Guides forcommissioning dental
specialties - Orthodontics
1

CLASSIFICATION: OFFICIALNHS England INFORMATION READER BOX
Directorate
Medical
Nursing
FinanceCommissioning Operations
Trans. & Corp. Ops.

Publications Gateway Reference:

Patients and Information
Commissioning Strategy

03084

Document Purpose

Guidance

Document Name

Guide for Commissioning Orthodontics

AuthorResource Author – NHS England, Chief Dental Officer team

Publication Date

29 September 2015

Target Audience

NHS England Dental Commissioners

Additional Circulation
List

Dental Public Health Team, Local Dental Network, Local Dental
Committees, Clinical Directors CDS, Health Education England Dental
Leads, Dental Schools Deans, Local Authority Directors of Public
Health, British Dental Association Leads, National Dental Associations
and Organisations, NHS England Regional Directors

Description

This document is to be used by commissioners to offer a consistent andcoherent approach. They describe the direction required to commission
dental specialist services. They will improve dental care and outcomesfor patients, ensure they receive the highest quality dental care in themost appropriate setting, by professionals with the required skills, whilst
ensuring value for money.

Cross ReferenceThis document should not be read in isolation and is part of suite of
documents including; Guide for Commissioning Specialist Dentistry
Services Introduction, Guide for Commissioning Oral Surgery/Oral
Medicine, Guide for Commissioning Special Care Dentistry, Equality &Health Inequalities supplement

Superseded Docs
(if applicable)
Action Required
Timing / Deadlines(if applicable)
Contact Details forfurther information

00
By 00 January 1900
Dionne Hilton
Area 6 B
Skipton House, 80 London Road
LondonSE1 6LH
07919 573 382
0Document Status
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the intranet is the controlled copy. Any printed copies of this document are not controlled. As acontrolled document, this document should not be saved onto local or network drives but should
always be accessed from the intranet.

2

Contents
1

Foreword .............................................................................................................. 52

Equality and Health Inequalities Statement .......................................................... 6

3

Executive summary .............................................................................................. 7

4

What is Orthodontics? ........................................................................................ 10

4.1 Description of the specialty ......................................................................... 10
4.2 Description of the national picture ............................................................... 10
4.3 Description of the workforce and training .................................................... 10
4.3.1 General Dental Practitioners (GDP) ..................................................... 11
4.3.2 Dentists with Enhanced Skills and Experience ..................................... 11
4.3.3 Specialists ............................................................................................ 11
4.3.4 Consultants........................................................................................... 11
4.3.5 Orthodontic Therapists ......................................................................... 11
4.4 Description of the complexity levels ............................................................ 12
4.4.1 General Principles ................................................................................ 12
4.4.2 General patient factors ......................................................................... 12
4.4.3 Patient’s oral environment .................................................................... 12
4.4.4 Clinically feasible and beneficial ........................................................... 13
4.4.5 Complexity Descriptors ......................................................................... 13
5 Summarised illustrative patient journey .............................................................. 15
6

Assessing need .................................................................................................. 16

6.1 Population ................................................................................................... 16
6.1.1 Quantification of need for Orthodontic treatment .................................. 16
7 Understanding current provision ........................................................................ 18
7.1 Service analysis .......................................................................................... 19
7.1.1 Primary care Orthodontic services in England ...................................... 19
7.1.2 Hospital Orthodontic services ............................................................... 19
7.1.3 Matching need to capacity .................................................................... 20
7.2 Quality and effectiveness ............................................................................ 20
7.3 Outcomes .................................................................................................... 21
8 Transforming services ........................................................................................ 22
8.1 Current models............................................................................................ 22
8.2 Current challenges ...................................................................................... 22
8.3 Current Workforce model ............................................................................ 23
9 Service redesign ................................................................................................ 24
9.1 Workforce implications ................................................................................ 25
9.2 Data collection implications ......................................................................... 25
10
Illustrative journey of a patient ......................................................................... 26
11

Procuring services ........................................................................................... 34

11.1
11.2

Minimum standard specification ............................................................... 34
Enablers and minimising barriers to transformation ................................. 363

12

Quality and outcome measures ....................................................................... 37

12.1
Patient reported outcome measures (PROMs) and Patient reported
experience measures (PREMs) ............................................................................ 37
12.2
Clinical outcome measures ...................................................................... 38
12.3
Dental Assurance Framework – Orthodontic indicators ........................... 38
13
Next steps ....................................................................................................... 40
Appendix 1 - Normative Need ................................................................................... 41
Appendix 2 - Patient Engagement ............................................................................. 42
Appendix 3 - Guidance on the Provision of Replacement Orthodontic Retainers ..... 50
Appendix 4 – Glossary of terms and acronyms ......................................................... 51
Appendix 5 – Orthodontic Commissioning Guide Working Group Membership ........ 52

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1 Foreword
NHS England produced the Five Year Forward View to set out ashared view of the challenges ahead and the choices about health andcare services in the future; it applies to all services, including dentistry.
This consensus on the need for change and the shared ambition for
the future is the context in which these Commissioning Guides for
Dental specialties have been produced. Clinicians, Commissioners
and patients have contributed to this work to describe how dental Care
Pathways should develop to deliver consistency and excellence incommissioning NHS dental services across the spectrum of providers
to benefit patients.
In order to deliver this vision and implement the pathway’s `a coalitionof the willing’, NHS England partners, HEE and PHE, specialist
societies and others who have contributed to their development willneed to respond in the implementation phase by unlocking structuraland cultural barriers to support transformational change in dental
service delivery.
It’s a future that will dissolve the artificial divide between primary dental
care and hospital specialists; one that will free specialist expertise fromoutdated service delivery and training models so all providers can work
together to focus on patients and their needs.
These guides set out a framework and implementation and the pace ofchange will vary across England. This will be an iterative process;therefore, it will be necessary to review and update these guides
regularly. However, implementation will require energy, bravedecisions and momentum, together with a willingness to share goodpractice, innovation and learning, as it emerges, to accelerate thespeed and impact of change to improve patient care.

52 Equality and Health Inequalities Statement
Promoting equality and addressing health inequalities are at the heartof NHS England’s values. Throughout the development of the policies
and processes cited in this document, we have:• Given due regard to the need to eliminate discrimination,harassment and victimisation, to advance equality of opportunity, andto foster good relations between people who share a relevant
protected characteristic (as cited under the Equality Act 2010) andthose who do not share it; and• Given regard to the need to reduce inequalities between patients inaccess to, and outcomes from, healthcare services and to ensureservices are provided in an integrated way where this might reduce
health inequalities.

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3 Executive summary
It is now widely recognised that the NHS needs transformational change to services,in order to promote health and deliver better outcomes for patients and ensure that
we commission effectively.
Progress has been made in improving oral health and access to services in general.
However, inequality in oral health experience and inequity in access to primary andspecialist care exists. These guides focus on the commissioning and delivery of
specialist Care Pathways; however, the gateway to specialist care relies on accessto efficient and effective primary dental care services. Whilst there has been some
improvement in general access over the past few years, Commissioners need toensure that they continue to meet their duties to commission primary care services
appropriate to the needs of their populations. This means making effective use ofavailable resources by challenging primary care providers to deliver care to those
who need it most and, by adopting appropriate recall intervals for those who can beseen less frequently, freeing capacity for access by new patients. Achieving
improvements in access to primary care will widen access to specialist care for those
who need it.

NHS England has developed these guides for commissioning dental specialties to be
used by Commissioners to offer a consistent and coherent approach. They describe
the direction required to commission dental specialist services. This will reflect theneed and complexity of patient care and the competency of the clinician required todeliver the clinical intervention, rather than by the setting within which the care isdelivered. Care will be delivered via a pathway approach which will provide clarity
and consistency for patients, the profession and Commissioners. There will benationally agreed minimum specifications for each service, including how quality andoutcomes are to be measured, which can be enhanced locally.
They will ensure there is national consistency in the NHS commissioning offer for
dental specialist services and how they are delivered. The pathway will also provide
consistency across England in agreeing, at a national level, as much of the detailaround commissioning; this includes referral criteria, core data set required onreferral, quality of environment and equipment, contractual frameworks etc., as wellas consistent measures of quality and outcomes. The frameworks describe theconcept of clinical engagement and leadership through Managed Clinical Networks(MCNs) which will work closely with Commissioners, Dental Local Professional
Networks (LPNs) and will describe and monitor the patient journey from primary careto specialist care.
The first phase of this work during 14/15 has included developing frameworks for thefollowing specialties: Orthodontics, Special Care Dentistry, Oral Surgery/ Oral
Medicine and Restorative dentistry. Further work on Restorative Mono-specialties,
Paediatric Dentistry and Supporting Specialties (Oral Radiology, Oral Microbiology
and Oral Pathology) will follow. This document provides a focus on Orthodontics andshould be read within the context of the overarching introductory guide as this7

