March 2012

Dental Public Health in Action A description of a specialist led primary care based oral surgery service H. Pope East Cheshire NHS Trust, UK Aim: To describe the establishment of a referral only oral surgery service in a primary care setting together with the challenges, benefits and successes of the service. Problem: In 1994 waiting times for hospital for oral surgery and maxillofacial procedures were unacceptably long. A proposal to establish a primary care oral surgery service aimed to complement the hospital-based service, reduce treatment delays. Outcome: Referrals commenced immediately in response to a managed launch with local dentists recognising the service as a source of expedient and convenient treatment for their patients. The service now treats up to 1300 patients per year. Learning points: New dental services to dentistry can encompass different specialities. Initial capital investment is needed to develop a more cost-effective service. Recruitment of suitable specialist staff is a critical for success. Staffing, organisation and funding must be sustained. Aim This paper describes the establishment of a referral only oral surgery service in a primary care setting in South Cheshire. The initial, and ongoing challenges are discussed alongside the benefits and successes of the service. Problem In 1994 the population within the boundaries of Cheshire Community Healthcare Trust (CCHT) was experiencing prolonged waits for assessment and admission to hospital for oral surgery and maxillofacial procedures. The lead for Dental Public Health and senior colleagues at the Regional Health Authority office proposed that the waiting times could be reduced and provision of oral surgery increased, by the establishment of an oral surgery service in a primary care setting. The proposed service was designed to meet the aims of:Improving local access to oral surgery provision Improving skill mix across the local health economy by accepting patients requiring mainly dento-alveolar procedures to release capacity within the hospital maxillofacial department for more complex procedures. Reducing per case costs to the health economy by reducing the need for costly out-of-hours waiting-list initiatives within the hospital sector. The development of the primary care based oral surgery service described below owes much to the vision of the local leads in Dental Public Health in addressing these aims. Reaction A primary care based oral surgery service was established as part of a specialised community dental service within a wider community health care provider unit. The local community dental service was being developed to move away from the provision of paediatric dental care with a small amount of adult special needs care towards a group of local clinics providing care complementary to both the General Dental Services and hospital maxillofacial surgery department. The oral surgery service was initially planned to employ a full-time dental surgeon across two organisational areas, accepting referrals from all three of the organisational areas then part of the South Cheshire Health Authority. The recruitment of an appropriately qualified and experienced oral and/or maxillofacial surgeon was crucial to the success of the proposal. The first successful candidate had general dental practice and teaching hospital experience and had undertaken oral surgery and IV sedation in both settings. Qualified dental nurses were also recruited to the team who immediately commenced training and education to gain dental radiography and conscious sedation post certification qualifications. Planning, construction and equipping of the surgeries was completed including the provision of intra oral and panoral radiography machines. The planned use of IV sedation necessitated the provision of defibrillator, blood pressure monitoring, pulse oximetry and recovery facilities: a level of equipment and support not previously available elsewhere in community dental clinics. Much of this preparation was validated retrospectively by McArdle (1997) who set out circumstances in which specialist dental services could be successfully located in primary care settings, improving accessibility to oral surgery for both professionals and patients. Letters of introduction were distributed to all local General Dental Practitioners (GDPs), inviting them to an open evening to meet the new staff and inspect the facilities. Guidance to colleagues in general practice included listing types of referral considered appropriate to the service. Correspondence to: Heather Pope, Clinical Director for Dental Services, East Cheshire NHS Trust, Eagle Bridge Health and Wellbeing Centre, Dunwoody Way, Crewe, Cheshire, CW1 3AW, UK. Email: [email protected]