40128 1P 1k May 04 (BAB) PO Box 777 London SE1 6XH - Dentists with Special Interests.pdf · Department of Health Publications PO Box 777 London SE1 6XH Tel: 08701 555 455 Fax: 01623

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www.doh.gov.uk/nhsplan

Faculty of General Dental Practitioners (UK)The Royal College of Surgeons of England

Department of Health / Faculty ofGeneral Dental Practitioners (UK)

Implementing a Scheme for Dentists with Special Interests (DwSIs)

May 2004

READER INFORMATION

Policy EstatesHR/Workforce PerformanceManagement IM&TPlanning FinanceClinical Partnership Working

Document Purpose Policy

ROC Ref: Gateway Ref: 2788

Title Implementing a Scheme for Dentists with Special Interests

Author FGDP (UK), Department of Health

Publication Date 31st May 2004

Target Audience PCT CEs, NHS Trusts CEs, SHAs CEs, WDC CEs, Medical Directors, Directors of HR, GDPs, LDCs, Salaried Dental Service, DPB

Circulation list Consultants in Dental Public Health, GDP Advisors

Description To provide information and advice to dentists and PCTs on a scheme for accrediting “dentists with special interests” within the NHS, in line with other areas of healthcare.

Cross Ref N/A

Superceded Docs N/A

Action required N/A

Timing N/A

Contact Details Dentists with Special Interests TeamDental PolicyArea 330aWellington House133-155 Waterloo RoadLondonSE1 [email protected]

For recipient use

Contents

Forewords 3

Introduction 6

• What are dentists with special interests (DwSIs)? 6

• What will a Primary Care Trust need to do? 7

• What does a dentist with a special interest need to do? 9

Principles 9

Delivering the scheme 11

• Developing a competency framework for the 11identification of DwSIs

• Generalist primary dental care competencies 11

• Special interest competencies 12

• Service development and quality assurance competencies 14

• Accreditation and maintenance of competencies 14

• Charges for dental treatment 15

Next steps 16

• National Development Group 16

Further information 17

• Contacts 17

Appendix 1 – National Development Group membership 18

Forewords

We are undertaking the greatest change to NHS Dentistry for over 50 years. The maindriver for this change is to provide a service that is better for patients, better for dentistsand their teams and better for the NHS.

Dentistry is being integrated fully within the NHS by giving Primary Care Trusts(PCTs) the responsibility for determining the oral health needs of their population andcommissioning the services that their residents need. As part of this process PCTs willwant to review the services provided to patients both in a primary and secondary caresetting.

By providing PCTs with an opportunity to contract with dentists who have developedspecial interests in addition to their generalist role, we will widen the choice available topatients in terms of the nature and locality of NHS dental care provided for them.

I believe that this is an ideal opportunity for dentists, who through experience and/ortraining have developed additional skills, and would wish these skills to be recognisedby their peers.

This development fits well within the future contract model for primary dental careservices and it is my intention to ensure that as we move into the new primary caredental services in 2005, PCTs will be able to contract with local dentists who havespecial interests and who have been able to demonstrate their competency to undertakehigh quality care.

Professor Raman BediChief Dental Officer of England

Services provided by GPs, nurses and Allied Health Professionals (AHPs) with specialinterests are already well established in the NHS, and are making a real difference topatients, and to the service as a whole. Patients can benefit from faster and moreconvenient access to secondary care services, without an unnecessary referral to hospital;this in turn helps to relieve pressure on the acute sector. Increasingly, as new services arecreated and led by practitioners with special interests, we are seeing the establishment ofmore integrated care pathways. Multi-disciplinary teams of appropriately qualifiedprofessionals are working across the interface between primary and secondary care tothe benefit of the patient. It is this opportunity for the planning and commissioning ofintegrated primary and secondary care services which in my view makes this initiativeparticularly timely for dentistry.

3Implementing a Scheme for Dentists with Special Interests

Systems to support the delivery of primary medical and primary dental care haveevolved in very different ways. Following the NHS Dentistry: Options for Change projectand with the move to PCT commissioning of dental services from 2005 there will besignificant changes in the way in which dental services are commissioned in the future.The new dental contract will provide a firm basis for the imaginative commissioning ofprimary care dental services, including the provision of secondary care services inprimary care settings.