highlights the concepts and principles and common challenges and solutions for all
dental specialties.
NHS England is committed to working and engaging with patients, carers and the
public in a wide range of ways. Throughout this process we have ensured thatpeople’s views are heard through having patient representatives on every group andby convening a patient review group, who have helped us develop the content. Thisis outlined in detail in the patient engagement and stakeholder engagement
appendices, in the overarching guide.
Moreover, it must be understood that ultimately it is the patient who should make thedecision about what treatment, if any, to undergo. The practitioner’s role is to adviseon treatments and options, and benefits and risks. This discussion between patientand practitioner should form the beginning of every patient journey and every
specialist care pathway. That includes patient consent to the information sharing
needed for their journey along a pathway.
The process of developing these patient involvement frameworks has also included
engagement with every stakeholder group that has an interest in dentistry, as
outlined in the acknowledgments, stakeholder engagement appendix andgovernance model in the appendices.
This is the beginning of a process. Locally, Commissioners need to undertake work
to understand the specialist services that are currently being provided, by who andwhere. The quality and quantity of those services, together with the impact and cost,need to be identified before any change or procurement takes place. Many
Commissioners and clinicians have already made progress on aspects of thisapproach locally. However, they need to measure themselves against the enablers
within each of the guides to understand what needs to happen next and agree local
priorities. Commissioners need support to identify current dental resources, to allow
flexibility locally, so decisions can be made, for example, in establishing MCNs that
may require investment or flexibility in contracting, such as the use ofCommissioning for Quality and Innovation payments (CQUIN). The work ofdeveloping the commissioning guides has identified a number of examples ofinnovative solutions and exploiting flexibility in current contracting forms. Locally,
Commissioners will need to consider investment and contractual flexibility to support
the implementation of new Care Pathways. The implementation of Care Pathways
could deliver efficiency gains in some areas; however, there may be a need toconsider the use of these savings as investment to pump prime change in otherareas of dentistry. The next phase of this work could support the validation andsharing of solutions to harness and communicate examples of good practice andinnovation. Some of the identified enablers will be more difficult to implement at a
local level; however, NHS England could support identified enablers to become areality at a national level. An example would be expanding the use of the NHS
number within dentistry.
There will be a particular emphasis on helping Commissioners to understand thefinancial impact of implementing the commissioning guides, to provide an estimate
for the associated upfront costs along with any expected financial savings to the
NHS. The initial work will involve needs assessment, understanding current
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provision, enabling consistent data collection and coding. Implementation support
will include the development of a commissioning pack to encourage effective andconsistent commissioning to benefit patients. Work on an additional set of guides will
also take place during this phase, focusing on Paediatrics, the SupportingSpecialties (Radiology, Oral Microbiology, Oral Pathology) and further detail on
Restorative mono-specialties (Endodontics, Periodontics, Prosthodontics).
An implementation phase will include supporting Commissioners to identify what
could and should be undertaken nationally or regionally, and what should be
supported by the Commissioning Support Unit locally. However, the first steps forCommissioners on the release of these first four strategic specialist commissioning
guides will be to review current local progress against the frameworks and pathways,
to assess local priorities, and agree what enablers need to be put in place, such as
establishing clinical networks and referral processes.
Commissioners need to be aware that the effective implementation of needs-led
dental specialist Care Pathways relies on maintaining and ensuring access toeffective primary dental care services, particularly for those groups in the population
who do not access care routinely or have additional needs. Producing these guides
is the first step in what is intended to be an iterative process. The Commissioners
who need to procure services in this transition can use the guides to complete needs
assessment, set minimum standards and service direction and ensure that proposed
outcomes and quality measures are included in service specifications. The guides,
including the accompanying overarching introductory framework, can be madeavailable to potential bidders. Tendering providers will need to include a statement intheir submissions on how they will work with Commissioners to comply with therequirements of the guides.
Commissioning the new pathways is intended to ensure improved access andquality.

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4 What is Orthodontics?
4.1 Description of the specialty
Orthodontics is the dental specialty concerned with facial growth, development of thedentition and occlusion, and the assessment, diagnosis, interception and treatmentof malocclusions and facial irregularities.

4.2 Description of the national picture
Orthodontic care includes the provision of advice and education for patients, parents
and other health-care professionals. It includes monitoring the development of teeth
and providing interceptive measures, with appliances where appropriate. The
majority of Orthodontic work is carried out with removable and fixed appliances when
all the deciduous teeth have been lost. In certain situations, input from otherdisciplines is required, such as Restorative/ Paediatric dentistry (patients withmissing or damaged adult teeth), or Maxillofacial and Oral Surgery (to manage
impacted teeth or significant jaw discrepancies beyond the scope of correction withbraces alone). Additional support services for complex multi-disciplinary treatments,
such as management of patients with cleft lip and palate, facial deformities orsyndromes may be required.
The Index of Orthodontic Treatment Need (IOTN) is a clinical assessment ofmalocclusion severity utilised within the NHS to select those individuals who would
benefit most from Orthodontic treatment. The majority of NHS Orthodontic treatment
above IOTN 3.6 is supervised or carried out by specialists.
Specialists will frequently operate a team approach to Orthodontic care with thesupport of primary care practitioners, Orthodontic therapists and Orthodontic nurses
working under their supervision.
The distribution of service providers at all levels will differ across NHS England. Care
Pathways should reflect need and local patient flows. They may look different across
NHS England, due to the current distribution of skills across primary and secondarycare.

4.3 Description of the workforce and training
Dental undergraduate training takes five years in the UK, following which, newly
qualified dentists are able to register with the General Dental Council (GDC). They
are required to undertake a twelve month period of Dental Foundation Training (FD)in the NHS in order to acquire a NHS performer’s number.
Training in Orthodontics, at both undergraduate level and during FD, is focussed on
diagnosis, assessment of treatment need and appropriate referral. Contemporary
teaching in Orthodontics at this level rarely includes the delivery of treatment.
Consequently, post FD, dentists will not have the required competencies to provide
Orthodontic care without further training.

104.3.1 General Dental Practitioners (GDP)On completion of FD, a GDP should have the skills to monitor the developing
occlusion and recognise a malocclusion. A GDP should be familiar with the use of
IOTN and be able to determine the suitability and commitment of a patient in order tosupport the Orthodontic referral decision to a specialist. A GDP should have thecompetency to manage the patient’s oral health during and following Orthodontic
care, including maintenance of patients’ post Orthodontic treatment.
4.3.2 Dentists with Enhanced Skills and Experience
Dentists with enhanced skills and experience have undertaken additional training todevelop further competencies. There is a wide variation among individual
practitioners of additional experience, qualifications and training undertaken.
4.3.3 Specialists
The award of the certificate of completion of specialty training (CCST) is the
responsibility of the General Dental Council (GDC). A CCST is awarded to a trainee
who has been allocated a national training number (NTN) by open competitive
appointment to a training programme approved as leading to the award of a CCST
and who has successfully completed that programme.
Training currently takes place in secondary care, in dental hospitals and Orthodontic
units in District General Hospitals. Registered specialists can provide a full range oftreatments within the competencies defined by the Curriculum of Specialist Training.
Some provide this treatment themselves but some also provide the treatment as partof a team utilising dentists with enhanced skills and experience and/ or Orthodontic
therapists. Some specialists train outside the UK, but may be eligible to work in the
UK; they will need to satisfy the GDC that they meet the requirements to beregistered as a specialist in the UK.
4.3.4 Consultants
Orthodontic treatment, in certain situations, may require a multidisciplinary teamapproach and this is often more appropriately offered by an individual at Consultant
level. Currently, this service is offered in a secondary or tertiary care setting in a
Dental Hospital or a District General Hospital. Such patients may be those with acleft lip and palate or other facial deformity that requires corrective treatment, often
involving surgery; complex restorative cases with multiple missing teeth may also
require such a multidisciplinary team approach. Such treatment is usually
Consultant-led and forms the basis for the centres for specialty training. Specialists
who wish to become Consultants in Orthodontics require a further two years training
beyond their specialty training. During this period, trainees are required to achieve
additional competencies in specific areas such as complex multidisciplinary care,leadership and training, not encountered during the three year specialty training
programme. Entry to this additional period of training is competitive. Completion oftraining is marked by passing the Intercollegiate Specialty Fellowship Examination(ISFE) awarded by The Royal College of Surgeons (RCS) and satisfactorycompletion of all Annual Review of Competence Progression (ARCPs).
4.3.5 Orthodontic Therapists
Orthodontic therapists are members of the Orthodontic treatment delivery team andwork under the guidance of a dentist or specialist. The GDC qualification for11

registration is the Diploma in Orthodontic Therapy. Orthodontic therapists can workin primary and secondary care and require treatment prescriptions with continuing
supervision throughout delivery of a Care Pathway. Orthodontic therapists cannot
undertake treatment planning and, at decision-making appointments, directaccessible supervision must be available to Orthodontic therapists.

4.4 Description of the complexity levels
There are several factors which need to be considered when describing thecomplexity level of an Orthodontic case. These include the type of malocclusion,technical difficulty in improving function and aesthetics, together with any patient
modifying factors.
4.4.1 General Principles

Orthodontic treatment should only be undertaken in situations where it is believed
to be in the patient’s best interests in terms of their oral health and/ or
psychosocial wellbeing.
In all situations, the clinical advantages and long-term benefits of Orthodontic
treatment should justify such treatment and outweigh any detrimental effects.
Patients will only be offered one course of NHS-funded routine Orthodontic
treatment, unless there are exceptional circumstances. Such cases include
where interceptive or growth dependent treatment has been undertaken and
IOTN remains greater than 3.6. Any patient not meeting these circumstances
would need to apply via their Commissioner who will seek clinical advice fromeither their dental LPN or MCN to approve a second course of treatment. Theremay be occasions when an appliance has to be removed during a course oftreatment to allow a patient to undergo other procedures such diagnostic
services. Recommencing treatment would not constitute a new course oftreatment.

4.4.2 General patient factors
The clinician should ensure that the co-operation, motivation, aspirations andgeneral health of the patient are consistent with the provision of Orthodontic
treatment, particularly their ability to maintain good oral hygiene to ensure no harm isdone. They should also ensure that the patient and carer are willing and able tocommit to frequent attendance, which may be during school hours, over the courseof Orthodontic treatment and are aware of the need to wear appliances. The
exception to this is patients requiring assessment for interceptive extractions oradvice only.
4.4.3 Patient’s oral environment
The clinician should ensure that an oral health assessment/ review has been carriedout and that the information collected and the risks identified are reviewed andshared with the patient before entering treatment.
It is not generally in the patient’s best interest to plan and deliver Orthodontic
treatment in the absence of a stable oral environment when the risk of dental
disease is high.

