MONITORING PROTOCOLS FOR

THE REFERRAL DENTAL SERVICE

Health and

Social Care

Board 2015

MONITORING PROTOCOLS FOR THE HSCB REFERRAL DENTAL SERVICE

As the Referral Dental Service was transferred fully from the Department of Health

(DHSSPSNI) to the Health and Social Care Board (HSCB) in 2011, this document

will replace the protocols published previously by the DHSSPSNI in January 2005.

AMENDED November 2015

EFFECTIVE December 2015

Updated March 2016

Reviewed and Updated August 2018

Arrangement of Protocols

1. Introduction

2. The process

3. Protocols for HSCB Referral Dental Officer (RDO) Codes

4. Procedures for targeted monitoring of General Dental Practitioners

5. Appendix 1 and Appendix 2: RDO process flowchart

6. Appendix 3: Letter to GDPs from HSCB RDS November 2015

7. Appendix 4: RDO Report Coding guide

8. Appendix 5: Probity Services SDR Codes Clarification paper 2013

9. Appendix 6: Record-Keeping MDS

10. Appendix 7: Patient FAQs leaflets (with link to RDS section of the BSO

website)

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1 INTRODUCTION

1.1 Background The Referral Dental Service (RDS) was set up in 1980 in Northern Ireland, based at the Department of Health and Social Services (DHSS), as a monitoring division within the Dental Branch (the DHSS became the DHSSPS in December 1999). The role of the RDS was to conduct post treatment examinations of patients with recent dental treatments under General Dental Service (GDS) Regulations. The function of the RDS officially transferred in August 2009 from DHSSPS (NI) to the remit of the Health and Social Care Board (HSCB) as a result of the reforms under the Review of Public Administration (RPA).The RDS physically transferred to the HSCB in the summer of 2011. The DHSSPS (NI) is now named the Department of Health (DoH)

1.2 The role and remit of the Referral Dental Service (RDS) The RDS is run by a small unit of Dental Advisers within the Directorate of Integrated Care (DOIC) at the HSCB. They conduct post treatment examinations of patients who have had recent dental treatment under NI General Dental Service regulations. The RDS exists to provide assurance to the HSCB (and thence to the

Department of Health) that Health Service dental treatment being provided in

Northern Ireland is carried out to a satisfactory standard and that the fees

claimed are appropriate.

1.3 The Referral Dental Officer (RDO) The RDOs are dental advisers employed by the HSCB. They work within the Directorate of Integrated Care (DOIC). They are registered dentists with significant and wide-ranging experience of working in General Dental Services.

1.4 Minimum Standards As stated in the “Minimum Standards for Dental Care and Treatment- Supporting Good Governance in Dental Practice” https://www.health-ni.gov.uk/publications/northern-ireland-minimum-standards-dental-care-and-treatment-2011

The HSCB is listed amongst the “organisations responsible for regulation, setting guidance and standards and monitoring of dental services in Northern Ireland” and included amongst its activities “Dental Advisers carry out post treatment examinations of patients to assure the quality and probity of Health Service dental work.” In particular, Standards 4, 5, 6, 7, 8 and 10 will be reviewed in the post treatment examination of patients.

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2 THE REVISED RDS PROCESS

2.1 The Development of the Revised RDS Process:

The BSO Information and Registration Unit (part of the Family Practitioner Services Unit based in HSC Business Services Organisation in Belfast) began working with the HSCB dental officer to determine what was required from a new RDS system, and what improvements could be made over the existing processes. The information unit produced the first prototype of the new RDS system in early 2012 and began to refine it with input from the potential user. This new BSO data based system has been refined with the undertaking of several RDS reviews including dental foundation trainee practitioners (DF1s), small random groups of dental practitioners in each local area, and pilot personal dental services (PDS) practitioners (e.g. Oasis Dental Care) since 2012, and full roll out of the revised RDS is to be undertaken in 2015. Please see Appendices 1, 2 and 3 for details of the process. 2.2 Revised RDS process The redesigned RDS database was developed to facilitate:

Random selection of patients treated by dental practitioners, identifying recent courses of treatment to be reviewed and producing letters as follows:

o Letters to the selected practitioners requesting that they forward clinical records relating to the above random selection (see Appendix 1).

o Letters to the selected practitioners advising of the date and place of examination designated for their patients and inviting comments relevant to the completion of the course of treatment (see Appendix 2).

As in the past, the practitioner may wish to attend the examination. This is normally arranged with the patient’s consent on the day of examination.

Letters to the sampled patients inviting them to attend for an examination; normally all ten patients identified in the records sample will be invited but this may be reduced, based on the records review.

RDS patient schedules or appointment lists will be available for Directorate of Integrated Care (DOIC) staff receiving phone calls from patients, prior to examination dates, and for information at clinic reception desks on the dates of the RDS examinations.

RDS patient schedules will also be provided to any pilot PDS practices facilitating the RDS examinations in their surgeries.

