Quality assurance in NHS primary care orthodontics 1. Introduction This brief paper aims to provide a more detailed overview of the quality assurance framework for the new orthodontic contract and to help PCTs ensure that they are built into their clinical governance processes for orthodontics.
2. Background England spends more public money on orthodontic services than any other country in the world. There are currently around 25,000 NHS orthodontic patients per year treated in hospitals and around 130,000 in primary care.
Primary care services are provided mostly by independent orthodontic practices. Levels of orthodontic provision vary significantly across the country based on practitioners’ past decisions as to where to set up practice.
April 2006 brought the biggest change in dental provision in England since the inception of the NHS in 1948. With the introduction of local dental commissioning PCTs are now better able to match levels of provision of orthodontic services with levels of need and commission services on a more integrated basis across primary and secondary care.
A new framework for orthodontic treatment was also introduced in April 2006. Designed to ensure that the assessment of orthodontic need is carried out more fairly and consistently this should make the best use of available resources.
The new system of needs assessment is based on the Index of Orthodontic Treatment Need (IOTN), which considers both the dental health of the patient (normally a child) and the aesthetic need for treatment. There is flexibility for practitioners to treat other cases falling outside the normal criteria where they judge there are exceptional circumstances based on the dental and oral condition of the patient.
Over time, PCT commissioning of orthodontic services should be adjusted to reflect an assessment of needs and planning priorities. There are already examples of PCTs expanding current orthodontic provision where this is appropriate.
Prior to the introduction of the new contract the Department of Health issued guidance to support PCTs understand the transitional and short term issues associated with the new arrangements. More recent guidance focused on providing advice to PCTs in relation to the strategic commissioning of orthodontic services including the assessment of orthodontic need. Available via the Primary Care Contracting web site, links to these publications can be found below for reference:
3. Local Quality Assurance Local quality assurance measures for the new orthodontic contract should involve a three-tiered approach including:
3i. Mandatory monitoring Assessment of treatment need using IOTN is mandatory for all cases. A description of the basics of IOTN is available at http://www.bos.org.uk/news/whatisiotn.htm. Additionally, it is a statutory requirement of the new orthodontic contract for contractors to monitor treatment outcomes for 20 cases (plus 10% of the remainder of their caseload) per annum.
To maximise the value of this exercise PCTs are may wish to discuss the process for the selection and assessment of cases with contractors. For example that 20 consecutive cases are selected and to help ensure accuracy and minimise bias, the contractors are encouraged to utilise the services of an independent third party calibrated in the use of IOTN and the PAR Index to assess the chosen cases.
The British Orthodontic Society (BOS) is currently establishing a network of calibrated individuals willing to offer their services at a local level. Further details are found via the BOS web site (http://www.bos.org.uk/). Commercial laboratories are also willing to offer this service to contractors.
3ii. Peer Review Self-assessment of treatment outcomes is inevitably subject to bias.
PCTs are therefore advised to work with their local contractors to establish a local clinical network to monitor all elements of the new contract including peer review of IOTN and PAR scores. Initially participation is voluntary. However where a new contract is awarded PCTs may seek to include
participation in a local clinical network and peer review as contractual requirements.
The British Orthodontic Society has produced a draft document outlining the essential features of an Orthodontic Managed Clinical Network from their perspective. Further details are available from their website.
3iii. Self-Regulation Self-assessment of all treatment outcomes using the Peer Assessment Rating (PAR Index) is voluntary. However where a new contract is awarded PCTs may seek to introduce this measure as a contractual requirement.
In order to support this activity, NHS Innovations have enlisted the services of computer software experts to develop the Orthdex programme used to record IOTN and PAR scores in the Bedfordshire pilot. A new version of the programme (including an on-line facility for submission, archiving and retrieval of data) should soon be commercially available.
The Clinical Outcome Monitoring Programme (COMP) software fulfils a similar role. Further details are available from the British Orthodontic Society website.
However, IOTN assessment and PAR scoring of cases by individuals not trained in the use of the indices is unlikely to be as meaningful as when performed by those who have undergone associated training. PCTs are therefore advised to encourage their contractors to undergo training and ideally to achieve calibration in IOTN and the PAR Index.
4. External monitoring by the NHSBSA Dental Services Division To underpin these local quality assurance measures the NHSBSA will also assist PCTs in monitoring the new contract. This support will include a rolling programme of clinical monitoring of orthodontic contracts. The NHSBSA is presently carrying out a review of the clinical monitoring services provided by the Dental Reference Service to support PCTs with clinical quality issues. Following completion of this review at the end of the year, further information will be made available to PCTs on the integrated clinical monitoring and risk management services provided by the NHSBSA.
5. Next steps by PCTs PCTs should:
Ensure that they are fully conversant with the proposed new quality assessment and outcome framework.
Together with their local contractors consider how they can best support them. For example this may include:
Making performers aware of the different tools to assist them to assess and record treatment need and outcome.
Organising Section 63 courses regarding IOTN and PAR scoring.
Encouraging and facilitating training and calibration in IOTN and the PAR Index.
Helping to establish a local orthodontic clinical network.
Make it clear within their clinical governance procedures the evidence they will be seeking from contractors regarding compliance with national regulations.