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Assynt House Beechwood Park Inverness, IV2 3BW Telephone: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk MINUTE of MEETING of the HIGHLAND AREA DENTAL COMMITTEE Board Room, Assynt House, Inverness 27 August 2014 – 6.30 pm Present: Mr Colin Crawford, (Chair) Mr Neal Drummond, GDP Mrs Catherine Lush, Clinical Dental Director Mr Gregor Muir, GDP Mr Duncan Railton, Associate Specialist, Raigmore Hospital In Attendance: Mrs Alex Fraser, Dental Services Manager Mr Malcolm Jones, Dental Practice Advisor Mr Tom McWilliam, Assistant Clinical Dental Director Brian Mitchell, Board Committee Administrator Dr Ken Proctor, Associate Medical Director (Primary Care) Mr Stuart Robb, Dental Practice Advisor 1 APOLOGIES & WELCOME An Apology for absence was received from Gordon McGovern and Elizabeth Reilly. 2 MINUTE OF MEETING HELD ON 28 MAY 2014 The Minute of the meeting held on 28 May 2014 was Approved subject to the following amendments: Page 3, Item 6, Line 15 – Amend to read “...to create capacity for inequality groups all ...” Page 3, Item 6, Line 21 – Amend to read “…,an informal dental Designated Patients Scheme…” The Committee agreed to consider the following Items at this point in the meeting. 3 ORAL SURGERY REFERRAL PACK Mr McWilliam spoke to the circulated NHSH Public Dental Services Referral Pack, issued in June 2014, incorporating reference to referral services and flowcharts, Patient Information Leaflets, referral forms and associated Guidance. It was noted key changes had been made in response to considerations of those both in and outwith the service in relation to avoiding treatment delay, providing a consistent point of referral, and enabling appropriate service monitoring and audit against appropriate Key Standards. Those key changes had included those in relation to the Referral Pathway for Primary Care oral referrals, and notification of the change in relation to the location of bariatric treatment service provision. It was noted the first service Annual Report, for 2012/13, had been published and considered by the Senior Management Team. During discussion, Mr McWilliam advised the 2013/14 Annual Report was in preparation and this would indicate an increase in referrals, including from GDPs. GMP referral levels were improving and there were a steady number of referrals from hospital services. On the issue of access for those otherwise unable to access GDP services, this was being considered as part of the Primary Care Strategy Review. There was reference to version control in relation to the various referral forms and documents, and Mr McWilliam agreed to consider annotating these for ease of reference as well as establishing if these were R4 compatible for use by GDPs. After discussion, the Committee: 4 Noted the circulated Oral Surgery Referral Pack. Agreed consideration would be given to annotation of referral documentation in relation to appropriate version control. Noted clarification would be sought as to R4 compatibility of documentation. RECRUITMENT OF PATIENTS FOR THE TEACHING WING Members had noted that the previously considered Oral Surgery Referral Pack had included an NHSH Student Referral Form and Inverness Dental Centre (IDC) Student Wing Patient Leaflet. It was reported that Undergraduate Trainees provided a range of Perio-Dental and Restorative treatments, and would welcome referrals from General Dental Practice especially in relation to children as well as restorative treatment. Any referrals should include as much detail as necessary to enable consideration for treatment and in this regard issues relating to future use of the SCi Gateway were being considered. There followed discussion as to how best to increase the level of referral to the IDC Student Wing for treatment and a number of suggestions were made including inclusion of an article in the next NHS Highland Newsletter and DPA Bytes publications, flyers for students attending University of the Highlands and Islands (UHI), and consideration of an article within “Scottish Dentists” and “Dentist Scotland” publications. The Committee otherwise Agreed that active recruitment of patients for the Teaching Wing be undertaken, including as per the suggestions made during discussion. 