I am therefore very pleased to welcome the publication of this document, Implementinga Scheme for Dentists with Special Interests (DwSIs). This is the latest in a series ofguides, which began in April 2002 with Implementing a Scheme for General Practitionerswith Special Interests,1 which first noted the potential for the development of the rolesof other health professionals, including dentists. Subsequent documents providedguidance for the development of nurses, AHPs and guidelines for GPs with specialinterests in 16 different clinical specialties, ranging from care for older people, to sexualhealth.2 The Modernisation Agency has also produced an excellent Step by Step Guideto setting up a general practitioner with a special interest (GPwSI) service3 and has adedicated team providing support to NHS organisations wishing to develop a widerrange of services in primary care.

The development of new roles for practitioners working in the community, makingbest use of their skills and experience, putting services closer to patients represents oneof the most exciting initiatives amongst those currently transforming the nature ofprimary care. The dental profession has an important contribution to thistransformation, and this guidance will hopefully provide some suggestions for thedevelopment of services to achieve this.

Dr David Colin-Thomé, National Director for Primary Care


1 Implementing a Scheme for General Practitioners with Special Interests (Department of Health, 2002).2 All guidance is available online at www.natpact.nhs.uk under Practitioners with Special Interests.3 Practitioners with Special Interests. A Step by Step Guide to setting up a general practitioner with a special

interest (GPwSI) service (National Primary and Care Trust Development Programme, 2003),www.gpwsi.org

The Faculty of General Dental Practitioners (UK) welcomed the emphasis inOptions for Change on the importance of developing education and training inthe primary dental care setting. That emphasis was very much in keeping withthe ambition encapsulated within the NHS plan of delivering a wider range ofservices within primary care.

A wide range of dental services has traditionally been delivered outside thesecondary care setting. The advent of PCT commissioning of dental services willprovide new opportunities for the organisation of these services in a way whichwill be complementary to the secondary care sector and provide more choice andaccessibility for patients. The challenge will be to ensure best use of dental skillsand resources in both areas.

The potential advantages to the NHS of the introduction of the concept of aDwSI service equate to those in medicine. DwSIs will provide quick access tolocal specialised skills in familiar surroundings in local communities. In addition,the concept will help support dentists in their professional development andallow those with special interests and expertise to apply their skills andknowledge for the benefit of patients and local services.4 DwSI services should becarefully planned in conjunction with secondary care services with the objectiveof improving the management of workload between primary and secondary careand, where appropriate, to relieve the pressure of referrals for specialist care intothe secondary sector.

The FGDP(UK) as a standard setting body for primary dental care welcomes thisinitiative. It will be important to create a framework which is effective in qualityassuring and benchmarking the skills of DwSIs. We look forward to working inpartnership with commissioning organisations and professional bodies to developframeworks for the identification and accreditation of DwSIs.

Mike MulcahyDeanFaculty of General Dental Practitioners (UK)


4 Department of Health/Royal College of General Practitioners: Implementing a scheme for GeneralPractitioners with Special Interests, April 2002

Introduction

What are dentists with special interests (DwSIs)?

1. The concept of a dentist with a special interest (DwSI) encompasses anydentist working in the primary care setting who provides services whichare in addition to their usual and important generalist role.

2. A wide range of dental services has traditionally been delivered outsidehospitals, including those provided by dentists who are on the specialistlists of the General Dental Council but who provide services outside theusual secondary care setting. The DwSI provides a service which iscomplementary to secondary services as a whole, but they do not replacethose dentists who have undergone the training required for entry to thespecialist lists. The DwSI is an independent practitioner who works withinthe limits of their competency in providing a special interest service and whorefers on where necessary.

3. The DwSI may deliver a clinical service beyond that normally provided by aprimary dental care practitioner or may deliver a particular type oftreatment. Individual DwSIs will be able to demonstrate their competenciesin special interest areas. PCTs will be able to contract with DwSIs to provideenhanced services with improved access to meet the identified needs of thelocal population.

