NHS England (London Region)

Intermediate (Level 2) Oral Surgery Service Specification

September 2016 (version 9)

CONTENTS

1National/local context and evidence base

1.1 NHS England Guide for Commissioning Oral Surgery and Oral Medicine

1.2 General legislation and guidance

1.3Legislation and guidance pertinent to Oral Surgery and Oral Medicine

2Scope

2.1Objectives

2.2Scope of the service

2.3Service requirements

2.4Accessibility

2.5Whole System Relationships

2.6Interdependencies

2.7Duration of service

3Service delivery

3.1 Service Model

3.2 Service Users

3.3Service Quality

3.4 Dental Referral Management System

3.5 Communication

3.6 Premises & Facilities/Equipment

3.7 Information Technology

3.8 Care Pathway(s)

4Referrals, access and acceptance criteria

4.1Geographic coverage/boundaries

4.2Location(s) of Service Delivery

4.3Days/Hours of Operation

4.4Referral route

4.5Response time and Detail and Prioritisation

5. Discharge criteria and planning

6.Prevention, self-care and patient and carer information...... 11

6.1Clinical Care/After Care...... 11

7.Units of dental activity to be delivered /Payment mechanism

8.Monitoring arrangements

9.Managed Clinical Networks (MCN)

10.Service implementation and timescales

Definitions

APPENDIX A......

Figure 1: Patient journey – oral surgery...... 18

1National/local context and evidence base

1.1 NHS England Guide for Commissioning Oral Surgery and Oral Medicine[1]

A significant proportion of procedures currently carried out in many secondary care services can and should be delivered by specialists and dentists in a primary care setting. The national commissioning guide for Oral Surgery and Oral Medicine22 provides a framework to support commissioners working with clinicians and patients to transform services at a local level, meeting local needs and achieving best value and sustainability for the resources available.The aim is to improve patient experience and clinical care through a high quality accessible and cost efficient service whilst dissolving the artificial divide between primary dental care and hospital specialists. These objectives are in line with NHS England and The Five Year Forward View3.

The Commissioning guide includes a care pathway for Oral Surgery services describing consistent national elements for Oral Surgery delivery, regardless of setting.This is to ensure a focus on patient outcomes and greater consistency in delivery of Oral Surgery services, both in the sequencing, effectiveness and quality of clinical care and the ‘journey’ that patients experience. Appendix B describes the illustrative patient journey for oral surgery and complexity levels described in the national commissioning guide for Oral Surgery.

1.2 General legislation and guidance

  • NHS Constitution for England, updated 2015[2]
  • Five Year Forward View, 2014[3]
  • Securing Excellence in commissioning NHS dental services, 2013[4]
  • Equity and excellence: Liberating the NHS, 2010[5]
  • Implementing care closer to home, modified 2009[6]
  • High Quality Care for All – NHS Next Stage Review Final Report, 2008[7]
  • NHS England Specialty Training, Health Education England[8](formerly, Modernising Medical Careers)
  • NHS Personal Dental Services Agreement[9]
  • Health Technical Memorandum 01-05: Decontamination in primary care dental practices, 2013[10]
  • Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER), 2012[11]
  • HIV-infected health care workers: Guidance on management and patient notification, 2005[12]
  • Equality Act, 2010[13]
  • Human Rights Act 1998[14]
  • Dental Practitioners’ Formulary[15]
  • GDC Scope of Practice guidance[16]
  • GDC Fitness to Practice advice[17]
  • GDC Standards for the Dental Team guidance[18]
  • Caldicott review: information governance in the health and care system, 2013[19]

1.3Legislation and guidance pertinent to Oral Surgery and Oral Medicine

  • NICE Technology Appraisals Guidance No.1 - Guidance on the Extraction of Wisdom Teeth, 2000[20]
  • Conscious sedation in the provision of dental care: report of an Expert Group on Sedation for Dentistry, Standing Dental Advisory Committee, 2003[21]

2Scope

2.1Objectives

2.1.1 NHS England (London Region) is looking to commission Level 2 Oral Surgery (OS) services by utilising General Dental Council (GDC) registered Oral Surgery specialists and accredited performers who undertake OS work at the competency level 2.

