Factsheet 7: Commissioning out-of-hours services

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1 Gateway Reference 5917 IMPLEMENTING LOCAL COMMISSIONING FOR PRIMARY CARE DENTISTRY 1. Background Factsheet 7: Commissioning out-of-hours services 1.1 Primary Care Trusts are formally responsible now and in the future for ensuring that appropriate out-of-hours emergency dental service arrangements are in place for residents and visitors to their area who are not registered with (or on a list of) a dentist. However, the Regulations relating to this responsibility change on 1 April Section 56 of the NHS Act 1977 provided former Family Health Services Authorities (FHSAs) with the power to commission Emergency Dental Services (EDS) and as a result PCTs have inherited a number of different arrangements that continue today. 1.3 The General Dental Service (GDS) Regulations (1990) require dentists to provide an out-of-hours service and/or treatment within a reasonable time for those patients currently registered with them. It has been generally accepted that this will require any necessary treatment to be undertaken within hours and that a verbal response be made within 6 hours. 1.4 The GDS regulations fall on 31 March 2006, and from 1 April 2006 PCTs will be responsible for ensuring that an appropriate out-of-hours service (OOH) is provided in its area. 1.5 PCTs now need to review and consider the development of local in and out-ofhours emergency dental services in line with new national changes to dentistry. From April 2006 all dentists will enter into a local contract arrangement with their PCT. At this point, the responsibility for out-of-hour emergency care will transfer to the PCT for local patients, whether or not they receive continuing care from a local practice, and also for visitors to the area. 1.6 The term out-of-hours does not refer to a fixed universally agreed period, but refers to services provided outside the scheduled opening hours of a particular surgery. 1.7 Emergency Dental Service expenditure (Section 56) associated with the management of existing arrangements will be devolved to PCTs in April Dentists gross fee recall attendance fees are not to be deduced from their calculated annual contract value (CACV). This is covered further in section PCTs must therefore begin to plan for these changes in the period leading up to April PCTs should normally consider managing out-of-hours services on a sector wide basis (i.e. across a number of current PCT areas and/ or linking with their other arrangements for out-of-hours care e.g. GP unscheduled care). In planning these changes PCTs should:

2 Review current service provision Map current service capacity and utilisation Consider models of service delivery Consider the range of treatment provided and patients covered as part of an OOH arrangement Review the service infrastructure requirements Consider the provision of complementary accessibility to in-hour urgent services Develop a strategy for disseminating information about the new arrangements to local residents. 2. Key Principles 2.1 Dental emergency classification Patients who require emergency care are those requiring immediate attention in order to minimise the risk of serious medical complications or prevent long-term dental complications. Their condition means they are most likely to present in Accident & Emergency departments with: Uncontrollable dental haemorrhage following extractions Rapidly increasing swelling around the throat or eye Trauma confined to the dental arches 2.2 Dental urgent classification Patients who require urgent care are those requiring attention for: severe dental and facial pain not controlled by over-the-counter preparations dental and soft tissue acute infection 2.3 Non-urgent dental conditions A number of individuals currently access care from OOH services who are not in pain and present for treatment regarding non-urgent problems. This may include: Patients not in pain Aesthetic problems (dislodged crowns and bridges) Patients with broken dentures Patients with hospital referral letters Patients requiring permanent restorations Non traumatic problems with orthodontic appliances Patients who have no significant pathology Patients requiring a second opinion Patients using EDS as their regular dentist Requiring surgical extractions (wisdom teeth) and are not in pain 2

