ORAL AND MAXILLOFACIAL SURGERY IN NHS HIGHLAND
Report by Mr Stuart Denholm, Clinical Director of Raigmore Hospital with financial amendments dated 23 March 2009
1 OBJECTIVE
Dr Roger Gibbins, Chief Executive of NHS Highland, commissioned Mr Denholm, Clinical Director of Raigmore Hospital to undertake an Impact Assessment on the report entitled Sustaining Oral Surgery and OMFS in the North of Scotland presented to the North of Scotland Planning Group on 12 November 2008.
2 BACKGROUND
Historically secondary care dental services in Highland have been provided by a single handed Oral and Maxillofacial Surgeon (OMFS). This individual was “singly” qualified in Oral Surgery but trained as an OMFS as was the norm at the time of his qualification, but this route of training is no longer available and there are few surgeons of this calibre and training available.
Since the retirement of the single-handed OMFS Surgeon in Inverness in April 2007, significant efforts have been made to find a sustainable solution for the provision of the future service. It has been impossible to appoint to this Consultant post in either OMFS or Oral Surgery.
Secondary care Dental services deliver dentoalveolar surgery, support primary care and Orthodontics; deal with trauma, sepsis, oral cancer and oral medicine.
OMFS are now dual qualified in dentistry and medicine and although theoretically they possess all the skills of a singly trained Oral Surgeon but with significant additional specialist surgical skills for complex care, understandably they tend to concentrate on a small volume of highly complex specialist procedures.
Singly qualified Oral Surgeons tend to be uncommon at present being concentrated in the academic Dental Schools. Training pathways for such individuals are currently being developed in recognition of the fact that the bulk of secondary care work can be undertaken by such clinicians, and this is being supported by NHSEducation in Scotland, but will be at least 5-6 years in completion.
The majority of the work required in NHSH is routine dento-alveolar surgery with few cases annually requiring specific, complex OMFS input. It is acknowledged that there is likely to be unmet need in NHS Highland patients, as the current information is based on activity of the historical model of service delivery.
In 2006, the North of Scotland Planning Group (NoSPG) established a sub group, chaired by Mr Richard Carey, Chief Executive of NHS Grampian entitled the North of Scotland Oral and Dental Health Sub Group. This group was to review all the specialist “Dental services” including Oral Surgery, Oral and Maxillofacial Surgery, Restorative Dentistry and Orthodontics. It was also to identify how this integrates with other services being provided in secondary and primary care. One of the priority areas was to develop a sustainable model of oral and maxillofacial surgery for the North of Scotland, especially pertinent to the needs and issues facing NHS Highland and Western Isles.
In 2007, the North of Scotland Public Health Network undertook a Needs Assessment of Oral and Dental Health in the North of Scotland. Simultaneously, Helen Strachan of the Oral and Dental Health Sub Group undertook a consultation with all of the North of Scotland Health Boards. The reports identified historic practice and attempted to project future need and workforce issues. A final report was presented to the North of Scotland Planning Group on 12 November 2008 with the recommendation to appoint 2 Oral Maxillofacial Surgeons in NHSHighland to provide services to NHS Highland, Western Isles and the Moray/Elgin region. The funding was agreed on a pro rata basis.
There are significant financial, professional, clinical and political issues arising from this whole topic and the recommendations within the report.
This paper describes the possible options in detail from an NHS Highland perspective to inform the debate and enable a final decision to be made as to the future shape of secondary care Oral and Maxillofacial services in Highland, and the wider North of Scotland.
There are significant cross professional medico-political issues.
The North of Scotland Planning Group commissioned a report to look at the provision of Oral Care across the area. This was 2 years in preparation and in part looked at the historic practices, an attempt to project future need and the future workforce issues. The recommendation from the report is to appoint 2 OMFS in NHSH working in a network within the NoSPG area and providing the service to NHSH, Elgin and Western Isles. This would be jointly funded on a pro-rata basis.