124.4.4 Clinically feasible and beneficial
Finally, the detailed clinical aspects of the proposed Orthodontic treatment should beconsidered to ensure that it will be beneficial to the patient.
4.4.5 Complexity Descriptors
Level 1:Treatment and care undertaken in NHS primary dental care mandatory
contracts and NHS England commissioning expectations of care provided.
Level 2:Treatment undertaken by practitioners, under specialist supervision and with aformal link to a consultant-led MCN. This includes dentists who haveenhanced skills and/ or experience; non-specialists who have demonstrated
the competencies detailed in the Curriculum for the Primary Care Dentist witha Special Interest in Orthodontics, either by obtaining the Diploma in Primary
Care Orthodontics or by demonstrating equivalence.
Level 3a:Treatment undertaken by practitioners who are on the Specialist List for
Orthodontics with a formal link to a consultant-led MCN. This is predominantly
primary care treatment which could be delivered in either a primary care orsecondary care setting.
Level 3b:Treatment undertaken by practitioners who are on the Specialist List for
Orthodontics and have undergone an approved period of further postspecialist training or who can demonstrate equivalence. Level 3b Orthodontic
treatment is generally delivered within a secondary care setting.
NB - The present curriculum was introduced in September 2010 and, therefore, theabove criteria should be interpreted with that in mind.
The level of complexity may change depending on one or more of the following
factors:••••

Medical History
Social Factors
Patient anxiety
Other patient-associated modifiers

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COMPLEXITY ASSESSMENT – ORTHODONTIC TREATMENT

Need and risk
screening andentry criteria

Level 1

Recognise malocclusion andnormal occlusion.
Ensure oral health is good prior toreferral
Perform basic Orthodontic
examination, review the level ofcomplexity and be familiar with
IOTN, explain to a patient what
Orthodontic treatment may involveand make valid and timely referrals
Monitor post-Orthodontic caremaintenanceWork to be carried out by
primary care

The benefits of Orthodontic treatment outweigh the risks
Orthodontic treatment needed and not precluded by either patient co-operation or
medical history

Level 3aLevel 2

Patients with developing
dentition requiring
straightforward interceptive
measures
Removable appliances inpatients without skeletal
discrepancies
Non-complex fixed appliancealignment in patients withoutskeletal discrepancies orsignificant anchorage
demands

Level 2 care delivery
requires a minimum of
50 case starts per year
per clinician
Patient modifying factors
may result in referral to 3a
or 3b
cases per year

Patients requiring
Orthodontic treatment forthe management of skeletal
discrepancies (removable,
functional and fixed
appliances)
Patients with restorative
problems, which do not
require complex
multidisciplinary care withsecondary care input
Patients with impacted teeth
where the Oral Surgery/
Orthodontics liaison can be
managed from specialist
practice
Advice to those providing
Level 1 or 2 care

Work to be referred toSpecialist services
Patient-modifying factors
may result in referral to
3b
14

Level 3b

Patients with clefts of the lip and/ or palate or
craniofacial syndromes
Patients with significant skeletal discrepancies
requiring combined Orthodontics andOrthognathic surgery
Patients who require Orthodontics and complex
Oral Surgery input (e.g., multiple impacted teeth)
Patient with complex restorative problems
requiring secondary care input in a
multidisciplinary environment
Patients with complex medical issues, including
psychological concerns, which require close
liaison with medical personnel locally.
Patients with medical, developmental or social
problems who would not be considered suitable
for treatment in specialist practiceComplex Orthodontic cases not considered
suitable for management in specialist practice
Referrals where advice or a second opinion isrequired from a secondary care Consultant (i.e.
to those providing Level 1, 2, 3a care)

Work to be referred to consultant
Specialist Services

5

Summarised illustrative patient journey

Patient presentation at primary care general
medical practice with Orthodontic condition

Patient does
not haveroutine carewith GDPGP advisepatient to attend
GDP to referpatient for
Orthodontic care

Patient hasroutine carewith GDPGP to advise
patient to attend
GDP unlessurgentPatient presentation at primary caregeneral dental practice with
Orthodontic condition
GDP to carry out oral health assessment
and assess Orthodontic need withreference to IOTN

Level 1/2/3
procedure withmodifying factors
GDP to refer patientfor Orthodontic
care, via referralmanagement
process

Level 1procedurePrimary careclinician toperform

Referral Management Process

Level 2 procedure/ condition
Specialist in Orthodontics or dentist
with additional skills and experience
to manage procedural or patientcomplexity

Level 3a procedure / Level 2
condition with modifying
factors
Specialist in Orthodontics toperform
15

Level 3b procedure / Level 3a or 2
condition with modifying factors
Specialist or Consultant in
Orthodontics (or their supervised
trainee/ SAS grade) to perform

6 Assessing need
6.1 Population
Measuring Orthodontic treatment need is an essential component of any
commissioning cycle. Commissioners should seek assistance from Public Health
England (PHE) Consultants in Dental Public Health to complete Orthodontic needs
assessments.
This section offers a skeleton outline of the process. Understanding need is not anexact science, and data including local demographics, patient views and current
service impact, need to be triangulated to give best estimate and reflect population
changes.
There are three main elements to assessing Orthodontic treatment need.
Normative need – the professionally-judged need in a population cohort using
a standardised clinical index such as IOTN. This represents the capacity tobenefit from healthcare.
Expressed need – patients with need presenting for treatment.
Demand – felt need – a patient’s perception of need. This is generally a poor
proxy for need and often reflects supply.

Undertaking population Orthodontic needs assessment and reviewing existing
service provision to meet the need is part of the process and, as a minimum, should
include: an audit of current providers and their service and contract delivery
performance an assessment of whether local Orthodontic services are sufficient to serve
the population and are currently in the right locations
The purpose of assessing Orthodontic treatment need is to determine if sufficienteffective Orthodontic care is currently commissioned for the local population and if
population projections will alter this needs assessment over the coming years. An
assessment of the need for Orthodontic services is necessary to inform long-term
decisions on the future of Orthodontic contracts.

6.1.1 Quantification of need for Orthodontic treatment
In 2008/9 an NHS epidemiological oral health survey of 12 year old children wasundertaken across England. As well as surveying oral health, Orthodontic need was
also assessed, giving for the first time a PCT-based epidemiological Orthodontic
needs assessment. The examiners were all calibrated with a Regional and National
standard and trained in IOTN assessment. The defining level for identifying
Orthodontic need to be present was a Dental Health Component (DHC) IOTN scoreof 4 or above (the same level used in the 2003 National Child Dental Health Survey)
and/ or an Aesthetic Component (AC) of 8 to 10.

16

The survey shows the amount of normative need. The population representative
sample indicated that the prevalence of Orthodontic clinical need is between 30.5% &33% of the population. The range is wide, but includes prevalence levels that havebeen found from previous research. Children with poor oral hygiene or active caries
were included in the assessment.
There are a number of methods for assessing need; however, published studies andsurveys have consistently reported that around one third of children, in any given
population, will need and want Orthodontic treatment. Demand is rising as the healthand expectations of the population improve. Commissioners need to know thedemographics and views of their 12 year old population and assess if there are anychanges in planning and developing services.

17

7 Understanding current provision
Currently, Orthodontic services are largely provided by specialist practitioners
operating within primary care. As well as specialist primary care services, there areproviders in primary care who provide Orthodontic services as part of a mixed
contract under general dental services. Orthodontic services are also provided insecondary care for complex cases and the provision of training. As well as the NHS,
there is a growing private market for the provision of services, particularly for adults.
Orthodontic services are in the main provided to children and adolescents. The Indexof Orthodontic Treatment Need (IOTN) is the criteria by which clinical need isassessed. This is currently set at IOTN 3.6 or above for NHS eligibility; however, therequirement for a patient to have excellent oral hygiene, want care and be prepared
to commit to the demands of treatment are as important.
Under current arrangements, it is largely the referring GDP who determines if, where
and when a patient is referred. This is usually based on historic arrangements andprimary care dentists are sometimes under pressure from patients and their parents
to make a referral to specialist services even when clinical conditions are not ideal.
Commissioners report that long lists of referrals awaiting assessment havedeveloped in some locations. This can result in early referrals being made, making it
difficult for Orthodontic providers to prioritise need and identify cases which require
early intervention. These waiting lists for assessment perpetuate primary careproviders’ behaviour to refer too early to ensure their patients reach the top of the
waiting list at the optimum time for treatment to commence. As a result, some
Orthodontic providers are using commissioned units of Orthodontic activity (UOAs)
for assessing unsuitable referrals and repeat reviews, rather than directing thisresource to new case starts.
Most recent service data trends from the NHS Business Services Authority(NHSBSA) FP 170 returns suggest the Orthodontic clinical community, working with
Commissioners and public health, have made progress in addressing this issue inmany localities. In the past year, assessment types altered, the assessment to review
reduced and assessment to accept increased. This is a good example of systemchanges, clinical, public health and Commissioner partnerships working to benefit
patients and increasing capacity of services within existing resources.

When patients do receive care there is evidence that they are satisfied with the carethat they have received. However, this element of information is generally collected
at treatment start and before patients have experienced care. Improved clinicaloutcomes are reported in the majority of Orthodontic contract delivery throughrequirements of Peer Assessment Review (PAR) scoring. PAR scoring is undertaken
on a sample of patients; therefore, outcomes of care and scores are not routinely
collected or reported.

