about orthodontics. And the reason why I think we felt that this might be particularly helpful is that this Society, and orthodontists in general, have been very keen and active in promoting and encouraging the setting up of local clinical networks, realising that the collaboration between those commissioning healthcare and those providing healthcare is all for the good in getting better healthcare for our patients. And extending the principle it’s become quite apparent, for quite understandable reasons, that whilst perhaps commissioning cataract operations or hip replacements is a fairly circumscribed and straightforward concept to get your head around as purchasers and commissioners, orthodontic treatment is a little bit different, so it might be welcome to get some more information about orthodontics

I hope very much that we give you some helpful information which will help you better commission care; about what orthodontics is; the scope of orthodontics which I think you’ll see from the first talk this morning, is very large. It extends over quite a range of degrees of problems for people.

The other thing I think that will become even more easy to understand is the longitudinal nature of orthodontic care, whereas having a cataract is a sort of wham bam thank you m’am, easy to count, no sort of delay in starting and finishing that procedure, orthodontics is a longitudinal course of treatment. The quickest treatments usually take a year. Really complicated cases, in the best hands, can often take two and a half years. And therefore the importance of continuity of care and the relationship between the provider of the care and the patients and their family is hugely important.

In terms of the information you will get today, I think it will be very helpful to clarify what is not immediately intuitive to commissioners of healthcare, and that is who does what in orthodontics? What about general dental practitioners who have an interest? What do we think about them? What should their role and their place be? Although most orthodontics is, and rightly should be, provided by specialists who have a specialist qualification, who’ve had a pretty longitudinal training in line with the longitudinal nature of providing orthodontic treatment, why do we have a hospital service? And there again, some of the labels, are not necessarily directly transferable from other sectors of healthcare for orthodontics, because you have primary care - well that relates to anything outside a hospital, and secondary care, - well that’s anything inside a hospital. But it’s not quite as clear cut as that in orthodontics. Most specialist orthodontic

Edited transcript of BOS PCT Day 2:

practitioners will quite rightly be described actually as secondary care providers and all their referrals will come from general practitioners.

I work in a teaching hospital, but also in a district general hospital, and my district general hospital, which is representative of general hospital orthodontic practice, over ninety percent of my referrals come from specialist orthodontic practitioners, so I suppose you could call my work tertiary care. And it wouldn’t really matter if I was in a hospital or out of the hospital what you call me, it wouldn’t change what I do, but it would be hugely important for the patients that I see that I’m in very, very close contact with all the other specialists that I need to work with, to figure out their rather tricky problems. So that will be something that, when illustrated on the screen, you may be pleased clarifies the situation. Although we do get involved in operations, there’s not too much blood and gore in, in orthodontics, and certainly not too much that you’ll see on the screen today.

There are one or two big things related to that, which are really important to us as orthodontists, and which we are wrestling with at the whole moment. It’s a problem which really impacts on our patients and which we have to get right. It’s the whole bringing together in the new frameworks which exist for training orthodontists. We have world-class training for orthodontists in this country. That’s not just me saying it or, or hubris, it really is the case. People are very envious at the way, over the last thirty or forty years, British orthodontic training has become really, really as good as any, if not better. And yet, because of changing, shifting responsibilities we need clarity; is it deaneries? Is it Royal Colleges? Is it the General County Council? Unless we move forward and get that to fit nicely in the new structures and guidelines we’re going to jeopardise this really rather important and unique way we have of providing orthodontic care in the future.

And a second thing we are hoping for this day is that it helps you with some of the questions you must surely be wrestling with. What do we do when we have waiting lists? And what are you going to do with your waiting lists? And there are certain if not knee-jerk, then certainly very understandable and unifiable, responses, like we’d better triage the waiting list, and that’s waiting in documents. If you’ve got a waiting list it’s probably got all sorts of dead wood on it and, and some of you will know, and others will perhaps need reminding, that in actual fact in orthodontics there are two waiting list, there’s a waiting list to see your orthodontist, and then there’s a waiting list having seen your orthodontist, to have treatment. And everybody on that waiting list to have treatment has already actually been triaged and filtered and met the requirements, and looking at those people again isn’t going to help. You can look at them again if you like, you can set up a central management of referrals, but then you have to think about the cost, and decide whether you are going to have two consultations then? And the delay, and any inconvenience. And although setting up a working party or having a centralised system may seem like a good idea, some of the experiences that will probably be shared are that round the country where that has happened it is very rarely, in our knowledge and experience so far, been held to be a success, and if not, why not? How can we

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avoid repeating blind avenues and mistakes if they aren’t really helpful and appropriate in our particular discipline?

So we hope to help you wrestle with some of those questions. If you want to find out how much orthodontics should be done in an area, you look at the literature and say perhaps thirty five percent of twelve year olds need it, what happens if you want to find out what the needs are in your area? Who are you going to do it with? What’s your relationship with consultants in dental public health? Do you have a consultant in dental public health? If you don’t have one where are you going to turn to for good, authoritative advice? Do you have a local clinical network? Is your source of orthodontics the person you know down the road who has the biggest contract, or you know socially, or do you actually have a fair and equitable and sensible and, and representative method of getting good professional advice? All those sort of things. If you do a needs assessment and it’s a really good one and you find in actual fact you’re meeting thirty five percent of your twelve year olds, but still you’ve got a waiting list, why is that? What are you going to do about it? Say, the needs assessment must be wrong or may.. if there’s cross boundary flows, are you in a position to collaborate with PCTs in neighbouring areas? And if you do, are you going to be able to get the money to flow, are you going to be able to charge them? Have you got the data to do that? Do you know how many people are coming into your area from neighbouring areas? It’s, those questions which I hope you’re wrestling with, and which we’ve got to learn about as orthodontists. And we hope that the, the two way flow during this day will help with those.

And then thirdly I think it’s fair to say that we’re a pretty positive lot as orthodontists, and the glass is usually much more than half full, even when there are challenges and difficulties. But it wouldn’t be helpful if we didn’t at least share some of the concerns that orthodontists have. There is a big clock ticking, orthodontic treatment takes say eighteen months, that’s a good target goal. Well within eighteen months of almost everybody’s contract ending. Orthodontists are starting patients now which they probably won’t finish if their contract isn’t renewed. And should they withhold that information, or say “well I can start you but I can’t promise I’m actually going to be here to finish”. And purchasers may say, well that’s pretty much an unfounded concern, don’t worry, the contract you get will be good and happy and equitable and we’ll probably just roll it on. But if you put yourself in a position of a provider who has an overwhelming monopoly purchaser of your services, as the clock gets within one course of treatment of your main contractor possibly withdrawing or dramatically changing the conditions of that contract, you can see why there are concerns. And why we are actually keen that people should have a sense of urgency about resolving their future plans.

Lastly I would just say, I hope you really enjoy the day, not just what goes on inside this room and, and from my experience of all conferences, part of the most useful bit will be the discussions over lunchtime. Traditionally at conferences you learn as much on the bar stool, or over lunch, as you do in the lectures, or at least that’s my excuse. But we also hope that you take the flavour of the conference as a whole. Wander round the trade areas, go into other lectures, talk to people. Pick up a general flavour while you’re here. I know the sun’s

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shining outside, but we’ve got people on all the doors to stop you leaving until you’ve got the maximum benefit from our conference. And we’ve got some great speakers, some really, really informative people here today. And I’m delighted we’ve got such a strong programme. I have to give my thanks to those, most of whom are sitting in this room, who’ve organised this day, and it’s now over to Keith Pearson to get the ball rolling. Ladies and gentlemen, have a good day.

Dr Keith Pearson, Chairman of the Orthodontic Specialists Group, British Orthodontic Society

KEITH PEARSON: I’m Keith Pearson and my role within the Society is to be Chairman of the Orthodontic Specialist Practitioners within the United Kingdom. And it’s my pleasure and privilege for the first part of this morning to introduce our first two speakers. And the first of these is David Morris. David is currently a consultant orthodontist in Leeds. And since 2006 he has been Head of the Department at Leeds Dental Institute and at Seacroft Hospital. He’s also the post-graduate orthodontic supervisor and trainer for the FTTA and specialist registrar posts, and in addition he is a member of the examiners panels of the Inter-Collegiate Membership in Orthodontics Examination. Within the British Orthodontic Society David currently serves as Chairman of the Clinical Standards Committee, and is our orthodontic representative on the Royal College, Faculty of Dental Surgery, Clinical Effectiveness Committee. David is speaking to us this morning on the justification of orthodontic treatment.