PROVISION OF ORAL AND MAXILLOFACIAL SERVICE IN NHS HIGHLAND
1 Current Service
The present funded service is based on a single-handed Consultant OMFS Surgeon supported by an Associate Specialist in Oral Surgery, 2 part time Clinical Assistants in Oral Surgery, 1 SHO and a General Dental Practitioner trained in Oral Surgery. However, at present the Associate Specialist is undertaking the Consultant locum. Therefore, the current model of service is as follows:
Ø Consultant and support staff as above.
Ø Outpatient clinics in Raigmore, Dingwall*, Fort Willian*, Caithness* and Western Isles Health Board*
Ø Operating sessions in Raigmore (GA), Caithness (LA) and WIHB LA*
Ø Basic dento-alveolar work
Ø Trauma assessment is made from local management as appropriate with onward referral
Ø Oral cancer is managed jointly with the ENT through the MDT with referrals to Aberdeen and Glasgow
Ø Oral medicine is undertaken with links to Glasgow for complex cases
Ø Joint working with Orthodontics, but no orthognathic surgery
Ø Training of junior staff
*These clinics/sessions are in abeyance under current working arrangements of the locum Consultant service.
2 Capacity and Demand
2.1 Demand
The net additions to the NHS Highland waiting list for new outpatient appointments for Oral Surgery have been an average of 1,800 p.a. (150 per month) for the last couple of years. However, due to the fluctuation in the actual monthly demand, and the requirement to meet the waiting times targets, capacity will need to be set to meet a theoretical demand of 2,100 to deal with the peak in demand (as per the standard model for these calculations). The current New to return ratio is 1:5 returns for every new outpatient seen.
The net additions to the NHS Highland waiting list for admissions have been an average of 350 p.a., with 46 patients referred for elective tertiary care.
2.2 Capacity
The capacity required to treat all of the above activity within NHS Highland has been modelled and the following requirements identified per annum.
Service / Demand / Clinical Session RequirementsNew Outpatients / 2100 / 210
Return Outpatients / 3150 / 315
Elective Surgery / 350 / 70
Tertiary Surgery / 46 / 35
Total Clinical Sessions / 630
Clinical Sessions required per week (42 weeks pa) / 15
2.3 Proposed Staffing and Job Plans
Table 1: The proposed Job Plans for 2 Consultants based at Raigmore supported by an Associate Specialist would provide the following sessions:
Highland / Other Boards / OtherRaigmore Hospital / Peripheral / Total
Activity
Theatre / Outpatient / Outpatient / W. Isles / Elgin / Admin/SPA / Total
Consultant 1 (Ave) / 1 / 3 / 2 / 6 / 1 / 0 / 3 / 10
Consultant 2 (Ave) / 1 / 2 / 0 / 3 / 0 / 3 / 4 / 10
Associate Specialist / 0 / 6 / 0 / 6 / 0 / 0 / 3 / 9
Total p.w. / 2 / 11 / 2 / 15 / 1 / 3 / 10 / 29
Total p.a. (based on 42 weeks) / 84 / 462 / 84 / 630 / 42 / 126 / 420 / 1218
Highland Requirements / 105 / 525 / 630
Variance / 21 / (21) / 0
This shows that, if current elective tertiary activity is to be treated in Highland, then more theatre sessions and less outpatient clinics may be required than are in the proposed Job Plans for the 2 Consultant posts. It should be noted that an estimate of 35 theatre sessions have been allowed for the repatriation of this work but depending on the case-mix of this complex cohort of patients, this may not be accurate and it should be noted that not all tertiary referrals underwent surgery (see Appendix 1).
This generic model purposely does not differentiate between oral and maxillofacial services, and the case-mix will determine the demand for services and what the appropriate specialisation of the Consultant staff should be.
If the demand for services does not increase, then the Highland capacity requirements for 630 clinical sessions will be able to deliver the 18 Weeks RTT target recurrently, providing any existing backlog is cleared with non-recurrent additional capacity, on the commencement of the new job plans being introduced.
2.4 Cost of Exiting Tertiary Services (2008)
The estimated current cost to NHS Highland for the tertiary services cases is £95k for the 46 elective cases and £18k for a further 8 emergency cases.
2.5 Analysis of Tertiary Referrals 2007
See Appendix 1.