5 MATTERS ARISING 5.1 Changes to Dental List There had been circulated letters advising of changes to the NHS Highland Dental List, along with an up to date version of the List. The Committee Noted the changes to the Dental List. 2 5.2 OMFS – CBCT Services At the meeting held on 28 May 2014 the Committee had agreed to write to the Chair of the Clinical Advisory Group (CAG) seeking clarification of the decision relating to stopping referrals of patients to Dundee requiring CBCT and emphasising the need for this form of imaging in appropriate cases. There had been circulated response from the Director of Public Health and Health Policy. Mr Railton advised that although specific patient groups could still be referred for CBCT imaging (mandibular third molars requiring extraction that are in intimate association with the inferior dental nerve and molar furcational defects) there remained many other clinical situations where CBCT was indicated where CAG would not support onward referral. The Scottish Health Technologies Group (SHTG) document cited by CAG was described as narrow in its remit only dealing with hard tissue pathology and so excludes cases such as dental implant assessment. He believed CBCT should be an imaging modality that is available to more patient groups than was now the case. He raised concerns that there had been inevitable delays in imaging being sanctioned and that this constituted poor patient care. There followed discussion, during which it was emphasised that the Clinical Advisory Group could only take decisions based on available evidence, not associated costs, and on this point the validity of the Scottish Health Technologies Group (SHTG) evidence, as opposed to that of SedentexCT was questioned. It was noted the Dental Clinical Governance and Risk Management Group (DCGRM) had also discussed this matter and had agreed the views of the Scottish Dental Clinical Effectiveness Programme (SDCEP) be sought. DCGRM had also raised the issue of governance in relation to image interpretation and it was suggested that Section Criteria for Radiography guidance may be of interest in this area. The Committee: Noted the circulated response from the Clinical Advisory Group Chair. Agreed to express concern that the expressed CAG decision would limit treatment assessment options for patients. Agreed further discussion be held with the Public Health Scientist regarding appropriate evidence for CBCT services. Mr T McWilliam was asked to leave the meeting for the following Item. 4 COMMITTEE MEMBERSHIP Members had been previously advised that there were two vacancies in relation to Committee membership, one each for a Salaried and Independent GDP Practitioner and had been asked to consider submitting nominations. It was noted that one nomination had been received from the GDP Sub Committee in relation to Ms L Garwood. The Public Dental Service would be requested to make a similar nomination in relation to the vacancy for a Salaried Practitioner. The Committee: Agreed to co-opt Ms L Garwood into the vacant GDP position. Agreed to invite nomination from the Public Dental Service in relation to the vacant Salaried Practitioner position. 3 Mr T McWilliam rejoined the meeting at this point. 5 PRIMARY CARE DENTAL STRATEGY UPDATE Mrs Lush spoke to the circulated SBAR briefing paper in relation to a Framework for rebalancing Primary Dental Care Service Providers and sought the views of members. This re-balancing was to reflect the Scottish Government Policy that, wherever possible, the independent contractor dentist is the preferred vehicle for the delivery of primary care dental services. The aim was to build on the strengths of each provider model to ensure accessible and sustainable services are in place for all; including priority groups and deprived and remote and rural communities through the PDS. The circulated document set out the assessment of issues relating to a re-balancing of providers and it was stated it had been estimated that a PDS presence would be required in all localities to meet the potential needs of approximately 20% of the population. Any shortfall in relevant funding would become a further cost pressure for the NHS Board. The exact number of patients impacted by re-balancing was unknown and would vary from location to location. In terms of planning for equitable, sustainable, affordable and accessible primary care dental services, there was a need to agree a set of parameters and proposals for these were outlined in detail in the circulated document. Mrs Lush further advised no decision had yet been made in relation to movement of patients. Matters relating to appropriate engagement were being discussed with the Head of Public Relations and Engagement. During discussion, it was confirmed that the proposed approach would differ between the North Highland and Argyll and Bute areas, with the proposed integrated Body Corporate in the latter area being subject to an appropriate Outcome Agreement with NHS Highland in relation to implementation of any agreed model of care. Mr