Public Health Wales & Hywel Dda Health Board Oral Health Plan for Hywel Dda Health Board
Local Oral Health Plan
Hywel Dda Health Board
Authors: Bryan Beardsworth, Asst Head of Primary Care & Dental Services, HDHB
Dr Hugh Bennett, Consultant in Dental Public Health, Public Health Wales
Date: December 2013 Version: 1
Publication/ Distribution:
Final Version to be sent to Welsh Government
Review Date: Continual
Purpose and Summary of Document:
Provide a framework to improve :-
a. the oral health of the population of Hywel Dda
b. access to dental services
c. quality assurance of dental services
Work Plan Reference:
Service Development / Health Improvement / Quality and Safety
Public Health Wales & Hywel Dda Health Board Oral Health Plan for Hywel Dda Health Board
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Delivering Good
Oral Health Together
An Oral Health and Dental
Service Improvement Plan for
Hywel Dda Health Board Reducing Inn Oral Reduced inequities
A Three Year Vision
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Foreword
On 18th March 2013, Welsh Government (WG) released a national Oral Health Delivery plan. In response to Hywel Dda Health Board must develop a local plan, indicating how it will achieve the aims and objectives set out by WG. This Local Oral Health Plan (LOHP) outlines an agenda for improving oral health and reducing oral health inequalities in Hywel Dda over the next three years and beyond. The LOHP raises some significant long term aims and objectives, However, it is vital that it also has a strong shorter term focus in order to begin the developments, The LOHP will be a evolving plan and subject to regular review and revision, to ensure the plan is reactive to changes in service need. To achieve our aims change is required. The skills, experience and dedication of the dental workforce are, and will remain, a vital resource upon which we will need to draw to achieve that change. Oral health is an intrinsic part of general health, and it is the responsibility of everyone involved in delivering health services to play a role in helping to deliver the oral health improvement we need to see. There remain significant differences between individuals with the best and worst oral health in Hywel Dda. We must improve the health of everyone in our area and pay particular attention to the young, and reduce inequalities. Services must be encouraged to deliver modern prevention orientated NHS dental services resulting in high quality care. Prevention is at the core of this plan. Reducing the risk factors that lead to oral disease is only possible if the delivery of dental services and oral health improvement programmes are orientated towards primary health care and prevention. One of our major goals must be to help people take responsibility for ensuring their own good oral health.
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Our Vision
Our vision is to improve the oral health of the people of Hywel Dda, and access to dental
services by delivering high quality services in an efficient & effective manner. The aim will
be to deliver services locally and from a Primary / Community Care setting wherever
possible.
To achieve this, the approach will be to focus on supporting the Designed to Smile
program and other oral health promotion programmes, clinical engagement, partnership
working and developing integrated care pathways.
Action Required
Adoption of this Local Oral Health Plan in order to provide a framework and to strategically
underpin improvements to oral health and the provision of dental services.
Due to current levels of funding, investment and geographical challenges, improvements in services will require the Health Board to work closely with neighbouring Health Boards, to take a regional approach to planning, commissioning and provision of services.
Delivering the Vision
The purpose of this document is to set a way forward for improving oral health and delivering on the actions set out the National Oral Health Plan 2013. Poor oral health blights the quality of life of those affected, failure to improve Oral Health will result in future generations suffering with its associated problems. Good oral health is to be valued; it is a major contributor to good general health.
Our key aims are to:-
• prevent poor oral health and reduce oral health inequalities.
• improve access to dentistry so that patients have timely access to emergency, urgent, routine and specialist dental services.
• address the inequalities in geographical distribution and numbers of the dental workforce in all three dental services.
Key Strategic Documents
• Together for Health - A National Oral Health Plan
• Together for Health - A 5-year vision for the NHS in Wales, sets out WG`s collective aim
• Our Health Future & Fairer Health Outcomes
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• Doing Well Doing Better: Standards for Health Services in Wales, sets out the standards for health services in Wales, including dental services.
To help deliver this Local Oral Health Plan (LOHP) the Health Board will need to work with
a wide range of dental service users, the dental workforce, other Local Health Boards
(LHBs), Public Health Wales (PHW), the Department of Dental Postgraduate Education,
the NHS Business Services Authority Dental Services Division and other partners,
including Education and Local Authority Social Services.
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Chapter 1
Oral Health Improvement
Our key aims are to:
• Reduce the prevalence of dental disease, especially in young children and other vulnerable groups.
• Reduce inequalities in the prevalence of oral disease.
• Increase the awareness of self-care through increasing the range of measures people can follow at home to improve and protect their oral health.
• Ensure that oral health improvement actions are evidence based. The LOHP has been informed by A Picture for Oral Health in Hywel Dda which provides an overview of oral health status (see appendix 1). In addition, the report NHS Primary Dental Care Provision in Wales, Exploring current service use and the distribution of services in relation to need Clinical and Applied Public Health Research, Cardiff University Dental School June 2011, presents the results of an in-depth analysis of dental care (excluding orthodontics) undertaken by general dental practitioners in Hywel Dda Health Board (HDHB). It expands on the Health Equity Audit reported in September 2010, with an emphasis on how current dental care relates to demographics within the Health Board area.
Demographics - What is happening to the population of Wales?
The population of Wales has gradually increased between 1999 and 2009 and now stands at nearly three million. During this time the number of people aged under 35 decreased by 2.6 percent while the number aged 65 and over increased by 9.1 percent. The number of live births in Wales increased from 32,325 in 2004 to 34,937 in 2009. The population is projected to increase further reaching 3.2 million by 2023, and continue to become gradually older. These demographic changes will have a major effect on service planning, development and delivery.
Approximately 10% of the population of Hywel Dda Health Board is aged over 75 and
this age group is predicted to double to 70,000 over the next 20 years
As patients retain teeth into older age there is likely to be a related increase in complex
dental problems, with increasingly complex medical co-morbidities and polypharmacy. This
will probably result in increasing demand for skilled general dentists and specialist
services.
Tooth Decay in Childhood
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The most common oral disease of childhood is dental caries, often called tooth decay. Children in Wales have the poorest dental health in Great Britain. Tooth decay is found in deprived and affluent communities but is more common and likely to affect more teeth per child in deprived communities. Therefore, while half of the 5 year old children across Wales have no decayed teeth, the other half experience a high disease burden and have on average four teeth decayed or filled or extracted. The trend in prevalence of child dental decay in Wales is generally static; this suggests that Wales is likely to have the poorest child dental health in Great Britain for some time. The dental health of Welsh 12 year olds has improved. There have been dramatic improvements in decay levels in permanent teeth since fluoridated toothpaste became widely available in the 1970s. However, despite this improved situation, Wales still lags behind the rest of the UK.
The Consequences of Poor Child Dental Health
The consequences are multiple, and all the more concerning because they affect the youngest in our society. Tooth decay commonly results in pain and infection, often resulting in sleepless nights, time off school and possible need for general anaesthesia to treat effectively. There is an impact on children`s general wellbeing, disruption of schooling, with parents and other family members having to cope with a child in pain. On average across Wales in a class of thirty 5-year-olds,four children would have experienced dental pain in the last 12 months. Table 1 gives an indication of the Health Board’s position in relation to the 2020 target.
Welsh Government Targets
Dental health targets were set for Wales in Eradicating Child Poverty in Wales - Measuring Success In summary:-
• By 2020 to reduce the levels and burden of decay at age 5 among the most deprived quintile of the population to that recorded for the middle deprived quintile.
• By 2020 to reduce the levels and burden of decay at age 12 among the most deprived quintile of the population to that recorded for the middle deprived quintile.
We intend to vigorously address this inequality in experience of child tooth decay over the next 5 years. For the most deprived fifth of 5 year old children in Wales, the average dmft (decayed, missing due to caries and filled index) was 2.7 in 2007-8 when the baseline was set. The national child poverty target is to bring this average down to 1.77 by 2020. The percentage with caries (%dmft>0) was 57.6% for the most deprived fifth of 5 year olds in 2007-08 and the national target for 2020 is 44.1% (Table 1).