Dr David Morris, Chairman of the Clinical Standards Committee, British Orthodontic Society

DAVID MORRIS: Thank you very much Keith and good morning to everybody. As you can see I’ve been given this rather small topic to provide a general overview of orthodontic treatment. So this is really for the purchasers and the commissioners in the room, I think my orthodontic colleagues can probably have a little extra snooze for, for half an hour or so. So my aims, and I look at the programme and I think I got a little bit carried away with my aims and objectives, but really my, aims today are to give you an introduction to orthodontics and what it involves. And also why, we’re actually having people seeking orthodontic treatment and what benefits they get. I’m sure there’ll be people out in the room who have either had their own orthodontic treatment or have had children who’ve had orthodontic treatment, so there is going to a variable amount of knowledge out there. So I, I hope I’m sort of pitching it at the level for everybody. I’m not going to bamboozle you with orthodontic terms, but there are two or three words that we use fairly regularly as orthodontists that I’ll make you familiar with. And we’re going to talk about the role of orthodontics within general dental and, and medical healthcare, and the benefits of orthodontic treatment. Then look at the demand and who is actually going to supply that demand.

OK, here are some definitions. Definition number one, what is orthodontics? Well it’s a branch of dentistry, so all orthodontists are actually qualified dentists who have done their basic dental degree, and then they’ve done further training prior to actually entering a three year orthodontic programme. We’re dealing

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with the development and management of deviations from the normal position of the teeth and jaws in the face, so it’s a real head and neck speciality. Now within that, the advantages with orthodontics is, in the main, that our results are achieved with the patient’s own teeth, which is obviously a benefit. So if we are avoiding long-term need for maintenance of artificial appliances in the mouth then that’s a good thing. The key thing is we have to have motivated patients and a relationship with the parents of the patients. You have to have a motivated and cooperative patient, who has to have a basic level of dental fitness as well. This is very important if we’re going to get the results that we want. Orthodontics does require expertise and skill, not just in the diagnosis, but in the carrying out of the, of the treatment. The length of treatment can vary, as we’ve heard, twelve months to up to two and a half years, depending on the complexity of the case.

As orthodontists we need to continue our knowledge and our knowledge-base. Orthodontics is always evolving and always changing. There are always new gadgets coming out, new, different types of appliances, and new claims. So we’ve got to keep up-to-date with all these things so that we can offer our patients the best choices. I truly believe that in many of our patients the results we can achieve can be life-changing. We’ll talk about that a little bit more, later.

I’m sure you’ve heard the word malocclusion. This is the simplest definition I can think of and looking at the key word here is appreciable. When we talk about ideal occlusion, ideal is really fictitious. Nobody has got an ideal occlusion; even the Hollywood stars with the perfect smiles have usually had a lot of crown and bridge work. For orthodontics we’re looking at appreciable differences from what we call normal occlusion; minor deviations that really shouldn’t be having treatment. First of all we’ve got to decide what are appreciable differences, (which is potentially subjective). And who considers them to be unacceptable? Is it the orthodontists? Is it the patient or is it the parent? And some times there’s a dilemma between the three people involved. We are also going to look at the prevalence of orthodontic problems.

You should all be aware of the Index of Orthodontic Treatment Need. It’s been around for over twenty years - it’s in use in this country and also internationally. By and large orthodontists have been ahead of the game with regard to the need for treatment. And many of us have been using this for many years now. Before it was even advised as a scale for national use. We’ve used the common sense approach. We’ve actually used it to know what needs treatment and what is relatively normal and doesn’t need treatment. But for those of you who aren’t as fully aware of it, we’ve got two components; the dental health component which grades malocclusions from one to five. One meaning mild and no need for treatment, and five meaning a great need for treatment. Then there’s the aesthetic component, which involves a series of photographs which I’ll show you in a minute, and we score those from one to ten. One meaning no need for treatment, and ten - a great need for treatment.

So when we’re looking at the IOTN, by and large we’re treating grades three, four and five and an aesthetic grade of six. That tends to be the sort of guidelines that we are actually sticking to. And you’ll find in specialist practice, they’re more

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likely to be treating those grade three, fours and fives. In hospital we tend to take on the fours and fives and the more severe ones. But we also need cases for training our post-graduate students - they can’t all just take on the most complex ones, initially they need to learn how to treat slightly less complex cases.

We are going to be looking at the actual traits, the features of a malocclusion, that mean patients have a great need for treatment. Things like missing teeth, or unerrupted teeth, buried teeth, overjet... there you go another term; meaning the horizontal distance between the upper and lower front teeth and how much the teeth stick out, which we’re going to talk about with regard to bullying, a bit later. And other features like cross-bites, where the upper-teeth are biting inside the lower ones, which is the wrong way round. So as with the aesthetic component, we have this rough cut-off-point where we are looking at certain definite needs for the sort of eight, nine and ten levels of the pictures. You can see pictures 1, 2 and 3, are what I call normal occlusion, where there’s no appreciable deviations from the normal. Whereas when you look at 8, 9 and 10, there are significant problems there. And those patients require treatment. So what’s the demand for orthodontic treatment? Well before we go there, we’ve got treatment need, which we’ve just talked about with the Index of Treatment Need. This really is clinician-led. The clinician is the gatekeeper really, for saying whether patients should have treatment or not and whether they’re able to have treatment.

We’ve got the demand. Now the demand has always outstripped the resources, which is why we need something like the IOTN to provide that sort of evidence, for either allowing or not allowing patients to have treatment on the NHS. The demand can be from the patients or from the parents, or both. So this is where the relationship with them is very important. And lastly, I think the important thing which we all ask our patients, is about their treatment wants. They’ve got to want to have the treatment. We need a motivated patient. That’s very important. That’s one of the first questions I will ask patients. Just because they’ve been referred doesn’t mean they necessarily want treatment. Sometimes they just want a half day off school. So we’ll look at the orthodontic prevalence of problems.

We’ve got the Child Dental Health Survey which is done every ten years, so the last one was 2003. And this had an orthodontic section in the overall dental health component. They found that forty two percent of twelve years olds, (and it was just looking at twelve year olds)...and when we get these figures bandied about twelve year olds, you know we’re not just treating twelve year olds, this will apply for eleven year olds, thirteen year olds and fourteen year olds, too. So bear that in mind; that we’re not just looking at twelve year olds, we’re treating more and more adults as well who have either not had available orthodontic treatment when they were younger, or never had the chance.

So looking again at the Index of Treatment Need’s fours and fives... Forty-two percent of twelve year olds were deemed to have a need for treatment. Interestingly there was a disparity between the patients that didn’t require treatment, (or the dentists who thought they didn’t require treatment), and the parents who thought they did. And in a smaller group, where it was the opposite way round; where the dentist felt that the child needed treatment, but the

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parents couldn’t see the problem. So there is a variability there and it’s all about patient education and dental awareness. I think dental awareness in this country has been improving steadily and increasing steadily over the years. We are certainly not, (and I don’t really want to be) at the same degree as the United States, but I think dental awareness, certainly in the last twenty year, has improved. And I think that’s part of the overall formula.

For example, I can’t possibly do an orthodontic talk without showing some teeth. So you’ll be seeing plenty of teeth, just to give you an idea of this dilemma between what the patient sees as a problem, and what the orthodontist sees as a problem. In this picture you will see Edward. He’s fifteen years of age and he’s come in, having been referred by his dentist. Now, when I look at him as an orthodontist who has been treating orthognatic cases that require jaw surgery, I look at him and think, right, I know exactly what to do. He needs to have a combined treatment with fixed braces and jaw surgery to correct his profile, because he’s got what’s called a cross-bite, which I mentioned earlier, where the upper teeth are biting inside the lower ones. But fortunately, (well not fortunately), but Edward doesn’t see that as a problem. His main problem is the fact that his fang tooth, his canine tooth, is just sticking out and it doesn’t look the same as the other side. And this is where it’s important that you’ve got to understand what the patient perceives is the problem, and you’ve really got to treat them for what they want. I can explain to Edward what would be involved to get a better result, an ideal result, but he’s got to make that decision as part of his informed decision-making. In fact he wasn’t keen on having surgery. He was fifteen and it’s the sort of thing we wouldn’t probably do until he was a little bit older anyway. So we just basically took out his small lateral incisor, which is that one there, and lined them up and closed up the spaces. For the orthodontists out there who wonder why I didn’t put any brackets on those central incisors, it’s because he had tiny roots on them.