18

7.1

Service analysis

7.1.1 Primary care Orthodontic services in England
There were 1109 primary care contracts open in England during 2013/14 that
included Orthodontic activity. There is a mix of Personal Dental Services (PDS)
Orthodontic agreements and General Dental Services (GDS) general andOrthodontic contracts. Table 2 below illustrates the estimated budgets/ contracted
UOAs for primary care Orthodontic services in England.
Table 2. Contract values, contracted UOAs and mean UOA values. Source: NHS BSA Vital
Signs (Dec ’13)

REGION: NORTHREGION: MIDLANDS AND EASTREGION: LONDONREGION: SOUTH

Contract Value(PDS only)

ALL Contracted
UOAs 2013/14(PDS and GDS)

Mean UOA
value (PDS
only)

£56,259,842.78£66,951,667.50£34,372,187.69£60,066,855.02£217,650,552.99

1,094,583
1,349,766
610,228
1,072,476
4,127,053£59.62£60.93£62.89£60.82£60.38England TOTAL
In addition to the activity commissioned through PDS agreements, there are 571,619
UOAs that are contracted through GDS mixed contracts. The range of values for
UOAs in these contracts is £15.17 to £80.19. Some of this range can be attributed to
the fact that not all activity type costs are separated in blended contracts. The actual
value will need to be determined by Commissioners to contribute to their local
Orthodontic needs assessment.
7.1.2 Hospital Orthodontic services
A recent needs assessment, carried out in Greater Manchester, estimated an annual
spend in secondary care for Orthodontic services of £3.6M (based on available 6month data). Commissioners in London estimated an annual cost across the London
region of £12.6M for secondary care. Data collection and costs accrued in theprovision of orthodontic services by Trusts is an area that needs significant for
improvement. We will need Trusts to work closely and transparently with
Commissioners in order to accurately report actual hospital based orthodontic activity
and costs if we are to formulate a true picture of this area of Orthodontic needs.
Table 3 below shows Orthodontic activity within secondary care between April 2012
and November 2012 for treatment function code 143 as a regional level summary of
the percentage of Orthodontic activity within dental secondary care specialist
outpatient activity.
Table 3: Source: Orthodontic outpatient activity as a percentage of secondary caredental outpatient activity.
Midlands andNorth
LondonSouth
England
East
25%
27%
24%
34%
27%

19

7.1.3 Matching need to capacity
It is necessary to determine whether commissioned capacity is meeting need. Thiscan be estimated by dividing the total contracted level of UOA activity by 21 (thenumber of UOAs per course of treatment) to provide an estimate of the number ofcase starts available in primary care. It is recognised that methods of assessment ofcapacity require updating, particularly for secondary care. In areas where mature
contracting arrangements with validated waiting list management processes in place,there is still an apparent mismatch of capacity and expressed need. Until a more
appropriate method of assessing capacity is developed, it is suggested that thecurrent resources allocated to Orthodontics (across PDS contracts, GDS contracts
and within secondary care) should be maintained.
The use of a referral management process would allow Commissioners to better
understand the need for specialist Orthodontic care, the level of care at which
treatment needs to be provided and where this care needs to be located. A local
referral management process would also identify where patients are being referredfrom, so demand can be managed better and resources directed to those who needcare the most.
Commissioners will need to assess their local need and demand against available
resources and commissioned activity so they can understand and address any
variance.

7.2 Quality and effectivenessThis guide has been produced to promote consistent value and quality of specialist
Orthodontic care provision to patients in England. There are inefficiencies in thesystem, such as long lists of patients referred awaiting assessment, incomplete
courses of treatment and cases of unnecessary referrals to secondary care. This
commissioning guide is intended to provide a better understanding of these issues
and ways to release resource and use it more effectively. It is intended to support asystem change. Use of this guide, in conjunction with the accompanying overarching
introductory framework, encourages Commissioners and Orthodontists to work
together to ensure that resources invested by the NHS in specialist care are used in
the most effective way, provide the best possible quality and quantity of care forpatients, and meet need rather than serve demand.
Value is not a short-term cost reduction, but it describes the optimum patient
outcome for a given investment. In Orthodontic contract terms this can be describedas achieving the greatest number of case completions with improved PAR scoreswithin a provider’s contract value. For Orthodontic service provision this means
directing much of the available resource for the completion of cases to a primary caresetting, ensuring that only those patients with greatest complexity are referred forcare within a secondary care setting (taking account of training requirements).
During transitional phases it may be necessary to consider current geographic
provision, as care may not be locally available in a primary care setting and patient
access needs to be maintained. It also means ensuring that the system does not use
resource to manage referrals that are not valid for specialist care because they have,for example, been referred too early, do not meet IOTN criteria, or are unsuitable.
20

As responsible clinical stewards, Orthodontic specialists can assist in leading change
and provide a more effective use of constrained resources by broadening theirinfluence within a MCN with primary care clinicians and other specialist providers toensure that referrals are timely and valid and Orthodontic care is delivered effectively
and efficiently.

7.3 Outcomes
Orthodontics is one specialty where a clinical outcome measure has been developedand is in use in both primary and secondary care. The PAR index is a fast, simple
and robust way of assessing the standard of Orthodontic treatment that an individual
provider is achieving.
The PAR index is primarily designed to look at the results of a group of patients,
rather than an individual patient, as there are always a small number of patientswhere the index does not fully represent the result obtained. However, only a sample
is collected and for its use to be accurate and reproducible, any individual completingPAR scoring service must be trained and calibrated.
As individual patient outcomes may be influenced by many factors, it has been
proposed that an appropriate quality standard would be that 75% of completed cases
should exhibit a reduction in PAR score greater than 70%, with 3%, or fewer,
completed cases having a reduction in PAR lower than 30%1.Other PROMs andPREMs should also be used to assess the quality of patient care.
There is a need to develop and validate a measure of impact of Orthodontic care ona patient. Eastman and Sheffield academic units and the British Orthodontic Society(BOS) are currently working on this.

1

McMullan R E, Doubleday B, Muir J D, Harradine N W, Williams J K 2003 Development of a treatment outcome standard as aresult of a clinical audit of the outcome of fixed appliance therapy undertaken by hospital-based consultant Orthodontists in the
UK. British Dental Journal 194: 81 – 84

21

8 Transforming services
8.1 Current models
The following bullet points summarise the current models of care operating for theprovision of Orthodontic services and have been discussed previously in the guide.











GDPs decide where and when to refer a patient.
Service provided in primary and secondary care settings.
IOTN used to determine access to NHS-funded Orthodontic treatment.
o Primary care: IOTN 3.6 and above
o Secondary care: usually IOTN 4 and above
Variable local referral pathways used with no national agreed Care Pathway.
Specific factors influence where patients are referred including:General and available access to primary dental careo Historic referral patterns/ local Care Pathways
o Patient satisfaction/preferenceo Geography (transport links) and availability of Orthodontic serviceso Teaching needs e.g. postgraduate and undergraduate programmeso Contracts and available resources (primary and secondary care)o Care and delivery is dependent upon access to services, experienceand knowledge of GDPs.
Specialty partnerships in place through local MCNs/ LCNs, but specificmanagement/ effectiveness of these differ from region to region.
Sample PAR outcome not routinely reported and cases are selected byprovidersPatient satisfaction collected and reported at case starts in primary care.

8.2 Current challenges
Commissioners and clinicians have identified a number of challenges in current
contracting and service delivery:















Contract regulations assign 21 UOAs on a case start
No incentive to complete cases or robustly follow-up case abandonments
No formal method of contracting for advice only service
Referrals that are not valid utilising specialist resource to ‘assess and review’and ‘assess and refuse’.
Perception that referrals for assessment are waiting lists
New process required to more effectively manage ‘transfer’ cases
Process required to manage contract close downs and transfer care to a newprovider on block
Process required for facilitating new entrants to the market
Relatively short-term contracts
Procurement rules and length of process
Skills and resources to complete accurate needs assessment
Performance management
Benefits of skill mix to all: patients, providers and Commissioners
Activity coding issues in secondary and primary care
22




Lack of use of NHS number as patient identifier makes tracking patients andvalidating multiple referrals difficult.
Addressing current 18 weeks issues with ‘waiting lists’ in primary care

8.3 Current Workforce modelPrimary care setting:o GDPso Dentist with additional enhanced skills and experienceo Specialist Practitioners
Secondary care setting: Consultant-led Hospital Service (Consultant, Specialty
Doctors and StRs)
Therapistso Work in both primary and secondary care setting23

9 Service redesign
The bullet points below set out the vision for the longer-term provision of Orthodontic
care. There are many of these which Commissioners can be progressing now,
creating and testing solutions which could be shared nationally. However, someelements will require agreement, validation and support at a national level before
whole scale implementation. The establishment of MCNs for Orthodontics will allow
clinicians to shape and influence service redesign by working with Commissioners
and patients. In developing, redesigning, procuring and monitoring services,arrangements should be made to involve patients, carers and the public, and theorganisations that advocate for them including HealthWatch. See Appendix 2.
Single point of entry to Orthodontic services
o Referral management process
o Agreed minimum data set in which all practitioners have received
appropriate training in making valid referrals (including use of IOTN,
importance of good oral hygiene and suitability of patient).
o Greater use of IT to allow use of NHS mail and NHS number
Agreed standards for waiting times both for assessment, advice and treatment‘starts’ from optimum treatment time.
Use of a nationally agreed Care Pathway to take into account:o Population and Geography
 Provision for freedom of movement and choice for patient,including the opportunity for second opinions.
 Needs-led procurement and planningo Complexity descriptors in: Level 2
 Level 3a Level 3bo Use of IOTN:
 Useful accepted standardised tool
 Use of extended IOTN (functional treatment need) for patients
who have dentofacial deformity
 Referrers will require training in use of IOTNo Training of future workforce: undergraduates, Dental Care
Professionals (DCPs), GDPs, Dentists with enhanced skills, andexperience, Specialists, Consultantso Opportunities to develop and enhance the use of skill mix in
Orthodontic care delivery to increase capacity within resourceso Maintenance of core skills and enhanced Continuing Professional
Development for all members of the Orthodontic teamo Quality assurance Use of quality measures for all patients e.g. PAR, Patient
Reported Outcome Measures (PROMs) and Patient Reported
Experience Measures (PREMs), repeat PAR score at end oftreatment Minimum number of cases treated per year Peer review and audit within the MCN
 Update the quality assurance framework
24





Contracto Use of alternative contracting frameworkso Stepped activity credits and alternative structures for allocation of
UOAs throughout course of treatment. This could include some UOAs
allocated at case completion.
o Use of KPIs for quality improvemento Agreed rate of activity credit and payment for interceptive care andsecond opinion/ advice
o Increase length of contract beyond current SFI limits and consider
staged procurement to ensure some level of stabilityo Unified activity coding
o Minimum case starts by a single performer delivering Level 2 pathways(suggested 50 case starts per annum; however, this will require further
consultation)
All Orthodontic providers must have a formal link to an MCN and be required
to take an active role within them. All referrals must go through the local
referral management process and quality assurance.

