Right place, right time, first time

14 April, 2011 / Infocus

Referral pathways help ensure that patients are referred to the right professional in the right place at the right time, first time. Pathways provide an excellent basis for standardisation and consistency, ensuring equity of access and care.

In 2009, the 18 Weeks Referral to Treatment Time Standard Dental Specialties Task and Finish Group, in conjunction with consultant dental colleagues, identified the need for national referral pathways and protocols in two high-volume dental specialties – orthodontics and oral surgery. The national pathways that were subsequently developed and are now published by that group, represent a clinical consensus across NHS Scotland. These pathways have also been endorsed by two professional bodies – The Scottish Orthodontic Consultants’ Group and the Scottish Oral and Maxillofacial Society, among other stakeholders.

18 Weeks Referral to Treatment Time (RTT) Standard

From December 2011, 18 weeks will become the maximum wait for referral to treatment for non-urgent patients in NHS Scotland. The 18 Weeks RTT Standard is different from previous waiting time targets because it does not focus on a single stage of treatment. Instead, it applies to the whole patient pathway from a referral, up to the point where treatment begins. Achieving the standard requires NHS Scotland to manage each patient’s journey in a timely and efficient manner.

Almost all patient pathways begin and end through primary and community health service. 18 Weeks RTT recognises the importance of whole-system working. The emphasis is on joint working, seeking collaborations between primary and secondary services and, where possible, ensuring diagnosis and treatment taking place local to the patient without the need for unnecessary hospital visits.

Dental Specialties Task and Finish Group

This is one of eight task and finish groups which exist as part of the 18 Weeks RTT programme. These groups bring together clinical and managerial specialists in each field. Its members support NHS Scotland, implement sustainable changes to improve their services. They seek opportunities for streamlining services and patient-focused improvements while ensuring that the appropriate drivers are in place to minimise the risk to delivery of the 18 Weeks RTT standard.

Getting started

The Scottish Government’s Service Redesign and Transformation Programme’s Improvement and Support Team hosted a series of national dental specialties events to engage with the dental community. Through a series of half-day ‘visioning’ events and masterclasses, they provided a forum to discuss collaborative working, delivery expectations, share best practice and consider how NHS Scotland might collectively address bottlenecks in creating a critical path for delivery.

A pathway sub-group was established for each specialty. Each pathway group had clinical representation. The orthodontic pathway had representation from primary and community care general dental practitioners, a primary care specialist orthodontic practitioner and secondary care consultant orthodontists.

The oral surgery pathway had clinical representation from primary care specialist practitioners, secondary care oral surgeons and secondary care oral and maxillofacial surgeons. The members of the group started the development process by identifying and collecting local protocols for review. Reviewing what already existed was an opportunity to see where there was good practice and avoid the duplication of existing protocols already used within NHS boards.

Transforming Dental Specialties event – March 2010

Chief Dental Officer Margie Taylor set the scene for this session, drawing on the policy document Better Health Better Care. Considering the changes in the Scottish population and associated increases in demand for services, Margie emphasised the need for agreed patient pathways in dental specialties.

David Morrant of NHS Ayrshire and Arran and Helen Devennie of NHS Highland each described the development of pathways for orthodontics and oral surgery respectively.

In his presentation, David highlighted five reasons why dental pathways are required:

  • to act as a statement of good referral practice
  • to provide a road map for the patient
  • to break a patient’s journey into recognisable steps
  • to identify where there might be avoidable delays
  • to identify areas for further development of technology or streamlining of the pathway.

Mike Lyon, Deputy Director of Delivery for the Scottish Government Health Directorate, presented analysis for 2007/2008, which showed that approximately 40 per cent of oral surgery activity consisted of simple extractions. Delegates were encouraged to agree pathways, which would encourage more work to be carried out in a primary or community care setting.

Patient pathways

The two pathways share a similar format. The first part is the patient pathway and this is separated into two elements – first point of contact care and specialist care and advice.

First point of contact care is the initial contact between the patient and primary care services. Specialist care and advice can take place in primary specialist and/or secondary care. The pathway identifies where referrals can be appropriately made.

The second part is a referral guidance table, which is aimed at the primary care practitioner. This goes into further detail of appropriate referrals, dependent on the assessment of the patient’s presenting condition.

The referral management tables can be used as a basis for discussions for agreement at local level. The intention is that they are tailored to accommodate local provision of these services, and although the fundamental principles must apply, local issues should be addressed accordingly.

Right place, right time, first time

The aim of the pathways is to ensure that patients are referred to the right professional in the right place at the right time, first time.

Achieving and sustaining this will require ongoing collaborative working between primary and secondary care dental colleagues. This collaboration will also contribute to ongoing education and professional development and to the further streamlining of pathways.

In brief

Patient pathways
From the 18 Weeks RTT website: www.18weeks.scot.nhs.uk

Oral surgery pathway

Orthodontic pathway

Dental specialties Task and finish group
On the 18 Weeks RTT website
click here.

Presentations from Transforming Dental Specialities Event
are available on the Scottish Health Service Centre website.
Search under ’view past events’.

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