2.3 The Examination Clinic a. A letter of invitation will be issued to the patient inviting them to attend for

post treatment examination at a specified centre (or in the case of the Pilot PDS practices, in the practices)

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If the patient decides not to attend they should contact the DOIC office from which the letter was issued and this is recorded on the attendance sheet.

b. Those patients who do not attend for the examination are recorded as such on the attendance sheet.

c. Patients who choose to accept the invitation and attend are examined by one of the RDOs.

d. Under the 1993 GDS Regulations, where a patient has been called by an RDO for examination a dentist ‘shall not, otherwise than in an emergency, provide any care and treatment to that patient and shall take all reasonable steps to facilitate the examination’.

e. Should the need arise for emergency treatment to be provided by the practitioner for any patient invited to attend an RDO examination, the practitioner may wish to advise the RDO in writing, by phone or by email in advance of the date of examination.

f. The record of the examination is made using a standardised format downloaded from the RDS database and forms the basis of the RDO report (see 2.4 below).

g. There are no fees paid to the patient for attendance. h. The examination is normally carried out in a Community Dental Services

(CDS) clinic, in a local regional hospital out-patient clinic or, in the case of pilot PDS practitioners, may be held at the practitioner’s surgery.

2.4 The RDO Report a. The RDO produces a report based on the clinical examination and any

other relevant information supplied by the dental practitioner. b. The report is given a coding as shown in Appendix 4. c. The dental practitioner is sent a copy of the report normally within 2-3

weeks of the patient examination. d. A copy of the RDO report should be retained in the patient’s records. e. The HSCB retains a copy of the report. f. Any further correspondence from the dental practitioner e.g. in the case of

a C coded report, should be directed to the RDO who completed the examination and produced the report.

g. When appropriate, the RDO will contact the Regional Lead for General Dental Services and Governance at HSCB to discuss the reports which give them particular cause for concern.

h. They will also bring these cases to the agenda of the bi-monthly NI Dental Advisers meetings.

2.5 References

When drafting reports, the RDOs will refer to those professional guidelines and standards which are widely used by the profession and by national and local regulatory bodies. RDOs will also refer to the extant regulations and legislation set by government bodies.

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Examples of such guidance standards and regulations include:

GDS Regulations NI 1993

GDC professional standards (see Standard 7.1)

NICE guidelines

Minimum Standards for Dental Care and Treatment

IR(ME)R

NRPB guidelines

FGDP publications including o Standards in Dentistry o Selection Criteria for Dental Radiography o Clinical Examination and Record Keeping (CERK) o Antimicrobial Prescribing for General Dental Practitioners

SDCEP “Drug prescribing for Dentistry” - 3rd edition. This is available at;: https://www.health-ni.gov.uk/publications/endorsement-sdcep-drug-prescribing-dentistry-dental-clinical-guidance-3rd-edition

This list is not exhaustive and other relevant guidance, standards and regulations will be referenced. 3 PROTOCOLS FOR RDO REPORT CODES (SEE ALSO APPENDIX 4: RDS

REPORT CODES)

3.1 The A and B codes: a. A report with an A Code does not require a reply or any further action from

the dental practitioner. b. A report with a B Code contains comments or information for the dental

practitioner. It does not require a response. c. All reports should be retained in the patient’s records (as per 2.4d)

3.2 The C Code: a. A report with a C code requires a response from the dental practitioner

within the time-frame specified in the report. b. All replies to C coded reports should be directed to the RDO who

produced the report. c. If a satisfactory response is provided, e.g. forwarding of relevant

records/radiographs, the RDO may close the case and will advise the practitioner accordingly. The code for the patient report or record keeping report may be changed to reflect the clarification or additional information provided; and may therefore be reassigned to an A or B code. This will be reflected in the data held on the RDS database.

d. Where appropriate, the RDO and the practitioner may discuss the findings of a report and agree a way forward e.g. further treatment for the patient, which should be confirmed in writing to the RDO before the issue may be closed.

e. Where the RDO identifies a specific or recurring issue, they will discuss the case or cases with the practitioner. This type of case may be

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notified/referred to the Regional Lead and the relevant local Dental Adviser for advice.

f. The Regional Lead may direct the RDOs to include a practitioner on annual review for a defined period.

g. When applicable, the case may be forwarded as a referral to the Probity Services division of the BSO.

h. Where record keeping issues and or/radiographic issues have been highlighted, the RDO will advise the practitioner that a further record call will be instigated within an agreed period. Upon successful completion of the second review, the RDO will close the issue and return the practitioner to routine and random review. (See letter from M Donaldson, Head of Dental Services- http://www.hscbusiness.hscni.net/pdf/Compliance_with_IR(MER)_19_Sept_2011.pdf )

i. Where the second review highlights similar ongoing issues, the practitioner will be referred to the Regional Lead (for GDS and Governance) for further action.

j. In order to ensure consistency and equality of approach to all cases, the RDOs will present cases of concern to the Dental Advisers at the bimonthly meetings for discussion.