So in another way I’m quite glad he didn’t want the full course of treatment because it would have posed another problem. So he got symmetry and he was happy. Was I happy? As an orthodontist who wants to get the best overall facial and dental result, probably not. But this is where it’s important that you actually take into account what the patient wants to happen.

On the other side of the coin is a patient who came to see me, and her main concern was the crowding of these lower front teeth. This is a common problem. Ninety five percent of the population will have crowding of the lower front teeth. This is what we would call a normal occlusion; it is normal to have this. It is abnormal to have perfectly straight lower front teeth. So this lady was quite hung up about it and she wanted to have treatment. Unfortunately, on the Index of Treatment Need, it’s too low. And because this is a natural thing, something that happens anyway, you have to question the need for any treatment for this. Certainly this sort of thing shouldn’t be offered for treatment on the NHS. If she’s very keen on having treatment, then she’d have to seek private arrangements to have it done. But I would certainly counsel the patients very strongly in the fact that minor problems... you’ve got to really correct them absolutely fully and keep them corrected for life. Otherwise the patients won’t be happy. So that’s just two examples.

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So why do people need orthodontic treatment? Well it will vary. I’m going to show you a list of a few reasons why. Some will be to improve the bite. We’ve heard the word malocclusion. Occlusion refers to the bit of the teeth, and in line with that, that will hopefully improve the function of the teeth, the way the teeth fit together, the way the patient can chew the food, etcetera. Improving their oral health generally. They should have a good basic level of dental health. But if we’re getting the teeth straighter and in some cases making them easier to clean, then there’s more likelihood of fewer problems later on. And there is certainly evidence coming through more and more now, that link problems with patients with gum disease to other sort of medical problems, such as cardiac problems. So there is evidence coming out more and more, that link a healthy mouth to a healthy body. So we need to keep that in mind as well.

Then there are some cases, and I’ll show you some cases shortly, for preventing dental trauma. Patients who have got very prominent upper front teeth, are at risk of having damage to those teeth in an early age, especially if they’re involved in contact sports and things like that. There are other patients who have abnormal wear of the teeth because of their bite, and if that is left to proceed long-term, that can cause problems later on. So as orthodontists we’re always looking long-term at things. We are always thinking ahead about what could happen, and if we can try and make things better now it will save long-term problems later on.

Improving dental appearance, I think that goes for most of them, and obviously that leads to a lot with crowding of the teeth. Generally, in modern man today, crowding of the teeth is fairly common. Whereas if you look at medieval teeth they didn’t have any crowding problems. A lot of that is due to the softer diet we have now. So mouths are getting smaller generally, but teeth are staying the same size, so we have more crowding.

And then are those patients who have got differences between their jaws, either due to abnormal growth, or not enough growth, or asymmetries where their actual face is not symmetrical. For them we need to look at ways we can actually improve their facial appearance, as well as their dental appearance.

The last one I really should put first, but I thought I’d leave to the end. And the reason is because I think it has probably one of the biggest benefits and pay-offs that patients get from orthodontic treatment. And that is looking at their wellbeing and their self-esteem. There are big social and emotional issues here. It’s something that we as a profession haven’t been great at looking at over the years, but we are coming to grips more and are trying to find ways of measuring this. It’s a difficult thing to measure, and it’s something that will change over time. I think the quality of life issues is very important. It’s one of the main reasons why patients will seek treatment. They might not admit this to you at first or even when you see them at the finish of their treatment. It might only become obvious later on when you see them during their retention period, that you realise what an effect it’s had on them, when they actually open up and tell you what effect it’s had.

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Dental appearance matters. You can’t get away from it. It’s a fact of life and it’s the media that drives it along as much as anybody. There’s the lovely smile of Rachel Stevens, but unfortunately we can’t all have smiles like that. And we’ve got the slightly worrying smile of Gordon Brown, down to the downright scary smile of Cherie Blair. We all look at the news and read the papers and we know how things like this are picked up on.

And keeping to the theme, (you can see what sort of television I watch!), and I’m in Scotland, so I’ve got to be careful what I say here - we’ve got Susan Boyle with an amazing voice, but you know she was lambasted because of her general appearance. And she had a significant makeover, which did involve some dental work as well as a new scarf! And Paul Potts. Again, what an amazing voice. Would he have got that multi-million pound record deal with those teeth? I think you can win a competition, but I don’t think you’d get the deal with those. And actually some of the orthodontists are wincing, visibly wincing. And he’s had his makeover. He’s still got that smile right though, I think, but he looks more in pain really doesn’t he? And, and more recently we’ve had Clare Balding getting in, into trouble. I don’t know if any of you heard about this, where she was interviewing the Grand National winner, Liam Treadwell, and she asked him to smile, and when he smiled he, (I couldn’t unfortunately get a really good close up picture of his teeth) but I suppose he has very strange shaped teeth. Spaces, odd, odd shaped teeth. And when he smiled she says, something like: “oh, oh don’t, oh don’t bother”. And then she said “well now you’ve won the race you can get your teeth sorted out”. She got a couple of thousand complaints from racing pundits. When Liam was asked about his teeth this is what he said: “you know I never thought about getting my teeth treated as it didn’t affect me”. And this is where it comes back to patient wants. For some patients, that would cause them significant psycho-social issues. And for others you’ve got to ask the patient to work this out.

On a side issue with this, two dentists, who obviously wanted to get the publicity, offered him treatment to have his teeth restored. And he said, “well if it’s free and it doesn’t affect my racing I’ll have it done”. So there, but I think that tells you another story really doesn’t it?

And just to show this talk is up to date, this is a piece in last week’s Metro Newspaper. This is Gordon. I don’t know Gordon, but he was asking his potential father-in-law for the hand of his daughter in marriage. And the father-in-law, who was a dentist said, “not on your nelly unless you get your teeth sorted out”. So he goes and gets his teeth sorted out, I don’t know if his father-in-law did it, or who did it, and now he’s able to marry his daughter, so it all ends happily. He didn’t have a shave, but he still managed to.

OK back to a little bit more reality. A couple of years ago I was involved in research with clinical psychologist colleagues in Leeds, looking at patients who were having combined orthodontic treatment with fixed braces and jaw surgery, to find out what goes through their minds when they make the decision to have what is a complex treatment involving an operation with risks. And the main theme that came out of that research, done partly through interviews with a psychologist, was that it was not for cosmetic reasons. They just wanted to look

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normal. Others just wanted to blend in. So these patients with these jaw discrepancies, (and you see this girl here who’s had before-and-after treatment) they just want to be Joe Normal. They don’t want to actually be different, they just feel they’re being either persecuted or bullied because of their appearance and they just want to blend into the crowd. So I think we need to remember that. It’s another example of what this sort of treatment can do, and the different effects that can have on a patient’s life overall.

Here’s another young lady who’s a nice bubbly girl in some respects, until you ask her to smile. And that was her smile [show image]. She was bullied and teased about her appearance. She’s a woman who’s about twenty five years old. Shortly after I took this photo she started crying, because she didn’t like smiling. She deliberately avoided it, and so when she was made to smile it brought all these emotions back. Some patients will open up to you quite soon when you’re seeing them, and others will take some time. But she’s gone through a complex course of treatment and that’s her finished result. She can certainly smile now with confidence and she no longer has the problems at work that she used to have.

When we talk about cosmetic treatment, or the C-word as I call it, we want to be careful here of what we are actually referring to. To my mind, cosmetic treatment is for patients or people who want to actually stand out from the crowd. This is where the difference lies. They actually don’t like being normal, they want to be above everybody else, in a way. So they want to stand out from the crowd. They want to look different in some way, and of course you know the other aspect now with cosmetic treatment is this age-defying treatment with things like Botox and collagen injections. An orthodontist isn’t dealing with any of that.

So we look at psycho-social aspects, which as I said earlier, is an area where more research is coming out now and we’re linking more with psychologists and psychiatrists, in order to try and really get into the heads of our patients. But there is plenty of evidence and research out there over the last twenty years, that’s shown that malocclusion can be quite a social handicap to patients and public attitudes. As people become more dentally aware they realise that certain things aren’t normal and so that will be picked on. Whether it is in the media, or just in the general public. There’s self-esteem, quality of life and general well-being. And these are all things that we can now measure, and I think we should be measuring. Because I think it’s one of the main outcomes of our treatment.

