5.9(a) Oral Surgery Service IB Report


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5.9(a) Oral Surgery Service IB Report

  1. 1. Highland NHS Board 6 April 2009 Item 5.9ORAL AND MAXILLOFACIAL SURGERY IN NHS HIGHLANDReport by Ian Bashford, Medical Director and Stuart Denholm, Clinical Director,Raigmore Hospital The Board is asked to: • Note the report by Mr Stuart Denholm. • Consider the various options for the provision of Oral and Maxillofacial Surgery in NHS Highland and to agree the recommendation of Option 1.1 PURPOSETo inform the Board of the North of Scotland Planning Group Oral and Dental Health SubGroup Report on the provision of Oral and Maxillofacial Surgery services in the North ofScotland as it pertains to NHS Highland, and consider a Board response to the implicationsfor NHS Highland.2 BACKGROUNDOral and maxillofacial surgery is a medical specialty that involved the diagnosis andtreatment of diseases affecting the mouth, jaws, face and neck. This specialty is regulatedunder the Medical Directives and training requires graduation in both dentistry and medicine.Oral and maxillofacial surgeons (OMFS) diagnose and manage trauma, deformity (includingorthognathic, cleft lip and palate and reconstruction), pathologies of the region (includinghead and neck cancer, temparo mandibular joint morbidity), pre prosthetic surgery,(implantology) and dento-alveolar surgery. Over 70% of all referrals are for dento-alveolarwork and approximately 10% are for trauma. This service interacts with other specialtiessuch as ENT, oncology, plastic surgery, orthopaedics, all other dental services and primarycare. Oral Surgeons are singly qualified Dentists with a postgraduate training in oral surgeryand are trained mainly to address dento-alveolar work. The delivery of oral and maxillofacialservices within the North of Scotland have been exceptionally difficult since the mid 1990sand NHS Grampian have often been reduced to a single consultant service. In April 2007,the singly qualified OMFS in NHS Highland retired and, therefore, the outreach service toNHS Western Isles ceased.In 2006, the North of Scotland Planning Group approved the establishment of an Oral Healthand Dental Sub Group under the chairmanship of Mr Richard Carey, Chief Executive ofNHS Grampian. One of the priority areas was to develop a sustainable model of Oral andMaxillofacial Surgery for the North of Scotland, especially pertinent to meeting the needs ofNHS Highland and Western Isles. In 2007, the North of Scotland Public Health Networkcommissioned an Oral and Dental Health Needs Assessment which was undertaken by theDental Health Service Research Institute in Dundee University. Simultaneously the Oral andDental Health Sub Group undertook a consultation programme with the North of ScotlandHealth Boards. The report had been discussed at the North of Scotland Planning Group on12 November 2008 and recommended: A model that will sustain oral and maxillofacial services across the North but especially meeting the needs of NHS Highland and Western Isles. 2
  2. 2.  The appointment of 2 OMFS Surgeons based in Inverness operating in a network with colleagues in NHS Grampian. The Surgeons would deliver services for NHS Highland, Western Isles and West Grampian in Elgin. The additional investment of between £360k - £400k, depending on the model of care, was to be allocated across some of the North of Scotland Boards. Orkney and Shetland already commission a service from NHS Grampian. The additional OMFS Consultant would be funded by 4 sessions from NHS Grampian, 4 sessions NHS Highland and 2 sessions NHS Western Isles, but the financial details were to be agreed at a later date.The report examined a large number of options including 2 OMFS Surgeons, 2 OralSurgeons, 1 Oral Surgeon and 1 OMFS Surgeon, 1 OMFS Surgeon, 1 Oral Surgeon and noservices provided in NHS Highland at all. The only model that appeared to be sustainable,appointable and clinical and professionally supported was the preferred option of 2 OMFSSurgeons based in Inverness.3 THE NHS HIGHLAND REPORTDr Roger Gibbins, Chief Executive, requested that Mr Stuart Denholm, Clinical Director ofRaigmore Hospital provide a report to identify the implications of the North of ScotlandPlanning Group report on NHS Highland.The present funded service is based on a single OMFS Consultant Surgeon supported by anumber of junior staff and tertiary referral. It has been impossible to appoint a locumConsultant to this post in either Oral Maxillofacial Surgery or Oral Surgery, and at present theAssociate Specialist in NHS Highland is undertaking the locum Consultant post, withreluctant cover from NHS Grampian. NHS Grampian has indicated that this