This is a submission from the British Orthodontic Society (BOS), which represents the interests of specialist orthodontists in primary care, secondary care, the university teachers, community orthodontists and dentists with a special interest (DwSIs) in orthodontics and the provision of best possible orthodontic care.

1.  INTRODUCTION

  1.1  Orthodontics is the branch of dentistry concerned with growth of the face, development of the teeth and bite, also of the prevention and correction of problems with the teeth and bite. Ideally patients are treated during pubertal growth (in their early teens), when facial growth is most active.

  1.2  The introduction of the new contract in April 2006 has been satisfactory for many established orthodontists. On many fronts it represents a considerable improvement on the old GDS contract. The BOS is pleased to have contributed constructively towards the structure of the new PDS contract.

  1.3  A key change has been the introduction of the Index of Orthodontic Treatment Need (IOTN) into NHS practice. IOTN differentiates between dental health needs and cosmetic improvements. The BOS supports the implementation of the IOTN as a selector for NHS treatment as an appropriate way to ration limited financial and manpower resources. The introduction of IOTN removes a group of patients whose need for treatment is low and are <IOTN 3.6—all above this in Groups >3.6, 4 and 5 are considered severe enough to require treatment under the NHS.

  1.4  From a provider/practice's point of view there is no doubt that the regular monthly payment arrangements, paid one month in arrears, have been helpful in having a balanced cash flow within practices. This compares to the large monthly fluctuations of old—often paid up to two years after a patient's treatment commenced.

  1.5  From a Primary Care Trust (PCT)/ Local Health Board (LHB) point of view, the fixing of Calculated Annual Contract Values (CACVs) also offers significant advantages in managing local dental budgets. The principles of local commissioning are to be welcomed. This assumes that appropriate "needs assessments" are carried out and funding levels are in place to address any additional need.

2.  THE ROLE OF PCTS IN COMMISSIONING ORTHODONTIC SERVICES

2a)  Establishment of CACVs and local budgets

  2a.1  Orthodontist's and general dentist's contract activity was set, using gross GDS earnings during the historic period October 2004 to September 2005. This was the baseline used to establish CACVs for providers and set local budgets for PCTs/LHBs. As in general dentistry, orthodontists were remunerated at the end of a course of treatment and so were paid in arrears. In general dentistry, this principle worked well as a means of establishing a CACV, because earnings over a year were a good reflection of activity. However, this principle does not apply well to orthodontics as many courses of treatment take two years.

  2a.2  As a result, income received by an orthodontic practice under the GDS actually reflected its activity up to two years previously. In the case of new practices, this effectively meant that the practice received little money at all for the first 18 months to two years.

  2a.3  The DoH effectively capped funding at the 2003-04 level with small annual increases. Since 2003-04 much growth has taken place which is not reflected in historic earnings. Funding has been capped at a level considerably lower than current activity. (See appendix A)

  2a.4  At a practice level, this had disastrous consequences for newly established and growing practices who were only offered very low or even zero contract values, despite the fact that many patients were in treatment. Following advice from the BOS, this problem had been recognized by the DoH who stated in previous correspondence to the PCTs; (Gateway Document 4449: Paragraph 7.5) "It is important to reassure new orthodontic practices that, when the reforms are introduced, the value of work commenced under the general dental services but not yet completed and therefore not reflected in payment history, will be reflected in the practice's contract value."

  2a.5  In summary—as a result of this flawed system for setting local budgets, funding was capped at a level which reflected activity up to two years before the baseline period. New practices were given inadequate contracts, often leading to loss of an NHS resource.

  2a.6  As local "needs assessments" were not taken into account, the funding remained in areas that were already well provided and areas of inadequate funding were not improved. Though PCTs understood the nature of the problem, they were powerless to act, as their budgets were set before any negotiations or "needs assessment" could take place.

2b)  Needs assessment of orthodontics

  2b.1  PCTs have a duty to assess and provide for the local dental health needs in their area, including orthodontics and to make appropriate provision to meet these needs.