3.3 The D and E Codes a. These codes will always be immediately referred to the Regional Lead for

GDS and Governance; and advised to the Head of Dental Services. The local Dental Adviser will be included in any communications.

b. On presenting the case, the RDO will seek the advice and direction of the Regional Lead in determining any immediate action.

c. If a patient report is coded D or E, more patients will automatically be called for examination, generally targeting the area of concern identified in the first place by the initial RDO session.

d. Management of these cases will be discussed by the Regional Lead, the Head of Dental Services and the local HSCB Dental Adviser with the RDO to ensure consistency and equality of approach to these cases.

e. Further action may involve referral to:

The Regional Professional Panel,

The Reference Committee,

The HSCB Disciplinary procedure,

General Dental Council,

National Clinical Assessment Service.

f. The Regional Lead may also direct a referral to the Probity Services division of the BSO if appropriate.

3.4 Radiograph Issues a. Previously when relevant radiographs were missing from the historical

form D4T (forwarded to practitioners from the DHSSPS RDS), an X code was returned on the patient report. The X code is no longer in use.

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b. Radiographs of poor quality or no diagnostic value will be awarded a C Coded report.

c. In the revised RDS process, the practitioner will be contacted directly by the RDO and requested to forward the relevant radiographs and radiographic reports.

d. Failure to submit the radiograph/s will institute recovery of appropriate fees; and may result in further records being called.

e. If the missing radiograph/s relate to root canal therapy, then the fees for the radiograph/s, the root canal therapy and the coronal restoration may be subject to recovery (the Statement of Dental Remuneration (SDR) states appropriate radiographs must be available).

f. Failure to locate a radiograph is not sufficient justification to retake the exposure. Where the clinical/ radiographic report is available in the patient record, the RDO will take cognisance of this.

4 PROCEDURES FOR TARGETED MONITORING OF DENTAL

PRACTITIONERS

4.1 Identification of dentists for targeted monitoring

Dental practitioners may be identified for targeted monitoring for any of the following reasons: a. As a result of routine treatment pattern monitoring or identification of

atypical treatment patterns by the Information and Registration unit in the BSO

b. As a result of concerns raised at HSCB practice inspections c. As a result of complaints by patients d. Information received from other GDPs or DCPs-whistleblowing (see GDC

“Standards for the Dental team” Standard 8 ) e. As a result of information collected during routine RDO examinations f. As a result of concerns raised by the Regulation and Quality

Improvement Authority (RQIA)

g. As a result of information/concerns raised by dental officers during probity reviews

4.2 Decision process and procedure for targeting/further monitoring

of a dental practitioner a. This will involve the Regional Lead for GDS and Governance, the Head of

Dental Services and the relevant Dental Adviser/s, (if a practitioner works in more than one practice).

b. The assistance of the Information and Registration Unit of the BSO will be engaged to provide the patient sample for examinations and /or clinical records reviews.

c. If an (or a further) RDO session is to be arranged, the dental practitioner will receive a letter advising them of the extended sample being reviewed, at the same time as their patients’ letters are forwarded (and the dental practitioner’s letter will be forwarded from the HSCB offices by special

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delivery). Only in very exceptional circumstances, the dental practitioner will not be notified at the same time as the patient letter is issued.

d. The number of patients to be called will be agreed with the Regional Lead and the profile of the patients to be sampled (i.e. if specific treatments are to be identified for review) will be agreed at that time.

e. This sample will then be uploaded to the RDS database to enable the HSCB staff to process the relevant documentation.

f. At this stage, it will also be agreed (as in 4.2a) whether the same or a different RDO will complete the requested RDS examinations. When necessary, the Regional Lead for the GDS may request more than one RDO to complete the examinations at one or more sites.

g. The results of the session will be reported informally on the day to the Regional Lead for the GDS and formally by written report within 10 days to the Regional Lead for the GDS and the Head of Dental Services.

h. Thereafter the results of these reports (and any further information collated at this period from other sources) will inform the decision process for the appropriate actions to be taken by the Regional Lead for the GDS, in consultation with the Head of Dental Services.

APPENDIX 1

5 RDS PROCESS FLOWCHARTS

RDS Risk Assurance Process (Targeted/Random)

# RNR

# RNR

* Initial Request

# Record Not Received

GDPs to have a minimum of 10 patients invited to attend for examination and their

records reviewed in any three year cycle *

Reminder Letter

sent if records

are not received

within 14 days

Letter issued to GDP(s) requesting the forwarding of complete records for the courses of

treatment identified, as per GDS Regs Paragraph 25 (3) (ii)

Practice

contacted by

Dental

Adviser/Business

Support Staff Referral to

Regional Lead

for GDS

Records received at HSCB offices

at

Records returned from HSCB office to the practitioner**

Dental Adviser reviews Records for:

Quality of Record

Probity

Compliance with IR(ME)R

Compliance with GDS regs

# RNR

**The HSCB will endeavour to return all records in a timely manner. However, the

return of records will depend on the outcome of the review(s). Should you require

your records urgently please contact your local HSCB office which issued the letter

requesting the records.