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There are no specific local health board targets, but we can use the Welsh targets as a bench mark. There has been an improvement in both average dmft and the %dmft>0 for children in Hywel Dda between 2007-08 and 2011-12 across all deprivation quintiles. Furthermore, the children living in the most deprived areas have an average dmft of 1.50 and a %dmft>0 of 34.9%, which are below the Wales targets for this group. But, when considering the ratio of the most deprived: middle deprived for average dmft it can be seen that Hywel Dda has experienced a widening of inequalities as the ratio has increased from 1.2 to 1.40 (Table 1). Table 1: Average dmft & %dmft>0 for 5 year olds by quintiles of deprivation index, for Wales and Hywel Dda Health Board
5 year olds 2011-12 5 year olds 2007- 08
WALES Hywel Dda Wales Hywel Dda
Mean DMFT
%DMFT>0 Mean DMFT
%DMFT>0
Mean DMFT
%DMFT>0 Mean DMFT
%DMFT>0
Least deprived 1.00 31.3 0.80 22.5 1.2 34.5 1.50 34.6
Second least deprived 1.2 32.8 1.2 33.0 1.6 41.3 1.9 48.2
Middle deprived 1.5 41.4 1.1 31.9 1.8 44.1 2.1 47.2
Second most deprived 1.9 48.3 1.6 42.9 2.0 49.2 1.9 47.2
Most deprived 2.2 51.5 1.5 34.9 2.7 57.6 2.5 52.9
All within area 1.6 41.4 1.2 33.1 2.0 47.6 2.0 47.4
Ratio – most deprived : middle deprived
1.4 1.2 1.4 1.1 1.5 1.3 1.2 1.1
Table 2: Average dmft & %dmft>0 for 5 year olds in Hywel Dda Health Board unitary authority areas, 2007-08 and 2011-12.
mean dmft %dmft>0
2011-12 2007-08 2011-12 2007-08
Carmarthenshire 1.0 2.2 30.6 53.2
Ceredigion 1.2 1.6 28.7 35.7
Pembrokeshire 1.6 1.8 38.8 44.9
Unitary authority breakdowns of average dmft and %dmft>0 are presented in Table 2, highlighting improvements in the oral health of 5 year olds, but it remains that approximately one third of 5 year olds experience decay. In 2008-9 the average DMFT for 12 year olds for Hywel Dda was 0.80 and for the most deprived group it was 1.18 (Table 3); the LHB needs to ensure that this reduces to 1.12 by 2020 to meet national targets.
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Table 3: Mean DMFT & %DMFT>0 for 12 year olds by quintiles of deprivation index, Wales and Hywel Dda Health Board
For Hywel Dda approximately 1330 children annually undergo a general anaesthetic for tooth extractions. This is unacceptable for what is an almost totally preventable disease. It is a risk to child health and wellbeing that would not be tolerated in other diseases, and this is one reason why we will continue to support Designed to Smile.
Common Risk Factor Approach
The most effective and efficient model for promoting oral health in the community is through the Common Risk Factor Approach. This involves partnership working to address the risk factors shared by common chronic diseases, such as tobacco smoking, poor diet, high alcohol consumption, injuries and a sedentary lifestyle. Coordinated targeting of such risk factors is likely to have an impact on reducing poor health associated with a range of conditions, including obesity, heart disease, stroke, cancers, diabetes and mental illness, as well as oral diseases. In oral health improvement our common risk factor approach is complemented with maximising fluoride delivery in community settings. The evidence supporting fluoride in reducing dental decay is well established. The fluoride interventions that are local priorities for action at a community level are fluoride toothpaste and fluoride varnish. Children who start brushing with fluoride toothpastes in infancy are less likely to develop tooth decay than those who start brushing later. In addition evidence supports the effectiveness of fluoride varnish in both permanent and primary (baby) teeth. Fluoride varnish as a topical treatment has a number of practical advantages as it is well received and considered safe, the application of fluoride varnish is simple, cheap to deliver and requires relatively little training.
mean
n
DMFT
T
%DMFT>0
0
mean
n
DMFT
T
%DMFT>0
0
mean
n
DMFT
T
%DMFT>0
0
mean
n
DMFT
T
%DMFT>
>
0
Least deprived
deprived
0.58
8
30.5
5
0.56
6
31.7
7
0.78
8
35.5
5
0.77
7
40.3
3
Second least deprived
deprived
0.74
4
35
5
0.59
9
27.8
8
0.96
6
41.4
4
1.06
6
44.4
4
Middle deprived
deprived
0.95
5
42.1
1
0.81
1
38.2
2
1.12
2
45.5
5
0.91
1
40.3
3
second most deprived
deprived
1.11
1
45.5
5
0.83
3
34.7
7
1.18
8
48.5
5
1.04
4
40.5
5
Most deprived
deprived
1.31
1
52.4
4
1.18
8
48.2
2
1.35
5
53.8
8
1.08
8
48.0
0 All within area
area
0.98
8
42.5
5
0.80
0
35.6
6
1.09
9
45.1
1
Ratio - most deprived:
deprived:
middle deprived
deprived
1.38
8
1.24
4
1.45
5
1.26
6
1.21
1
1.18
8
1.19
9
1.19
9
WALES
S
Hywel Dda
Dda
WALES
S
Hywel Dda
Dda
12 year olds 2004-05
05
12 year olds 2008-09
09
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Welsh Government is current piloting a new style of Dental Contract which may allow a greater emphasis on health promotion, preventative care and integration with other health services.
Designed to Smile
For several decades Scotland has put great effort into preventing decay in children. Lately through its Childsmile programme, Scotland has been rewarded with significant improvements in child dental health achieving its 2010 targets, and confirming that a sustained national oral health programme can deliver significant improvement in a nation`s oral health. The Welsh Government has no current plans to fluoridate water supplies in Wales. The Welsh Government acknowledges that in view of the poor dental health in Wales, the introduction of water fluoridation has the potential to deliver significant health gains and address health inequalities. It is sensitive to the fact that there are some small groups of people opposed to it. In 2009, in the absence of water fluoridation, the Welsh Government launched the
Expansion of Designed to Smile – A National Oral Health Improvement Programme,
Wales’ national child oral health improvement programme. The programme sets out to
improve oral health in children by targeting preventative care in areas of greatest need.
These areas are identified according to the highest need as shown by Townsend scores,
the Welsh Index of Multiple Deprivation, dmft dental planning areas (DPA), Communities
First, Flying Start and local knowledge.
The program is underpinned by an evidence based review carried out by Dental Public Health at Cardiff University, the D2S website http://www.designedtosmile.co.uk provides a useful national resource for dentists, parents, teachers and other health professionals. It also provides information on local programmes. Significant progress has been made across Hywel Dda. There have been substantial
increases in the numbers of settings taking part in the supervised toothbrushing element of
the programme.
The programme is overseen by the Designed to Smile Steering Group, whose role it is to
manage the overall work programme and the effective use of the budget to deliver on the
service objectives.
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Action Required Continue to support the D2S programme. Production of an annual costed development and delivery plan. Ongoing monitoring of the D2S budget to ensure effective expenditure against the annual financial plan. Regular reporting to the Dental Planning, Performance & Delivery Board, on the roll-out of the scheme to new areas.
Practice Based Prevention
Dentists have a duty to provide preventive advice for patients who attend for dental treatment and are referred to;
Delivering Better Oral Health: An evidence based toolkit for prevention.
Prevention and Management of Dental Caries in Children, Scottish Dental Clinical Effectiveness programme.
Oral Cancer
Many cases of oral cancer could be prevented, the most important aetiological factors in the cause of oral cancer have long been known as tobacco usage and excess consumption of alcohol. These factors together are thought to account for up to three-quarters of oral cancer cases in Europe.
WG recently published Together Against Cancer: A Cancer Delivery Plan for Wales.