9.1 Workforce implications







Multidisciplinary care managed through local MCNso Consultant-led with administrative support required Cleft (already established) Orthognathic (secondary care) Oral Surgery
 Restorative
 Paediatric Dentistry
Appropriate workforce available to deliver care (e.g. for hypodontia patients)
Effective communication with Commissioners and dental LPN throughOrthodontic MCN to ensure high quality patient care
Development of training models to improve quality and cost effectiveness todeliver additional benefit to patients
Framework for maintenance of core skills and enhanced CPD.

9.2 Data collection implications
The illustrative patient journey below describes a number of performance datacollection items which providers will need to generate themselves. This will require
local performance management from Commissioners, with support and engagementfrom a managed clinical network. Commissioners can also, with support from an
MCN, generate much of the needs assessment information required. See Section 12of the accompanying overarching introductory framework.

25

10 Illustrative journey of a patient
The suggested metrics and enablers throughout the illustrative patient journey should be considered locally:

Identifying Care Pathway for Patients - Orthodontic Level 1/ Level 2/ Level 3 Complexity
Primary Care Dentist
Standards
Metrics

Illustrative Patient
Journey
Providers of GDS/ PDS primarycare should ensure that Level 1
care (Procedure/ conditions to be
performed or managed by adentist commensurate with levelof competence as defined by the
Curriculum for Dental Foundation
Training or its equivalent) is
provided to the expected standard
within the contract.



All other expected standards.
Adherence to NHS England
Orthodontic referral guidance(to be produced)Timely valid referrals

Timely accurate extractions
as requested by Orthodontic
providerRecognise malocclusion andnormal occlusion. Understand theimportance of monitoring thedeveloping occlusion

Evaluate the potential need for
Orthodontic treatment and be
familiar with the Index of
Orthodontic Treatment Need
(IOTN) in order to support referral
decision making and advice topatients on alternative options if
they do not meet IOTN criteria.



Data submissions alignedwith that expected of GDS
contract

Referral quality and validity:

Effective primary caremanagement with regard tooral hygiene during
Orthodontic care and inmaintenance post-treatment



Caries controlled at referral
unless special circumstancesGood oral hygiene unlessspecial circumstances

Referrals should relate to aknowledge of IOTN and(PwLD) or other special
needs/ modifying factors

Patients referred need, want
and are suitable for
Orthodontic treatment oradvice.

Enablers
Consultant led local Orthodontic
MCN communicating with
GDS/PDS primary care
contractors under the umbrella ofa local professional network.

Accessible IOTN update training
to ensure primary carepractitioner competency
Contract reform:

Consultant led MCN

Retainer replacement guidance
produced. See Appendix 3
NHS England Orthodontic referral
guidance to be developed
NHS England approved patient
information leaflet to be
developed.

26

Ensure patient is: Caries free unlessopinion is being soughtwith regard to special
circumstances.
 Aware of the importanceof maintaining good oral
hygiene throughout
Orthodontic treatment.



NHS England approved
patient information leaflet to
be issued to the patient at
the point of referral.(to be
produced)Retainer replacement
guidance to be available

Primary care dentists should
explain to patients what
Orthodontic treatment may
involve including: removable appliances
and/ or fixed appliances
and what these mightentail possible length oftreatment and requiredcommitment to attend andcomplete treatment
 the risks and benefits of
Orthodontic treatment
Be able to make valid and timelyreferrals adhering to NHSEngland Orthodontic referral
guidelines (to be produced)
Monitoring post-Orthodontic caremaintenance27

Referral
Illustrative Patient
Journey












Referrer completes thereferral form ensuringconsistent required data set iscomplete (to be developed)
The referral must include all
relevant medical history
The referral must include any
available relevant radiographs
It is explained to patientsreferred for Orthodontic
assessment that they may notmeet criteria for NHS
treatment where need isborderline
Relevant information isprovided to the patient –standard, age-appropriate
NHS England approved leaflet(to be produced)
Patient choice of preferredproviders for the appropriate
level of specialist carerequired.
Dentist referring within one
week of the decision to referbeing madeStandards










Only refer patients who want
Orthodontic care
Referrals adhere to
Orthodontic referral guidance,
including timely referral
requirements
Consistent and accurate data
set of referrer details
Consistent and accurate data
set of patient demographics
and contact details
Specific relevant medical
history communicated toOrthodontic provider
Patient has good oral hygieneor, if complex, Orthodontic
need or other specialdifficulties (e.g. PwLD)
Patient receives informationon Orthodontic care andunderstands level ofcommitment on entering
specialist Care Pathway

Metrics

Enablers

 % of referrals received thathave complete referrer details

Electronic pro-forma and referral
processes

 % of referrals received thathave complete patient
demographic and contact
details

Agreed data set and national
Orthodontic referral guidance

 % of referrals that are valid withregard to OH % of patients who are informed
and understand what
Orthodontic therapy may entail
 % of patients who meet NHS
criteria, want and are suitablefor Orthodontic care or advice
 % of patients who are referred
within 1 week of decision torefer.

28

Accessible IOTN update training
to ensure primary carepractitioner knowledge of Index
and awareness of NHS England
Orthodontic referral guidelines
and expectations
Nationally agreed Orthodontic
information for patients available
Orthodontic providers’ patient
preparation information and maps
available to referrers
Waiting lists, Outcome andperformance indicators of all
specialist providers available toreferrersAssessing the referral
Standards
Metrics

Illustrative Patient Journey
Patients who do not meet NHS
criteria or are unsuitable fortreatment should be referred backto dentist.
 Patient and referrer informedof decision within 1 month of
Orthodontic provider receiving
the referral
Relevant medical and social
history details included with
any other relevant patient
factors
Appointment offered to patient
within 1 month of decision for
full Orthodontic assessment% of referral forms that are
deemed valid% of referrals forms received
that confirm patient need,want and are suitable for
specialist Orthodontic care oradviceEnablers
All dental providers to haveaccess to NHS numbers as theunique reference number acrossthe pathway
Referral decision can be tracked
electronically by both referrer andpatient
Validation of referrals for full
Orthodontic assessment

 Patient to be informed of
waiting times for all eligible
Orthodontic providers

Direct booking procedures
Responsive Level 3b services
available in secondary caresetting (Multi-disciplinary team MDT) Primary care dentist only
allowed to refer once to aselected specialist provider
unless malocclusion changes.
Multiple referrals to multiple
providers are not acceptable.

Contract Reform –Volume and cost Service Level
Agreement for validation/assessment

Dental Hospitals in acute setting
and District General Hospitals will
require Level 2/3a cases fortraining

UOA spread more evenly
throughout the course oftreatment with some being
reserved for completion oftreatment
Cost for treatment in either
primary or secondary care setting
should be equalised for Level 2

29

care
Transform PG training so that
Level 3a care training is provided
and supported in a primary caresetting where it makes sense to
do so.
Greater use of technology tosupport electronic transfer of
information

30

Patient seen – assessment
Specialist care level 2/3
Standards
Metrics

Illustrative Patient
Journey Patient has all information
about Orthodontic assessment,
treatment options, average
length of treatment and what
committing to care will involve.

 Information will include waitingtimes by Orthodontic provider
 Patient has all necessary maps
and information about setting Ensure valid consent
 Information on appliance andout-of-hours care after
procedure Patients are fully informed
about the risks and benefits of
Orthodontic treatment including
the likely need for long-term
retention to maintain completealignment.
 Referral process includes
assessment for advice on ongoing management, such as
the need for extractions.







Competence and qualificationof Orthodontic team meets thelevel of care provision
Formal appraisal, peer review
and outcome measures (e.g.
audited PAR scores) in place
for all clinicians through amanaged clinical network
Access to appropriate
premises and equipment suchas radiographic facilities
Dental Panoramic
Tomography, Lateral
Cephalometric radiograph andany drugs and equipment
made available asrecommended by ResearchCouncil UK
Disability Discrimination Act,
Equality Act and CQC
compliant








Patient has choice of
appointment time subject toavailability of provider, but all
providers should be able tooffer appointments outside ofschool times
All providers are working
within an MCN and not31% of referral forms that are
deemed valid% of referrals forms received
that confirm patient need,want and are suitable for
specialist Orthodontic care oradvice% of DNAs/ cancellations by
patient
Provider CQC compliance% of appointments available
outside of school hours andterm time.