APPENDIX 2

Clinical Examination

2-3 weeks in advance of the clinic session

3 Weeks (normally)

APPENDIX 3

Letters issued to patients advising

them of date, time and location of

examination clinic

Advisory letter to GDP informing them of

patients called and the date, time and

location of examination clinic

Patients attending clinic are examined by Dental Adviser following

standardised protocols

Dental Adviser issues report to GDP in respect of records reviewed and clinical

examinations

Any Practitioner queries regarding RDS reports will be dealt with by the RDS

Dental Advisers. Reports highlighting significant concerns will be referred to the

Regional Lead for General Dental Services and Governance.

The results will be stored on the RDS Database

6 LETTER TO GDPs FROM HSCB RDS November 2015

To: All GDPs and pilot PDS dentists All Dental Advisers

Referral Dental Service HSCB Western Office Gransha Park House 15 Gransha Park Clooney Road LONDONDERRY BT47 6FN Tel : 02895361010 Web Site : www.hscboard.hscni.net Our Ref: CMcQ/EC Date: 20 November 2015

Dear Colleague RE: MODERNISATION OF THE REFERRAL DENTAL SERVICE The Referral Dental Service (RDS) was transferred from the DHSSPS to the HSCB with the Review of Public Administration. However, the aims of the service remain unchanged: to monitor the quality and probity of dental care provided under GDS and (pilot) PDS. The RDS has undergone significant reform. The new service is now being managed

by two Dental Advisers, Mrs Catherine McQuillan (Western and Northern areas) and

Mr William Priestley (Belfast, South-eastern and Southern areas) with the assistance

of the administrative support staff of the Directorate of Integrated Care. Overall

coordination of the RDS will be from the HSCB’s Western office in Gransha Park.

Utilising a newly designed RDS database, a pilot of the revised RDS process started

in summer 2012 with the dental foundation trainees (DF1s). Thereafter on an interim

risk assurance basis, the process was rolled out to include all pilot PDS dentists, a

small sample of random and routine reviews of practitioners in each area and

targeted reviews of practitioners where issues/concerns were identified. With the

addition of the new dental adviser, Mr William Priestley, full implementation of the

RDS process is being rolled out in each area. Specialist practitioners working in the

GDS are also included in the RDS monitoring process.

Appendix 1 outlines the standard element of the new process through which HSCB

Dental Advisers will endeavour to gain the required assurances from a sample of

patient records and patient examinations (Appendix 2). The new RDS leaflets are

available on the BSO website at:

http://www.hscbusiness.hscni.net/services/2649.htm

If you have any queries concerning the above, please contact Mrs Catherine

McQuillan, preferably by email (catherine.mcquillan@hscni.net)

Yours sincerely

Dental Adviser/RDS, HSCB Western Office, Health and Social Care Board

APPENDIX 4 7 RDO REPORT CODING GUIDE

Referral Dental Service

Report Codes

Code A = Satisfactory (patient report and records review report) Code B = Dental Adviser/RDO wishes to comment/advise dentist (patient report or records review report); or bring to the notice of the dentist further treatment required since HS545/EDI submission (patient report). Code C = Dental Adviser/RDO does not agree with the completed HS45/EDI submission (patient report) and a reply is required within 14 days. Code D = Dental Adviser/RDO does not agree to a major extent with the completed treatment/ or the dentist has contacted the patient prior to the examination for non-emergency treatment (patient report/or records review report). Code E = Dental Adviser/RDO disagrees fundamentally with the completed treatment (patient report) Regarding Code C and records reviews Where C Codes are accorded to records reviews, the suffix identifies the specific issue: Probity (Cp), Quality (Cq) Probity and Quality (Cpq) Compliance with the GDS Regs (Cregs) When a Dental Adviser/RDO seeks clarification of the content of the records or further records are required, a reply is required from the practitioner within 14 days. Where no records are returned after a reminder has been issued, Code Cpq will automatically be applied in the practitioner report. This will then institute a referral to the Regional Lead for GDS and Governance who will decide on an appropriate course of action. Regarding Codes D and E Any report coded D or E will always result in more patients/record cards being called for examination and notification to the Regional Lead for GDS and/or other Dental Advisers and the Probity Division. Potential outcomes include:

Fee recovery

Referral to Regional Professional Panel (RPP)

Disciplinary action possible

Referral to the GDC/NCAS

APPENDIX 5

MEMORANDUM TO CONTRACTORS

TO ALL CONTRACTORS ON THE

DENTAL LIST

MDS 727

December 2016

CLARIFICATION OF CODES IN SDR

FOR PROBITY PURPOSES

Operations Directorate

Family Practitioner Services

2 Franklin Street

BELFAST

BT2 8DQ

Tel: 0300 555 0113

PROBITY SERVICES

CLARIFICATION OF CODES IN SDR FOR PROBITY PURPOSES

Purpose of the paper: The purpose of this paper is to provide clarification to all

GDPs in terms of how patient records are assessed for assurance by Dental Probity

Advisers against certain codes within the Statement of Dental Remuneration.