The risk of developing oral cancer increases with age and in the UK the majority of cases (87%) occur in people aged 50 or over. In the UK the gender ratio, male to female cases, has decreased from around 5:1 fifty years ago to less than 2:1 today. Many oral cancer patients are diagnosed at a late stage in their disease. The overall prognosis would be considerably improved if patients could be diagnosed earlier. Like most cancers, survival is better for younger than older patients. After the improvement in survival over time was analysed by deprivation group, it became clear that most of the improvement had occurred in the affluent group (Coleman et al 1999).
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Preventing Oral Cancer
Cancer Research UK states, “at least three-quarters of oral cancers could be prevented by
the elimination of tobacco smoking and a reduction in alcohol consumption”. The removal
of these two risk factors also reduces the risk of secondary tumours in people with oral
cancer. The debate on screening is ongoing but better still would be the primary
prevention of at least three quarters of cases through the elimination of tobacco
consumption and the moderation of alcohol-intake, further information can be found at
http://info.cancerresearchuk.org/cancerstats/types/oral/prevention/.
Smoking cessation is associated with a rapid reduction in the risk of oral cancers, with a 50% reduction in risk within 3 to 5 years. Ten years after smoking cessation, the risk for ex-smokers approaches that for life-long non-smokers. Protection against solar irradiation would further reduce the incidence of lip cancers. Patient delay has been cited as the main reason for late presentation and it seems probable that in both high-risk groups and the general population, neither the symptoms of oral cancer nor the main risk factors are well understood. With rising incidence rates, in younger age groups whose expectation of cancer is low, public education is urgently needed, including the increasing evidence of the role of papiloma viruses in cancer aetiology.
Action Required The Health Board will work with Dental Practices in order to support local and national smoking cessation initiatives. Ensure Practitioners have access to high quality post graduate training & high risk groups are targeted by national campaigns.
Oral Cancer patients require specialist dental assessment, treatment and post operative
rehabilitation. We will create efficient care pathways and commission appropriate specialist
dental services to meet the need of these patients.
Adult Dental Health
Successive Adult Dental Health surveys have shown that the percentage of adults in Wales who are without their own teeth has fallen from 37% (1978) to 10% (2009). Complete tooth loss is now more or less confined to those aged 55 years and older, it can be reasonably predicted that the improvements in adult dental health will continue, however of greater concern is the inequality of dental health in adults.
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The impact of socio-economic inequalities on children’s oral health has been discussed earlier, and they also impact on adult oral health. The percentage of individual adults with at least one carious tooth at the time of the 2009 Adult Dental Health Survey varied from 26% of those in professional and managerial positions rising to 37% of those with routine or manual occupations. The percentage of individuals with bleeding gums (an indicator of poor periodontal health) rose from 49% to 59% across the same social-economic spectrum. Overall the data shows that those from manual occupations were judged to be 43% less likely to have excellent oral health compared with professional and managerial groups. In this context the Health Board remains committed to ensuring all dental commissioning, targets resource to areas of need.
Vulnerable Groups
The Welsh Government set out a requirement for Health Boards to provide for the oral health improvement needs of the most vulnerable groups in the population in Ministerial Letter EH/ML/014/08: Dental Services for Vulnerable People and the Role of the Community Dental Service. The description of an individual as vulnerable will vary from time to time, but there are some groups of people for whom there is evidence of health inequality and thus vulnerability. For example, the frail and elderly, people with impairment and disability, people with mental health and medical problems, those with anxiety and phobia, prisoners and the homeless. A strategic approach is required to develop effective services for vulnerable adults and to ensure the current inequalities in access to, and uptake of, services can be addressed and monitored. WG recently published a Special Care Dentistry Implementation Plan.
Action Required The Health Board will seek to implement the national SCD Implementation Plan within their future planning of dental services, to ensure oral care is integrated into the general health and social care plans and pathways. Continue to work with colleagues in ABMU in the development of the South West Wales Managed Clinical Network for Special Care Dentistry.
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Nursing and Residential Homes
WG commissioned two surveys of nursing and residential homes to investigate how their residents access dental care, and to help us get a better understanding of their oral health status and needs of those residents. The surveys showed that many homes do not have written procedures in place to highlight whether individuals have teeth or dentures, dental problems or a desire to see a dentist or are in fact already receiving care from a GDP.
As a direct result of the survey WG published an advice leaflet for residential and nursing homes in Wales, Accessing Dental Care for older people in care homes in Wales June 2011. This leaflet provides information on the importance of oral health care for older people and how they can access dentistry in Wales.
Domiciliary care is currently provided by the Community Dental Service to patients in both nursing and residential homes as well as people who are housebound within their own homes. Robust acceptance criteria is in place for the service.
Action Required In light of the likely demographic changes, it is essential that the need for this service continues to be monitored and integrated into future service planning.
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Chapter 2
The Planning, Development and Delivery of Dental Services
Developing a Strategic Delivery Programme for Dental
Services
Welsh Government have set out Dental Access and addressing Oral Health Inequalities amongst its priorities in its Programme for Government 2011, the planning of services based on need and not demand is vital. Currently Hywel Dda Health Board;
• Provides Community Dental Services.
• Commissions General Dental Services (GDS) from external contractors.
• Commissions Consultant lead Hospital Dental Services (HDS) from ABMU
• Commissions Oral Surgery from external contractors. Ensuring integration between the above and clear care pathways are essential in order to improve delivery of dental services and improve oral health outcomes. The Health Board’s Dental Planning Performance & Delivery Board (DPPDB) has a vital role in setting and overseeing the strategic development agenda for dentistry. It is also important that there is clear Executive Director responsibility for dentistry.
Action Required Ensure the Dental Planning Performance & Delivery Board is led by an Executive Director.
The aim of the DPPDB is to ensure the provision of effective and efficient dental services for the population served by the Health Board within available resources and meeting required targets set by the Welsh Government. In summary, the objectives of the group are to:
• Develop channels for communication and partnership working.
• Develop integration of service through the planning process.
• Encourage a patient journey/pathway approach, breaking down Primary/Secondary distinctions.
• Ensure clinical work is carried out in the most appropriate environment by the most appropriate service.
• Ensure a system-wide approach is taken to implement service plans.
• Ensure all operational targets are met.
• Manage financial resources within the allocated funding envelope.
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Integrating Dental Services
To achieve maximum oral heath gain and efficiency in the delivery of services, primary, community and hospital dental services must be viewed as complementary. We believe that robust local planning of dental services in this context will allow the NHS to develop the most appropriate services and target resources to where they are most needed. We wish to work with our dental service providers, in all sectors, in the development of our clinical services strategy. Aligning planning across all three dental services as described above has the advantage of integrating service provision. Continuing to develop a more robust management structure, supported by the DPPDB will help to facilitate this work. Figure 1. Structure of General Management and Administration of Dental Services
We need to ensure that the right patient is seen by the right service, our vision of how the level of complexity of care is catered for within the role of each service, is set out in figure 2.
Dental Planning, Performance &
Delivery Board
Community Dental
Services Management
Group
Designed to
Smile Steering
Group
Managed
Clinical
Networks
Dental
Services
Team
Dental Operational Group
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Figure 2
*Care that is technically and or medically complex and / or requiring multi disciplinary care
Hospital
Dental
Services*
Specialist Dental Services in
Primary and/or Community Care
(including DWSIs)
General Dental Practice
Routine care, emergency dental care, primary care
orthodontics, intravenous sedation, oral health education.
Community Dental Services
Clinical services including paediatrics, inhalation sedation,
special needs, epidemiology, screening, oral health promotion
Self Care
Advice from professionals, toothbrush and paste for infants, health snacks and drinks in
early years and school, community oral health promoters, links to Designed to Smile
Increasing cost of
care
Increasing
number of
patients
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Health Board Dental Advisory Structures
The Strategic Dental Services Planning Group will be a key mechanism for focusing advice. In addition, we need to have in place a structure to fulfil the statutory requirement for us to consult with the Local Dental Committee (LDC).
Action Required
We will ensure that the Health Board has adequate measures in place to ensure dental
professional advice, including access to that of Consultant in Dental Public Health and
Dental Practice Advice from Public Health Wales.
Work with Dyfed Powys LDC in order to fulfil the statutory requirement for us to consult
with a Local Dental Committee.