4. Services which have traditionally been provided outside the hospital settinginclude some provided by dentists who fall within this scheme’s definition ofa DwSI. The concept is not therefore new. The value of the scheme rests in:

• Developing the concept of special interests for a wider group ofpractitioners for the benefit of patients.

• Providing better definition for existing special interest services andmaking them available to more commissioning PCTs.

• Enhancing the value of special interest services through improvedcollaboration between the primary and secondary care sectors, aprocess which will be led by PCT commissioning.

5. Special interests may be demonstrated by dentists through the completion offormal training programmes. Other dentists will be able to offer experiencebased evidence. This document explains work which will be undertaken todevelop clinical competency frameworks which will provide advice andinformation for PCTs on the appointment of DwSIs.


What will a Primary Care Trust need to do?

6. PCTs have responsibility for reviewing the health needs of theirpopulation and commissioning services to meet those needs. From 2005PCTs will have full responsibility for commissioning both primary andsecondary dental services. The concept of services provided by a DwSI isone of a range of options the PCT will wish to consider in the planningand commissioning of services to meet the health needs of theirpopulation.

7. In determining the oral health needs of their population and whether aDwSI service is appropriate, PCTs will wish to consider:

• Current demand/capacity for a service.

• The existing range of services available.

• Access to specialist care locally.

• An evaluation of the type of referrals made into secondary care, andworking with both primary and secondary care clinicians,identification of care which could appropriately be taken into anewly created service involving a DwSI.

8. The PCT will also wish to consider the specification for a DwSI post andservice based on the local needs assessment and the resulting servicepriorities. The identified service need may be for the delivery of a rangeof services in one particular clinical area, or may relate to a narrowerrange of defined treatments.

9. The first clinical competency frameworks to be made available will be:

• Orthodontics

• Dento-alveolar surgery

• Periodontics

• Endodontics

10. Following the development of competency frameworks in these areas,consideration will be given to further areas for development. These arelikely to be influenced by work being undertaken under Options forChange and personal dental service pilots.


11. As paragraph 4 acknowledges, the concept of a dentist with a specialinterest is not new. The intention of this scheme, however, is to movetowards a framework which will support the accreditation of DwSIswithin a quality assurance framework which can be relied upon by PCTsand the patients using their services. As part of their new commissioningrole, PCTs may wish to review existing services against the competencyframeworks as they become available.

12. This scheme focuses primarily on DwSIs delivering clinical services.PCTs will also wish to consider whether certain clinically related skills arerequired for particular DwSI roles. Additionally, PCTs may be assisted intheir commissioning role by dentists with skills in areas such as dentalpublic health, service planning and quality assurance. These clinicallyrelated competencies are referred to in paragraphs 29 to 31.

Example of a DwSI service – what does a PCT need to do?

A Primary Care Trust is dealing with a waiting list for the extraction ofimpacted wisdom teeth at its local district general hospital. A sample analysis of the case mix has indicated a range of cases from complex (severe distoangular unerupted impaction) through to less complex cases (almost fullyerupted non impacted wisdom teeth with some pericoronal infection). It isestimated that one half of the cases require the services of the consultant at thedistrict general hospital, whilst the remainder are less complex cases whichcould be treated within a primary care setting.

A dentist working in a large multi-surgery practice has been undertaking aclinical attachment in the hospital’s oral and maxillo-facial department and hasdeveloped skills in dento-alveolar surgery.

The practitioner’s competencies are accredited against the national frameworkfor dento-alveolar surgery.

The PCT in consultation with the local consultant agrees to contract with thepractitioner for a defined number of cases within his/her competencies to betreated at his/her practice within a primary care setting. The district generalhospital will retain a case mix suitable for training purposes.

The PCT contracts with the DwSI for a defined caseload.


What does a dentist with a special interest need to do?

13. Primary dental care practitioners with a special interest as a first stepmight wish to contact their local PCTs with details of their CV andparticular skills. The special interest may encompass a range of skills inone clinical area or may be restricted to one type of treatment. Theappointment of a DwSI will be led by the PCTs’ assessment of oralhealth need measured against existing service provision.

Example of a DwSI - what does a dentist need to do?