1 - EXAMINATION AND REPORT

Fees for clinical examination, treatment planning, patient management, advice

(including the issue of a prescription other than in connection with Item 37 (treatment

of acute conditions) and report:

ITEM CODE 0101

1(a) - Clinical examination, advice, charting (including monitoring of periodontal

status) and report.

In order to assure this item for payment there must be evidence in the patient

record that the patient’s mouth has been examined and that a charting has

been recorded which reflects, where appropriate, changes to the previous

examination.

ITEM CODE 0111

1(b) - Extensive clinical examination, advice, charting (including charting of

periodontal status) and report.

In order to assure this item for payment there must be evidence in the patient

record that the patient’s mouth has been examined and that a charting has

been recorded which reflects, where appropriate, changes to the previous

examination as well as a BPE/CPITN score recorded.

ITEM CODE 0121

1(c) - Full case assessment (including full charting and report of periodontal status),

treatment planning and report

In order to assure this item for payment there must be evidence in the patient

record of a full dental charting plus a full perio charting - where the perio

charting is to include at least one pocket depth per tooth.

Where Item Code 0121 is claimed as part of orthodontic treatment an

appropriate assessment form must be completed.

2 - PROCEDURES TO ASSIST DIAGNOSIS AND TREATMENT PLANNING

ITEM CODES 0201, 0202, 0203 & 0204

2(a) - Radiographic examination and radiological report.

In order to assure these items for payment there must be evidence to indicate

that the radiographs have been reviewed and any relevant finding(s) noted.

PLEASE NOTE THE FOLLOWING IN RESPECT OF RADIOGRAPHS

Where any radiograph is not present a recovery of the fee paid will normally be

sought (even where there is a report present).

Probity Services accepts that on occasion a radiograph may not be present in the

record for reasons such as the radiograph being required for an onward referral to a

hospital or specialist dentist or due to the radiograph being lost in transit by BSO. In

such instances Probity Services will not seek recovery of fees as long as there is

evidence to indicate why the radiograph is not available

Probity Services expect to find a radiological report on all radiographs taken. Failure

to provide this report may result in a recovery of the fee being sought.

Radiographs graded 1 or 2 will be assured for payment. Radiographs graded 3 will

not be assured for payment and a recovery of the fee will be sought.

ITEM CODE 0211

Study casts, where the treatment proposed is in connection with treatment under

items 18 (bridges), or 32 (orthodontics), or in other cases of special complexity, or

where requested by the Committee.

Probity will not, as a rule, request that the models are forwarded along with the

records. However, in order to assure this item for payment the models should

be recorded in the patient record and made available if required.

10 - NON-SURGICAL TREATMENT

ITEM CODE 1011

10(b) - Treatment of periodontal diseases requiring more than 1 visit, including oral

hygiene instruction, scaling, polishing and marginal correction of fillings.

In order to assure this item for payment there must be evidence to indicate

that the above treatment has been provided on 2 separate dates within a single

course of treatment.

ITEM CODE 1021

10(c) - Non-surgical treatment of chronic periodontal diseases, including oral hygiene

instruction, over a minimum of 3 visits, with not less than one month between the first

and third visit and with re-evaluation of the patient’s condition (to include full

periodontal charting) at a further visit not less than 2 complete calendar months after

the active treatment is complete. Treatment to include root planing, deep scaling

and, where required, marginal correction of restorations, irrigation of periodontal

pockets, sub gingival curettage and/or gingival packing of affected teeth, and all

necessary scaling and polishing.

In order to assure this item for payment there must be evidence to indicate

that the above treatment has been provided on at least 3 separate dates with at

least one month between the first and third visit. There must be evidence of a

full periodontal charting being taken not less than 2 complete calendar months

after the active treatment is complete.

14 - PERMANENT FILLINGS

Including any dressings, pulp capping, or other preparatory treatment, but excluding

associated treatment appropriate to item 15 (endodontics).

ITEM CODE 1441

14(e) - Treatment of early or small carious lesions in pits and fissures of permanent

or retained deciduous teeth, by the application of a fissure sealant to all pits and

fissures, including, where necessary, removal of caries and insertion of composite

resin and/or glass ionomer cement in the cavity and normally not more than 6 teeth

to be treated. Where more than 6 teeth are to be treated appropriate radiographs

must be available.

In order to assure this item for payment there must be evidence (i.e. charting

or radiograph(s) ) demonstrating early caries in the teeth to be treated and also

clear evidence of the procedure in the records.

ITEM CODE 1461

14(g) - Treatment of any surface of a permanent tooth using glass ionomer cement,

where the tooth would otherwise be extracted but this is contra-indicated by

exceptional medical or dental conditions.

