Memorandum by the British Orthodontic
Society (DS 09)
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.
1.1 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 3.6all
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 oldoften paid up to two years after a patient's
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
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 summaryas 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,
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.
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 canineswe know that
in 14% there will be resorption and damage to adjacent incisor
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
2c.2 The aims of the Local Orthodontic MCN
Co-ordinate the local provision of
orthodontic care in conjunction with the funding agencies (PCTs
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
Assure access for patients to the
most appropriate orthodontic care.
Enhance communication between providers.
Act as a source of advice on orthodontic
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
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
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
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
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
4. NUMBERS OF
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
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!
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
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
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
8. THE EXTENT
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.
9.1 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
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
30% had waiting lists in excess of
40 weeks for patients in need of treatment before treatment could
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
OF NHS ORTHODONTIC
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
10.2 Retention of orthodontic specialists
within the UK remains good. If contract values reduce significantly,
this might change.
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
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
12. INDEX OF
|BOS||The British Orthodontic Society
||LHB||Local Health Board
|BSA||Business Services Authority
||MCN||Managed Clinical Network
|CACV||Calculated Annual Contract Value
||MOrth||Membership in Orthodontics
|DoH||Department of Health
||NHS||National Health Service
|DwSI||Dentist with a Special Interest
||PAR||Peer Review Assessment
||Primary Dental Services|
|FDS||Fellowship in Dental Surgery
||PCT||Primary Care Trust
|GDP||General Dental Practitioner
||RCS||Royal College of Surgeons
|GDS||General Dental Services
|IOTN||Index of Orthodontic Treatment Need
PH Brook, WC Shaw. The development of an index of orthodontic
treatment need. European Journal of Orthodontics, 1989
Aug; 11(3):309-20 Back
CD Stephens. Standing Dental Adisory Committee-report of an expert
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