  2b.2  Historically, most large scale studies[2],[3] looking at treatment need, agree that approximately 30% of children need orthodontic treatment on health grounds. Up to 50% of children have an IOTN score of 3.6 or above; these figures are supported by the 2003 National Dental Health Survey[4]. The prevalence of objective need for orthodontic treatment has remained consistent over the last 30 years.

  2b.3  The Department of Health document "Strategic Commissioning of Primary Care Orthodontic Services" (Gateway document 7105), Para 4.5 states: "In planning orthodontic services, PCTs should be aware that the 2003 National Child Dental Health Survey found that 35% of 12 year olds are likely to have a need for treatment."

  However, Para 4.5 also states: "Not all parents and children agree with a professionally assessed need and conversely, a small proportion feel, that treatment is needed when clinically no need is recognised. The 2003 survey estimated that 58% of the parents of 12 year old children with a clinical need felt that their children did not need orthodontic treatment."

  2b.4  The presumption that 58% of parents or children feel they do not wish treatment means that the patients with a known orthodontic problem may not have the opportunity of being given appropriate specialist advice.

  2b.5  To illustrate the problems resulting from such an approach, two clinical examples are presented. Specialist orthodontists know that if patients have upper front teeth protruding more than 9 mm, there are known long term risks of damage through trauma for approximately 50% of these patients. This data is derived from previous dental health surveys. A second example is that of patients with palatally misplaced canines—we know that in 14% there will be resorption and damage to adjacent incisor roots.

  2b.6  We therefore question the reduction of need from 35% to 15% as recommended by the DoH. We understand that patients must not be forced to have treatment, but they should be fully informed of the risks and benefits of treatment and allowed to give informed consent to treatment after a consultation.

  2b.7  A local "needs assessment" is an excellent proposition, as long as the local providers are involved in discussions with the PCTs. The BOS feel this should be based on the identified 35% with a great need for orthodontic treatment derived from the 2003 Child Dental Health Survey.

2c)  Managed clinical networks

  2c.1  The BOS believes that the most appropriate way to manage referrals in the interests of the PCT, patients and the specialist providers both in primary and secondary care, is through joint consultation in Managed Local Orthodontic Clinical Networks (MCNs). The MCN should include all the local orthodontic specialists, DwSIs, a representative of the PCT, preferably the dental lead and a representative of the Local Dental Committee (LDC).

  2c.2  The aims of the Local Orthodontic MCN are to:

—  Co-ordinate the local provision of orthodontic care in conjunction with the funding agencies (PCTs or equivalent).

—  Ensure the highest standard of orthodontic care is provided by the local orthodontic workforce.

—  Develop short, medium and long-term strategies with regard to maintenance and development of orthodontic provision.

—  Assure access for patients to the most appropriate orthodontic care.

—  Enhance communication between providers.

—  Act as a source of advice on orthodontic provision.

  2c.3  All BOS members have been strongly advised by the Society to establish local MCNs and work closely with their PCTs.

2d)  The 18 week rule in secondary care

  2d.1  The introduction of the 18 week rule and other changes to secondary care provision will disturb the local balance of orthodontic care.

  2d.2  Dental services provided by undergraduate dental students in teaching hospitals are exempted from the 18 week rule. This exemption has not been applied to postgraduate orthodontic students. Current postgraduate training programmes provide pre-selected patients to the supervised care of trainees at the beginning of their training. Implementation will mean that orthodontic trainers cannot hold waiting lists of suitable patients for trainees. The consequence is that fewer patients will be taken on for treatment in areas with a postgraduate course.

  2d.3  There is no requirement to apply the 18 week rule in primary care and without doubt hospital waiting lists will be transferred from secondary care specialists to primary care specialists. The areas with long secondary care waiting lists are often areas with low provision in primary care.

  2d.4  The MCN therefore has a vital role in co-ordinating care across all the local providers in consultation with the PCTs, which reflects the variation of provision around the country.

2e)  DwSIs in orthodontics

  2e.1  Dentists with a special interest in orthodontics (DwSIs) provide orthodontic care, in appropriate circumstances. Currently they work in specialist practices in primary care under the supervision of a specialist, or work in areas of need with the link of a consultant specialist in secondary care. DwSIs are best suited to take on cases under the supervision of a specialist, especially in an area of low population density that cannot logistically support a specialist practice.