Enablers
Appropriate contracting
mechanisms

working in isolation

Level 2 and 3 careStandards
Metrics

Illustrative Patient
Journey
Ensure good communication
with patient’s GDP throughout
treatment.
Referral to MDT e.g.
Restorative, Oral Surgery,
Maxillo-facial Surgery, Paediatric
Dentistry, Plastic Surgery ifnecessary
Monitor patient’s compliance oforal hygiene throughout
treatment and inform patient/carer and GDP if support isnecessary.
Undertake Orthodontic treatment
to a high standard and in a time
efficient manner.
Patient has all necessary
information on advised self-care
and who to contact during
treatment should there be a
problem.













Start treatment within 18
weeks of initial assessment if
patient meets necessaryreferral criteria
Timely management ofproblems during treatment
Consistent and accurate
record keeping
Patients able to contact theOrthodontic providers during
surgery hours throughout thecourse of treatment andmaintenance period
Inter-visit length i.e. length
between appointments should
be appropriate to meet
optimal clinical standards
Ensure valid consent fortreatment is obtained
throughout the course oftreatment
Appropriate supervision of
Orthodontic therapists andother non-specialist providers









32

% of patients who are readyfor treatment and commence
within 18 weeks or decision totreat% of incomplete or
abandoned treatments
PAR scoring recorded forevery completed case.
Robust external audit of PAR
and outcomes reported andreviewed through the
managed clinical network% of completed cases

Enablers
Effective use of resources e.g.
skill mix
Consistent diagnostic andprocedure used by all Level 2 and3 care providers
The workforce with the relevant
training to deliver care
Access to appropriate MDT whererequired.
Clear distinction between levels ofcareIllustrative Patient
Journey
Patient has all necessary
information at end of active
treatment on retention regime andwho to contact should there be a
problem what to expect in the retention
periodAt discharge from the Orthodontic
provider, following the supervised
retention period, the patient isgiven all the necessary
information regarding on-going
management of retention andwhat they can expect from theirGDP. Relapse is often minimal,
but all patients differ to the extent
that it occurs.

Discharge MaintenanceStandards
Metrics
 Patient-friendly information
available in a number offormats including information
on what to expect and who tocontact and what to do if
problems occurPROMs collected andreported on routinely
within one month ofcompletion of care

Enablers
Provider has all details ofreferring dentist correct from initialreferral data
Discharge information to referrer

Through provider home check
reporting and surveys
 GDP informed of patient’s
discharge within 1 month GDP and patient given
discharge and retention plan







33

Did you get what you
needed?
Did you have any
problems over course oftreatment?
Did you need to seek
advice or assistanceoutside of scheduled
appointments?
If the problem you werereferred with caused you
to be unable to eat
comfortably or socialise
with confidence – is thatnow resolved?
Would you recommend
this provider to a friend?

Responsive administrative
support11 Procuring services
11.1 Minimum standard specification
Minimum Service Specification
All Level 2 and Level 3 care must meet the minimum service specification as detailed
in the introductory guide for all Level 1 care together with the additional elements as
described below.
Level 2 Care
Staff Composition/ Workforce
The staff composition will be as follows:• Dentists with additional skills andexperience to manage the procedural or
patient complexity in Orthodontics• Suitably trained and experienced dental
healthcare professionals i.e. dental nurses/
hygienists• A qualified dental nurse who will support
the Orthodontist at all times.

Level 3 Care
As Level 2 care, but to include• Suitably experienced and qualified
specialist Orthodontists with the following
qualifications: FDS(Orth)RCS (Level 3b)/MOrth (Level 3a) or equivalent and must beon the GDC Orthodontist specialist list.

The provider will ensure:• That robust practice management is inplace to address issues arising from thepatient pathway e.g. validation of patientdata, management of patient complaints andissues, management of clinical information.
• That all dental/ Orthodontic staff must havethe appropriate clinical indemnity, either
through an approved defence organisation or
through their employment• That all staff supplied have valid
registrations and evidence of continuing
professional development for on-goingregistration including participation in peer
review and audit• That the performers have the skills tomanage vulnerable patients who may haveaddiction, mental health illnesses andanxiety/ phobia.

Days/ hours of operations
The service must be provided at times most As Level 2
convenient to patients, including earlymornings and late afternoon appointments toensure school children are not discriminatedagainst. Consideration should be given to
evening or weekend appointments and it isexpected that a minimum number of after
school sessions should be made available
per week.

Patient Focus
Providers will ensure that patients areprovided with relevant verbal and written34

information in a variety of formats, where
necessary utilising a translator service,outlining the service. They will also be
required to provide information concerning
the outcome of the assessment, such thatthe patient is clear why a specific treatment
opinion has been selected.
Prior to initiation of treatment, the patientand/ or carer should be provided with thefollowing information verbally and in writing: Treatment plan including length oftreatment and frequency of visits What to expect during treatment
 What is expected of them including
self-care, compliance and under whatcircumstances treatment will beterminated e.g. poor attendance, poor
oral hygiene, abusive behaviour
 Any additional costs the patients may
experiencee.g.
paymentforreplacement of broken appliances
under Regulation 11 and equipment
such as wax, toothbrushes etc.
The information should be given in such a
way that it supports the patient’s ability togive formal consent to initiate treatment.
Providers will be required to: Ensure the patient has a clear
understanding in advance of what will
happen to them during the treatment,
who will be responsible for delivering
each element of care and why, forexample, the patient may be returned totheir GDP for extractions
 Ensure valid consent is gained from all
patients prior to initiating assessment
and/ or treatment
 Have effective and robust arrangements
in place to promote and safeguard thehealth and wellbeing of young people
and vulnerable adults
 Have in place a policy that meets theCommissioners’ and CQC requirements
for Safeguarding Child/ Young Person
Equipment/facilities
 Ensure that all equipment conforms
with health and safety regulations
and nationally accepted standards
and is maintained regularly in linewith national and manufacturers

35








guidelines – providing annual reports
to the Commissioners detailingcomplianceBe responsible for the funding of
consumables, laboratory work anddental appliances
Ensure any dental laboratory services
used meet with GDC guidance andEU legislation
Ensure that safe processes andworking environment are in place.
This will include training of staff inrelevant processes and procedures
Ensure all legal requirements relating
to radiological guidance are met.
Appropriate premises and equipment
such as radiographic facilities e.g.
DentalPanoramic
Tomography,
Lateral Cephalometric radiographand any drugs and equipment madeavailable as recommended by
Research Council UK

OtherAll providers will be required to become
active members of their local MCN

11.2 Enablers and minimising barriers to transformation
The minimum standards that Commissioners will include within a specification havebeen described. This will include the local population need, the aims and objectivesof this service, a description of the patient journey, service standards, key service
outcomes, location of provider premises, data collection and reporting, and tariffcosts. The enablers that would assist Commissioners and clinicians in implementing
transformed services are outlined above. The risks and barriers will be explored andhints and tips to overcome these. Innovation is about using the flexibility in theregulations to allow better value and outcomes for the investment made.
Meeting the needs and access of vulnerable groups need to be considered and theprocess for monitoring access and outcomes agreed to align with the pathway.

36

12 Quality and outcome measures
The illustrative patient journey suggests metrics that can be applied across the
Orthodontic Care Pathway. It is expected that Commissioners and local MCNs will
select and develop reporting mechanisms for locally relevant metrics along with therequired PAR scoring, and PROMs and PREMs measures, as detailed below.
High-level assurance relating to contractual delivery is monitored via the current
Orthodontic indicators of NHS England’s Dental Assurance Framework.

12.1 Patient reported outcome measures (PROMs) and Patientreported experience measures (PREMs)
The use of appropriate PROMs and PREMs will be essential to benchmark services.
The measures should be patient-focused and consider potential inequalities
throughout the patient journey. Appropriate tools should consider the different ways
in which service users can provide feedback and different service users’communication needs.
PROMs/ PREMs should include data which can be collected by services at a local
level, as well as data which can be collected centrally using national surveys and,
where possible these data should be triangulated. There should be evidence todemonstrate that PROMs/ PREMs are representative of the patient groups treatedand not just those who can easily provide feedback.
There is a requirement for NHS services to implement the ‘Friends and Family’ test.
Commissioners need to understand and recognise that, given the patient base for
Orthodontic services, the question is unlikely to be consistently interpreted within theintended context since those services may not be appropriate or applicable to otherfamily members or friends of the patient.
Generic PROMs & PREMs have been developed for all specialist services and thesecan be referenced in Section 16 of the Guide for Commissioning Specialist Dentistry
Services.
Whilst an Orthodontic-specific PREM has been developed, work is still on-going todevelop and agree an Orthodontic-specific PROM. The age group of people
undergoing Orthodontic treatment will be a specific factor in how these develop.
The specialty-specific PREM for Orthodontics is:

Were you able to book an appointment with your NHS Orthodontist at a timethat suited your schedule? e.g. able to book an appointment outside school
hours if necessary, etc.

1 Yes, I was able to book an appointment at a convenient time for me
2 No, I had to book an appointment at an inconvenient time for me
3 N/A
4 Additional comments

37

With regard to this additional specialty-specific PREM, many service users may
particularly value other more qualitative aspects of the service provided such as
having adequate time to understand and for delivery of their care, feeling valued as aservice user and the attitude and approach of staff members.
As a more qualitative measure it may also be helpful for services to show how they
have evaluated, reflected upon, responded to, and acted upon feedback and how
services are being developed to improve patient experience as a result of the
feedback received.

12.2 Clinical outcome measures
MCNs in Orthodontics can begin to use PAR results to audit and review clinicaloutcomes to support improved quality.