3 2.4 When considering the future configuration and availability of services, PCTs will need to ensure that services are aimed at those individuals with urgent dental need who require advice and/or treatment and are unable to wait until the next available in-hour service. 2.5 When considering the future provision of local dental out-of-hours services, there are a number of national key principles to which PCTs should adhere. These include the need to ensure that: Dental OOH services are integrated with the local medical OOH services model, where possible and appropriate. A form of triage is in place for individuals requiring access to dental OOH services. The form of triage is at the discretion of PCTs. Patients should have access to advice (not necessarily on a face-toface basis). Patients should have access to clinical treatment OOHs, when necessary. All patients should have access to the same high quality OOH service, irrespective as to where they live. 2.6 When planning services, PCTs are also reminded that: Dental OOH services should form part of the PCT s overall service commissioning framework and public communication strategy Genuine dental emergencies are rare Dental OOH advice can be provided to a population across a large geographical area through telephone triage and a dentist on call with access to dental facilities Dental OOH services should not be seen as a substitute for provision of urgent dental care available in core working hours, commissioned as open access sessions as part of Personal Dental Service (PDS) pilot arrangements 2.7 It is important that PCTs come together under the umbrella of Strategic Health Authorities (SHAs) to consider how best to manage or redistribute resources to meet local needs. 2.8 When considering the future provision of OOH services, there are a number of local principles which PCTs may also wish to consider, for example that the service configuration in the future should: Be developed in line with the population s need whilst recognising that patients who do not actually need urgent treatment may require reassurance about their treatment needs. Ensure that assessment procedures and protocols enable those patients who are actually in pain receive urgent treatment. Enable the consistent prioritisation of patients to ensure that those whose condition cannot be deferred to the next available in-hour dental service receive care, as appropriate Enable sufficient flexibility in the system to allow local circumstances to be accommodated and good practice to be enhanced 3

4 Be linked to NHS Direct or a local call handling service. 3. Funding arrangements PCTs have now received details of their dental budgets for 2006/07. Set out as part of these budgets is the funding associated with the central recharges made by the PCT for Emergency Dental Services (EDS) activity during 2004/ Dentists where recall attendance fees form part of the CACV 4.1 Dentists that provide occasional care to patients in need of urgent care outside their normal practice hours are entitled to claim a recall attendance fee as part of the general dental service. The majority of dentists claim very few recall attendance fees per annum. 4.2 Income associated with any recall attendance claims during the reference period (1 October September 2005) will be reflected in a dentist s calculated contract annual value (CACV). These fees will remain within the dentist s CACV from April 2006 and have not be deducted. 4.3 Where a dentist has earned 1,000 or more from recall attendance claims during the reference period, then the PCT will need to agree with the dentist a commensurate value of activity in line with the new contracting currency, units of dental activity (UDAs). 4.4 It is therefore important that PCTs review dentists prescribing profiles prior to CACV validation meetings with respect of the value of recall attendance income during the reference period. 5. Service models 5.1 When considering a model framework for future OOH services, PCTs may find it helpful to break it into three components: i. The gatekeeper of the service (triage stage) ii. Provision of the service (delivery stage) iii. Availability of complementary services during normal working hours. A model for managing patients is set out in Appendix Dental triage systems The concept of triaging presenting patients in an emergency healthcare environment is now a widely accepted and routine assessment procedure in virtually all UK A&E departments and other institutions, utilising dedicated triaging staff. There is a distinct benefit to be obtained from having standardised triage protocols across a PCT or group of PCTs The philosophy behind operating the triage has three simple components: 4

5 It needs to give priority to patients where a delay in time could have significant impact on the outcome of subsequent treatment It needs to give priority to those where a delay in consultation may compromise general health and; The triage process needs to be standardised Models of triage Essentially, models of triage can be categorised simply as open or closed door and first level triage and second level triage systems. (a) Open door Open door triaging by definition allows the patient access to a walk-in service and requires some form of initial assessment to move beyond first come, first seen. Typically such open door triaging can be clinician or nurse led. (b) Closed door Typically the closed-door system involves initial triage via a telephone service. The patient usually accesses this initial triage by contacting a local help line number or NHS Direct. (c) First level triage/initial call streaming For example, NHS Direct employs the combination of general nurses using computer-assisted diagnostic tools to screen patients with medical and dental conditions, together with providing information and advice about local OOH services. The prioritisation system will screen individuals who require to seen at an A & E Department. (d) Second level triage/clinical assessment In addition to level one triage, some dental OOH services have now also put in place level two triage. This is where following the initial screening, a local medical call handling service or NHS Direct will manage and forward enquirers to a dedicated dental clinician or nurse. Having participated in a further telephone conversation, the patient episode may either: I. be concluded on the telephone (self help/advice), or II. the patient is referred to the nearest out-of-hours service, or III. arrangements are made for a home visit, or IV. an ambulance is called. 5