Managing the GDS
The Health Board will continue to develop a Performance Management Framework for the management of dental contracts. This will facilitate a consistent application of contracting arrangements and management policy.
Action Required Continue to engage with stakeholders in order to continually improve and implement a performance management framework.
Access to General Dental Services
The following map shows the location and number of GDS & PDS contracts. Implementation of the Performance Management Framework will help identify inefficiencies ensuring maximum resource is directed to patient care, by way of ;
• compliance with NICE guidelines on recall intervals.
• robust monitoring of inappropriate claiming.
• application of Guidance on Management of NHS Orthodontics in Primary Care.
• Improved integration of GDS with other dental services.
• that one off funding initiatives are based upon need and not demand, and have a high probability of health gain outcome.
We will also do our best to encourage incentives to assist the setting up / longer term support of practices in areas of low access and high need.
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Urgent Access (Midweek & Weekend)
For patients who do not have access to regular NHS dental care, the Health Board
provides a number of access sessions across 7 days in multiple locations throughout the
Health Board area.
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General Dental Practices in Hywel Dda
CARMARTHENSHIRE
PEMBROKESHIRE
HAVERFORDWEST
x5
FISHGUARD
x2
ST DAVIDS
x1
MILFORD HAVEN
x4
NARBERTH
x2
WHITLAND
x2
CARMARTHEN x7
(1)
BURRY PORT
x1
LLANELLI x5
LLWYNHENDY
x1
LLANDEILO
x3
CROSSHANDS
x1
TUMBLE
x1
AMMANFORD
x2
LLANDOVERY
x1
BRYNAMMAN x1
CEREDIGION
LAMPETER
x1
ABERYSTWYTH
x 5
CARDIGAN
x2
PEMBROKE
x1
PEMB D
x1
ABERYSTWYTH x5
NEWCASTLE EMLYN
x1
CARMARTHENSHIRE PRACTICES x23:
AMMANFORD
1. Brynteg Dental Practice
2. IDH, Margaret Street Dental Practice
BRYNAMMAN
1. Brynteg Dental Practice
BURRY PORT
1. Achddu Villa Dental Practice
CARMARTHEN
1. AJ Bhattacherjee
2. Brynteg Dental Practice
3. Capel Dental Practice
4. Old Oak Dental Practice
5. SJ Lewis
6. The Parade (orthodontics)
CROSSHANDS
1. Llandeilo Road Dental Practice
LLANDEILO
1. Celtic Dental Practice
2. RAD Phillips
3. Tywi Dental Practice
LLANDOVERY
1. RAD Phillips
LLANELLI
1. Avenue Villa Dental Practice
2. Berwen Dental Practice
3. IDH, Mill Lane Dental Practice
4. Murray Street Dental Practice
LLWYNHENDY
1. Warren Davies Ltd,
TUMBLE
1. Llannon Road Dental Practice
WHITLAND
1. IDH, Hendy Gwyn Dental Practice
2. King Edward Street Dental Practice
PEMBROKESHIRE PRACTICES x16:
FISHGUARD
1. Vergam Terrace Dental Practice
2. West Street Dental Practice
HAVERFORDWEST
1. Dew Street Dental Practice
2. DM Snape
3. Portfield Dental Practice
4. Rhos Cottage Dental Practice
5. Whitecross, The Candle Stores Practice
MILFORD HAVEN
1. Charles Street Dental Practice
2. Haven Dental Practice
3. My Smile Centre
4. Whitecross, Robert Street Practice
NARBERTH
1. HW Jones
2. Winchester House Dental Practice
PEMBROKE
1. Westgate House Dental Practice
PEMBROKE DOCK
1. DB Mothibi
ST DAVIDS
St David’s Dental Practice
CEREDIGION PRACTICES x9:
ABERYSTWYTH
1. Denticare Ltd, Friar’s Park
2. Denticare Ltd, North Parade
3. Eastgate Dental Practice
4. MR Saddington
5. Portland Street Dental Practice
CARDIGAN
1. IDH, Feidr Fair Dental Practice
2. The Charlsfield Dental Practice
LAMPETER
1. Denticare Ltd, The Barn
NEWCASTLE EMLYN
1. Deintyddfa Emlyn
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Primary Care Orthodontic Services
Demand for orthodontic services has been rising for many years, however the service
must be provided in terms of need, a point strongly made in both national and local
reviews of orthodontic services and reiterated in the National Oral Health Plan. Orthodontic
provision must be placed in context with other dental health priorities. In general terms the
dental health of 5 year olds in Wales is the worst in Great Britain. As mentioned earlier in
the document, within Hywel Dda approximately 1330 children annually undergo a general
anaesthetic for removal of decayed teeth, which is almost a preventable disease.
Orthodontic spend within the general dental services currently makes up a significant
percentage of the total funding of primary dental services, it is vital that continued funding
is based upon sound needs assessment, prioritisation and an integrated approach
between the orthodontic dental service providers. A balance in the prioritisation of NHS
dental resources has to be determined.
The current NHS primary care orthodontic contract, pays providers up front, theoretically a
provider of orthodontics might never complete a case and yet still get paid in full. Ideally,
future orthodontic contracts will have an improved outcome based structure.
Key Strategic Documents
National Assembly for Wales – Orthodontic Services in Wales WG Response PHW Orthodontic Needs Assessment in Mid and West Wales
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Summary of orthodontic service provision in Hywel Dda
Figure 5 – Orthodontic Referrals received April 12 – March 13
National clinical criteria determine eligibility for Orthodontic Services, patients must meet the requirements of the Index of Treatment Need (IOTN) to be eligible for NHS treatment. This helps ensure Orthodontic resources are targeted toward need, not demand. Welsh Government published guidance on the management on Orthodontics in Primary Care. In general this called for improvement in the efficiency and effectiveness of the orthodontic services delivered in Wales. Local and National reviews suggest current levels of Orthodontic funding meet the need of the population, but this will only be realised with effective procurement and contracting, appropriate referral behaviour and performance management. Progress has been made with Hywel Dda and ABMU by the development of an Orthodontic Managed Clinical Network for South West Wales.
Action Required Continue to implement the Welsh Government`s Guidance on Management of NHS Orthodontics in Primary Care.
Pembrokeshire Ceredigion Carmarthenshire Other
Orthodontic Referrals
0
200
400
600
800
1000
1200
1400
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Community Dental Services
We remain committed to the provision of a Community Dental Services (CDS). Patients should be treated in GDS unless there are clear reasons for them to be treated in CDS or Hospital Dental Services. WG issued guidance on the role of the Community Dental Services in Ministerial Letter EH/ML/014/08: Dental Services for Vulnerable People and the Role of the Community Dental
Service and was reiterated in further Ministerial Letter in March 2012.
The Community Dental Service should include:
• provision of facilities for a full range of treatment to children who have experienced difficulty in obtaining treatment in the GDS, or for whom there is evidence that they would not otherwise seek treatment from the GDS.
• provision of facilities for a full range of treatment to children and adults who due to their special circumstances require special care dentistry, and/or have experienced difficulty in obtaining treatment from other services or would not have otherwise sought treatment from other services.
In addition the CDS performs other important roles, e.g. screening, providing the field workers of epidemiology surveys and health promotion. A review of the CDS Estate is currently being carried out by Public Health Wales, to identify if the estate is fit for purpose and ensure all sites are used effectively and efficiently. The review will look at all opportunities to ensure wherever possible that sites are multi chair and able to support a range of treatment services.
Action Required
Review the current status of the Hywel Dda CDS in the context of Welsh Government
(WG) guidance and the review of the CDS conducted 3 years ago. In particular to;
Implement the recommendation & ensure the Estate is fit for purpose.
Ensure the skills and skill mix within the service are being used to maximum effect, to
further ensure equitable service provision across the health board.
Develop the focus toward caring for vulnerable groups.
Establish a CDS management group to manage workload and develop the service
equitably across the Health Board & produce a 3 year Service Development Plan.