  2e.2  Planned replacement of DwSIs has not been given appropriate attention by PCTs. In the long term, there are key DwSIs in areas of need who on retirement have no obvious means of replacement. Careful planning is required to train new DwSIs in such areas of need. Strategically placed DwSIs will need someone to be targeted locally, to be supported financially in their training. There is then a need for a planned hand over of an orthodontic contract with PCTs, to the newly trained DwSI.

3.  NUMBERS OF NHS ORTHODONTISTS AND THE NUMBERS OF PATIENTS REGISTERED WITH THEM

  3.1  There is an under-supply of orthodontic treatment provision in the UK due in part to a dearth of specialist trained orthodontists. As a country, the UK is 15th out of 17 countries in Europe in terms of orthodontic provision. There is currently one orthodontist per 73,000 people. Germany and Austria top the table with 1 per 30,000. Only Spain and Turkey are worse off.

  3.2  The UK three year postgraduate orthodontic training programme is recognised as one of the best in the world, but the number of UK students in training is inadequate for national needs, as a consequence of chronic under-funding over several decades.

  3.3  We have no accurate figures as to the numbers of registered patients with specialist orthodontists and DwSIs in orthodontics, because this is so varied, but many colleagues have capacity to take on more NHS cases for treatment, if contracts were increased.

4.  NUMBERS OF PRIVATE SECTOR ORTHODONTISTS AND THE NUMBERS OF PATIENTS REGISTERED WITH THEM

  4.1  There are very few exclusively private orthodontic practices in the UK, such as there are, are mainly in London. However, with the changes in orthodontic provision following introduction of the new contract, this is increasing. The exclusion of cases <IOTN 3.6 from NHS treatment, has increased the number of patients who wish private care. Increasing orthodontic waiting lists, caused by limitations imposed by the new contract levels, is also contributing to more private practice treatment.

  4.2  In the 2007 BOS survey, specialist members estimated that they are treating 15% of their patient numbers privately and that 58% of practices have growing numbers of private patients. Previously, the estimate is that most practices would treat approximately 5% of private patients.

5.  THE WORK OF ALLIED PROFESSIONS

5a)  Orthodontic therapists

  5a.1  The first two courses for orthodontic therapists have begun this year in Leeds and Bristol; they will be a very important part of the future skill mix. We look forward to engaging in discussions as to the best way to work with orthodontic therapists in specialist orthodontic treatments in primary and secondary care. Inevitably this will require a review of the means of funding such new additions to the work-force.

5b)  Orthodontic technicians

  5b.1  As with technical provision in general dentistry, there are fewer orthodontic appliances being manufactured by orthodontic laboratories. There have therefore been a number of redundancies in orthodontic labs and rather poignantly at this year's British Orthodontic Conference; the prize for the best young laboratory trainee was awarded to a young trainee who had been made redundant just before the Conference!

6.  PATIENTS' ACCESS TO NHS ORTHODONTIC CARE

Uneven orthodontic provision

  6.1  The historic differences in orthodontic provision, around England and Wales have been perpetuated. Areas of good provision remain well served, but those areas with poor orthodontic provision still have low contract levels of orthodontic care. This is often made worse by the fact that these areas are also poorly served for general dental care and as a consequence, (DwSIs) in orthodontics often have their orthodontic contracts converted into general dental contracts further reducing the level of orthodontics.

  6.2  Approximately 35 orthodontists complete three years of publicly funded postgraduate specialist training in orthodontics every autumn and look for employment in the NHS. Because of the reduction in orthodontic contracting, many new specialist post-graduates cannot easily find work in the National Health Service. There are opportunities to employ these newly qualified specialist orthodontists in the areas of poor provision, but growth funding is not being provided to facilitate this.

7.  THE QUALITY OF CARE PROVIDED TO PATIENTS

  7.1  Orthodontics has a very robust measure of outcome in the Peer Assessment Rating (PAR), which has been in use for nearly 20 years. The quality of orthodontic treatment outcome will be reviewed at two levels.