In order to assure this item for payment there must be evidence of an

exceptional condition (see specific guidance for examples). A patient with an

‘exceptional condition’ would be one who is at significant risk of serious local

or systemic complications arising from a dental extraction.

See table below for examples

Please note that this list is not exhaustive nor is it directive

15 - ENDODONTIC TREATMENT

Including opening root canal(s) for drainage, pulp extirpation, incision of an abscess

and any necessary dressings and all other preparatory treatment and attention in

connection therewith, except for treatment appropriate to items 2 (diagnosis), 14

(fillings), 16 (veneers), 17 (inlays and crowns), 18 (bridges), or 25 (sedations) and,

except for the dressing or temporary protection of a tooth, where the permanent

restoration is not provided.

Condition Example

Complex cardiac conditions

Prosthetic Valve, Previous Endocarditis, Transplants with valvulopathy, Certain congenital defects (CHDs): Cyanotic congenital heart diseases. Within 6 months of complete repair of CHD. Residual defect following repair of CHD.

Bleeding disorders Factor VIII (Haemophilia A), Factor IX (Haemophilia B), Warfarin or Other Bleeding Disorders

Cancer Patients Prior to treatment for cancer, Those under active treatment by chemotherapy or radiotherapy or under medication prescribed by an oncologist.

Bisphosphonates Person receiving or due to start intravenous bisphosphonates. Long term high dose oral bisphosphonates cases will be considered on a case-by-case basis.

Neurological Disorders Multiple Sclerosis, Dementias, Parkinson’s Disease, Acquired brain injury, Epilepsy, Cerebral Palsy

Immuno-suppressed Patients with significant immunosuppression problems such as persons with HIV, or persons who are receiving medication as organ transplant patients.

Hepatitis C

Pre-operative Hip/joint replacement and cardiac surgery

Diabetes Type I and Type II

Persons with insulin or non-insulin diabetes

Genetic/ Congenital Down’s Syndrome, Cystic Fibrosis, Malignant Hyperthermia

Intellectual Disability Person in receipt of care or services for intellectual disabilities

Sensory Disability Person in receipt of care or services for sensory disabilities

Dental Vulnerability Cleft Palate, Sjogren’s Syndrome, Long stay residents of Nursing Homes, Persons on a Methadone therapy program

Pregnant/Nursing Mothers

Established Dental Phobia

ITEM CODE 1501

15(a) - Root filling of each canal of a permanent tooth with a permanent radio-

opaque filling material, normally not more than 3 teeth being treated under this item

in a course of treatment.

In order to assure this item for payment there should be evidence that all

canals have been filled to a suitable standard. Where this evidence is not

present (e.g. not all canals filled, canal not fully obturated, radiograph

missing/Grade 3 radiograph) the Dental Adviser may consider whether an

incomplete fee is allowed.

22 - EXTRACTIONS OF SPECIAL DIFFICULTY AND OTHER ORAL SURGERY

Extractions and other oral surgery not included in items 10 (periodontics), 15

(endodontics) and 21 (extractions):

ITEM CODE 2201

22(a) - Removal of buried root, unerupted tooth, impacted tooth or exostosed tooth,

involving the raising and replacement or a surgical flap with any necessary suturing,

including all associated attention except in connection with post-operative

haemorrhage requiring additional visit(s).

(1) Involving soft tissue only

In order to assure this item for payment there must be evidence to support the

fact that the tooth could not be routinely extracted and that a surgical flap was

raised and replaced.

23 - POST OPERATIVE CARE

ITEM CODE 2301

23(a) - Treatment for arrest of abnormal haemorrhage, including abnormal

haemorrhage following dental treatment provided otherwise than part of general

dental services.

(1) Arrest of haemorrhage, other than under items 23(a)(2) and/or 23(b)

In order to assure this item for payment there must be evidence to support the

fact that the patient had to re-attend the surgery to receive further treatment

for the arrest of haemorrhage.

25 – SEDATION

ITEM CODE 2571

25(c) - Administration of a single intravenous sedative agent or inhalation sedation

by and under the direct and constant supervision of the dentist carrying out the

treatment where, in the opinion of the dentist, any necessary treatment could not

otherwise be provided because of a physical or mental handicap, or a form of mental

illness requiring medical attention, or disproportionate dental anxiety.

In order to assure this item for payment there must be evidence in the record

to support the administration of Relative Analgesia.

32 – ORTHODONTIC TREATMENT

Including any necessary oral hygiene instruction and general patient management.

ITEM CODE 3231

32(b)(1) – Supervision of retention for a period of not less than 5 complete calendar

months

ITEM CODE 3232

Additional fee for each further period of supervision of not less than 2 complete

calendar months, normally subject to a maximum of 2 such periods

In order to assure these items for payment there must be evidence in the

record to confirm that the practitioner has seen the patient at least once during

each supervision period claimed.

ITEM CODE 3244

32(C)(4)- Repairing a fixed appliance involving the replacing of 2 or more brackets,

bands, arch wires or auxiliaries or any combination thereof in 1 arch.