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Dental General Anaesthetic Services
It is imperative that where possible we must seek to reduce the GA need by ensuring the continued development of community based programmes promoting better oral health using initiatives, e.g. the D2S and Healthy Schools programme. In addition, development of alternative patterns of care e.g. developing the Specialist Dental Paediatric services and workforce and building the capacity of alternative treatments such as sedation.
Action Required
Develop a strategy which seeks to reduce the number of GAs, e.g. where appropriate provide services such as conscious sedation.
Hospital Dental Services The Health board will work with ABMU in order to take a regional approach to service delivery. We need to further develop integrated care pathways and establishment systems for managing referrals into Specialist Services in Primary and Secondary Care, including the introduction of a universal referral proformas, monitoring and evaluation of referral processes in a transparent and equitable manner.
Action Required
Build upon the current working links between Hywel Dda and ABMU Health Boards to
foster a “regional” perspective to planning and delivery of Specialist Dental Services.
Move any dental treatment that is inappropriate for Secondary Care into the Primary, Community and Independent services. Develop robust referral criteria within simplified and integrated care pathways to assist referrers in making the most appropriate choice of care for their patients. Support the further development of referral management systems.
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Oral Surgery
Currently all Oral Surgery is commissioned outside the boundaries of Hywel Dda, resulting in significant travel for patients.
Action Required Develop a commissioning framework for Oral Surgery that seeks to provide services locally wherever possible utilizing a mix of service providers.
The Welsh Dental Committee (WDC) is considering the Review of Oral Surgery conducted
by the Dental Programme Board of NHS Medical Education England and how this may be
applied in Wales. The WDC will report findings to the WG.
Restorative Dentistry
The majority of patients will receive their restorative dental care in the GDS. Hospital based restorative dentistry provides services to those patients with conditions such as cancer, some congenital conditions and trauma. In addition, it provides GDPs with specialist treatment planning allowing them to treat more cases within primary care. This demand is likely to increase as a result of demographic changes.
Action Required Support the regional Operative Dentistry working group in its development toward a Managed Clinical Network for Restorative Dentistry.
Orthodontics
Complex cases that are unable to be treated within Primary Care, are referred into Secondary Care, the service is currently provided by ABMU from Morriston Hospital, Swansea.
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Action Required Continue to support the South West Wales Orthodontic Managed Clinical Network developing improved referral guidelines, agreed monitoring arrangements, and addressing the following issues:- i) Inappropriate referrals where dentists refer children too early, thus inflating waiting lists and causing patients and parents undue concern. ii) Multiple referrals to the limited number of providers available, which again artificially inflate waiting lists. iii) Assessment to treatment ratios – ensuring that patients assessed for treatment receive the treatment in line with timescales set out in Welsh Government guidance, rather than a frequent assessment process without progression to treatment. iv) Identification and appropriate management of urgent referrals.
Specialist Paediatric Dentistry
The Specialist Paediatric Dental service is currently limited to a Consultant who is
dedicated to supporting Cleft Lip and Palate (CLP) services within the Maxillofacial Unit at
Morriston.
There is no other Specialist Paediatric Dental provision in any of the dental services
across Hywel Dda or ABMU Health Board areas. The nearest centre for Specialist
Paediatric Dental Services is at the Cardiff Dental Hospital, however it is not currently
accepting referrals from practices west of Bridgend.
Action Required
Request PHW undertake a review of access to specialist dental paediatric for Hywel Dda
children.
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Chapter 3
Quality and Safety
Assuring Quality and Safe Dental Services
‘Doing Well, Doing Better – Standards for Health Services in Wales’, sets out the Welsh Assembly Government's common framework of standards to support the NHS and partner organisations in providing effective, timely and quality services across all healthcare settings. The revised standards came into force the 1st April 2010. The updated framework of standards presents the requirements of what is expected of all health services in all settings.
Standards provide a consistent framework that enables health services to look across the range of their services in an integrated way to ensure that all that they do is of the highest quality and that they are, “doing the right thing, at the right time, for the right patient in the right place and with the right staff”. The standards are used by all NHS organisations at all levels and across all activities as a key source of assurance to enable them to determine what areas of healthcare are doing well and those that may need to do better.
The Standards are incorporated into a number of key assurance systems in dental care, including the Self Assessment Quality Assurance system in GDS and Dental Reference Service practice visits and reporting. The Health Board will ensure all dental staff are appropriately trained and knowledgeable to enable them to have the skills and competencies to deliver the care needed. In addition, dental staff need clinical and service environments which support the delivery of high quality dental care. The care provided should be evidence based with clinical audit and significant event analysis in place to monitor and improve existing dental practice. It is vital that as a Health Board we have systems in place which recognise and act upon poor performance.
The Wider Picture in Quality and Safety Improvement in
Dentistry
In Wales we are fortunate to benefit from strong working links between the office of the Chief Dental Officer for Wales, Public Health Wales Dental Team, Health Boards, the NHS Wales Shared Services Partnership, the Department of Postgraduate Dental Education and the Dental Reference Service. This is particularly beneficial to how, in Wales, we support and deal with practices and practitioners whose performance gives rise to concern.
It will be important to retain and build on the processes and systems in the future to ensure that the dental team can continue to deliver a high quality, safe and effective service. One
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specific area we need to focus on as a Health Board is the support provided for non UK qualified dentists commencing work with the NHS GDS in Wales. Performance measures in dentistry should improve the ability to measure effectiveness of care and use of service. As we have indicated above we will begin to standardise high level reporting and have requested Public Health Wales to develop a GDS Governance Framework and an annual Reporting Matrix. This reporting will embrace Quality and Safety. In Hywel Dda / Wales the Dental Reference Service (DRS) visiting programme, inspecting and reporting on every practice with a GDS/PDS contract on a three year cycle effectively ceased 31 March 2013. In the interim arrangements have been made nationally for the DRS to retain visiting to those practices deemed of presenting a higher risk, while the PHW Dental team will visit new and refurbished practices. The dental public health team of Public Health Wales also manages the annual Quality Assurance Self-Assessment process on behalf of the Health Board, whereby every contracted practice is requested to make a QAS return. The returns are collated, scrutinised and reported to the Health Board. The Private Dentistry (Wales) Regulations 2008 came into force on 1 January 2009. These regulations require all dentists that practice any private dentistry in Hywel Dda / Wales to be registered with Healthcare Inspectorate Wales (HIW). HIW have an arrangement with the DRS to visit and report on private practices to the same standards as applied to NHS practices across all of Wales.
Information and Communication Technology in Dentistry
General Dental Services – the WG primary dental care strategy, Routes to Reform 2002, stated that, “The needs assessment identified that general dental practitioners consider they have fared badly in IT developments when compared with their colleagues in the General Medical Services and perceive this as further evidence that they are not embraced fully within the NHS Family. It is of concern that this statement still holds credence some 10 years later and we are determined to address this. The extent to which Hywel Dda practices utilise information technology varies widely. At one end of the spectrum some practices are fully computerised and utilise complex patient management systems, which are capable of maintaining clinical records (including digital radiographs); organising appointment scheduling and patient recall systems. They can also transmit claims directly by electronic transfer to the Dental Practice Board. On the other hand, some practices barely make use of information technology, if at all. However, since 2002 the percentage of practices transmitting claims by electronic transfer has increased but some practices still submit paper claims.
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Community Dental Services - Since 2002 there has been development of IT infrastructure within many of the CDS services across Wales. This has not been mirrored in Hywel Dda. It is of concern that the Hywel Dda CDS still does not have an integrated IT infrastructure which is a reasonable expectation of any modern NHS dental service provider. Developing and enhancing the information and technology infrastructure within community and primary care dentistry is important for the future effectiveness and efficiency of these services. It is also vital if they are to function in an integrated way with the wider "NHS family”.
Occupational Health for General Dental Practitioners and their
Teams
The Health Board will look to implement a service that supports Primary Care Dental Teams by funding Occupation Health Support.
Action Required Implement an OH service for all dental contractors.