Back in 1980, with his longitudinal research on the effects of malocclusion, Bill Shaw stated that the person’s dental appearance can significantly affect how they feel about themselves and more importantly, how others perceive them. So that’s quite strong statement really.

So I think we need to look beyond the teeth. As orthodontists we can get a bit anally retentive looking at a set of models and bask in the glory of how well they fit together. I think we need to look at the whole person and, and the effect that the orthodontic treatment can have on them. Certainly that’s why I do orthodontics. I love my job. The buzz I get from seeing patients, how grateful

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they are and how they open up, changing from introverts to extroverts. The parents sometimes don’t thank me when that happens, but that’s the great buzz of orthodontics, you can see you’re making a difference to somebody’s life and how they’re actually carrying out the rest of their day to day living. So we need to measure it and we need to quantify it. And that’s easier said than done.

Some recent research to back all this up shows that patients who had dental trauma already and by and large, a third of nine year olds will have had some knock on their front teeth by the time they reach the age of nine. So we need to see these patients at a suitable time. But a group in Sheffield found that even at eleven and twelve years old, children were viewing other children who had had trauma to their teeth, with either broken teeth or chipped teeth or teeth that had gone darker, negatively. So even at that age, it’s starting. The take-away message from their paper was that a healthy mouth gives a positive image to others as well. And I think, as those earlier slides I showed of Gordon Brown and Cherie Blair, that all forms part of the picture.

And so onto the subject of children and bullying. Bullying is something we don’t know how much is out there. I’m sure there’s a lot more than we know about, and it doesn’t just happen to children. There are plenty of adults out there who get bullied because of their dental appearance. Just this Sunday, Cera, in his MSC study found that twelve percent of these referred patients, (and I think this was in the Kent area), were actually bullied because of their prominent teeth. That’s a significant percentage. And they found, when they looked at these children, that they had less social competence and also interestingly less athletic competence. It didn’t actually affect their scholarly activities and their learning, but other studies have shown that it can affect that as well. But interestingly, obviously this has affected those playing sports and being part of a team as well. I think that was quite an interesting finding. And as a result, these children also had lower self-esteem. So, there’s potential damage happening to these children at quite an early age. The Index of Treatment Need though, wasn’t found to be a good predictor of bullying and so the IOTN is not a panacea, it can only do so much. So I think we need to ask our patients about this. Some will tell you that the reason they are there is because of bullying and they’re aware of that. Or the parents will tell you. So if we don’t ask the question we won’t get the answer.

Here’s another young lad. He too, was certainly being bullied at school. He has got prominent upper front teeth and spacing. And you know kids will call him Goofy or Bugs Bunny; all those sort of original nicknames! And he goes through his treatment...(this is now four or five years after he has finished his treatment)... and he has even got the confidence to have an earring now. So I think that says something. It has made a big difference to this young man’s life.

Trauma. We talked earlier about people with prominent teeth being more likely to bash them. Children obviously do play sports, they do ride bikes and they do go skateboarding. Orthodontists! If we can try and intercept problems and we can perceive a problem happening in the future, we want to try and sort it out early. Because that, in the long term, is going to save a lot of hassle and work for the patient as well as potential heartbreak. And it’s going to save money too, because patients who actually bash their front teeth and need some treatment

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such as bridge work or implants, over the rest of their life, are going to find it quite expensive. As well as long-term maintenance during the time the device is in their mouth. So we like to intercept problems if we can. But we’ve got to see them early enough in order to intercept the problem. So this is an area where we’re always trying to have continual dialogue with our GDP colleagues, encouraging them to refer these patients at the suitable time.

Forty-five percent of you know the risk of damage to the patient with protruding teeth, which is a very high percentage. And if we can treat them at the right age (and at a younger age) then we’re going to avoid the long-term problems of teeth which have been traumatised and need repeated restoration.

Here’s an example of a boy who unfortunately we didn’t see early enough. You can see, one of his front teeth what has been bashed is slightly darker. He lost the blood supply to that tooth and it’s gone darker. So he needs what’s called a root filling, which he’s had done. But it doesn’t get rid of that dark appearance there. The reason why he has bashed the tooth is because of a much increased overjet - his upper teeth are ahead of where they should be. So he has now got an issue of an increased overjet, but also a darker tooth. It sticks out like a sore thumb really. I’ll give you an idea of what treatment we can do for this sort of case. Here’s some headgear being worn, which you may be aware of. Headgear which will be used in the evenings and night-time. We can use a different functional appliance which can try and promote the lower jaw to come forwards to form into a better position with the upper front teeth, and so improve his profile. Once we get to that position, his overjet is reduced. Now we need to get on with fixed braces to actually get the bite of the teeth correct. And that can easily be a two year course of treatment from start to finish. There he is before his treatment... and this is now five years after his treatment. He has had that front tooth improved to a degree by his dentist, with some composite and some form of acrylic veneer, I think. So there we are; before and after. The difference in his appearance is very favourable and he’s a very confident young man at university at the moment.

This document, which is just being updated by the BOS, is something I really want to make the PCT personnel aware of. It’s really a guide for practitioners on what things to look out for in their child patients. Orthodontic screening of these problems should be done about the age of nine to ten. It’s something that we will have available in the next month. This might not be the cover we use, but it’s going to be something along these lines. What we’re looking for is the PCTs to distribute this to their GDPs in their region. It gives a lot of good, clinical information about what things to do, when to refer and what things to look out for. So keep your eyes peeled for this and hopefully through the managed clinical networks, we’ll be able to let you know when it’s available.

One of the things highlighted in that document is the problems some people will have with late referrals and patients who have canine teeth (or fangs) that have gone off-track. We know there is good evidence to show us that these can often go off-track for one reason or another. But removing the baby canine tooth early

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will allow the actual adult tooth to drop into position. And nothing more would be required. If that is not spotted and is missed, then we end up with a situation where the canine becomes buried in the roof of the mouth, and then it opens up a whole scenario of a two year course of treatment. As orthodontists, we’re trying to keep things simple, if we can. If there is a simple way we can intercept now which is going to save the patient a lot of hassle, a lot of appointments and save the NHS money, then that can only be a good thing.

This example shows the patient did have the left one taken out, but for some reason they went back to the dentist to get the other one taken out. It’s a good example that shows how the left one is improving and it’s going drop into place nicely, whereas the one on the other side is continuing to go off-track, and that is going to need further treatment.

This is Melissa. Again there was difficulty in taking a smiling photo. It’s slightly out of focus because she would continually move around as you were asking her to smile. And even though I said; “it’s not the video camera I’m using”, she wouldn’t stay still because she didn’t like smiling. She was aware of what her problem was. She’s got a canine that has partially come through. She’s in her early twenties, so she’s ten years beyond when these teeth should have come through. And she’s got another canine which has not come through and she’s missing one of her front teeth. So she’s got a few problems going on there. But with orthodontics and with our surgery colleagues we can uncover these teeth and drag them kicking and screaming into position. This was a good two-year course of treatment and it shows a series of how we brought the canines into place. And how we close up spaces as well, so we avoid bridgework, ongoing maintenance and cost for the patient. I’m not responsible for her hairstyle, so I can’t say that’s improved. But she’s smiling better now. So again; before and after, just to give you an idea of what things can be done; before and after smiling.

OK, another young lad who, I think we’ll all agree, has got a significant problem. A very set-back lower-jaw. And I’m not being unkind to him, but his upper teeth sort of walked in about three minutes before the rest did! It was that big a problem.He was very concerned about it and quiet about it. We actually treated him early; at about the age of ten years of age. But knowing that degree of problem we’re not going to fix it just with a functional appliance. So we partially reduced it and then carried on with fixed braces and surgery. So here he is at the end of his treatment showing quite a significant difference.

This will be a common sight for many of the orthodontists; patients who have prominent, upper front teeth, sticking out. You can imagine the nicknames she gets called at school. As well as her prominent teeth she’s got slightly odd-shaped teeth as well. And again, we are using a headgear and functional appliance to try and encourage growth of that lower jaw. We can get to this stage and then we have got to deal with the crowding issue. That is what we are currently doing. So we’re in, we’re getting into fixed appliances now for her, to sort out the crowding and the bite. There’s a lot of these treatments there... before and at the current stage she is now. And again from the front now, see

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how her lips are competent, meaning they can meet together and protect the teeth, without her making a lot of effort.