G Muir referred to support for PDS dentists wishing to become GDP practitioners and was advised PDS practitioners could request relevant support from the NHS Board to enable a lease of premises etc however it was emphasised that as a rule the NHS Board did not support single-handed practice. All relevant options around such issues had yet to be fully scoped. It was noted that one of the agreed proposed parameters for the planning of services was that all patients should have a choice of GDP provider wherever possible, and it was emphasised that again market forces would be allowed to prevail wherever possible. Mrs Lush advised that the circulated document was for discussion and comment at this stage and that once relevant parameters had been agreed there would be consultation with relevant Independent Contractors, public/patient representatives, stakeholders etc. The paper was not for wider discussion at this stage. After discussion, the Committee Noted the circulated proposed Framework for re-balancing Primary Dental Care Service Providers. Noted relevant comments should be relayed to Mrs C Lush or Mr N Drummond. Mr T McWilliam left the meeting at this point. 7 DECONTAMINATION There were no formal matters discussed in relation to this Item. 8 OUT OF HOURS SERVICE There had been circulated Third Annual Report for the Out of Hours Service 2011/13 which had been previously ratified by the Dental Clinical Governance and Risk 4 Management Group. The Report incorporated a service review and summary of developments as well as challenges encountered. It was noted that the cost of OOH services was at the lowest since commencement in 2008. The Report also outlined a summary of results and associated recommendations arising from a series of audits during 2011-2013 in relation to relevant Key Performance Indicators (KPIs). Issues relating to the pilot of an OOH pro-forma and provision of feedback to a patient’s registered dentist were also outlined. Cross-boundary working with NHS Grampian remained in place and continued to benefit relevant patients. The Report further went on to outline the position in relation to basic life support, development of a detailed action plan following an NHS QIS review, a review of the interface between NHS24/SEDS and NHSH, inclusion of Maxillofacial Consultant support into the OOH service, Complaints and Serious Adverse Events, patient feedback, and dentist feedback. The Report also included a series of priority, ongoing and routine activity recommendations as focus for the period of the next report. There was included an Argyll and Bute CHP Statement for 2011-13 incorporating elements relating to sustainability, frequency of commitment, difficulties encountered, KPIs, the interface between NHS24/SEDS and NHSH and a conclusion that a recent antimicrobial prescribing audit had suggested that closer attention be given to clinical governance issues. During discussion, it was noted that the standard of record keeping required to be improved and in this regard Mr Robb advised that adequacy of relevant clinician notes could also be improved. Mrs Lush emphasised the importance of a clear documentary audit trail for clinical treatment, advising that appropriate documentation had been tested on a number of occasions. Mr Muir stated that provision of an electronic pro-forma document would aid consistency of information provision by virtue of automatic data population reducing the time required for completion of each document. Mrs Fraser advised that a number of issues were being considered, including e-documentation and the potential for document completion by Dental Nurses. After discussion, the Committee otherwise Noted the Third Annual Report for the Out of Hours Service. 9 HOSPITAL SERVICES 9.1 OMFS Members were advised that advertisement for a second OMFS Consultant had been unsuccessful and no decision had been taken on whether to re-advertise at this time. Management of more complex surgery for Oncology patients continues to be delivered from Aberdeen. The Committee Noted the position. 9.2 Orthodontic Members were advised there was no waiting list for treatment at this time and that additional capacity continued to be provided within Raigmore from NHS Grampian. The Tain Dental Practice now employed a Dentist with Special Interest and this in turn was a boost to capacity within Highland. The Committee Noted the position. 5 9.3 Restorative Members were advised that issues relating to decontamination of surgical equipment continued to be raised. Mrs Lush advised the Board Nurse Director had written seeking clarification on a particular issue around this area and relevant issues were also to be escalated to Health Protection Scotland (HPS). The matter of CBCT referral had been discussed earlier on the Agenda. The Committee so Noted. 