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Chapter 4
Delivering the Plan
This Local Oral Health Plan sets out to strengthen delivery of dental care and improve oral health in our communities, it outlines a co-ordinated approach and maps out a vision. We must have a robust mechanism in place to take forward the actions we have set out above and deliver the Plan. This will provide a means whereby planners and providers will be held accountable for assessing oral health needs, proposing actions to improve oral health and the contracting of and direct provision of services in their locality. Improving oral health and integrating dental services should become an integral part of the Health Board`s delivery plans. The implementation plan will be fluid and respond to service demands as they arise. It will be led by an Executive Director with a supporting management structure. Key support into this structure will be provided from estates, HR and finance. In this way dental services will be enabled to develop across the Health Board.
Summary of Actions
Oral Health Improvement
Designed to Smile Continue to support and monitor the D2S programme to ensure it delivers the programmes aims.
Implement the reporting framework, currently under production at WG.
Continue to ensure the programme further integrates
with the GDS.
Oral Cancer Work with WG & PHW to ensure high risk groups are targeted by national campaigns.
Work to extend the Tobacco Control Action plan into dental services.
Ensure service providers have access to high quality
postgraduate training to address educational needs.
Encourage dentists and their teams to discuss the risks
with their patients of smoking and alcohol.
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Service Planning, Development and Delivery
Integrated Planning Establish clear Executive Director leadership through the Dental Planning, Performance and Delivery Board.
Embed oral health and dental services into strategic planning across the Health Board. It is essential strong links exist across Primary Dental Care and Specialist services in order to ensure clear patient pathways are developed and services are easily accessible.
Ensure adequate measures are in place in order to obtain professional advice. Continue to engage with the Consultant in Dental Public Health & the Dental Practice Advisor (Public Health Wales),
Continue to respond to WG dental policy, e.g. Special Care Dentistry Implementation Plan, by way of taking a regional approach and development of a Managed Clinical Networks.
In partnership with the Local Authority and voluntary
sector, ensure that oral care is integrated into general
health and social care plans/pathways of patients with
complex medical and social problems.
Workforce Seek to develop a functioning relationship Local Dental Committee (LDC) for Hywel Dda (and Powys). The Health Board has a statutory obligation to consult the LDC for all future proposals.
Develop occupation health support for all dental teams
within Hywel Dda.
General Dental Services Continual assessment & monitoring of dental services to evidence whether commissioned services meet the needs of the population and ensure services are based on need from within the ring-fenced budget.
Implement patient pathways to ensure patients are sign posted to appropriate services in appropriate settings.
Investigate the opportunity to commission further dental
services in the GDS, for example an Emergency,
Urgent & Routine Dental Service for patients that do not
currently have access to routine dental services.
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Specialist Dental Services Build upon the current links between Hywel Dda and ABMU Health Boards to foster a “regional” approach to the planning and delivery of Specialist Dental Services.
Investigate opportunities to develop specialist services locally within Hywel Dda to improve local access & achieve cost savings / increased capacity.
Seek to develop complementary provision by Dentists
with Enhanced Skills (DwES), wherever appropriate.
Orthodontics Ensure that funding for orthodontics is based on need
and not demand. Develop an assessment service in
order to quantify current levels of need and ensure any
future investment in orthodontics is justified, specifically
in relation to other oral health improvement and dental
service priorities.
Oral Surgery Explore the opportunity to develop a Minor Oral
Surgery Service to be delivered locally from within a
Primary / Community Care setting.
Build upon the current working links between Hywel
Dda and ABMU Health Boards & explore the
possibilities of joint commissioning of services.
Review referral management systems, develop robust
referral criteria, simplify care pathways in order to assist
referrers in making the most appropriate choice for care
and ensure timely clinical care.
Restorative Dentistry Incorporate the specialties of Special Care and
Restorative Dentistry into clinical networks across
Hywel Dda and ABMU.
Use these groups to develop a regional approach to
improving services and local delivery where possible.
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Community Dental Service To develop a truly unified service, ensuring a standardised service is provided across the three counties.
Produce a service development plan to identify potential areas of growth & opportunities to integrate with all other dental services.
Review the service specification to ensure it meets the needs of the population and is delivered locally where possible.
Special Care Dentistry Strengthen the provision through CDS care by recruitment of clinical staff with appropriate skills. Where possible reintroduce a local service for assessment and treatment for adults and children with special needs, that require access to sedation and general anaesthetic services and direct them to the most appropriate provider.
Paediatric Dentistry Regionally there is a lack of a Consultant lead
Paediatric Dental services. In the context of the high
demand for child dental GAs and some emerging
evidence of repeat GAs – to work with ABMU to
investigate any opportunities to develop this speciality.
Request that PHW carries out a review of access to
specialist dental paediatric care for Hywel Dda children.
General Anaesthetic &
Sedation Services
In context of the above, consider ways to reduce the
numbers of General Anaesthetics (especially for
children) and consider ways to advocate the need for
continuity of care in accordance with the National Oral
Health Plan.
Domiciliary Services Review Domiciliary services and establish a single Domiciliary Policy for Hywel Dda with common standards.
Investigate the possibility of a dual approach to service
delivery, combining the GDS and CDS.
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Quality & Safety
Clinical Governance Support national dental practice based audits.
Ensure all primary and community dental settings meet the essential requirements of HTM01-05 and continue to work towards best practice.
Continue to take part in national dental practice visits programmes and the annual self-assessment of practice QAS.
Integrate clinical governance management issues into a
performance management framework, to create a high
level Reporting Matrix, covering service activity and
quality and safety.
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Appendix 1
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Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
1. Develop a Local
Oral Health Plan to
address the oral
health needs of their
residents, and clearly
describe how they
will ensure good
governance in
commissioning and
delivery of all dental
services (p17)
Local Oral Health Plans to
be in place by 31
December 2013
Board approved LOHP by
31st
December 2013
Draft consultation with all
contract holders.
Prepare find draft, formally
consult LDC.
Engage with ABMU as
neighbouring health board and
HDS provider.
Present to Board on 23rd
November
Submission to WG
Production of an
agreed plan for the
Health Board
Dec 2013
2. Health Boards will
be expected to work
with dentists and
their teams, and all
other relevant
stakeholders to
develop and support
delivery of Local Oral
Health Plans (p 36)
WG will seek assurance
that this action point is
being addressed, how it is
being achieved, and
specifically that
structures are in place to
receive multi-professional
dental advice, including
that of a consultant
specialist in Dental Public
Health
For all stakeholder to
have the opportunity to
contribute to the
document.
Document co-authored
by the Consultant in
Dental Public Health.
Consultation with all Contract
Holders & the LDC.
Engagement with CDS & D2S
Engagement with ABMU
Submitted LOHP to
WG.
Detailed annual
review of the LOHP
with the CDO.
Dec 2013
and on
going.
Appendix 2 – National Oral Health Plan – Action Matrix
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Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
3. Ensure the
continued
participation in
evidence based
community oral
health promotion
programmes
particularly the
Designed to Smile
and Healthy Schools
programmes (p 28).
Evidence that CDS
Designed to Smile Teams
are fulfilling the
standards in the Designed
to Smile quality
framework. WG will seek
assurance from HBs,
including the CDS, of
participation in evidence
based community health
promotion initiatives
which may include
smoking cessation,
alcohol and nutrition.
Local D2S team involved
in drafting the LOHP
Local D2S program
fulfilling the standards in
the D2S quality
framework
CDS participation in
community HP initiatives
which may include
smoking cessation,
alcohol and nutrition
Improved CDS links with
the GDS.
Development of robust
and comprehensive
Service Specification,
including a annual plan
and measurable
outcomes.
CDS Organisational
Review .
Ensure the D2S steering group
provides strategic management
for the programme.
D2S team to support schools
and nurseries to continue
participating in the programme
and to encourage daily
brushing. Recruitment of
additional schools and
nurseries.
Increase provision of clinical
interventions e.g. fissure
sealant and fluoride varnish
through mobile dental unit and
domiciliary kit.
Delivery of priorities in annual
plan.
Achievement of
the 11 standards.
Number of
locations
participating in the
programme
Number of children
receiving FS & FV.
Reporting-
Annual financial
report to WG
Activity/workforce
etc to WOHIU as
required.