In the Steele Report, which was published back in June, there was little direct orthodontic mention except in two or three places. Things that we can apply to orthodontists however, was about the skill mix and the emphasis on quality, which I was very pleased to see. There was a line in the report which wasn’t really explained, it was just stated; the profession knows what quality looks like. It was a very open-ended sort of thing to state. I would hope that all professionals would know what quality looks like. It’s really up to us to explain to patients and providers of healthcare what we mean by that. And it states, regarding the skill mix, that really complex, demanding treatments, (and I’ll put orthodontics into that category), should be provided by dentists who are skilled and trained to do that to a high quality. And I think we’d all agree with that. In our skill mix, I think the PCT personnel really need to look in their area of what is the available orthodontic workforce, which will vary. Very few places will have all these possibilities. But we go from the dental school, and there are only ten in the country, so many areas won’t have that luxury. But there are under-graduates who can provide a certain amount of simple orthodontic treatment as part of their learning, and there are post-graduates in training grades - the future specialists who are going to go out into the community. There are also the academics who are teaching us the theory and research. The complex cases that need to be seen by more than one discipline should be rightly treated in the hospital service. And you’ve got the district generals, and a lot of these link in with the dental hospitals, forming a hub and spoke arrangement; a lot like myself who work at both a dental school and at a district general hospital. So there’s a link and a continuity there. And we’ll have training grades in those places as well.

We have the specialist orthodontic practitioners who make up the bulk of the society. They too have gone through three years of training and they will be treating patients in their community with UOA contracts with their PCTs. And then we have the other groups: dentist and dentists–with-special-interests, I’m including the GDPs here as well (and this is something that there is a document produced by the BOS about. It is available on the website and you should have probably received the address for this). With regards to the dentists with special interests, we need to make sure that they are being assessed properly by the PCTs using some form of assessment, probably involving the managed clinical network group there.

More recently the orthodontic therapists have come on board. This is quite a new innovation in the last couple of years. The main thing is that they have to be supervised by a dentist or orthodontist. They cannot work alone and so there are limitations to what they can do. I think what I see the managed clinical network really providing is a way of coordinating which orthodontic services are available in the community, so the right patients are treated in the right place at the right time by the right people. I think that is a role of the committee.

Now I’m finishing shortly, you’ll be glad to know. Orthodontic quality is a really big issue with me. Quality of care should form part of the overall clinical

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governance of anybody’s practice or any hospital unit. And so we should have some way of monitoring our outcomes. I think orthodontics is ahead of the game with that. You know, we have been doing this for ten, twenty years already with the PAR Index. I am sure a lot of you already know about the PAR Index, in which practitioners have to record a certain percentage of their treated cases. But I think I will just make the point here that for the PAR Index to be used properly, people doing the PAR should be calibrated, they should be independent, and they should be looking at random cases. In my view, it is absolutely pointless for practitioners to be PAR scoring their own cases. If they are not calibrated, they might not be doing it correctly, and there will be bias and the risk of just cherry-picking cases. So again, if you’re not aware of the BOS website there’s a list, and it’s getting longer all the time, of just over thirty people who are calibrated PAR scorers around the country who can offer their services to help with this measuring outcome for your region. So look at that, and contact your local district general hospital as well to find out if there are any others that are calibrated. But I would certainly recommend that you try and get calibrated people for this.

Patients can have ways of actually finding out how we’re doing in our treatment. So that means satisfaction questionnaires. And again, on the BOS website there is a satisfaction questionnaire for patients which has been validated, it’s been tested, so there’s no need to reinvent the wheel and it can be downloaded and used as it is. And we hope to bring on board things like oral-health, quality-of-life questionnaires as well. We are getting patients’ answers to how they feel about their treatment. So I think that they are the two main ways we need to look at recording outcomes. I would recommend the website to you, the BOS website – www.bos.org.uk - It’s got loads of information on there, loads of things you can download and keep, so please have a good navigation around that.

In summary, I’ve given you a wealth of evidence of what benefits orthodontic treatment can provide. This dilemma between the need for treatment, the want for treatment and the demand for treatment, is not always equal and so we need, as clinicians, to be aware of all the factors that are involved and to involve our patients in those decisions. The benefits, especially the psycho-social aspects, I think are very important and I’ve talked about that. And we need to efficiently use our available workforce so that people are doing the right sort of treatment, within their own capacity. That is going to be best for patients. And that’s really what we want as orthodontists. We want to do the best for our patients.

And assessing the treatment outcome is very important, we need to know that people are treating to a high standard and are continuing to do that. I think another take-away line is; orthodontics isn’t just black and white. It is a bit more complicated than that. So I hope this has given you an oversight into the overall speciality.

KEITH PEARSON: Thank you very much David for that important introduction to the value of orthodontic treatment. Our second speaker is Richard Jones, to whom we must be thankful for this whole day. Richard is a full-time specialist orthodontist and is Director of a large group of orthodontic practices based in Kent and Sussex. He is

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http://www.bos.org.uk/


currently our Chairman of the Orthodontic Practice Committee of the British Orthodontic Society. This committee represents the interest of the Society in relation to the new contractual arrangements in primary and secondary care. Richard played a key role in negotiations surrounding the implementation of the new contract, and in particular the transition from the old GDS contract to the new PDS arrangements. Being a Welshman his interests outside orthodontics relate mainly of course to Welsh rugby, and with that a strong dislike of the English national rugby teams. He’s apparently a long-time admirer of Tom Jones, and has more than a passing interest in old cars, but there’s a strange dislike of the smell of petrol. And for some unknown reason Cocker Spaniels. He’s here to speak to us today on the PDS contract, fact and fiction.

Dr Richard Jones, Chairman of the Orthodontic Practice Committee, British Orthodontic Society

RICHARD JONES: Thanks Keith. A very interesting introduction and I, for the record have nothing against other types of Spaniels, it’s just Cocker Spaniels. Welcome everyone today. I’m really pleased to see so many of you have made the effort to come up and join us for this first, new venture for us. Now the first two talks, David’s and mine, are really to give you a bit of background about the whole day. I’m going to start with two apologies actually. The first is to those of you in the audience for whom a lot of what I’m going to say is very well known to you. But we are conscious that a lot of people have perhaps become involved in orthodontic commissioning over the last few years who perhaps weren’t involved at the start of the new contract. So what I really want to do is give you a little bit of history of how we’ve got to where we are today, what orthodontic provision was like prior to the new contract and how we’ve got to where we are today. Which brings me onto the second apology, which is that I don’t want my talk to come across as just a bit of a moan. At face value it might come across as that, but it isn’t. For the record, I’m actually very supportive of the new contract. I think there were a lot of big improvements compared with where we’ve come from. And whilst, with hindsight, which is always a wonderful thing, there are things that might have been done differently, and there are still a few problems, which I’m going to highlight, I do think it’s a big improvement. And we do have a wonderful opportunity over the next few years to work together to, most importantly of all, improve the service that we offer our patients.

Now just out of interest, a little straw poll. I know we have a bit of a mixed audience today, a few providers and various committee members from the BOS, the vast majority of you are involved in commissioning of some sort. But of those of you involved in commissioning, just a quick show of hands; How many of you were in post or involved in orthodontic commissioning in April 2006? OK. I’d probably say that was half of the commissioners. So quite a few weren’t. I hope this will be relevant and of interest to you. I’m going to give you a bit of background, highlight a few of the issues, but also I think, as we go through the course of the day, there will be a few common themes, and hopefully as we go through the day we’ll also come up with some solutions for some of these problems as well.

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Keith’s already told you a little bit about my background, so I’m not going to dwell on that, but my main role in the Society now is running the Orthodontic Practice Committee, which I suppose is the Orthodontic equivalent of the General Dental Practice Committee. We mirror their activity in terms of liaising with other professional bodies, Department of Health, BDA, etcetera, on contractual and commissioning issues.

In this talk I’m going to give you a little bit of background about what the old system was like and the problems with GDS. A bit about the benefits of the new system and in particular, the fundamental differences between the two which are still to this day a little bit misunderstood. And that has created some problems. And then finally the issue of the transition from GDS to PDS. And I know this, in some ways is now historic, three and a half years into the new contract, but it’s still to this day, creating a few problems. I’ll raise some of those problems and hopefully other speakers today will address some of those problems as well.