  7.2  The Dental Practice Division of the BSA have an orthodontic group who will be required to randomly check practices who take on >200 patient starts each year. There is a local peer review process which is the joint responsibility of the PCTs and the MCNs. The MCNs are committed to ensure the highest standard of orthodontic care is provided by the local orthodontic workforce.

8.  THE EXTENT TO WHICH ORTHODONTISTS ARE ENCOURAGED TO PROVIDE PREVENTATIVE CARE AND ADVICE

  8.1  There are a number of areas in which early orthodontic intervention can prevent a more serious problem developing. The BOS believe that every child should be seen by a specialist orthodontist to assess the orthodontic treatment need. There has been a reduction in the quantity of orthodontics taught to undergraduate dental students. Advice from an orthodontist is often required.

  8.2  In the context of general dentistry however, prevention is not an area in which orthodontists have a major role. All involved in orthodontic care will encourage patients to use the highest standards of oral health to reduce the possibility of damage to the teeth. Patients will not normally be taken on for orthodontic treatment if they have poor oral health or have active caries.

9.  ORTHODONTISTS' WORKLOADS AND INCOMES

  9.1  As stated earlier the new contract gives better cash flow, but a significant number of specialists have spare capacity to take on more patients for treatment.

  9.2  From the DoH point of view, a principal objective of the new contract was to contain the expansion of the NHS service which was responding to patient demand without any control. This limitation has now been achieved in orthodontics at a level, two years previous to April 2006.

  9.3  Under the new contract, there is no provision for establishing new practices by an enterprising practitioner who sees an area of treatment need. There is no provision for expanding a practice with growing waiting lists, by recruiting a new provider or orthodontic therapist. This perpetuates the uneven distribution of orthodontics around England and Wales as stated in section 6.

  9.4  A survey of BOS members in February 2007 found:

—  50% of orthodontic practices were in a steady state because of fixed volume NHS contracts but

—  58% were experiencing a growth in their number of private patients

—  55% of practices were experiencing an increased demand for private treatment for children and

—  30% of practices believed this was due to a lack of NHS provision

—  30% of practices had waiting lists for new patient assessments of treatment need in excess of 21 weeks and

—  30% had waiting lists in excess of 40 weeks for patients in need of treatment before treatment could be started.

  9.5  The new contract has achieved the Government's objective of containing the supply of NHS orthodontic treatment but this ignores the demand. It is leaves patients in certain areas of the country without NHS care.

10.  THE RECRUITMENT AND RETENTION OF NHS ORTHODONTIC PROVIDERS

  10.1  Recruitment of dentists to specialist orthodontics remains high, orthodontics is a specialist area with a great deal of interest to many newly qualified dentists. The problem remains that there is a need for additional funding for training.

  10.2  Retention of orthodontic specialists within the UK remains good. If contract values reduce significantly, this might change.

11.  EXECUTIVE SUMMARY

  11.1  The BOS is satisfied with the nature of the PDS agreement. We are pleased that we have been able to play an active role in the development of the contract.

  11.2  The use of historic earnings has been an inappropriate way of establishing contract values in orthodontics. This has resulted in national and local funding levels being capped, well below the level of activity at the start of the new contract. Areas of low provision have remained low. Many new or growing practices have been given inadequate contract values leading to inability to provide NHS care despite demonstrable need and mounting waiting lists.

  11.3  Appropriate "needs assessment" should have been carried out before the implementation of the new contract and the establishment of local budgets.

  11.4  The new arrangements perpetuate the inequality of orthodontic provision around England and Wales.

  11.5  Training numbers for specialists remains low and there are not appropriate means of training and replacing strategically placed DwSIs. The BOS welcomes the advent of orthodontic therapists to the workforce.

  11.6  As local commissioning becomes established, increased co-operation between PCTs, primary and secondary care providers is necessary to ensure that local need is met as efficiently as possible. The BOS feels that the establishment of local MCNs involving all orthodontic providers and PCTs are the key to realising this goal.

12.  INDEX OF ABBREVIATIONS

3   CD Stephens. Standing Dental Adisory Committee-report of an expert group. Back

4   Chesnutt I, Pendry L, Harker R, The Orthodontic Condition of Children from Children's Dental Health in the UK 2003, Office of National Statistics, London December 2004 Back