Compliance with
WG D2S Quality
Framework
D2S Steering Grp –
annual costed
development plan
2014
ongoing
July every
year
ongoing
Appendix 2 – National Oral Health Plan – Action Matrix
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Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
Creation and
delivery of
measurable
outcomes tool /
reporting
mechanism.
4. Liaise with the
Cancer Networks and
the Head and Neck
Cancer National
Specialist Advisory
Group to ensure that
the Welsh Cancer
standards (2005) are
implemented. Health
Boards to work
together to ensure
evidence based,
multi-disciplinary
care is available to all
their patients
diagnosed with oral
cancer. We will seek
assurance that any
identified variation in
Evidence of (i) cross
border discussions on
oral cancer services and
(ii) liaison with Head and
Neck Cancer National
Steering Group.
Cancer Delivery Plans
include details on
addressing oral cancer.
Full participation in
National Head and Neck
Cancer Audit as required
under the NCAORP.
Long term outcome:
reduction in the
percentage of oral cancer
Continue to deliver
effective, evidence based
audited services with
links where necessary to
other Health Boards.
Local reporting and
benchmarking against the
national audit
Collate data on oral cancer
cases including staging of
cancer in HDHB / Review
referral systems for oral
cancers with Maxillofacial Unit
at Morriston Hospital and with
any other relevant secondary
provider.
Status reports
March 2014
March 2015
ongoing
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Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
treatment outcomes
is addressed by the
Cancer Networks
(page 14).
patients presenting at
stage 3 or 4 and an
increase in the
percentage of patients
presenting with Stage 1
or 2.
5. Use the
recommendations
from the Special Care
Dentistry
Implementation Plan
in ensuring that the
needs of all
vulnerable groups
are addressed (page
15).
Regionally agreed referral
and care pathways are in
place for patients who
require advice from, or
treatment in, specialist
dental services.
WG will review LOHPs to
ensure the
recommendations have
been taken into account
in developing services for
people with special
needs.
Development of
regionally agreed referral
and care pathways
through joint Special Care
Dentistry Managed
Clinical Network (HD &
ABMU).
Increased joint working
with ABMU.
Development of
workforce skill mix.
Participate in regional SCD
MCN.
Determine SCD provision in
ABMU and HD HB’s and
available workforce.
Establish clear referral and
acceptance criteria for SCD.
Establish referral and care
pathways and publish
pathways.
Improved SCD GA list facility at
WGH.
Improved availability of
conscious sedation.
Annual Plans for
the delivery and
Planning of
services.
Specific section in
the CDS service
specification,
detailing referral
and acceptance
criteria.
Sedation referrals.
Transmucosal
techniques used.
Enhanced clinical
support available.
2013-14
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Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
Support for Mouth care for
Adults in Hospital Programme.
Development of SCD data
collection to allow informed
future service planning.
CD workforce development.
Improved links with SCD patient
support groups.
Data collection for
SCD referrals and
patients seen.
Improved training
in SCD available.
Involvement in
MCN
6. Following
recommendations by
the National
Assembly Children
and Young People
Committee collect
annual data on the
number of children
who receive dental
treatment under GA
(p 36).
Data collated and
reported on a quarterly
basis to the Board /
responsible Committee
on numbers of children
receiving dental
treatment under GA.
Each HB will be required
to complete an annual
return to WG for this
issue.
Referral management
process in place for child
GA referrals and new
service model in place
Quarterly submission to
DSPG of referral and
outcome activity
Annual review of service
including clinical audit
Annual report to Board
Annual submission to WG
Create a Service Specification of
a Child GA service, including a
reporting mechanism.
Establish regular data collection
for consideration at DSPG &
DCGC
Implementation of a service as
per specification, and annual
review.
Reporting of
Service usage to
DPPDB.
April 2014.
Appendix 2 – National Oral Health Plan – Action Matrix
Public Health Wales & Hywel Dda Health Board Oral Health Plan for Hywel Dda Health Board
Date: Dec 2013 Version: 1 Page: 51 of 58
Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
delivered
7. Keep up to date
information on
waiting lists for
vulnerable people
who require dental
treatment under GA,
and ensure that
patients do not wait
longer than Welsh
Government
guidelines (page 28).
Data collated and
reported on a quarterly
basis to the Board /
responsible Committee
on waiting lists and times
for vulnerable people
who require dental
treatment under GA.
Patients do not wait
longer than WG waiting
time guidelines.
Implementation of data
collection and waiting list
management.
Improvement plans to
ensure compliance with
WG guidance on waiting
times.
Identification of patients
waiting more than the
advised waiting times.
Implementation of data
collection system.
Reporting system developed.
SCD GA waiting list down to 6
months over 5 years
Continued
reduction in
waiting times.
Annual report and
service plan
detailing
achievements and
aims.
2013-2016
8. Work together to
develop regionally
agreed referral and
care pathways which
will promote efficient
patient care and
better working across
GDS, CDS and HDS
(page 30).
Action is taken to identify
areas where there is
limited access to both
primary and secondary
NHS dental services and
to improve access where
there are localised
problems (access includes
geographical / specialist
services / provision for
children and vulnerable
groups). There is effective
Enable a combination of
the Referral Management
Centre and direct referral
pathways to ensure
patients can access
services in a safe and
timely manner.
Engage with all service
providers to ensure most
appropriate methods are
implemented.
Development of a Dental
Service Handbook for all
Stakeholders. To include
comprehensive details on all
services.
Development of a Website for
both service users and service
providers.
Continual reviews of all services
and pathways & engagement
Reduction in
episode s of
patients not
following the
correct pathway.
Creation,
documentation &
implementation of
effective patient
pathways that
promote quick
Appendix 2 – National Oral Health Plan – Action Matrix
Public Health Wales & Hywel Dda Health Board Oral Health Plan for Hywel Dda Health Board
Date: Dec 2013 Version: 1 Page: 52 of 58
Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
and proper use of ring-
fenced dental budgets
against the specific
services to which they are
allocated.
with stakeholders on service
development.
Build on relationship with all
Dental Service providers to
continually shape the service to
meet the needs of patients.
access to services
in an appropriate
care setting.
Annual reporting
of Dental Budget
to WG at annual
review meeting.
9. Work with PGMDE
to ensure dental
teams have access to
high quality
postgraduate training
to address
educational needs in
oral cancer, including
information on
appropriate Third
Sector organisations
and websites which
patients can access
for evidence based
advice and support
(page 13).
Collect the number and
percentage of primary
care dental team
members who have
received training in risks
for patients associated
with smoking and
alcohol.
Identify the number and
percentage of primary
care dental team
members who have
received core training in
recognition of oral
cancer, understanding
associated risks factors
and local referral
To have developed
robust links with PGDME
and to ensure that CPD is
supported appropriately.
Data collected from PGMDE
and included in annual plans.
Implementation of local CPD
events.
At GDS contractual reviews
discuss oral cancer issues with
contractors.
Work with CDS/PHW and
LDC/GDS to raise oral cancer
awareness with patients
Increased levels of
training on a local
level for dentists
and their teams to
participate in.
Dental services
participation in
national and local
promotional
initiatives
October
2014 and
ongoing.
Appendix 2 – National Oral Health Plan – Action Matrix
Public Health Wales & Hywel Dda Health Board Oral Health Plan for Hywel Dda Health Board
Date: Dec 2013 Version: 1 Page: 53 of 58
Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
pathways.
10. Work with
PGMDE to ensure
that the dental
actions contained
within the Tobacco
Control Action Plan
(TCAP) are taken
forward (page 13).
WG will seek assurance
that this is being
achieved.
To have an increased
number of dentists who
have undertaken brief
intervention training.
Provide Health Board
wide support to the Lead
agencies.
Ensure promotion of plan to
Dental Practices & include
during annual visits.
Increase in the
numbers of
patients who stop
smoking and
remain smoke free.
2013 - 2016
11. Take account of
and participate in the
1000 Lives Plus
programme to
Improve Mouth Care
for Adult Patients in
Hospital (page 16).