I’m a bit of a Clint Eastwood fan, and so I’m going to try and introduce a little bit of humour into what would otherwise be a fairly dry talk. We’re going to talk first of all about The Good; the problems with the old system, a lot of the benefits of the new system. Then we’ll talk about The Bad; some of the things which in hindsight perhaps, could have been done a little bit better and handled a bit better, with the whole budgeting surrounding orthodontics when we went into the new contract, and the issue of historic earnings and contract values. And finally The Ugly. Now I know that Keith said that I played an instrumental role in this transition, so I suppose I have to take some of the blame for this. But there was a difficult transition between the two systems, and I think whilst we did manage to handle it as well as we could, to this date there were still some ongoing problems relating to this. And a lot of this concerns the slightly misunderstood nature of the new contract.

Continuing with the Clint Eastwood theme, just for a few UOAs more, I want to finish up then with a little bit of talk about the Steele Report. David’s touched on this already and I know Sue Gregory will be mentioning this in her talk, but I want to pick on a couple of little items that perhaps the others haven’t mentioned. And also a little bit of a look ahead into the future over the next eighteen months, and perhaps even more so; what’s going to happen post 2011. Nigel raised this issue earlier on, so I want to perhaps just raise a few questions, and I’m hoping as we go through the day we’ll also have some answers that we can share on these subjects.

So what about the good and the principles of the new contract? Well we have to understand where we came from. Until 2006 orthodontic practice, or practitioners, were remunerated in much the same way as general dental practitioners, under what was called the General Dental Services Contract. This was an item of service type system, very different from the current system. In essence when you treated a patient you simply ticked a box showing the things that you did; which appliances you used, etc. Payment was based on the statement of remuneration and which was very similar to the dentists the old FP17. And that was basically how orthodontic provision in practice was funded.

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There were a number of problems from both sides for practitioners like myself and commissioners. It was an exceptionally complicated system. There were a huge multitude of possible combinations of claims. One of the biggest problems as a businessman was that cases like in general dentistry were paid in arrears. Now in general dentistry this wasn’t a big issue. If a patient started a course of treatment generally it might involve an exam, a scale and polish perhaps, some restorative work. But in most cases this was over within a matter of weeks or months at most. But in orthodontics, courses of treatment often went on for two years. And this meant that as a business we were basically being paid two years after we started the treatment. Now this created a big problem for new practitioners, new practices that were setting up, who had to fund their business whilst they had no income coming in for approximately two years. But it also created very unpredictable income streams, which made running a business difficult. But probably the biggest problem was the fact that it introduced a big problem when it came to using historical earnings as a baseline when we went into the new contract. I’ll come to that in a bit more detail.

From the commissioners’ point of view, the old system wasn’t ideal. You did have this scenario where effectively you could have two identical cases treated by two separate people, and the amount of money involved was vastly different, because of the way they treated the cases. There was perhaps a tendency, and I think this is a fair comment under the old contract; there was a tendency in some small circles for over-prescription. There was no restriction on treatment. David’s already touched on IOTN, which is one of the favourable things about the new contract. But this didn’t exist historically. And so there was a tendency to over-prescribe not just in terms of the appliances, but in terms of perhaps treating patients who didn’t require treatment on health grounds. There was essentially no capping of funding. Also there was, with the old system, a degree of inequitable provision in certain parts of the country. And residual areas within the country where there really was unaddressed treatment need. So not ideal really.

Which leads us on to where we are now. And the PDS contract, as you all know, came into play in 2006 after discussions going on for several years. A number of changes had been proposed before we finally adopted the system that we now have. The basic underpinning principles, most of you will be very familiar with these, are very much the same as the general dental contract. At the time there was a three year income protection offered to providers. Essentially, each provider was given a calculated annual contract value, which was based on historic earnings between the period October 1st 2004 and September 2005. This was then divided into twelve equal, monthly payments, and everybody at the time who held a GDS contract was eligible to a PDS contract.

Unlike dentistry, there were lots of pilot schemes, although very few of the pilot schemes actually resembled the final dental contract. But luckily in orthodontics, actually there was quite a lot of good piloting and in fact Sue Gregory, who’s here today, was very instrumental in setting up the Bedfordshire pilot scheme, upon which primarily the current contract is largely based. So there was an opportunity to pilot this scheme and we were very grateful as a society to also be

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involved in negotiations when it came to actually implementing the contract as well.

There was one fundamental difference with the General Dental Contract, and that was that it was recommended that because of the long-term nature of orthodontic treatment the initial contract should be a five year contract as opposed to the initial three years in general dentistry. But there are fundamental differences. Now if GDS, the old contract was very much just a fee per item, and the PDS, (and I’ll come to a bit more detail on this in a moment), wasn’t the same. In essence, in GDS every contract, every form represented an individual contract directly attached to that patient. It was a fee for that case, to take the case to completion. GDS, PDS is not really like that at all. The fundamental difference really is that it is not a payment per patient. It isn’t a case of twenty one units per case.

Basically the PDS contract is an ongoing contract to provide a complete service for the duration that a provider holds that contract, and no longer. In effect it just includes everything you’d be expected to do as an orthodontist, so it includes assessment, it includes starts, it includes the repairs which were previously paid for as an item of service, it includes retention, and it includes progressing and treating an on-going caseload. So it doesn’t represent some of the misconceptions; it doesn’t necessarily represent a payment per case and it is not a payment in advance either. It is simply, in some ways more akin to a salaried position. I, as a provider just pay an annual fee to provide a complete service. And the day my contract ends, for whatever reason, that responsibility would pass to the person who takes over that contract. That issue of transfer of contracts is something we’ll be returning to a little bit later in the day.

This has been described in various documents, although I think this concept is still a little bit misunderstood. Even Department of Health guidance doesn’t explain this fundamental difference between PDS and GDS perhaps as well as it could. And this misunderstood nature of PDS has created quite a few problems. I’m constantly called into various negotiations or disputes between providers and PCTs, and a lot of the disputes do relate to misconceptions about the nature of the new contract. And in particular, it has created issues when a contract ends, for whatever reason, whether it’s for retirement, whether it’s perhaps for someone selling a practice, for whatever reason.

For example I was involved in a dispute, in the not too distant past, where a practice sale was going ahead. A three-way discussion had taken place between the seller, the buyer and the PCT. But yet they were involved in a rather complex series of negotiations to negotiate how much payment the person taking over the contract should be given from the person relinquishing the contract to finish off the old cases. And they were working it out on an old item of service type arrangement, trying to calculate what percentage of each case was left to complete the cases. And this represents -with all three people in this arrangement - a misconception of the nature of PDS. So there are some issues relating to this.

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One thing I want to throw into the mix is the issue of recurrent and non-recurrent funding, which complicates this and muddies the waters slightly. Having said, with PDS that payment is not a payment related to each patient, to take that patient to completion, when a contractor ends the contract, their responsibility also ends. It’s not quite the same if you consider non-recurrent funding, and I know a lot of you will perhaps at times, have issued some non-recurrent funding to a provider. Perhaps to address a waiting list, etc. And we ourselves have been involved in receiving such funding. Now this is slightly different because if a commissioner comes to me and says, you know Richard, can we commission an extra two thousand UOAs from you, that doesn’t come with an ongoing caseload, it’s basically a fresh start. Also that funding will stop. It will perhaps be paid for over twelve months, perhaps as a lump sum. So that in effect is an item of service payment. It is non-recurrent funding related to taking a group of patients to completion. So that is slightly different. In some ways if you have recurrent funding running alongside non-recurrent funding you’ve got two different payment mechanisms, and that can muddy the waters when it comes to the transfer of contract. Because whereas with my recurrent funding if I perhaps sold my practice, that responsibility and that funding may pass to a new provider, with the patients I’ve been paid to treat on a non-recurrent basis, I have basically been paid to complete their cares. So it just muddies the waters slightly. I just wanted to throw that into the mix, and it’s something that maybe needs a little bit of further thought.

So summarising the good things, (and there are a lot of them), I think from the Department of Health and PCTs and Commissioners’ point of view it does cap the funding. The introduction of IOTN really does direct treatment towards people who most need it. It does eliminate some of the problems we’ve had in the past with over-prescription, in terms of appliances, and also in terms of treating patients who perhaps don’t require it. From the providers’ point of view there are a lot of benefits as well. We’ve moved away from this system where we were basically paid two years in arrears, it’s a regular income stream as well.