2.1.2 NHS England Guidelines for the appointment and accreditation

performers who undertake work at the competency level 2in Minor Oral Surgery are in development. The purpose of the guidelines is to set out a framework for appointing, accrediting and re-accreditation of Dentists undertake OS work at the competency level 2 within primary care IMOS Centres. In doing so it brings together previous guidance from the Department of Health, current Guidance for commissioning Oral surgery from NHS England and the principles underpinning Good Medical and Dental Practice.

2.1.3The NHS England commissioning guidance for Oral Surgery sets out a framework for Minor Oral Surgery within a Managed Clinical Network (MCN), ensuring that the complexity of the patient or procedure matches the skills and setting of the individual providing the treatment.An MCN will be established to oversee the implementation and the functioning of the specialist pathway, including quality improvement, mentorship, education, audit and leadership. The Chair will be accountable to commissioners and will be responsible to the Local Dental Network (LDN). It will be consultant-led where possible and all Level 2 and 3 Oral Surgery/Oral Medicine providers will play an active role and will have a formal link tothe MCN.

2.2Scope of the service

2.2.1 The Service will provide oral surgery for patients being referred by NHS England (London Region)General Dental Practitioners (GDPs).

2.2.2The service will work to a time-limited Personal Dental Services (PDS) agreement and provide consistent, high quality care based on quality assurance principles as set out in a PDS agreement.

2.2.3 The Level 2 service is defined as “procedures/conditions to be performed or managed by a clinician with enhanced skills, competence and experience who may or may not be on a specialist list. This care may require specialist equipment or environment standards but can usually be provided in a primary care setting”.

2.2.4 Delivering the following principles - the service should:

  1. Improve access and reduce waiting times for OS services for London residents
  2. Give patients flexibility, choice and equity of access
  3. Respond to the needs of London residentsin providing an appropriate range of minor oral surgery procedures within a primary care setting
  4. Reduce the number of inappropriate referrals into secondary care
  5. Comply with Personal Dental Services (PDS) regulations
  6. Recognise that high quality healthcare is multidisciplinary and should be delivered through good working relationships with others
  7. Develop an appropriate skill mix within a clinical network to be established
  8. Offer high quality healthcare with continually improving services and development for staff
  9. Establish a positive working relationship between NHS England (London Region),the LDN,the service provider and referring dentists

2.2.5The performer must be included on a primary care dental performer’s list and the GDCSpecialist List for Oral Surgery, or be an accredited to undertake OS work at the competency level 2

2.3Service requirements

2.3.1NHS England (London Region) requires the Level 2 OS service to be provided within a suitable primary, acute or community care setting.

2.3.2This will be a service consisting of:

  1. Patients referred by their General Dental Practitioner (GDP) and referred to the primary care minor oral surgery service provider(s) on the appropriate referral form (See Appendix A for example referral form).
  1. If a Referral Management System has been implemented, Patients referred by their General Dental Practitioner (GDP) via the dental referral management (triage) service and referred to the primary care minor oral surgery service provider(s) by the stated method
  1. All patients including internal referrals will be triaged.
  1. The Level 2 service will include examination, diagnosis, investigation, management and treatment and after care as appropriate.

2.3.3The Provider shall treat the patients, or if unable to treat based on assessment, will refer back to the original GDP, onward to secondary care and if applicable back to dental referral management (triage) service.

2.3.4NHS England (London Region) will work with secondary care to assess the impact of the service on secondary care.

2.3.5The Provider shall accept appropriate referrals made under protocol from GDPs for patients who are NHS England (London Region) registered with NHS England (London Region)General Medical Practitioners.Patients who are outside the London Region should be referred to services within the areas of residency.

2.3.6Both the referring dentist and the provider shall undertake a patient assessment during which options for treatment will be discussed with the patient. See 2.3.3

2.3.7The Provider shall gain informed written consent from the patient for surgical intervention.

2.3.8Patients will be referred to the service in accordance with agreed criteria and shall be treated, where appropriate, under local anaesthesia.

2.3.9Patients under a NHS course of treatment shall have a Band 2 course of treatment openedand charged as appropriate by the referring dentist. A copy of FP17 referral notice shall be completed and included with the referral. No additional charges shall be levied to the patient.