Participation in 1000
Lives Plus programme to
Improve Mouth Care for
Adult Patients in Hospital
as evidenced by active
mini collaborative in
place, and data reported
to dental programme
manager.
Full implementation of
1000 Lives Plus
Programme ‘Improving
Mouth Care for Adult
Patients in Hospital’ into
identified priority areas.
Identification of priority area &
Oral Health Champions.
Delivery of training for Oral
Champions & mouth care
processes implemented in
nurse care metrics.
Annual review
detailing
outcomes.
CDS Annual Review
2013 – 2014
12. Include issues
relating to primary
dental care as part of
their annual primary
care reporting
process, and include
them in their Annual
Quality Statement
WG will seek assurance
that actions in the Quality
Delivery Plan (QDP) are
being addressed in
relation to dentistry and
dental patients, including
Action 5 of the QDP on
measuring patient
Undertake Board
development sessions
and provide briefing
papers to ensure
awareness of issues
relating to primary care
dental services and their
interface with community
Board approval of the LOHP.
Regular update reports.
Review of the actions within
the QDP to ensure that dental
services are included.
Joined up plans
and
communication
across the Health
Board on the
delivery of
effective and
efficient dental
October
2014
Appendix 2 – National Oral Health Plan – Action Matrix
Public Health Wales & Hywel Dda Health Board Oral Health Plan for Hywel Dda Health Board
Date: Dec 2013 Version: 1 Page: 54 of 58
Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
(page 21). satisfaction.
and secondary care, and
that these are included in
the Annual Quality
Statement where
appropriate.
services.
13. Work with LDC to
review the
occupational support
they provide, and
develop an
occupational health
programme for all
members of the
dental team in
general dental
practice (page 34).
An NHS GDS dental team
occupational health
service is in place, has
been agreed with the LDC
and publicised to GDS
dental teams.
To implemented a OHS
for all GDPs and their
associated clinical staff
Agreement of a Service
Specification with LDC.
Agreement of a Service Level
Agreement within the Health
Board for the delivery of the
service
Advising GDPs of the service
availability and of the Well
Being at Work service
Implementation of
service
Dec2013
14. Support the CDS
to work with
educational providers
to ensure consistent
evidence based oral
health input to all
pre-registration
nurse courses in
Wales, and to
address training for
WG will seek assurance
from CDS services that
they are working
appropriately with local
nurse education
providers, and that the
training requirements of
Health Care Support
Workers have been
identified and addressed.
Development and use of
an evidenced based oral
health education
framework for Pre –
registration nurses &
Health Care Support
Workers.
Define the service within the
CDS Service Specification.
Identify outcomes
in annual report.
April 2014
Appendix 2 – National Oral Health Plan – Action Matrix
Public Health Wales & Hywel Dda Health Board Oral Health Plan for Hywel Dda Health Board
Date: Dec 2013 Version: 1 Page: 55 of 58
Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
Health Care Support
Workers (page 31).
15. Ensure that high
risk groups are
targeted by national
campaigns (e.g.
Mouth Cancer
Awareness and
National Smile
months (page 13).
WG will seek assurance
that LHBs take a
proactive approach to
target local high risk
groups in suitable
national campaigns e.g.
clarification of plans to
link National Smile Month
(May/June) with delivery
of Designed to Smile and
Oral Cancer Awareness
month (October).
A multidisciplinary
approach is taken to
raising the awareness of
national campaigns.
Ensuring that national
campaigns are publicised via
the Health Board
Communications Team
That links are made between
national campaigns and local
awareness raising
Identify resources to ensure a
multidisciplinary approach.
Report outcomes
in annual report.
Greater public
awareness of oral
health campaigns
and how they link
to local initiatives
and dental
services.
2013-2016
16. In partnership
with the Local
Authority and the
Third Sector, ensure
oral care is
integrated into the
general health and
social care plans/
pathways of patients
with complex
medical and social
problems (page 15).
WG will seek assurance
that this is being taken
forward and evidence as
to how partnership
arrangements are
being/will be developed,
together with the
relevant timeframes.
Develop links with the
Third Sector to increase
the
Convene a meeting with key
Local Authority Stakeholders to
scope issues
Second Step Action
Establish a LHB / LA oral health
liaison group
Oral care is
integrated into the
general health and
social care plans
2014
Appendix 2 – National Oral Health Plan – Action Matrix
Public Health Wales & Hywel Dda Health Board Oral Health Plan for Hywel Dda Health Board
Date: Dec 2013 Version: 1 Page: 56 of 58
Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
17. Plans must
contain specific
actions regarding the
management of the
current GDS contract:
- enhance contract
monitoring and
reviews on GDS/PDS
contracts with high
value Units of Dental
Activity (UDA);
- ensure better
compliance with NICE
guidelines on recall
intervals;
- monitor “splitting”
courses of treatment;
- work to the interim
Guidance of NHS
Orthodontics in
Primary Care,
particularly during
contract renewal
(pages 41 and 27).
WG will seek assurance
that LOHP commitments
are progressed and
achieved.
HBs to ensure that
providers of NHS
orthodontic services have
separate PDS agreements
and established that staff
are appropriately skilled
and qualified. HBs should
be mindful of advice of
their local orthodontic
Managed Clinical
Network.
Implementation of a
Contract Management
Framework (CMF).
Develop policies for the
management of
contractual issues
Agree CMF with LDC.
Implement CMF and continually
review to ensure it provides a
framework for robust contract
management across all dental
services.
Report outcomes
in annual report.
April 2014
and on
going
Appendix 2 – National Oral Health Plan – Action Matrix
Public Health Wales & Hywel Dda Health Board Oral Health Plan for Hywel Dda Health Board
Date: Dec 2013 Version: 1 Page: 57 of 58
Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
18. Use BSDH
guidelines in
developing plans for
the delivery of
domiciliary care
(page 26).
WG will seek assurance
that the guidelines are
used and a monitoring
process is in place.
Domiciliary Services to be
provided using BSDH
guidelines.
Integrate guidance into the
service specification for CDS.
Develop a data collection tool,
to inform future service
planning.
Implementation of
service
specification for
CDS.
April 2014
19. Develop
alternative patterns
of care e.g.
increasing the
specialist dental
paediatric services
and dental paediatric
DwES workforce, and
building the capacity
of alternative
treatments such as
sedation where
feasible (page 28).
This action links with No’s
5, 8 and 16 in terms of
developing regionally
agreed referral care
pathways. Recognising
that this action will
require longer term
planning, WG will seek
assurance that plans are
in place to identify and
address local needs.
To investigate alternative
models of service delivery
that include the use of
DwES’s within the CDS.
Undertake a review of CDS
organisational structure and
identify key priorities of the
service.
Questionnaire to GDS to assess
interest of performers and
providers in providing ot
training towards
Enhanced status
Detail outcome of
CDS service
planning within
annual report.
Report
April 2015
April 2014
20. Develop clear
plans on how
residents will access
specialist dental
services in Primary
Care (specialists/
This action links with No’s
5, 8 and 16 in terms of
developing regionally
agreed referral care
pathways. Recognising
that this action will
Review Dental budget to
inform future planning of
service, to enable an
integrated approach to
the delivery of a wide
range of dental services.
Operate services under robust
frameworks, with appropriate
reviews.
Detail plans in
annual reports and
service planning.
April 2014
and on
going
Appendix 2 – National Oral Health Plan – Action Matrix
Public Health Wales & Hywel Dda Health Board Oral Health Plan for Hywel Dda Health Board
Date: Dec 2013 Version: 1 Page: 58 of 58
Actions for Health
Boards
WG expected outcome HB expected outcome The defined process to deliver
the action in stages
Measurable
outcomes
Timeline
DwES), the CDS and /
or secondary care,
and ensure an
integrated approach
to the delivery of
these services (page
30).
require longer term
planning, WG will seek
assurance that plans are
in place to identify and
address local needs
Enable a combination of
the Referral Management
Centre and direct referral
pathways to ensure
patients can access
services in a safe and
timely manner.
Appendix 2 – National Oral Health Plan – Action Matrix
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