2.6 Current Waiting List Initiatives to Maintain Targets in 2008/2009
Number of Clinics 35
Financial Cost £52,285
2.7 Summary of Capacity Issues
To meet the current and projected demand, it can be observed that 2 Consultants in OMFS and an Associate Specialist in Oral Surgery is required.
OPTIONS FOR ORAL AND MAXILLOFACIAL SURGERY
Option 1: Two Oral and Maxillofacial Surgeons based in Inverness within a North of Scotland OMFS network providing care to Western Isles and Moray.
Option 2: One Consultant Oral Surgeon and 1 Consultant OMFS based in Inverness, but not within in a North of Scotland network.
Option3: One single handed Consultant Oral Surgeon in Inverness with no on-call commitment and a 9-5 service.
Option 3A: One single handed Consultant Oral Surgeon based in Inverness with a limited on-call service.
Option 4A: Two Consultant Oral Surgeons based in Inverness with no on-call commitment and therefore a 9-5 service.
Option 4B: Two Oral Surgeons based in Inverness with a limited on-call service.
Option 5: No Oral Surgery or OMF services provided directly by NHS Highland but contracted from an external provider.
The ‘option appraisal’ methodology and exercise is identified in Appendix 2. The result indicates that Options 1 and 2 score significantly higher than all the others, with Option 1 being the preferred model.
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GENERAL ISSUES OF CONCERN RELATING TO THE OPTIONS
1 Consultant Appointments
There is no local or national support for the appointment of single handed Consultant posts generally and surgical services in particular. The Surgical Senate is opposed to single handed surgical appointments due to issues of clinical governance, lack of peer support, professional isolation and an impossibility of being European Working Time Regulations compliant.
2 Extra Programme Activities (EPAs)
EPAs may be required to cover any on-call commitment and provide cross cover for leave where agreed. In appointments made without EPAs, these may be offered mutually as the true demands of the service become clearer over time. In a highly competitive job market, a post with no EPAs will be seen as less attractive particularly in an area with little option for private practice.
3 Western Isles
Historically, NHS Highland has provided service to the Western Isles but since April 2006 this has ceased. With the continuing development of the WHIB clinical strategy and the potential associated obligate networks, the pragmatic decision has been taken only to include service to WIHB in the proposed NoSPG model, Option 1.
4 Workforce Issues
There is an existing limited pool of Oral Surgeons at present. There is no specific training programme for Oral Surgery but this is being developed by NHS Education Scotland. NHSHighland were unable to recruit to a locum post in either Oral Surgery or OMFS and currently the Associate Specialist is undertaking this role. There is a small but very powerful cohort of OMFS Consultants in Scotland and the UK, who have a significant influence and are awaiting the outcome with interest.
5 Job Planning
One Consultant post will give 10 weeks absence per year and 2 posts therefore gives 20 weeks absence per year. There may well be difficulties with covering both NHS Highland and elsewhere. It should be noted that a post based in NHS Highland to cover all Elgin needs will not suffice to meet demand all year and, therefore, cover for Elgin will be required from the 6 OMFS Consultants working collaboratively in the North of Scotland. This would need formal agreement by NOSPG as well as NHS Grampian.
6 On-Call
A 1 in 1 or 1 in 2 on-call rota is now no longer feasible or acceptable and, therefore, the need for additional cover from elsewhere will be required. If the model had 2 OMFS Surgeons in Inverness, then Aberdeen would be required formally to agree to be involved to make this a maximum 1 in 4 rota for each OMFS Surgeon with support from the North of Scotland network to cover when required. This is agreed in principle at the present time but the arrangements have not been formally agreed. If the model of 1 OMFS Surgeon plus 1 Oral Surgeon is considered in Inverness, then the Aberdeen surgeons have made it quite clear that they will not support the involvement of an Oral Surgeon and, therefore, there are significant issues with on-call cover in both oral surgery and maxillofacial surgery. If the model was only oral surgery then all emergency oral and maxillofacial work would be required to be transferred to an OMFS centre. Consideration would need to be given as to how trauma was assessed within NHS Highland in the interim period.