2.4Accessibility

2.4.1The availability of the Level 2 service will be agreed by the commissioner.

2.4.2On receipt of correctly triaged referral, patients will be offered a choice of appointment by the OS service practice.

2.4.3The provider shall obtain and maintain a valid NHS.net account.

2.4.4The Provider will deal with emergencies involving their oral surgery patients as required

withintheir PDS agreement, and will provide out of hours cover for patients under their treatment forOS.

2.4.5In the event of an unexpected complication occurring with care provided by the Provider, a clear communication pathway shall be agreed with the Consultants in Oral Surgery (OS) and Maxillofacial Surgery (OMFS) in secondary care.

2.5Whole System Relationships

2.5.1 The Provider shall work collaboratively with Commissioners to further develop services.

2.5.2 The Provider shall develop positive working partnerships with other providers and GDP’s to facilitate integrated working.

2.5.3 The Provider shall ensure that all NHS patients have the following basic rights:

  1. continuity and consistency of service
  2. a service that is equitable for all users
  3. to be addressed by their chosen title and/or name
  4. to have their personal dignity respected
  5. to have their confidentiality respected
  6. a right to complain without fear or recrimination
  7. no discrimination on the basis of gender, ethnicity, sexual orientation

2.6Interdependencies

2.6.1For the purposes of this specification the NHS England (London Region) is expected to triage 100% of new referrals through a new dental referral management system (details to be confirmed).

2.7Duration of service

2.7.1 The contract for the service shall be for five years, with the intention to have an option to extend for a further period of two years.

3Service delivery

3.1 Service Model

3.1.1 The specification requires the Provider to deliver Level 2 OS services to patientswho are Londonresidents registered with NHS England a (London Region) GMP, or referred bygeneral and specialist dental practitioners, hospital specialists, and practitioners inthe community and salaried services in accordance with published criteria. Patients shall betreated under local anaesthesia. NHSE are currently scoping the inclusion of a RMS with the intention of commissioning at some stage. Once in place it will be adopted by general and specialist dental practioners, and hospital specialists and practioners in the in the community and salaried services in accordance with the guidelines set by NHSE

3.1.2 The range of procedures which can be performed under this Level 2 agreement include:

  • Surgical removal of uncomplicated third molars involving bone removal
  • Surgical removal of buried roots and fractured or residual root fragments
  • Management and surgical removal of uncomplicated ectopic teeth (including supernumerary teeth)
  • Management and surgical exposure of teeth to include bonding of orthodontic bracket or chain
  • Surgical endodontics
  • Minor soft tissue surgery to remove apparent non-suspicious lesions with appropriate histopathological assessment and diagnosis

3.1.3 This does not preclude other procedures that the Provider can demonstrate to be within theirclinical competency. The Provider shallbe expected to exercise his/her clinical judgement as to the suitability of the patient to be treated within an intermediate care setting.

3.2 Service Users

3.2.1 The service users comprise:

  1. NHS patients including under 18 years; who have been referred by their GDP to the triage service, having been clinically assessed and deemed suitable to have their treatment provided in a primary care setting by accredited providers of minor oral surgery.
  2. NHS patients including under 18 years; assessed by the triageservice will be offered an appointment with a Level 2 Provider, who will treat the patient and then discharge them back to the referring GDP.

3.3Service Quality

3.3.1 The Provider shall be required to have a quality assurance process that ensures;

  1. all dental care provided is appropriate and of a consistent quality
  2. effective measures for infection control which comply with HTM 01-05
  3. all legal requirements relating to health & safety in the workplace are satisfied
  4. all legal requirements relating to the GDC in respect of the continuing professional development of dentists and the dental team are satisfied. All clinicians performing within this contract to be appropriately registered professionally; and should be included on the OS specialist list (this includes the specialty previously called Surgical Dentistry) or performers who undertake OS competency at level 2..
  5. Dental nurses should be appropriately qualified and registered or be enrolled in a

recognised training programme.