A practitioner has attended numerous courses in full denture provision and hasattended a directed educational course to develop his skills. But the patientbase within his particular practice does not fully utilise the skill he hasdeveloped.

He registers his interest in this area of clinical provision with his PCT, whichdeals with a population with a higher age profile and has a high number ofelderly patients in the care home setting.

The PCT identifies the level of service needed, and the practitioner isaccredited as a DwSI through the presentation of evidence of competencies.The PCT then contracts with the practitioner for a defined number of casesper year, with the service to be delivered within a local dental facility or inspecified patient locations, for example nursing homes.

Principles

14. DwSIs may be directly employed (by either Primary Care Trusts or AcuteTrusts) or may be commissioned as independent contractors. Furtherinformation will be published on processes for appointing DwSIsalongside the clinical competency frameworks for each area.

15. The provision of special interest services and the appointment of DwSIswill be led by the following principles:

• The appointment of a DwSI will only follow a local needsassessment and design of service to meet a defined need.

• As a part of this process, the PCT will consult local stakeholdersand facilitate support for the service from local clinicians in boththe primary and secondary sectors and potential users of the service.


• There will often be a partnership between the specialist service andthe DwSI in planning and delivering an integrated service andtreatment appropriate to individual patient needs. Localpractitioners will retain the right of direct access to secondaryservices where they consider this appropriate.

• Appointment of a DwSI will be on the basis of evidence ofsuccessful acquisition of competencies, through either the provisionof experience based evidence or externally taught quality assuredprogrammes. Nationally the Faculty of General DentalPractitioners (UK) will advise on the suitability of courses anddiplomas for general practitioners with special interests. Locally thepostgraduate dental deans will play a major role in providing adviceon appropriate training to meet requirements set out in the clinicalcompetency frameworks.

• It is recommended that the precise service to be provided is definedwithin a clear contractual framework.

• The PCT will wish to ensure that the working environment of theDwSI enables the dentist to practise their special interest to therequired level. It is recommended that guidance for theaccreditation of premises is developed in line with the level ofservice provided, and that premises are accredited to host thespecific agreed services.

• Any DwSI service will also be the subject of regular evaluation in thecontext of delivery of the aims and objectives of the service and thedevelopment of local health planning. This should include an annualappraisal of the DwSI (see paragraph 34).

16. If a DwSI is an independent contractor he or she should be asked toconfirm indemnity cover with their defence organisation. Confirmationof an appropriate level of indemnity cover will feature as a part of thecontractual arrangement between the PCT and the dentist. If the DwSI isemployed directly by the Primary Care Trust or Acute Trust, they will becovered by the Clinical Negligence Scheme for Trusts run by the NHSLitigation Authority. The PCT may therefore wish to notify the NHSLitigation Authority and their own legal advisors of their proposedscheme and discuss it with them. However, in all circumstances DwSIsare advised to notify their indemnity organisation.

17. The dental defence organisations will have a continuing interest asstakeholders in view of the scheme’s role in defining and maintainingstandards.


Delivering the scheme

Developing a competency framework for the identificationof DwSIs

18. Identified service needs may be for the delivery of a range of services inone particular clinical area, may relate to a narrower range of definedtreatments, and may involve specified non-clinical competencies.

19. Competency frameworks will therefore be developed which can be usedflexibly according to local definition of the requirements for theparticular role. Competency frameworks will include selection criteria forPCTs and will provide information on essential and desirable attributesfor appointment.

Generalist primary dental care competencies

20. In accordance with the definition of a DwSI, the PCT should ensurethat the dentist is competent and experienced in the delivery ofgeneralist primary dental care services in addition to being competent intheir special interest area.

21. Evidence of training and experience for competencies in generalist skillswill be provided through a portfolio approach which should flow fromthe requirements of clinical governance. The portfolio demonstratesevidence of key competencies in the following areas:

• Prevention and management of medical emergencies

• Cross infection control

• Record keeping

• Radio-imaging

• Legislation in primary dental practice

• Staff training and personal training

• Communication skills


22. The MFGDP(UK)’s coursework module, which also requires an auditand case presentation, is one means by which general competencies canbe demonstrated. The coursework module is assessed and accredited bythe FGDP(UK).

