NIHR Signal Redesigning oral surgery with enhanced primary dental care, electronic referral and triage may save overall costs

Published on 15 May 2018

An electronic referral system including consultant-led triage and an advanced oral surgery service in primary care results in fewer people requiring oral surgery in hospital. It comes at a lower overall cost than the previous arrangement. About two-thirds of patients could be treated safely in enhanced primary settings rather than hospital.

This NIHR-funded study implemented several changes, an electronic referral system which standardised and improved the level of information provided in referrals. Commissioners also provided funding for an advanced service provided in primary care. Once set up, consultants were able to decide if patients should be treated out of hospital or if more complex cases should come to hospital. Triage performed by primary care dentists was less efficient than that by consultants.

The advanced primary care level two service was able to treat people quickly in local settings, freeing up some secondary-care resources for the most complex cases.

This study supports implementing new service models, but the potential to save costs seems to depend on who conducts the triage and the local commissioning and tariff arrangements.

Share your views on the research.

Why was this study needed?

In recent years, primary-care dentists have referred increasing numbers of patients to secondary care services for oral surgery. Some of this increase is because people keep their teeth longer, and older people often have other medical conditions that make their care more complex.

Another factor that may have contributed to the increase is that dentists are paid the same for referring a patient as for doing the treatment themselves. In 2016–17, there were nearly one million hospital attendances for oral surgery in England. There is little data about whether these referrals were appropriate.

This study aimed to assess whether a service redesign in one Primary Care Trust could make better use of resources through:

  • introducing an electronic referral management system
  • consultant-led triage or primary care dentist triage
  • a new advanced primary-care oral surgery service

What did this study do?

This was a mixed methods study. The first phase looked at the accuracy of triage by oral surgery consultants in deciding on the appropriate setting for treatment based on referral information only, the reference standard here was the face to face decisions made by consultants. The settings could be primary care, advanced primary care or secondary care.

The new electronic referral management system was set up across all 27 dental practices. After a year, they introduced consultant-led triage of the referrals. At the same time, a new advanced primary care oral surgery service was commissioned from a single qualified provider. A year later they switched to triage by primary-care dentists. Patients’ views on advanced primary care services providing oral surgery were recorded.

This study was conducted in one region in England, and the same savings might not be found in other areas.

What did it find?

  • The initial consultant’s triage based on referral information agreed with their assessment after meeting the patient in 76% of cases. Only 11-20% of referrals actually needed secondary care, suggesting the new electronic system and remote triage was cautious in this first phase.
  • In the year after introducing the electronic referral management system, referrals dropped by 11%, and a further drop in referrals was seen in 2015 when consultant-led triage was instated. When primary-care dentists began making referral decisions in 2016, referrals increased slightly.
  • Consultant-led triage resulted in cost savings of £108 per referral, whereas the cost savings for primary-care dentist triage were £84 per referral.
  • About two-thirds of patients (67.2%) could be treated safely in advanced primary care services.
  • The advanced primary care service was acceptable to patients, who only expected to be treated in hospital if they had been referred there previously. Patients preferred the shorter waiting times and the convenience of local treatment.

What does current guidance say on this issue?

Medical Education England 2010 recommendations include ensuring that specialist oral surgery services are consultant-led. Ideally, this is by consultant oral surgeons. The services should be provided in both primary and secondary care settings, with the services in secondary care being consultant-delivered. Cases that could be managed in primary care should not be referred to secondary care.

They also recommend that managed clinical networks and referral management systems be established. This should ensure that patients requiring treatment by oral surgery, and oral and maxillofacial surgeons, are assessed and referred to the most appropriate primary or secondary care provider.

What are the implications?

Many regions have already established collaborative networks or may have a different mix of services available locally. This study supports current recommendations on setting up networks for consultant-led oral surgery referrals.

It seems that savings may be maximised by having consultants make decisions about the level of care needed by patients referred for oral surgery. However, hospitals vary in how they claim for the work done and this could influence the savings that are realised in practice.

Advanced primary care based services are popular with patients as they avoid the need for travel. These can probably be justified by the costs saved and that they free-up secondary care services for the most complex cases.

Citation and Funding

Goldthorpe J, Walsh T, Tickle M, et al. An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study. Health Serv Deliv Res. 2018;6(8).

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme (project number HSDR06080).

Bibliography

NHS Digital. Hospital outpatient activity, 2016-17. Leeds: NHS Digital; 2017.

Dental Programme Board and MEE. Review of oral surgery services and training. London: Dental Programme Board and Medical Education England; 2010.

Why was this study needed?

