‘These initiatives are hugely valuable'

A network of Community Dental Services CIC (CDS CIC) Support Practices has been established in the East Midlands to relieve the pressure on waiting times for paediatric patients in the aftermath of the pandemic. Operated by CDS CIC and general dental practices in the East Midlands the aim of the Support Practices is to deliver a high-quality service for children requiring level one care. BDJ In Practice spoke to Nicola Milner, Chief Operating Officer for CDS CIC, to find out more about the project.

Could you tell me more about the Support Practices - where did the idea come from?

Closer working with our GDS colleagues has always been an aim for community dental services. The pressures during the pandemic, where Community Dental Services CIC (CDS CIC) provided urgent dental clinics for COVID positive patients, had a really significant impact on waiting lists. The impact on dentistry in general led to a decreased throughput of patients due to additional cross infection procedures. The subsequent significant backlog of patients demanded a different approach and commissioners and clinicians in the East Midlands were keen to introduce options that were already being explored in other areas across the country.

Colleagues in the West Midlands and Greater Manchester were already using the Support Practice Scheme successfully when we were approached by the East Midlands Primary Care Team to see if we would be interested in setting up a similar pilot scheme. The aim of the pilot is to relieve pressure on the community dental services by securing additional capacity through child-friendly community dental services Support Practices who would assess selected referrals and then provide level 1 care. The practices understand that many of these referrals are for children who are anxious and need excellent behaviour management techniques. The Support Practices are also supported to utilise the treatment techniques proven to be successful such as Silver Diamine Fluoride and stainless-steel crowns. Patients are cared for by the whole dental team including dentists and dental therapists.

There are multiple objectives; to deliver a high-quality service to paediatric patients requiring level 1 care (as specified in the Commissioning Standard for Paediatric Dentistry), to reduce pressures on the community dental services and enable more children to be seen and treated and to reduce waiting times for treatment for paediatric patients and other vulnerable individuals requiring specialist community dental services care.

We also aim to provide additional dedicated sessions to ensure prioritisation of children in line with the Standard Operating Procedure. Where slots are not filled by referrals from CDS CIC, paediatric patients referred through 111 or Looked After Children unable to access general dental care were prioritised. The project also aims to collect performance and referral data to inform any future shared care commissioning models.

Practices in the East Midlands were selected by an Expression of Interest process with applicants being reviewed and assessed against the service specification and a list of eligibility criteria by a panel of Commissioners, MCN chairs, Dental Public Health Consultants and representatives from the community dental service. Once accepted onto the CDS CIC Support Practice Scheme, practices received additional hands-on training and had access to on-line training in paediatric dentistry.

All paediatric patients referred to CDS CIC are triaged by clinical members of the team and those identified as suitable for level 1 care are transferred to the Support Practice. A letter is sent to the patient advising them they will be seen at the support practice. The support practice contacts the patient and provides a course of treatment then discharges the child back to the referring dentist.

If the Support Practice finds the care becomes more complex, they are returned to the community dental service and resume their original place on the waiting list. No patients are disadvantaged by having been transferred to a Support Practice.

© Lisa Wiltse/The Image Bank/Getty Images Plus

How engaged have the practices involved been?

Initially we had to find a model that worked for both Support Practices and the community dental service and this took time. Most of the patients we now send to the Support Practices are transferred directly from our assessment waiting list. They are usually children who appear from the referral to need simple restorative treatment or minimally invasive interventions to stabilise and maintain their oral health, but they are often quite young and anxious. Treatment could involve simple restorations, extractions, hall crowns or the application of Silver Diamine Fluoride. We see the Support Practices as valuable partners. Practices have sent members of their team to shadow our paediatric colleagues and have attended paediatric study days run by CDS CIC. When I've met with the clinical teams from our Support Practices, they have told me how they have found being a support practice valuable as it has upskilled the team and that they find giving children a positive dental experience really rewarding.

How would you describe the backlog and waiting times for paediatric patients across the East Midlands?

We are seeing an increase in referrals into CDS CIC. This is likely to be multifactorial. Challenges in accessing general dental services has led to an increase in referrals from other health professionals such as GPs and community nurses. Many children were also unable to access routine dental appointments during the pandemic, therefore, the dental surgery is an unfamiliar environment which can increase dental anxiety and cause challenges if they need treatment. Difficulties finding a family dentist can mean children are unable to access preventive care such as fluoride varnish. Children are often unfamiliar with dental care due to a continuing lack of access in primary care, so they are often presenting with more advanced dental decay. This may also account for the increase in referrals from our colleagues in general practice.

How vital are they in relieving the pressure on waiting times?

Up to the end of April 2024 we had transferred 376 patients over to the three Support Practices that CDS CIC partners within the East Midlands. These are patients who would otherwise have been waiting for treatment on our assessment waiting list. This has freed up 33 days, plus the time we would have spent carrying out treatment, for our dentists to assess and treat the more complex patients. We are currently auditing the numbers of patients who the Support Practices find more complex and therefore transfer back to CDS CIC. Anecdotally, we know that this is a very small number of patients and they usually need treatment with sedation or general anaesthetic. This shows that our triage teams in the East Midlands are now skilled in identifying which referrals to send to the Support Practices and that they now have the necessary skills to be able to treat the patients we refer.

How welcome has the network been so far?

Transferring level 1 patients to the Support Practices allows the specially trained staff within CDS CIC to focus on treating the most complex paediatric patients who really need our specialist care. It increases access for children identified as having an oral health need who would otherwise be waiting for assessment or treatment on our waiting list. We are incredibly grateful to our colleagues in the Support Practices in Leicestershire, Derbyshire, and Nottinghamshire, and we have really appreciated working in partnership with them to treat our paediatric patients. I would encourage any GDPs who are given the opportunity to become a Support Practice to consider applying. The feedback from parents of the children referred has been positive as they appreciate the reduction in waiting times.

Touching on referrals specifically, is the community dental service being unnecessarily burdened? Could the referral pathway be improved for the benefit of patients and practitioners alike?

As I previously alluded to, the challenges in accessing general dental services means we are currently seeing an increase in demand for community dental services. Specifically, the COVID generation of children have had reduced access to acclimatisation, preventative care, and Delivering Better Oral Health advice for parents. Improving access, I believe would reduce the number of referrals from other health professionals and GDPs as children would be able to access early preventative care. The current contract can make it challenging for colleagues in general practice to dedicate the time they need to treat anxious children, and this is where the Support Practices have developed skills treating these children. Through the Managed Clinical Networks locally and nationally, CDS CIC continues try to find innovative ways to treat both paediatric and special care patients and improve patient care, alongside our colleagues in GDS.

The pandemic clearly had a huge impact on services across the spectrum - how valuable are initiatives like this in providing blueprints for others to follow in other areas of high need?

These initiatives are hugely valuable as they upskill our GDS colleagues and reduce waiting times for patients. All community dental services throughout the country have different acceptance criteria and so the model needs to be adapted for each service. I had meetings with colleagues in the West Midlands when the pilot was in its infancy to learn from their experience then adapted it for our services in the East Midlands. We didn't get it right straight away, but now we feel we have a model that works both for CDS CIC in the East Midlands and the Support Practices. ◆