Dental clinical standards and the role of managed clinical networks

The recent publication of the independent investigation of the NHS in England by Lord Darzi underlined the difficult situation that the NHS is currently in and that change needs to happen. One area that was highlighted is where patients end up in hospital when they may have been able to receive their care in the community.

Dental clinical standards

The importance of clinical pathways, where care being given by the right professionals rather than setting, has been recognised in dentistry since 2015, when the first commissioning guides were published by NHS England. The aim of these guides is to support the development and delivery of appropriate patient pathways in dentistry.

Since the initial publications of the guides in 2015, the guides have been reviewed, updated into clinical standards, with new standards regularly being published.

Alongside the specific clinical standards that have been published, for example, orthodontics, oral surgery and special care dentistry. There is a supporting overarching commissioning guide as well. The full list of standards can be found at https://www.england.nhs.uk/primary-care/dentistry/dental-commissioning/dental-specialties/

The focus of the standards is to ensure that the most appropriate clinician provides the care required by the patient linked to the level of complexity of care the patient requires. It is not about where that care is delivered. There are three levels of care that may be required, and the guides set out who can deliver what:

Level 1 – a general dental practitioner undertaking the care that their standard competencies allows.
Level 2 – a clinician with enhanced skills and experience.
Level 3 – a specialist practitioner or consultant.

The complexity assessment for orthodontic treatment is shown below as an example of how these are set.

The patient pathway will start in primary care, where all appropriate care should be given before being referred on if needed. Where in the past this may have gone straight into a secondary care provider, the pathway recognises that dentists with specialised training or experience may be able to provide care within primary or community settings and then if it is appropriate the patients journey can continue into secondary care. It is recognised that although level 3 care may require delivery by a consultant or specialist it does not have to be in the secondary care setting.

Whilst each Standard is specific to that speciality they follow the same format:

• A description of the speciality
• An overview of workforce and training
• An understanding of the specific population need and giving commissioners a method to collate and understand local need and to assess the impact of current services in meeting that need
• Quality standards and metrics for competency of clinicians and treatment environment including equipment
• Generic and specialty-specific patient reported outcome measures (PROMs) and patient reported experience measures (PREMs). As well as these measures, local measures can be added if there is capacity to measure and report on them.

These clinical standards provide a national framework for care delivery models but allows for localisation as appropriate to the needs of the patients in a particular area.

Managed clinical networks

Having standards alone though are not enough, as they need to be effectively implemented within commissioning organisations. To this end managed clinical networks (MCNs) were developed alongside the original commissioning guides. These were put in place by NHS England area and regional teams. Following the delegation of dental commissioning to integrated care boards (ICBs) the responsibilities for these MCNs now sit with the ICB.

MCN’s are a linked group of professionals and organisations from primary, secondary and tertiary care, working together, unconstrained by existing boundaries between services. These include relevant clinical staff, including those from other primary care areas, commissioners, and patient representatives. An MCN should be led by a local consultant in the relevant speciality.

They are asked to develop and implement the pathway for their speciality, looking at the complexities of care, current provision, development of the provision and introducing a robust referral management system. As there will be a number of different speciality MCNs in an ICB, part of the commissioners role within the MCN is to ensure that there isn’t duplication of work and that the referral management system is in place across all specialities.

Each ICB will have different governance structures to where MCNs report into but whatever that looks like, they should be seen as a key part of the commissioning process, they do not work in silo and should be a voice within the local dental network (LDN) to contribute to the planning, prioritisation and delivery of dental care for patients within the ICB boundary.

Following delegation ICBs now have an opportunity to review, revamp and re-energise their MCNs. PCC would be happy to support any ICB who wishes to undertake this review. Contact enquiries@pcc-cic.org.uk for further information.

Wendy Crew, adviser