9.4 18 Week RTT Members were advised there continued to be breaches of the relevant target, with the local position in relation to Anaesthetic services being a contributory factor. The Committee so Noted. 10 PROVISION OF PAEDIATRIC DENTISTRY There had been circulated paper, discussed at a recent meeting of the North of Scotland Planning Group, in relation to a proposed service model based on a North of Scotland Network/Managed Clinical Network approach. This model had emerged after engagement with Paediatric Dentistry colleagues across the six northern NHS Boards. The model sought to ensure contribution to multi-disciplinary Paediatric dentistry care, contribution to education and training, provision of support and advice to primary care dental services, enable working with other professionals, ensure clinical leadership, ensure accessibility of service, and ensure contribution to service development. If agreed, an appropriate business case would be developed for consideration. The views of members were sought. Mrs Lush advised there currently were issues relating to issues such as training pathways and associated case mix. Whilst Childsmile had been a positive development there was recognition that patients/cases requiring General Anaesthetic would be more complex in nature, making treatment planning more difficult. There can also be issues relating to trauma. Current Paediatric Consultant support to NHSH was provided from NHS Tayside. She stated that the pathway for medically compromised patients was working well however there were issues when patients returned to NHSH. The Committee otherwise Noted the circulated proposed network service model discussion document. 11 DENTAL CLINICAL GOVERNANCE AND RISK MANAGEMENT GROUP 11.1 Minute of Meeting held on 11 June 2014 Members were advised that the draft Combined Practice Inspections Report would be submitted to the next meeting. 6 The Committee: Noted the circulated minute. Noted draft Combined Practice Inspections Report would be submitted to next meeting. 11.2 Draft Guidance on Dental Management of Patients Taking Anticoagulant Drugs Outside a General Hospital Setting Mr Railton spoke to the draft guidance document, which had been circulated for comment, advising this had been based on a similar Policy operated in NHS Tayside. He advised issues to be considered included guidance in relation to patients on dual/multiple therapies and also the matter of point of care testing. Mr Crawford stated there was a need to ensure that any final document reflect the position in Argyll and Bute CHP and was consistent with advice from NHS Greater Glasgow and Clyde. It was noted this matter had also been discussed by the NHSH GP Sub Committee. The Committee: Noted the draft Guidance document. Noted relevant comments should be relayed to Mr Railton in early course. 11.3 Draft Protocol for Assessment of Paracetamol Overdose There had been circulated draft Protocol for Assessment of Paracetamol Overdose document, which had been ratified by the Policies, Procedures and Guidelines Sub Group of the Area Drugs and Therapeutics Committee. It was reported that further changes would be required to this draft document and that the final iteration would be referred back for formal approval in September 2014 prior to eventual publication. The Committee otherwise Noted the circulated draft protocol document. 12 FOR INFORMATION 12.1 Area Clinical Forum – Draft Minute and Action Plan from Meeting held on 29 May 2014 There had been circulated relevant Minute and Action Plan from the Area Clinical Forum meeting held on 29 May 2014. Mr Crawford confirmed he had given an update to the NHSH Annual Review in relation to the formation of the Public Dental Service. The Committee Noted the circulated draft Minute and Action Plan. 12.2 Committee Meeting Schedule 2015 The Committee Agreed the following dates for meetings in 2015: 25 February 27 May 26 August 25 November 7 13 ANY OTHER BUSINESS 13.1 Consultant in Dental Public Health Mrs Lush confirmed that an appointment had been made to the relevant Consultant position, based in NHS Grampian. Provision of advice to NHS Highland would be subject to an appropriate Service Level Agreement. The Committee Agreed to invite the newly appointed Consultant in Dental Public Health to address the meeting in February 2015. 13 DATE OF NEXT MEETING The next meeting of the Area Dental Committee will be held on 26 November 2014, in the Board Room, Assynt House, Inverness. The meeting closed at 8.50pm 8