6 Managing triage in this way means that effective OOH dental advice can be provided for a large area with limited resources. Individuals with clinical need for treatment will be seen promptly following triage, and the time of dental professionals will be used to greatest effect. The experience of schemes operating in this way is that the number of individual requiring face-to-face contact with a dentist is significantly reduced. 5.3 Peak load management There will be times of the year such as Christmas, New Year, Easter and other Bank Holidays, when patient demands may be considerably higher. Many existing dental out-of-hour services already make provision for these periods, and it is important that in the future such factors be also considered as part of the new arrangements. Solutions may lie in a flexible approach, such as the extension of out-of-hours opening hours or having more practitioners on call should they be required. 5.4 Clinical advice Access to advice from a suitability-qualified clinician (dentist or dental nurse) is imperative. The way in which such advice is accessed will be dependent upon local circumstances and could be managed in a number of different ways. For example the clinician may be: on-call to provide advice only; on call and then shall be the same practitioner who subsequently provides any treatment at an out-of-hours centre, if required; already based at an out-of-hours centre; based at a central point and provides advice to patients only on behalf of a number of PCTs/SHAs. 6. Reviewing out-of-hours dental service provision A review of the delivery of out-of-hours dental services in each area should consider the following criteria: Out-of-hours centres should be located so as to provide patients, dentists and their teams with a safe, appropriate, accessible environment; Out-of-hour centres should be accessible to patients according to local needs, both with respect to opening hours and the required travelling distance; Out-of-hour services should be cost effective and present good value for money. 7. Location of services 7.1 A variety of settings currently host out-of-hours dental services, including community dental service health centres and hospital premises. 6

7 7.2 PCTs will need to assess the location of services in light of their appropriateness for the populations that they aim to serve. Whilst large centralised centres may be appropriate for urban areas, rural needs may necessitate a number of satellite services. Other factors that should also be considered include: proximity and links to Accident & Emergency Departments; accessibility for disabled patients. 7.3 Primary care centres Primary Care Centres are growing in numbers. They provide the best practice environment for both medical and dental out-of-hour services. PCTs may therefore wish to plan, where possible, for dentistry to be included as part of existing or future Primary Care Centre developments within their area. New partnerships with existing health service sectors may also provide alternative solutions. Dental Access Centres may offer a suitable base. 8. Availability of out-of-hour services 8.1 Any national standardisation of opening times removes local flexibility. PCTs may consider for example that, after about 10:30 p.m., a clinician would be on call to respond to calls triaged through by NHS Direct or local call centres but would not routinely be in attendance at a centre if one is operated. 8.2 When considering opening times in the future, it should however be borne in mind that the new out-of-hours system is likely to result in a significant reduction in patients assessing face- to- face consultations with a dentist, including those later in the evening. 9. Availability of treatment and dispensing medication 9.1 Treatment available to patients as part of an out-of-hours consultation will be confined to that necessary for the relief of pain. 9.2 Currently some out-of-hour services only dispense a limited supply of medication to patients, whilst others will dispense a complete course. Like other components of the out-of-hours system, protocols regarding the future dispensing of medication, such as painkillers and antibiotic drugs, should be flexible so as to accommodate local circumstances whilst not compromising the needs of the patient. 9.3 Factors influencing dispensing protocols include the: ability to safely and appropriately store larger quantities of medication, both during and outside opening hours; proximity of a pharmacy to the service. For example, services based within hospitals with a pharmacy may obviate the need for a further trip to a community pharmacy the next day. 7

8 10. Accident and emergency departments Patients with dental complaints commonly access A&E departments as well as GPs as a potential source of care. PCTs should consider the need for triage systems implemented at the door as patients enter A&E also consider the 'primary care' dental needs and direct patients to appropriate services. 11. Information flows 11.1 An integrated OOH model will need to consider the need for information to be shared safely and quickly between all appropriate individuals and organisations A call to NHS Direct or a local call handling service which has included a consultation with a nurse or dentist may result in a negotiation with the patient as to a time at which they will be seen at out-of-hours service or visited at home. Information will therefore need to flow from the end point of the triage to the outof-hour service. Information should include: patient's details patient's dental data 11.3 It should be noted that all immediate and future data transfer systems will have to conform to current regulations regarding Data Protection and Confidentiality. December

9 Service Model APPENDIX 1 A model for managing dental patients out of hours is shown below: General or dental information service The patient makes a single call Ambulance A&E Self care NHS Direct or local on call service/helpline Out-of-hours medical service GDP calls back the patient Advice Pharmacy Appointment to attend out-ofhours centre GDP calls back the patient Advice Face-To-Face Consultation by GDP in out-of-hours centre or at home 9