model is notsustainable over time. The present model is unsatisfactory in terms of staff and clinicalgovernance, is not meeting present demand and the required utilisation of waiting listinitiatives is onerous on the current incumbent. The model will not meet projected futuredemand. The service is also limited to oral surgery and does not provide oral andmaxillofacial surgery and that is referred to the Grampian tertiary service. There is nosupport for other specialties in NHS Highland such as orthodontics, orthopaedics, ENTsurgery or primary and secondary care dental services.The implications for NHS Highland were examined and referred to the following models ofcare.Option 1: Two Oral and Maxillofacial Surgeons based in Inverness within a North of Scotland OMFS network providing care to Western Isles and Moray.Option 2: One Consultant Oral Surgeon and 1 Consultant OMFS based in Inverness, but not within in a North of Scotland network.Option 3: One single handed Consultant Oral Surgeon in Inverness with no on-call commitment and a 9-5 service.Option 3A: One single handed Consultant Oral Surgeon based in Inverness with a limited on-call service.Option 4A: Two Consultant Oral Surgeons based in Inverness with no on-call commitment and therefore a 9-5 service.Option 4B: Two Oral Surgeons based in Inverness with a limited on-call service.Option 5: No Oral Surgery or OMF services provided directly by NHS Highland but contracted from an external provider. 3
  3. 3. A costing methodology was applied to the various Options and the cost profile is as follows:Option Option Description Total CostOption 1A 2 x OMFS Consultants (10+2) £825,362Option 1B 2 x OMFS Consultants (10+0) £676,380Option 2 1 x OMFS and 1 x Oral Consultants (10+0) £871,531Option 3A 1 x Oral Consultant without OOH cover (10+0) £621,455Option 3B 1 x Oral consultant with OOH cover (10+0) £571,138Option 4 2 x Oral Consultant (10+0) £885,130Option 5 No local Oral/OMFS service £1,024,847The cost of providing the OMFS service in 2008/09 included a budget of £637,065; a cost of£175,607 for locum cover and Waiting List monies to meet demand and targets; and£128,981 was charged for tertiary referrals to Grampian and Greater Glasgow and Clyde.The total cost to provide this service in NHS Highland in 2008/09 was £941,653.The Recommendation of this report is adopt Option 1 with the appointment of 2 OMFSConsultant Surgeons based in Inverness working within a North of Scotland Network. TheConsultant Job Plan of 10+2 will cover the need and demand of NHS Highland, Grampianand Western Isles, but it is recommended that the consultant post be advertised as a 10 PAcontract, with the ability to increase as a result of demand and need in the future.4 CONTRIBUTION TO BOARD OBJECTIVESThis proposed model of service will meet the key objectives to provide a safe andsustainable, quality service in oral and maxillofacial surgery and to meet the present andfuture needs of NHS Highland. This solution will meet the needs of patients as locally aspossible and address Targets and objectives contained with the Local Delivery Plan.5 GOVERNANCE IMPLICATIONS 5.1 Staff Governance The new model of care will provide a sustainable and appropriate service, be compliant with European Working Time Regulation, produce a supportive environment for staff to develop skills and competencies and will aid the recruitment and retention of staff. 5.2 Patient and Public Involvement This model will plan and deliver services which are appropriate to the needs and the diversity of the local population and ensure that the right staff are available in the right place with the correct skills and competencies. 5.3 Clinical Governance This will deliver a safe, sustainable, high quality integrated service not only for NHS Highland but throughout the North of Scotland maintaining the appropriate standards of care required. The quality of care to patients will increase, there will be a reduction in clinical risk and patient safety should be ensured and maintained. 5.4 Financial Impact This will have a significant financial impact on NHS Highland. Depending on the details of the Consultant Contract agreed, the implications will be between £150,000 and £200,000. Income from NHS Grampian and NHS Western Isles, if confirmed, will offset this to a degree. 4
  4. 4. 6 IMPACT ASSESSMENT – EQUALITY & DIVERSITYThis report has not undergone an Equality and Diversity Impact Assessment. However, it willimprove accessibility to residents of all parts of NHS Highland whilst maintaining andpotentially improving the range of facilities for the whole community.Ian Bashford Stuart DenholmBoard Medical Director Clinical Director, Raigmore Hospital23 March 2009 2