12.3 Dental Assurance Framework – Orthodontic indicators
NHS England’s Dental Assurance Framework provides a set of indicators thatprovide high level assurance for Commissioners, whilst recognising that no one set ofindicators could, in itself, provide absolute assurance of quality, nor could it
necessarily identify best practice. It is designed to assure Commissioners that
contract holders and providers are on course to meet their obligations under theircontract/ agreement. The current Orthodontic indicators are detailed below and aremeasureable via existing datasets.
Indicator
Assessment
O1. Assessments by category

O2. Age at assessment

Treatment
O3. Cases reported concluded asa function assess and fit applianceO4. Type of appliance used

Outcomes
O5. UOAs reported per completed
case

Metric% of assessments that are:
Assess and accept
Assess and refuse
Assess and review% of reported assessments and review
where patient is aged 9 years or
younger
Ratio of reported concluded(completed, abandoned or
discontinued) courses of treatment toreported assess and fit appliance.
% of concluded (completed,abandoned or discontinued) courses oftreatment reported as using removableappliances only (all outcomes,
including completed, abandoned or
discontinued)
Ratio of the number of UOAs reported
per reported completed case (notincluding abandoned or discontinued
cases)

38

O6. Reported PAR scoring

O7. Abandoned or discontinued
care

Expected number of cases PAR
scored based on completed courses oftreatment reported versus actual
number of cases reported PAR scored(year to date).
% of concluded (completed,abandoned or discontinued) courses oftreatment where treatment is reported
as abandoned or discontinued

39

13 Next steps
This guide provides a strategic framework for commissioning Orthodontic services in
the future. Following publication there will be further work on implementation;
however, the enablers, direction and tools are articulated and can be used byCommissioners to make progress locally and begin to set the groundwork forchange.
Commissioners, as a minimum, should ensure that they have completed a needs
assessment and review current service provision. Establishing MCN networks linked
to Dental LPNs and Commissioners would also assist in making progress to achieve
the aims of this guide and develop partnership working with clinicians.

40Appendix 1 - Normative Need

Normative
Need

Estimated
Need and
DemandEstimated 12year
population
alreadywearing anappliance

Total

NHS England Region

12-year-old
Population(Mid-2008)% ofchildren
examined

NumberNumberNumberNorth

190,263

32.9%

37,637

11,32548,962

Midlands and East

187,21533.0%

35,804

14,70750,511

London81,522

30.4%

10,685

5,853

16,538South

162,232

30.5%

29,766

14,62044,386

ENGLAND

621,232

31.7%

113,892

46,505160,397

Table 1: Normative (Clinically Defined) Orthodontic Need in England
Source: NHS Epidemiological Survey of 12 year old children 2008/9 – NW Public Health7
Observatory 201041

Appendix 2 - Patient Engagement
Orthodontics Commissioning Guide: participation report
Analysis of feedback from children and young people’s participation in thedevelopment of the framework for Orthodontics commissioning and actions to
be taken by dental Commissioners
1. Introduction
During 2014-15, NHS England has produced a strategic framework forcommissioning Orthodontics, one of a series of planned commissioning guides tosupport more effective commissioning of dental services. As Orthodontics services
are heavily used by children and young people, it was important to get insights fromthis group on the services, and some participation activity was designed to support
this. This targeted activity complemented the wider patient and public voice (PPV),
obtained via the PPV representatives on the working groups which produced theguides, and the overall Patient Review Group.
Insights were intended to support a patient focus in the framework, especially in
relation to influencing patient experience measures and implementation approaches.
In addition, we wanted to test a participation approach that could be used by NHS
England colleagues more widely to support a patient-focused approach tocommissioning Orthodontics. There is considerable scope to increase theinvolvement of patients and public, particularly young people, in commissioning
dental services, both nationally and locally, and at all stages of the commissioning
cycle from needs assessment through to service procurement and monitoring. This
relatively small piece of engagement has yielded a rich range of insights andpotential service improvement ideas that can be built on in future work.
2. Participation approach
A combination of digital engagement and face-to-face focus groups was used to
involve children, young people and their parents/ carers in a dialogue about
Orthodontics. The digital engagement comprised two evening tweetchats using#orthodontics. These attracted small numbers of young people and their parents, but
yielded some useful insights that were then drawn out in the focus group discussions.
The two Storifys of the tweets can be viewed at:https://storify.com/bethjp/o
https://storify.com/bethjp/orthodontics
We then ran two focus groups in different parts of the country, with about 16 children
and young people participating in total, aged between 9 and 21 and coming from awide variety of locations. Annex A below includes the discussion guide used.
The activity was supported by two voluntary sector organisations that are part of NHS
England’s Voluntary Sector Strategic Partnership: NCB (National Children’s Bureau)
and NCVYS (National Council for Voluntary Youth Services). They helped plan theengagement and organise the focus groups including recruitment, hosting, organising
travel and expenses, supporting facilitation, and ensuring safeguarding and risk
assessment processes were adhered to. Members of the Orthodontics guide working
group supported both the tweetchats and the focus groups, and NHS England’s
public voice team helped design the engagement, linked up with partners, developed
a discussion framework, and facilitated digital and face-to-face dialogue.

42

3. Feedback and actions
Feedback

Actions to consider

1. Communications - general Needed throughout patient journey –not just at start of treatment.
Discharge/follow up important too Participants wanted information in a
way they could understand, thatanswered their questions and focussed
on how it will feel
 Comments related to verbal andwritten communication
 Need to take into account that it can be
hard to retain information during a long
treatment period
 Skills to communicate with teenagers;
not patronising, speaking to young
person, not their parents
 Clear advice and explanations e.g. of
NHS scoring system for treatment
eligibility, what to eat, what treatment
choices are Manage expectations and provide
clarity and honesty on issues such as
how painful treatment will be, length oftreatment, when treatment can begin
2. Communications –written/video/online
 Existing British Orthodontic Society
leaflets not felt to be very children andyoung people friendly (lots of words!)
 Any information given to young people
should be co-produced with young
people to make the language andappearance more appropriate.
 Information and leaflets could be more
direct in presenting the facts; rather
than saying 'Y could happen if you
don't eat the right things' being more
direct and saying 'don't eat x, y, z..' They did not want to be presented withworst case scenarios in the literature
given, and wanted information to be
helpful and not repeating things they
already know.
 Preference for take away information
to be in more useable formats, such as
business card sized.
 Did not find video with advice on what

43










Develop Patient RelatedExperience Measures (PREMs)
relating to verbal and written
communication by Orthodontist
serviceSpecifications for new Orthodontics
contracts to include requirement for
Patient Related Experience
Measures (PREMs) on
communication

British Orthodontic Society to be
asked to consider developing somechildren and young people focused
information, using the contacts fromthe participation activity to support
co-production (children and young
people who took part, NHS England
Youth Forum, voluntary sector
organisations)Also consider what online
information is available on
Orthodontics via NHS Choices
Specifications for new Orthodontics
contracts to include requirement forpatients starting treatment to begiven verbal and written information
on where to find more information,
what to do if not happy withtreatment, how to get a second
opinionto eat etc. helpful – soon forgotten.
Preference to written information which
Orthodontist talks through Request for online one-stop shop or
Orthodontics information – young
people currently don’t know where togo for information in relation to: choiceof practice; knowing what practices dowhat treatments; finding out the rules
on second opinions; what you areentitled to and what is different indifferent places; difference between
NHS and non NHS services; what to
do if not happy with treatment
3. Waiting times
 Variation in experience on this Need clarity on waiting times, once
referred Need clarity if required to wait fortreatmentConsider measuring waiting time
performance of Orthodontic
providers as part of contract
monitoring and comparing differentareas

4. Timing of appointments Access to emergency appointments a
concern for some
 Request for appointment availability
outside school times for NHS as wellas private patients: more earlymorning, evening and weekend
appointments
 Schools not always supportive abouttime out for Orthodontic treatment



5. Continuity of care and follow-up
 Some experienced different
Orthodontists throughout treatment
 Affected continuity of care Some participants not happy with
discharge and follow-up arrangementsSpecifications for contracts could
require Orthodontics practices togive patients written information on
how to access emergency
appointments
Availability of appointments outsideschool times should be a key
criterion when reviewing contracts
in tender processes
Dental Local Professional Networks
could take shared action tocommunicate with schools in theirarea about supporting young
people to attend for Orthodontic
treatment
Develop Patient RelatedExperience Measures (PREMs)
relating to continuity of care anddischarge arrangements

6. Consistency on costs and payments  Variation in whether patients pay whenbraces break, or get replacements free
 Varying range of ‘extras’ that have tobe paid for, including storage box,
starter pack44

Include recommendation incommissioning guide that storageboxes should be provided as
standard
Specifications for new Orthodontic
contracts to include requirements

on what items should be provided
free of charge
7. Participants generally happy with
Orthodontics services
 Majority of those who participated inthis engagement were positive about
the outcomes of their treatment
 Positive outcomes mentioned were:straight teeth; improved self-esteem;
eating and speaking improvement



Develop Patient RelatedExperience Measures (PREMs) toinclude these positive outcomes

4. Next steps

Use feedback to inform on-going Orthodontics commissioning work throughout
England especially in relation to informing specifications, tender andmonitoring processes, and development of Patient Related Experience
MeasuresShare this report and the Annex detailing the participation methodology withdental Commissioners and providers using channels such as dental Local
Professional Networks, Managed Clinical Networks, NHS England dental
leads meetings, NHS England National Dental Commissioning Group.