23. It would also be reasonable to assume that a practitioner should haveacquired a minimum period of experience post vocational or generalprofessional training, and have ideally acquired a postgraduatequalification. It is proposed that three years postgraduate experience beregarded as a minimum, assuming the achievement of a postgraduatequalification, or a longer demonstration of the application ofcompetencies in the primary dental care setting may be appropriate inthe absence of a postgraduate qualification.

Special interest competencies

24. Some general dental practitioners may have acquired the necessaryspecial interest competences through recent and relevant diplomas andcertificates, which will provide evidence of learning and training and canbe equated to a set number of hours of learning and supervision.

25. However, there will also be a number of practitioners, likely to be in themajority, who will demonstrate clinical special interests on the basis ofwork based learning, training and experience.

26. The development of clinical competency frameworks will enable theaccreditation of the knowledge, skills and experience necessary for theDwSI:

• A portfolio based on the clinical competency framework willdemonstrate the practitioner’s skills in treatment planning, deliveryand evaluation. Some direct observation of the practitioner’s skillsmay be necessary.

• Practitioners may also demonstrate skills and experience throughclinical attachments undertaken, the number of proceduresundertaken in a particular area, or length of time in practice in thearea concerned and knowledge through attendance at appropriatecourses.

• There should be evidence of attendance at relevant courses andtraining linked to learning gaps as identified through a compulsorypersonal development plan linked to an appraisal.

• Patient feedback should also be included in the portfolio.


27. Assessment and accreditation of the practitioner will be required on thebasis of the portfolio. This is dealt with in paragraphs 32 to 34.

28. Work will also be undertaken to develop training programmes to assistpractitioners in developing special interest skills relating to thecompetencies defined for each area. These may be formal taughtprogrammes or a combination of taught and portfolio basedcomponents, but the approach will be flexible to assist busy practitionersin the workplace.

Example of a DwSI service – special interest competencies

A comprehensive consultant orthodontic service is not available locally. An 11-year-old patient requires treatment for large overjet. It will require frequentmonitoring during treatment. A minimum of one hour’s travelling in schooltime will be required for appointments at the nearest secondary care serviceand there is a waiting time for a first appointment.

There are local practitioners who have an interest in orthodontics. There arealso practitioners with experience in orthodontics who, whilst not immediatelylocal, can provide a more accessible service than that provided by the nearestsecondary service.

The Primary Care Trust identifies the need for a DwSI service:

• As not immediately available the PCT may need to seek expert assistancethrough national networks to assist in defining local caseload and thelevel of clinical competency required to deal with these.

• Through the accreditation of local practitioners who have developedexperience in orthodontics, it provides an initial source of referral fororthodontic advice.

• Working with contracts and protocols agreed with the PCT andorthodontic specialists, the DwSI decides which cases to treat and whichshould be referred to specialists. Referral to the secondary or specialistcare setting will always be appropriate for some cases, but he/she mayalso refer to other DwSI colleagues with identified skills in treatingparticular conditions.


Service development and quality assurance competencies

29. The PCT may identify a need for a special interest service which requiresskills in service development and quality assurance. In defining a DwSIrole, the PCT may wish to consider whether skills in the following areasare required in addition to the generalist primary care and special interestclinical competencies:

• Leadership

• Negotiation

• Commissioning

• Change management

• Dental public health

• Audit and clinical governance

• Education and training

30. Some of these skills may be demonstrated through the completion ofaccredited and quality assured training programmes. The FGDP(UK)’sCertificate in Leadership and Management is one example.

31. Alternatively, these competencies may also be demonstrated by aprofessional development portfolio and maintained through a personaldevelopment plan and appraisal.

Accreditation and maintenance of competencies

32. There needs to be a system for the accreditation of competencies. Thiswill need to find the right balance of practicality for the practitioner witha busy NHS commitment and the requirements of the local PCT, whilstalso providing a level of accreditation which can be relied upon.

33. The competency frameworks will provide a system of assessment andaccreditation with information on processes for appointing DwSIs.Accreditation will be facilitated by the FGDP(UK) in collaboration withspecialist advisers provided by a variety of organisations including thedental faculties and the specialist organisations.