3.3.2The Provider shallbe expected to demonstrate Level 2 competencies as described in the NHS England Guide for Commissioning Oral Surgery and Oral Medicine[22];

  1. examination and diagnosis
  2. treatment planning and patient management
  3. clinical practice – medical & dental emergencies
  4. clinical practice – anesthesia, pain and anxiety control/surgery (basic surgical principles)/surgery specific procedures (as relevant)/non surgical management of hard and soft tissues
  5. communication – patients and relatives/clinical teams, peers and other professionals
  6. professionalism – ethics and legislation

3.3.3 The Provider shallbe required to;

  1. demonstrate evidence of staff competence for all staff
  2. ensure record keeping is of an appropriate standard
  3. ensure appropriate patient booking systems are in place
  4. ensure systems are in place for dealing with emergencies
  5. ensure systems are in place for accessing translation services, if required
  6. ensure a complaints system is in place for patients and carers

3.3.4 The Provider shallbe responsible for assuring quality through both case and patient audit.

3.3.5 The Provider shall, at any time on receipt of reasonable notice (two working days), allow representatives of NHS England (London Region) to visit the premises on a working day in order to undertakean inspection of the premises and to assess compliance with statutory and health and safetyrequirements.

3.4Dental Referral Management System

There will be no RMS at this stage , However NHSEngland ( London region)is currently scoping this service with an intention to commission at some stage subject to financial requirements and assurances with adherence to national policy and proecdure . All successful awards must have the IT infrastructure to send and receive electronic referrals including digital x-ray imaging.

3.5 Communication

3.5.1 Some patients requiring oral surgery services will have special communication needs. Signage and accessible information such as ‘Easy read’ that take into account the additional needs of these patients must be appropriate to the individual needs of each patient. Large print or easy read appointment cards should be available, if required. Waiting area includes appropriate seating and communication aids as well as adequate space for people who use wheelchairs or mobility scooters.22

3.5.2 The patient should be communicated with effectively to ensure that they understand what treatment is being proposed and any potential complications.

3.5.3The patients’ treatment needs and any treatment plans advised or undertaken must becommunicated to the referring practitioner.

3.5.4 Any radiographs, study models etc., provided by the referring practitioner should be returned on completion of the treatment or forwarded to the Level 3 providers, where patients are referred.

3.6 Premises & Facilities/Equipment

3.6.1 The service must be provided in a location that is accessible by all members of the community and with good transport links.

3.6.2 The premises shall be accessible to emergency vehicles.

3.6.3. The following are statutory minimum requirements that must be met by the Provider:

a) Employers Liability Insurance

b) Electricity at Work Regulations (Portable Applicance Testing)

c) Pressure Vessel & Autoclave Regulations

d) Ionising Radiation Protection Regulations

e) Hazardous Substances Risk Assessment and COSHH Assessment

f) RIDDOR

g) Compliance with Water Bye-Laws

h) Compliance with Resuscitation Council and British National Formulary Guidelines for Medical Emergencies in Dental Practice with reference to:

  • Emergency drugs including portable oxygen supply
  • Portable self powered suction
  • Airway adjuncts
  • Monitoring equipment (as appropriate)
  • Arrangements for storage and disposal of clinical waste and sharps
  • Current cross-infection control guidelines
  • Defibrillator

3.6.4 Additionally the Provider shall ensure that all those involved in the provision of the service haveadequate Professional Indemnity cover.

3.6.5 Premises shall be subject to inspection by the Dental Practice Adviser and Infection Control Nurse to ensure they meet all statutory requirements for the Level 2 OS service.

3.6.6 The provider shallbe responsible for set-up costs. The following would be required as a minimum by any provider wishing to provide oral surgery from their premises:

a)Appropriate surgical equipment and instruments/disposable items

b)Orthopantomograph (OPG)

c)Chair

d)Operating light

e)High volume aspiration

f)Reception and waiting room

g)Adequate staffing levels

h)Car parking and/or pick up facilities

i)Pre and post-operative instructions, consent and medical history forms

j)Wheel chair access

k)Emergency equipment and drugs

3.7Information Technology

The Provider shall be expected to be linked to an approved clinical system that allows effective storing of

  • electronic patient records
  • can send and retrieve electronic communication including radiographs.
  • The use of NHS.net
  • Broadband access with full use of e-mail and the intranet
  • Transmit activity data electronically to NHSEngland( London region)
  • Electronic transmission of data to the NHSBSA
  • To follow all NHS Information Governance requirements?

The operation and purchase of anyIT will be the responsibility of the provider.