Annex A: Discussion guide – for reference and future use/ adaption in primarycare commissioning
This discussion guide was produced by the Public Voice team at NHS England tosupport engagement of children and young people in Orthodontics commissioning. It
was used in February 2015 for focus group discussions organised with support fromvoluntary sector partners. The discussion guide is reproduced here so that it can beadapted for use for engaging children and young people in commissioning: locally,nationally, in dental services or more broadly across other service areas.
When might this approach be used?
 To seek insights from children and young people when carrying out a needs
assessment in relation to a particular service
 To get insights that can shape service specifications and subsequentprocurement and monitoring of a contracted service; for example,
Orthodontics, general dentistry.
For more information and advice on using this focus group guide, contact:
NHS England Public Voice team: england.nhs.participation@nhs.net
Background notes
The purpose of the focus groups was to get insights from children and young people
that could support a patient focus in the commissioning guide for Orthodontics, andinfluence patient experience measures and implementation approaches.
Focus group participants were children and young people who had self-selected forthe focus groups, but with the requirement that they were aged between 9 and 18
and had recently had Orthodontics treatment. We ran 1-2 groups divided by age, withan additional separate group for parents/ carers to share experience.

45

The groups were recruited to and hosted by voluntary sector partners NCB (National
Children’s Bureau and NCVYS (National Council for Voluntary Youth Services).
Members of the public voice team supported overall facilitation. Members of the
Orthodontics working group introduced the project, asked questions, and captured
comments.

Session outline
Time
Activity
1030am Prebrief for staff involved in focus
groupsWho

Comments

Hosts (NCB/
NCYVS) tosign in, check
paperwork

NHS E/ working
group staff towelcome, chat toparticipants.
Need to make sure
we get participants’ages and areas
where received
treatment

11.20am Introductions

Led by hosts(NCB/
NCYVS)

Suitable ice breakercan be used e.g.
human bingo

11.30am Setting the scene (adapt as
appropriate) What is Orthodontics?
 We are looking at how wemanage Orthodontics services
in England This is about getting goodNHS Orthodontics services,that provide excellent
treatment wherever you are in
the country, communicate
clearly what’s being done andwhy, and what the patientneeds to do, gives people thesupport that they need, isgood value for money Group of people are producing
a guide to how we plan andbuy Orthodontics in England.
Will be used by managers andOrthodontists to develop andimprove services
 On the group are
Orthodontists, managers of

DentalUsing visual props –Commissioner leaflets, photos andor provider
appliance models

11am

Sign in and welcome attendees46



dental services, and 3 patient
representatives
Orthodontics services aremostly used by children andyoung people, so we wanted
to talk to you and get yourviews and ideas to influence
the work we are doing

11.40am General questions andanswers

Facilitators
manage andensure groupkeeps to time

This may be very
short if people arequiet, in which casemove straight togroup discussion

11.50am Split into groups

Facilitatorsorganiseparticipants into
groups2 or 3 groups basedon age: 11 and under,
12 and over, plus
group for parents/
carers depending on
resource to facilitate
this

Focus group questions:
Agree on day
1. Who has had a brace fitted who does whator something similar?
When did you have it?
(show photo of brace)
2. If you are waiting fortreatment or at the
beginning of treatment,
what do you hope
Orthodontics can do foryou?
Prompts – make you feeldifferently about yourappearance? Make eatingeasier?
3. How did you feel when you
were at the Orthodontist?
(show photo of Orthodontist
with patient)
Prompts: Were you happy
with how it went? Were thestaff kind? What were thebest bits? What were theworst bits? E.g. being able
to choose colours, missing
school, pain, length of

Need to havesomeone in eachgroup asking
questions.
Be aware of striking abalance between
making sureeveryone has
opportunity tocontribute and putting
people on the spot,
as children will not
like the latter! Need toassess on the day
and make a
judgement.
Try to ensure that the
dialogue is not
dominated by one or
two individuals andbring dialogue back to
the key topics if
people start todigress.
Need a notetaker ineach group or other12 noon47

treatment, feeling selfconscious? What made you
feel that way?
4. Did the Orthodontist explain
the treatment clearly toyou?
Prompts: did you
understand the
explanations? Could you
ask questions? Did theylisten to you? Did you knowhow you might feel during
the treatment, how long it
would last?
5. What have the benefits
been to you of wearing abrace (or whatever else you
had done) – are you glad
you had the treatment?
Prompts: has it changed
how you feel about
yourself?
6. May need to miss this one
out for younger group if
attention is flagging, andhave a longer comfort
break[What could be done
differently/ better when you
go to the Orthodontist?
Prompts: If you were in
charge of treating people
your age – what would you
do? What about waiting fortreatment; what the staff
are like; how you are told
about what to expect; what
the environment is like at
the Orthodontist
12.35pm Stretch legs – 5 min break
Bring everyone back together
Explain how we will use thethings you told us today
Commit to come back toparticipants and tell them what
we did about what they told us.
Tell them about other relevant
engagement activities,
especially relating to children

48

way of capturingcomments e.g.
participants write
notes for sticky wall
Note; if you run aseparate group forparents/ carers, thesequestions will need to
be tweaked so they
are appropriate. May
want to add aquestion about
waiting time forseeing an
Orthodontist andstarting treatment.

Commissioners
and facilitators

If any of participants
are already engaged
in health and social
care (e.g. on NHS
England Youth
Forum), useful to getthem to speak briefly
about thisand young people, bothnational and local. Mention
NHS England Youth Forum(Facebook page – regular
events)12.50pm Hand out thank you vouchers/
travel and have lunch/ lightrefreshments

49

Appendix 3 - Guidance on the Provision of Replacement
Orthodontic Retainers
The purpose of this guidance is to set out NHS England’s policy regarding themanagement of patients who require (or request) the repair or replacement of NHSfunded Orthodontic retainers.
1.

NHS Orthodontic contract holders:

1.1 Retainers lost or broken beyond repair by an act or omission by the patient:
Where a retainer is lost or broken beyond repair by an act or omission by the patient
this should be managed using Regulation 11 of the NHS Dental Charges Regulations
2005 (30% of a Band 3 patient charge per retainer). No UOAs are credited, but thecontract holder is entitled to retain the patient charge.
1.2 Repair or replacement necessitated by ‘fair wear and tear’:1.2.1 During the supervised retention period (normally a minimum of 12months):
The repair or replacement should be provided free of charge to the patient (with no
UOAs credited).
1.2.2 After discharge:
Refer to the British Orthodontic Society guidance ‘Liability of Practitioners forcontinuing care after completion of active treatment’.
2.

NHS contract holders with no Orthodontic element within their contract:

Contract holders with no Orthodontic element within their contract should manage
patients who request the repair or replacement of Orthodontic retainers in thefollowing way:
2.1 Within the supervised retention period (up to 12 months after active
treatment):
Refer back to the Orthodontic contractor where treatment was provided.
2.2 Beyond the supervised retention period:
Refer back to the Orthodontic contractor where treatment was provided.
The NHS GDS Regulations (2005) do not permit holders of mandatory services
contracts to claim UDA activity for the repair/ replacement of Orthodontic retainers.

50Appendix 4 – Glossary of terms and acronyms
AC

Aesthetic component

ARCP

Annual Review of Competence Progression

CCST

Certificate of Completion of Training

CQC

Care Quality Commission

CQUIN

Commissioning for Quality and Innovation payment framework
enables Commissioners to reward excellence, by linking a
proportion of English healthcare providers' income to theachievement of local quality improvement goals.

DES

Dentist with Enhanced Skills

DGH

District General Hospital

DHC

Dental health component

DNA

Did Not Attend

FDS

Faculty of Dental Surgery

FTFoundation Trainee

GDC

General Dental Council

GDP

General Dental Practitioner

GDS

General Dental Services

IFR

Individual Funding Request

IOTN

Index of Orthodontic Treatment Need

ISFEIntercollegiate Specialty Fellowship Examination

LDN

Local Dental Network – Also known as Dental Local Professional
Network

LPN

Local Professional Network

MDT

Multi-disciplinary TeamNTN

National Training Number

ONS

Office of National Statistics

PAR

Peer Assessment Review

PDS

Primary Dental Services

PREM

Patient Reported Experience Measure

PROM

Patient Reported Outcome Measure

RCS

Royal College of Surgeons

UOA

Units of Orthodontic Activity

51

Appendix 5 – Orthodontic Commissioning Guide Working
Group Membership
Alice Benton

Chair of the Working Group and Regional Lead for Dentistry &Optometry, London

Nikki Atack

Faculty of Dental Surgery

Dirk Bister

Association of Dental Hospitals

Colette Bridgman

Consultant in Dental Public Health (Guides Support)

Donna Campbell

Orthodontic Therapist

Paul Cook

COPDEND

Eddie Crouch

Primary Care

Richard Cure

Faculty of General Dental Practice

Rob Dalziel

Healthwatch Dudley

Guy Deeming

British Orthodontic Society, Chair BOS Specialist GroupPauline Fletcher

Primary Care Commissioning Manager (Dental), Cumbria andNorth East

Ruth Gasser

NHS Business Services Authority, Head of Dental Policy

Rob Haley

Primary Care Commissioning (Commissioning Guides Support)

Nick Hall

Primary Care

Jim Harris

Patient / public representative

Dionne Hilton

NHS England, Dental Pathways Programme Manager

Natalie Jones

Primary Care Contract Manager, Wessex

Serbjit KaurNHS England, Deputy Chief Dental Officer

Brian Kelly

NHS Business Services Authority

Fraser McDonald

Association of Dental Hospitals

Mike McGrady

Public Health England, Specialist Training Registrar in Dental
Public HealthJohn Milne

British Dental Association

Jane Moore

Dental Local Professional Network

Carol Reece

NHS England, Senior Programme Manager, Dental, Pharmacy
and Optical

Lucy RidsdaleFoundation training representative

James Spencer

COPDEND

Julie TheakerContract Manager (Dental and Optometry), Derbyshire andNottinghamshire

Helen Tippett

Secondary Care

Colin Wallis

British Orthodontic Society

Mark Welch

Patient / public representative52