34. The PCT will need to ensure, on an annual basis, that the DwSI ismaintaining levels of competence. This should involve:

• Provision of a mentor.

• Participation in 15 hours of verifiable CPD in the special interestarea as a demonstration of commitment (in addition to the basicGDC requirement for 15 hours of verifiable CPD per year).

• Participation in clinical networks which include other DwSIs withthe same special interests and specialist mentors.

• Annual appraisal of generalist and special interest areas andmaintenance of a personal development plan, and a confirmationof the maintenance of the previously demonstrated standards ofclinical governance.

Charges for dental treatment

35. Unlike special interest developments in other healthcare areas, indentistry, the transferring of non-exempt adult patients from a secondarycare setting to a primary care setting for treatment raises an issue ofliability for patient charges unless exemptions apply. A factor in this willbe the way in which Primary Care Trusts design and commission specialinterest services.

Harry Cayton, director for patients and the public, has led a review oncharges for dental treatment. The impact of this review will need to beconsidered as further development work takes place on the DwSI schemeand PCTs will be provided with further information on this in duecourse.


Next steps

National Development Group

36. The Chief Dental Officer has established a National DevelopmentGroup with the brief to commission the development of clinicalcompetency frameworks in conjunction with the dental faculties,specialist and professional organisations. These frameworks will provideguidance to PCTs on the identification and accreditation of DwSIs. TheNational Development Group includes representatives of the professionalbodies, PCTs and the patient and public perspective. The Group willdelegate the production of guidance to individual working groupsinvolving appropriate stakeholders and coordinated by the FGDP(UK).

37. The initial priorities will be those identified in this document, but thesewill evolve as the scheme progresses.

38. Whilst the framework designed for each area is likely to differ, theintention will be to produce guidance, which can be used flexibly atvarious levels:

• To provide a checklist of core competencies for DwSIs in definedspecial interest areas which can be used as a tool by PCTs in servicedesign.

• To identify the evidence required to demonstrate competencies.

• To provide a framework for the submission of evidence ofcompetencies for accreditation.

39. The National Development Group will act as a reference groupresponsible for the quality assurance of competency frameworks for eachclinical area.


Further information

40. As work on the scheme progresses, further information will be available from:

The National Primary and Care Trust Development Programme(NatPact) website: www.natpact.nhs.uk

The Chief Dental Officer’s Section of the DoH website:www.dh.gov.uk/cdo

The Faculty of General Dental Practitioners (UK):www.rcseng.ac.uk/fgdp under the ‘latest news’ section

Contacts

Tony Jenner, Project Lead, Department of HealthSharon Drake, Project Manager, Department of Health,Email: [email protected]

Dentists with Special InterestsDental PolicyArea 330aWellington House133 – 155 Waterloo RoadLondonSE1 8UG


Appendix 1

National Development Group membership

Frances Blunden Principal Policy Adviser – Health Consumers’Association

Janet Clarke Chair, Central Committee for Community DentalServices and Public Health Dentistry

Barry Cockcroft Deputy Chief Dental Officer, Department of Health

Kathy Doran Chief Executive, Birkenhead and Wallasey PCT

Sharon Drake Deputy Registrar/Project ManagerFGDP(UK)/Department of Health

Tony Jenner Head of Policy Development, Department of Health(Chair)

Stuart Johnson Chairman, NHS Sub Group of GDPC

John Langford West Midlands South SHA, Department of Health

John Lowry Dean, Faculty of Dental Surgery

Hew Mathewson President, General Dental Council

Alasdair Miller Postgraduate Dental Dean, University of Bristol

Mike Mulcahy Dean, Faculty of General Dental Practitioners (UK)

Nikolaus Palmer General Dental Practitioner

Mabel Slater Director of Professionals Complementary to Dentistry,Guy’s, King’s & St Thomas’ Trust

Claire Whittington Department of Health


40128 1P 1k May 04 (BAB) PO Box 777 London SE1 6XH - Dentists with Special Interests.pdf · Department of Health Publications PO Box 777 London SE1 6XH Tel: 08701 555 455 Fax: 01623

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