At this point I want to give you a little bit of background about the UOA and the concept of this. Originally when I was involved, along with Keith Pearson and a few others, in discussing the, the orthodontic contract, it wasn’t proposed to have a unit of activity. In fact going back to the original pilot schemes, very few had such a concept really. With the Bedford Pilot Scheme essentially, activity was based on historical activity. But a unit of currency wasn’t applied in the same way that we have it. However, we thought it was quite important, and the reason for this is we wanted to level the playing field a little bit. We were aware that around the country there were vast discrepancies in what people were effectively being paid per case, because again sadly in some cases this was because of bad clinical practice; perhaps over-prescription. And we didn’t think it was fair that if we based it purely on historic activity, and you had practitioner A who treated a hundred cases in a year, practitioner B who managed to treat two hundred cases a year for the same level of funding, we didn’t think it was fair that moving forwards, the practitioner who had perhaps been guilty of over-prescription was effectively being paid twice as much for the same productivity. So we thought it was useful to try and introduce some sort of value. And that’s why this concept

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of the unit of orthodontic activity came about. And in fact it was then adopted in dentistry as well as the UDA.

And essentially the way it works is, as I’m sure you’re all familiar, there are really only three claims of any note. An assessment effectively produces a unit of activity; a treatment is twenty and interceptive treatment on young kids is three. Perhaps moving forwards this is something we need to revisit and perhaps a slightly more flexible structure might be better. But again in keeping with PDS it’s important to note that it’s not necessarily twenty units to treat that case. These are basically just triggers. They’re just a measure of overall activity and a contract will be for a certain number of UOAs. In October 2005, when we did the calculations for the historic activity, at that point the notional fee that was adopted nationally was £55, although when we moved into the new contract there was immediately an uplift in the 2.5% uplift that was received that year. So in effect, when we moved into the new contract in 2006 already there was a slight increase. And there has been an annual increase every year, although this year as you know there was very, very little increase in that value.

To give you an example, a normal patient over ten years old essentially at the point of starting the treatment, generated twenty one units of activity, which included all their treatments, including their retention. And for as long as I held that contract I would be obliged to continue progressing that patient’s treatment. There was also the theory at the time that because IOTN was directing treatment to those more needy cases, that cases on average were perhaps slightly more demanding than they had been under the old contract.

One of the other key things that came in with the new contract was the supposedly more stringent monitoring. And this is a theme David Morris already touched on and we will be coming back to later in the day, when we will be covering this in a bit more depth. PAR: There are various indexes out there, but PAR is perhaps the best understood, and whilst it has some limitations, it is probably the most suitable. Now it was always the proposal when we talked about the new contract that it should be the first twenty cases, plus 10% thereafter. And I think by making it the first twenty cases, that took the element of choice away from providers. But somehow that got lost along the way. And the mandatory obligations are simply for twenty cases plus 10%. But, as David highlighted, providers are at perfect liberty to choose, to hand-pick those cases, and they don’t have to be assessed independently or by a calibrated operator. So it does mean that it brings into question the validity of the monitoring, as it stands. I’ll come back to this a little bit later, when we talk about the Steele Report. This is perhaps something we should revisit locally and nationally, to try and introduce some far more stringent and robust monitoring as we move forward. Again I won’t dwell on IOTN as David has touched on it already, but another benefit of the new contract was the introduction of IOTN. And not only does it mean that treatment is really being addressed and aimed at people who really need it and would benefit from it, but it’s a very useful counselling tool as well, when it comes to explaining to patients, parents and dentists, why patients may or may not be entitled to NHS treatment. I think that is something that we would certainly welcome.

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So there are lots and lots of good things about the new contract, but there were some bad. And certainly most of the bad things initially surrounded the issue of budgeting, contract values and the concept of historic earnings. So recapping the historic earnings, or the calculated value, was based on the period October 1st

2004 to 2005. It was based on all payments received, although UOAs were only calculated based on the clinical payments. If you look back at the historic schedules there would be payments for things like audit, for various other payments as well, and they didn’t come into the calculation; they weren’t divided by £55. That explains why there are slight differences throughout the country now in terms of UOA values. Basically the actual UOA value was £55 to start. It has increased incrementally and those slight discrepancies are accounted for by the non-clinical payments, which still appear on the schedules. They’ve been perpetuated but they’re not divided by £55. And that’s why there are minor discrepancies throughout the countries.

In most years there’s been an uplift. This current year is a slight exception. So what’s the problem with that? Surely that all sounds perfectly fair and reasonable? Well the problem relates to the fact that in orthodontics we were paid in arrears. In general dentistry that wasn’t an issue. I think over that period, that historic period, earnings were a fair reflection of activity due in that time. If we return to the old GDS, and it was quite complicated, having said we were paid in arrears that wasn’t quite true, that’s a little bit simplistic. Things like exams records, etc, were paid at the start of treatment. There was a small payment; 20% of the treatment cost paid at three months after the start. The remainder came at the end of the treatment, and then the retention was paid separately a year later. So it was a pretty complex equation. But it basically meant that for your income to actually reflect what was being done, it took about three years for that to level off. And that meant that DPB payments over that period of time didn’t actually reflect the activity that was being carried out and as a result, historic earnings were a very poor indicator of activity in orthodontics.

Now this was something that was raised at the time. If we look at DPB expenditure due in that time there was a fairly steady increase in expenditure annually from 1992 right through to the period of historic earnings. And that graph continued for a year or two after that as well, until we actually went into the new contract. But in every year what it basically meant was the expenditure actually reflected the activity two years previously. So that increase in expenditure obviously did reflect an increase in activity throughout the country. But as a result, it meant that when we went into the new contract at April 2006, budgets nationally at a PCT level and at a local practice level, were basically fixed, reflecting activity two years before that - and that created some problems. It meant that nationally the budget probably wasn’t quite the size it would have been if we’d carried on with the old contract. It meant that at a smaller, local level those practices that were new and setting up, ended up with extremely small, and sometimes in some cases, zero contract value, despite the fact that they were working and providing a service. And it also meant that around the country those areas of treatment-need, where there was a shortage of orthodontists, continued to have a low funding level. Those areas that were well provided for ended up with plenty of funding. So it didn’t address those problems.

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Hindsight is a wonderful thing, but the contract values were basically calculated and allocated before there was any negotiation whatsoever. And those of you who were around and involved in orthodontic commissioning at the time may remember that basically there was very little negotiation with orthodontic providers at the time. In fact at one point most PCTs said, look don’t talk to the orthodontists at this stage until we sort of get things sorted out. So the contract values were essentially set in stone before negotiation, based on historic earnings and no needs assessment had been carried at this stage. The PDS contracts were then awarded. (We obviously have the transitional issues to go through which I’ll come to). In a lot of areas since then, needs assessments have been carried out to assess provision. But in hindsight, perhaps that should have been the first step. And whilst we talked about the new contract for many years, when it finally came to putting it in place, it all seemed a little bit rushed. Perhaps in hindsight we should have done it a slightly different way.

I will give you a case study, just to show how that worked. One of our practices in Sevenoaks was quite a new practice at the time. During the historic period the income or the historic earnings were nearly £120,000. But during that period the practice had started a hundred and sixty cases and finished only seventy, which is typical in a growing practice. We were starting more than we were finishing. And, and in fact the caseload at that point was over three hundred, not atypical for a hundred and fifty starts a year. So again it shows that the practice is growing. But we were given a contract value of £117,000, and at that funding level, despite the fact we get six hundred referrals a year, we could only start fifty three cases a year, compared with a hundred and sixty in the historic period. Now thankfully there’s a happy end to this story. And more recently this particular PCT have carried out a proper needs assessment in discussion with their consultant in dental public health. They have gone through a proper procurement programme. They have commissioned some more orthodontic treatment and we have successfully tendered for a contract which brings up the provision to a level in fact greater than it was in 2004. So the system has worked, but it’s taken three and a half years to rectify that problem. And this, sadly is despite reassurances at the time from the Department of Health, that this wouldn’t happen. There were reassurances in this particular gateway document that these issues would be taken into account, and sadly that wasn’t the case,

Anyway, moving on to the Ugly and the transitional issues. These are things that still cause issues to this day. To recap, the old GDS was paid in arrears on a fee per item. PDS is paid currently for a service. It’s a completely different concept. What about those cases, which at the point we went into PDS, hadn’t finished their treatment? What happened about those? Well this was obviously something we needed to discuss. And there were numerous ways of tackling this problem that we talked about at the time. One was to go through every single case, in much the same way as the old contract. If, under the old contract for example, I had a patient who left me or went to another part of the country, we would assess how much work I’d done and I would be paid according to that. And the new person taking on the treatment would be paid according to what was left.