In order to assure this item for payment there must be evidence in the record

to indicate that 2 or more metal items have been replaced (i.e. replaced with

new metal items) within the same arch at the same visit.

Please note the following in respect of Item 3244:

The items requiring replacement should be clearly identified at the beginning of the notes for the treatment on the day.

Placement of a progressive arch wire does not constitute a metal item for repair; this is included in the overall fee per appliance-“(including routine fixed appliance maintenance as necessary”)- see item 32(a).

Only one metal item replaced and arch wire fitted as per planned routine fixed appliance maintenance does not comply with a claim for item 3244

No details of arch wire change and only one bracket replaced- claim cannot be verified

Repositioning of brackets does not constitute a repair

The 2 metal items must be replaced in the same arch i.e. one bracket from one arch and one from the second does not constitute a repair; certainly not 2 repairs.

The 2 (necessary) metal items should be replaced at the same visit i.e. no half repairs from different dates

Re-cementing of a molar band/s or re-cementing of TPAs or other anchorage reinforcement devices does not constitute a replacement of a metal item.

37 – TREATMENT URGENTLY REQUIRED FOR ACUTE CONDITIONS

For conditions of the gingivae/oral mucosa (including pericoronitis, ulcers and

herpetic lesions), including any necessary oral hygiene instruction and/or the issue of

a prescription

ITEM CODE 3701

In order to assure this item for payment there must be evidence in the record

to indicate that an acute gingival or mucosal condition was present and

required treatment. Note fees are not payable under this item code for:

Acute conditions of dental or alveolar origin e.g. dental abscess,

irreversible pulpitis

Chronic conditions e.g. draining sinus, chronic periodontal disease

APPENDIX 6

9 RECORD KEEPING MDS

Paragraph 25, General Dental Services Regulations (Terms of Service)

Schedule 2- Records/Record Keeping

25 (1) “A dentist shall keep a full accurate and contemporaneous record...”1 2 3,

25 (2) Retention of records

25 (3) Producing records on request to HSCB (including RDS)

25 (4) Computerised records

Subsequent to an analysis of GDS records forwarded and reviewed by the HSCB Dental Advisers/RDOs in the past months, the following common issues/concerns were noted: Record keeping issues: Radiographic issues-

o Justification of radiographic exposures must be recorded 4 5 6 7 o Radiographic reports must be provided and available in the notes2 o Practitioners should review the NRPB guidance and ensure a quality

assurance programme to maintain standards is established5. o http://www.hscbusiness.hscni.net/pdf/Quality_Assessment_of_Radiograph

s.pdf 13% of practitioners in one recent period were advised to consider radiographic

image quality, radiographic processing or radiographic report audits.3 6 7 8 RCT radiographs:

o Good quality radiographs should be available to confirm or establish the standard of care provided (please see also the proviso to item 15 of the SDR) 2 6

Periodontal treatment : o Pocket depths should be recorded and available for periodontal disease

cases1 2 3 9 o All treatment procedures/ progressive clinical notes should be recorded and

available; where appropriate, a planned review date identified 1 2 3 9

1 Standards for the Dental team, General Dental Council

2 Clinical examination & Record-Keeping- FGDP(UK) Good Practice Guidelines, 2

3rd Edition

2016 3 Standards in Dentistry, FGDP(UK) 1

st Edition 2006

4 Northern Ireland Minimum Standards for Dental Care and Treatment 2011 (Standards 8 and 10)

5 The National Radiological Protection Board (NRPB) Guidelines:

“Guidance notes for dental practitioners on the safe use of x-ray equipment”; 2001 6Selection Criteria for Dental Radiography, FGDP(UK) Good Practice Guidelines, 3

rd Edition 2013

7 IR(ME)R 2000

8 Letter from Michael Donaldson, HSCB, to all dental practitioners

http://www.hscbusiness.hscni.net/pdf/Compliance_with_IR(MER)_19_Sept_2011.pdf 9 Probity Services papers 201 and 2016 update- Clarification of codes in SDR for probity purposes

http://www.hscbusiness.hscni.net/pdf/CLARIFICATION_OF_CODES_IN_SDR_FOR_PROBITY_PURPOSES.pdf http://www.hscbusiness.hscni.net/services/2669.htm

Details of claim not matching notes:

o Please review Appendix 5 of the Monitoring Protocols for the Referral Dental Service for advice on clarification of the requirements to assure submitted claims.

o Also available at: http://www.hscbusiness.hscni.net/pdf/CLARIFICATION_OF_CODES_IN_SDR_FOR_PROBITY_PURPOSES.pdf

In relation to Local Anaesthetic details:

o Full documentation should be entered in patient notes and include identification of the local anaesthetic used, dose administered, concentration, presence or absence of any other agent 1 2 3

o Batch number and expiry date may be recorded in the patient notes or should be available from stock control systems or quality control measures

