Sunday, 17 September 2017

How are the Community Dental Services changing?

I have mentioned in my previous post about special care dentistry that recently there have been some changes in how the Community Dental Services (CDS) are functioning; certainly in London. Here I shall outline how the services I have worked in have changed...



Why?

Last year, the tenders for the community dental services in London ran out and so different trusts and other organisations such as social enterprises were able to bid for each service area. The trust who held the contract for one of the services I work in lost the bid for the provision of the CDS in East London. What this means is that the NHS commissioners decided that another trust will be given the contract to provide the service; in this case at a lower contract value. 

The reason is the push for more and more services to be provided in general practice which is more cost effective for the NHS for example the provision of out of hours emergency dental services which used to be part of some CDS. Together with this is encouraging GDPs to treat certain groups of patients in practice rather than refer to CDS as our management of these patients wouldn't be any different to how they would be managed in practice. 

New Referral Criteria

So naturally with a cut in funding means CDS will be seeing fewer patients; therefore referral criteria have changed and become much stricter. If you see the post I linked earlier on in the post, you can see the types of patients we used to see. We only accept referrals that are deemed Level 2 or above by NHS England for both special care and paediatric dentistry. What this means is:
  • We now only accept paediatric referrals where there has been a failed attempt at treatment with their GDP or children with complex medical or social problems or learning disabilities. We expect GDPs to acclimatise children in practice
  • We no longer accept referrals for patients with blood born viruses e.g. HIV unless they fit into one of the other criteria
  • We only accept those with complex medical problems if this directly impacts a patient's treatment in a way a GDP could not manage e.g. if a patient is on warfarin, a GDP can liaise the patient's warfarin clinic if required
  • We do not keep many patients for recalls within the service; instead we complete courses of treatments then discharge to their GDP i.e. promotion of shared care
  • A GDP cannot refer a child directly to a hospital, the CDS triages the patient and acts as a gateway for general anaesthesia - similarly for special care adults this applies
  • There is one universal referral form in London for paediatric dental services; similarly in special care adults
  • We are seeing fewer phobics and encouraging GDPs to refer for one off treatments e.g. extractions to practices with sedation contracts
  • Our domiciliary service is now only for patients who are truly housebound. Patients who can make it to clinics in taxis or transport are now being booked into clinics rather than receiving home visits 


Closure of clinics and services

Naturally, with a changeover in overseeing trusts some of our sites had to be closed as the new trust does not own the buildings. This has been difficult for patients as they now need to travel much further to access our clinics and unfortunately has meant our previous close links with undergraduate training in East London are much weaker so sharing care is much more difficult. 

Not only have services been affected in East London but London wide. I used to also work on bank at the urgent dental service based in community in North London. Since the re-tender i.e. April, the funding was removed for this walk in urgent care service. Ultimately, this results in putting pressure on the remaining services e.g. out of hours GDP services and acute dental departments in teaching hospitals. 

There are exciting times ahead however; with our service winning the homeless dental provision which is planned to be based on our mobile dental units. 

These changes although already in motion, undoubtedly will take time to filter down to referrers and others in the profession. I am still repeatedly sending back inappropriate referrals or discharging patients and it can be frustrating as some of these patients are still waiting months on our waiting lists unnecessarily. 

Click to access information from commissioners about Levels of care in Special Care Dentistry and Paediatrics to ensure your next referral to the CDS is appropriate!



I'd love to hear how these changes have affected both GDPs or other CDS services throughout the country. Let me know in the comments below. 


Wednesday, 6 September 2017

5 Books Every Dentist Should Read

I've been meaning to write this post for a while as it has been some time since I've written a self-improvement post. Here are some of my favourite non-fiction books I think every dentist should read...



1. Your Inner Fish - Neil Shubin


I was recommended this book in my first year of dental school by our anatomy profession when learning about embryology and the pharyngeal arches. He was explaining to us how these correspond to gills and can be traced through evolution and thus recommended Your Inner Fish.

The book is written by a paleontologist and professor of anatomy who traces where our organs originated millions of years ago and the chapter which particularly interested me as a dental student was how our heads were organised like that of a long-extinct jawless fish.

I would recommend this book, not only to revise your embryology, but to learn more about the history of evolution and how it links to us as humans - it's also written very well and doesn't have a textbook vibe unlike many books written by scientists.





2. It's All In Your Head - Suzanne O'Sullivan


I randomly picked this book up on one of my frequent browses in Waterstones. At the time, I had recently experienced some troublesome patients at the walk-in acute dental departments that I was working in who I suspected to have undiagnosed mental health issues. So the title really jumped out at me. 

Since then, I have been to talks within Special Care Dentistry where this book has been recommended. It is written by a neurologist who tells of cases where she has seen and attempted treatment for patients with psychosomatic illnesses i.e. illnesses with no organic cause. When reading some of the cases it did remind of some patients I have seen while working in a special care environment. For example, I have treated a patient with dissociative or non-epileptic seizures or patients with severe Chronic Fatigue Syndrome. 

Again, an easy read which you'll finish quickly. In fact my copy has done the rounds with several of my friends and colleagues it's been that popular! It did change my judgements about conditions like chronic fatigue and fibromyalgia and I feel like I take psychological treatments for conditions like these much more seriously - in fact I have referred patients with facial pain onto clinics where psychotherapy can be an adjunctive treatment as a result of reading this book. 

3. Cure - Jo Marchant


A book I downloaded from Audible this book really caught my eye as a medic, I have been trained in the use of medicine in healing rather than any other means and I have a few patients who have experienced other means of healing e.g. alternative medicine. 

The author discusses how the mind can heal the body from alternative medicine, to meditation to the use of placebos. 

On the surface perhaps many medics brush off the importance of the power of the brain over our body; but how many times have you seen a severely anxious patient yell in pain when you are extracting a tooth when you know the tooth is numb? I recently had a lady who yelled when I wasn't even touching the tooth! You could say she wasn't feeling pain but she was just scared; however, if she could control her anxiety better perhaps with your assistance, she would not have reacted in such a way i.e. used the power of her mind to overcome her anxiety.




4. Bad Pharma - Ben Goldacre


From the writer of the book Bad Science (which is on my to read list), Bad Pharma is a must read for all doctors. I picked this book up in a charity shop and it is quite a thick read but in the age of Evidence Based Medicine and Dentistry, it's really surprising what the author reveals. 

Written by a doctor, he tells of examples of how the Pharmaceutical business sometimes mislead the public as well as the medical industry and how it has lead to harm to patients for example the use of Tamiflu in the Bird Flu outbreak. 

5. When Breath Becomes Air - Paul Kalanithi


I only finished this book in the past month and many other people recommended this to me. Although I bought the book, I ended up listening to the audiobook on the way to work, which proved rather awkward during the last chapter as I was walking down the road with tears in my eyes!

It is a true story written by a neurosurgeon and his journey through his cancer diagnosis. It is excellently written and really tugs at your heart strings. As dentists, if we suffered with conditions that we diagnose frequently, the implications may not be so serious, but the author addresses how we can become insensitive to diagnoses we see all the time; despite the impact they may have on peoples' lives, as well as what we really find important in our lives like family, friends or a career. 

I would just read the last 2 chapters in private, if like me, you can get a little teary!





Have you read any of these books? What did you think of them? Are there any other books you would also recommend? Let me know in the comments below. 



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