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So one possibility was to do that for every single case in the country. Now that was going to be a nightmare, so we decided that it would be far better if we could agree a global figure. Which is where I got involved. We did quite a few audits on lots of lots of patients in large, established practices and it was fair to say that at any one point every patient in a practice was, on average, halfway through their treatment. i.e. for every patient starting, you had one finishing. For every patient at their second visit, you had one visit from one who was one from finishing etc. However, the longer appointments did happen at the start of the treatment, and all the material costs also were front loaded.

So after a little bit of maths and knocking around with various spreadsheets, we came to an agreement that, on average, the value of the work completed but not yet finished or paid for, was 70% per case. And that was where we came up with this 70% payment for the patients who hadn’t completed their treatment. So what about this missing 30%? We were paid 70%, what about the other 30%? Now this is a question that to this day we still get asked regularly by orthodontists and by various PCTs. Was the UOA value uplifted at that point to make it bigger than it should have been, to account for finishing those cases? Well this wasn’t helped by one document which came out at the time, which was the Orthodontic Hints And Tips document, which stated; the UOA value takes into account the 30% for funding completion of cases started in the GDS. And whilst that is true it is a little bit simplistic and misleading as I’ll now show.

To understand this, we need to return to the nature of PDS. And as I say it’s a completely different concept to GDS. It’s not a payment per patient. It is simply a payment for me to treat people whilst I hold that contract. So the continuing care of patients is always included as a part of the contract. Now when we went into the new contract, of course we didn’t have anyone that I’d started under the new arrangements, but I had a whole host of patients I had yet to complete from the old arrangements. So those patients became my ongoing cases. Now three years on, every year I’ve got some patients from the previous year. So the philosophy just continues. So there were always cases every year that are incomplete from the previous year.

The original UOA value was actually based on analysis of the pilot’s studies. And in fact the Bedford Pilot Scheme didn’t have the UOA concept that we currently have. But what happened was that it was revisited and the concept of UOAs was applied retrospectively to the pilot study to work out what was a reasonable UOA value. And the activity levels in the Bedford Pilot Scheme were linked to their own historic activity. And so it is entirely true to say that the UOA value has been set at a level that includes treatment of old cases. But it is misleading to say that it was artificially inflated by 30% to complete the old cases.

So just a couple of things on which to finish, to give you a bit of food for thought. All of you will be all too aware of the Steele Report. And I just want to pick on a couple of things, David’s touched on one or two of these already, and Sue Gregory is going to cover this in more detail. Generally I think we welcome the outcome of the Steele Report and it’s been generally very well received by all; the BDA and by the Department of Health. It is, as Sue has said, a very

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comprehensive document. One of the things that I think we would welcome is the importance it places on quality assurance. This is something that at the moment I think we need to look at developing further. The Steele Report says we recommend that a high priority is given to developing a consistent set of quality measures. But it also points out that the local PCT should not need to develop their own quality measures, i.e. we shouldn’t really have to reinvent the wheel. This does represent a waste of resource. So I think this is an opportunity for perhaps the British Orthodontic Society to work together with the Department of Health, perhaps with the BSA as well, and feed information to clinical networks to develop some more robust quality assurance. Perhaps focussing on things like patient satisfaction.

Luckily orthodontics lends itself quite well to measurable outcomes. We do already have some good indexes, such as PAR, but I think it is important that we apply them in a much more independent and randomised way than we currently do to get some valid data. I think that’s a really positive thing to come out of the Steele Report and something that we can all work together to achieve.

One of the other criticisms of the Health Select Committee Report, picked up in the Steele Report too, which I think is in some ways a fair comment, and demonstrated by our little straw poll earlier, is that there has been a lot of changeover in PCTs. A lot of you have perhaps come into orthodontic commissioning over the last year or two. And whilst there’s been a very steep learning curve, and a lot of people have really picked up the principles very quickly, there is perhaps a slight lack of guidance on some issues. There is perhaps a lack of opportunities to exchange ideas and share learning. And I think perhaps in the past, a lack of local engagements as well. And whilst they are problems, there are lots of opportunities now to share, to solve these. And that’s one of the principles of today, to create an opportunity for commissioners to get together, with providers as well, to share ideas and share good practice. The concept of managed clinical networks again is something that we’ve been pushing hard to develop the last couple of years. And there are documents on the British Orthodontic Society website that will hopefully help PCTS and local networks establish themselves. So the Steele Report said, we recommend that PCTs should be required to demonstrate good organisational structured, including senior leadership, strong clinical engagements and that perhaps strategic health authorities and the Department of Health oversee this process. We would welcome that and I hope that we can work together towards achieving that as well.

We feel strongly that shared learning is the way forward, hence the reason for today. And hence the reason we have set up a commissioning section on our website. A lot of the documents that David Morris has referred to are downloadable on that website, as are all the documents to do with managed clinical networks. I should mention, if you haven’t already picked it up, all the content from today’s talk is also going to be on the website in the not too distant future as well, and we also hope on the Primary Care Commissioning website as well.

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So we fully believe in the value of local engagement, as highlighted by the Steele Report and clinical networks. And we really do want to work towards you in helping establish those. And I think most areas of the country do have clinical networks established now, although they are working to varying degrees of success, but hopefully that is something that we can work towards. We want to try and introduce a managed clinical network newsletter, where good practices can be shared between managed clinical networks as well.

Post 2011 is the final thing I want to talk about. Nigel Harradine touched on this a little bit earlier on. It’s only eighteen months away, and it is coming around alarmingly quickly. As mentioned, orthodontic treatment does take a long time, and continuity of care is important. There are various things that are coming on the horizon now, the increased skill mix, which is something that’s happened over the last five years. We now have therapists and we now have dentists with special interests. Obviously these need to come into the equation. We are conscious that, and I think it’s only reasonable, that primary care trusts do ensure they are getting value for money. And we want to work with you to ensure that is the case.

But one thing that I would like to highlight is the importance of actually starting the process of renegotiation. Now I, like many people, don’t believe it’s going to be a problem when we get to that point, but I think it’s important to understand that a lot of orthodontic businesses are independent businesses and a lot of them need not just verbal reassurance but perhaps written reassurance, particularly when it comes to finance in business and raising finance to invest in businesses. Nowadays banks aren’t amenable to a nod and a wink, and you know from personal experience I’ve experienced this recently, that banks are looking for assurances and contracts beyond 2011, to ensure that we can continue to invest in practices. Now I am aware of a few primary care trusts who have already gone through this process, and there are some providers I’ve been speaking to the last few days who have already extended their contracts to 2016. But I think this is now something that should be very much on the agenda.

To wrap up then, generally returning to our good, bad and ugly theme, there have been lots of good things about the new contract. It has enabled us to perhaps control orthodontics expenditure. IOTN has been very welcome. The new contract has eliminated over-prescription. And from a business point of view there are lots of benefits; the regular payment and the regular income stream. Nationally and at a local level though, the initial way the funding was calculated has created problems. There are continued issues over GDS and PDS and the transition, whilst we worked it out as scientifically as we could, was sadly open to abuse. It was quite difficult, and there are still ongoing issues. The inequitable provision geographically hasn’t yet been addressed, although thankfully we are starting to see proper needs-assessments being carried out and new procurement programmes. So gradually there has been investment in dentistry so hopefully gradually, that is something that we can see addressed. Although the Steele Report did recommend that in future, funding will be dealt with geographically according to need rather than historic income. So it will be interesting to see what some people here think how that might be achieved.

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And because of the misunderstood nature of PDS, there is a potential difficult end of contract, for whatever reason, whether it’s retirement, sales, etc. In general I think we would consider the new contract to be fair and it is a massive improvement on what we had before. But the problems persist due to the funding levels, the difference between GDS and PDS, and perhaps the lack of shared learning at the moment. But hopefully this is something we’re going to correct. And there is still the nagging uncertainty of what happens post 2011, despite lots of the reassurances. I personally don’t think it is a problem, but I think it is important that we actually deal with this formally, fairly soon.

But I think the future is bright. Whilst there have been issues, and in hindsight things may have been done slightly differently, I think we now have a lot of opportunities to rectify these problems and work together towards creating a better service for patients.

KEITH PEARSON: Thank you very much Richard for that overview of the PDS Agreement, I think it’s very important that we all understand where the PDS Agreement came from, where we are now, and where we’re heading to.

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Part one

Documents

Transcript of Part one