In recent years, primary-care dentists have referred increasing numbers of patients to secondary care services for oral surgery. Some of this increase is because people keep their teeth longer, and older people often have other medical conditions that make their care more complex.

Another factor that may have contributed to the increase is that dentists are paid the same for referring a patient as for doing the treatment themselves. In 2016–17, there were nearly one million hospital attendances for oral surgery in England. There is little data about whether these referrals were appropriate.

This study aimed to assess whether a service redesign in one Primary Care Trust could make better use of resources through:

  • introducing an electronic referral management system
  • consultant-led triage or primary care dentist triage
  • a new advanced primary-care oral surgery service

What did this study do?

This was a mixed methods study. The first phase looked at the accuracy of triage by oral surgery consultants in deciding on the appropriate setting for treatment based on referral information only, the reference standard here was the face to face decisions made by consultants. The settings could be primary care, advanced primary care or secondary care.

The new electronic referral management system was set up across all 27 dental practices. After a year, they introduced consultant-led triage of the referrals. At the same time, a new advanced primary care oral surgery service was commissioned from a single qualified provider. A year later they switched to triage by primary-care dentists. Patients’ views on advanced primary care services providing oral surgery were recorded.

This study was conducted in one region in England, and the same savings might not be found in other areas.

What did it find?

  • The initial consultant’s triage based on referral information agreed with their assessment after meeting the patient in 76% of cases. Only 11-20% of referrals actually needed secondary care, suggesting the new electronic system and remote triage was cautious in this first phase.
  • In the year after introducing the electronic referral management system, referrals dropped by 11%, and a further drop in referrals was seen in 2015 when consultant-led triage was instated. When primary-care dentists began making referral decisions in 2016, referrals increased slightly.
  • Consultant-led triage resulted in cost savings of £108 per referral, whereas the cost savings for primary-care dentist triage were £84 per referral.
  • About two-thirds of patients (67.2%) could be treated safely in advanced primary care services.
  • The advanced primary care service was acceptable to patients, who only expected to be treated in hospital if they had been referred there previously. Patients preferred the shorter waiting times and the convenience of local treatment.

What does current guidance say on this issue?

Medical Education England 2010 recommendations include ensuring that specialist oral surgery services are consultant-led. Ideally, this is by consultant oral surgeons. The services should be provided in both primary and secondary care settings, with the services in secondary care being consultant-delivered. Cases that could be managed in primary care should not be referred to secondary care.

They also recommend that managed clinical networks and referral management systems be established. This should ensure that patients requiring treatment by oral surgery, and oral and maxillofacial surgeons, are assessed and referred to the most appropriate primary or secondary care provider.

What are the implications?

Many regions have already established collaborative networks or may have a different mix of services available locally. This study supports current recommendations on setting up networks for consultant-led oral surgery referrals.

It seems that savings may be maximised by having consultants make decisions about the level of care needed by patients referred for oral surgery. However, hospitals vary in how they claim for the work done and this could influence the savings that are realised in practice.

Advanced primary care based services are popular with patients as they avoid the need for travel. These can probably be justified by the costs saved and that they free-up secondary care services for the most complex cases.

Citation and Funding

Goldthorpe J, Walsh T, Tickle M, et al. An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study. Health Serv Deliv Res. 2018;6(8).

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme (project number HSDR06080).

Bibliography

NHS Digital. Hospital outpatient activity, 2016-17. Leeds: NHS Digital; 2017.

Dental Programme Board and MEE. Review of oral surgery services and training. London: Dental Programme Board and Medical Education England; 2010.

An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study

Published on 23 February 2018

Goldthorpe J, Walsh T, Tickle M, Birch S, Hill H, Sanders C, Coulthard P & Pretty I A.

Health Services and Delivery Research Volume 6 Issue 8 , 2018

Background Oral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction. Research questions Can an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services? Design A mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation. Setting The ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital. Participants Patients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation. Interventions A consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service. Main outcome measures Diagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described. Results In the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern. Conclusions Implementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively. Study limitations The geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals. Future work The findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Expert commentary

Well-organised referral from primary to secondary care and subsequent management is important in ensuring that patients receive the right care, in the right place at the right time.

The electronic referral system implemented and evaluated in this study has demonstrated the potential to improve patient care pathways and to make more efficient use of limited resources.

Such a system has the potential to ensure that all necessary patient and diagnostic information is included with the referral. This will facilitate communication when patients are transferred between clinicians and settings providing different levels of care.

Professor Ivor G. Chestnutt, Clinical Director, University Dental Hospital, Cardiff