In relation to Prescribing notes Please see the April 2016 letter from the CDO endorsing the SDCEP “Drug prescribing for Dentistry” - 3rd edition at: https://www.health-ni.gov.uk/publications/endorsement-sdcep-drug-prescribing-dentistry-dental-clinical-guidance-3rd-edition Please see GDC Guidance on prescribing medicines (September 2013) “You must make an appropriate assessment of your patient’s condition, prescribe within your competence and keep accurate records”

Advice is also available in: o The Prescribing page and the GDS monthly newsletters on the BSO

website: http://www.hscbusiness.hscni.net/services/2670.htm http://www.hscbusiness.hscni.net/services/2784.htm

o Antimicrobial Prescribing for General Dental Practitioners, FGDP(UK) 2nd edition available at : https://www.fgdp.org.uk/guidance-standards/antimicrobial-prescribing-gdps

In relation to Sedation notes (for Relative Analgesia or IV Sedation): o An update of the medical history should be available o justification and consent recorded o and procedural notes recorded1 2 3 10

If you need to make any amendments to a patient’s records you must make sure

that the changes are clearly marked up and dated. Use of correction fluids in patient notes is not recommended .1 2 11

In relation to the Retention of patient records, the following applies:

Minimum of 6 years as per GDS NI 1993 regs

10

Standards for Conscious Sedation in the provision of dental care - Intercollegiate Advisory Committee for

Conscious Sedation in Dentistry 2015 11

Orthodontic Records: collection and management, Clinical Governance Directorate of the British Orthodontic

Society 2015

Retention of laboratory dockets and availability of the statement of manufacture or SOM (as per GDC advice 2010) is recommended for all removable or fixed prostheses fitted.

Also in relation to Adherence to GDS Regs:

Time for records or replies to HSCB requests for clarification or replies to referral dental service reports to be received by the HSCB should not exceed 14 days

Incomplete patient records or incorrect records were forwarded in a number of cases

All treatment procedures must be recorded in the patient record

Electronic or Computerised records: Increasingly the patient records received by the officers of the HSCB and the BSO are in an electronic or computerised format. Practitioners are reminded that the same obligations exist for the management of electronic or computerised records under paragraph 25, subparagraphs (1) (2) and (3) i.e. that the same level of detail is required as in handwritten records. Recently the dental advisers, in both the HSCB and the BSO, have reported that in some cases, very limited clinical records have been forwarded when requested; and that correspondence to elicit further information or clinical submissions has been necessitated on an increasing number of occasions. Contact us:

The Dental Advisers in your area will be happy to respond to any queries in relation

to records reviews or subsequent requests for further information. Contact numbers

for the local offices are available on the HS48 form on the BSO website:

http://www.hscbusiness.hscni.net/pdf/HS48_Application_Form_June2017

Further information can be found about learning points from record reviews in the

HSCB Governance presentation available on the BSO Website:

http://www.hscbusiness.hscni.net/pdf/New%20Starts%20Presentation%20(May%20

2018).ppt

APPENDIX 7 10 PATIENT FAQs LEAFLETS (WITH LINK TO RDS SECTION OF THE BSO WEBSITE)

Examination by a Referral Dental Officer

Answering your Questions

QUESTION ANSWER

Why is this happening? The HSCB has a duty to you, both as a Health Service patient and as a tax payer to ensure that the dental treatment in the General Dental Service is satisfactory and that the amount of fees claimed for this treatment is appropriate. Your attendance can help to improve the service.

Why have I been chosen? Why has my child been chosen?

Every year the HSCB, through the BSO, chooses a random sample of people who have recently had dental treatment. It is important that you know that this invitation for you to attend does not imply any criticism of your dentist or the treatment you have received. When you signed the form at your dentist’s surgery, you agreed to be seen by a Dental Officer. Referral Dental Officers are experienced dentists who give unbiased, independent clinical opinions to a number of organisations. Further information can be obtained from the BSO website: http://www.hscbusiness.hscni.net/services/2649.htm

Will my dentist be told about my examination?

Your dentist has been told about you being invited for examination and is being kept fully informed. These examinations are a routine part of being a Health Service dentist, and help to ensure that dentists are providing the best care to their patients.

What happens at the examination?

The examination should only take about 15 minutes. No treatment will be done. Your dentist is free to attend, but normally his or her commitments to patients make this unlikely.

What happens if I’m not able to come on the date you invite me?

If you cannot attend, please telephone us as soon as possible on 02895 361010

Do I need to bring anything to the appointments?

Please bring any dentures, bite guards or orthodontic appliances, including any that you are not using at present.

Do I need to tell my employer? If you need time off work to attend, please ask your employer. The attached letter, i.e. your invitation, and this information should help him or her to understand why we would be grateful for your attendance.

What happens now?

If you can come, we look forward to see you at the time and place detailed in the invitation letter sent you.

I have more questions. Who can I ask?

If you have any further questions, we will be happy to answer them. Either telephone us on 028 95361010 or write to Referral Dental Service, HSCB, Gransha Park House, 15 Gransha Park, Clooney Road, Londonderry BT47 6FN