All descriptions of prevention in the current RHCG DGA pathway of care were gained from internal stakeholders. External stakeholders were unable to comment as their roles, and thus knowledge, were out-with the immediate pathway of care. This section is separated into current prevention in the pathway of care at each stage, and is there an overall need for action in the pathway of care in relation to prevention.
6.1.1 Current prevention in the pathway of care
The RHCG DGA pathway of care comprises five stages of delivery as outlined in the ‘GAP Arrow’ (Figure 15, page 54); referral, vetting, paediatric assessment clinic, day of DGA treatment, and follow-up. Current provision of prevention is outlined for each.
6.1.1.1 Stage 1: Referral for DGA
Prevention at the point of referral for DGA was variable, and the perception from the PDS Dentists was that prevention was ‘being done, but not by the
GDPs’. Another PDS Dentist stated that ‘[prevention] is not being done as much as it should be in general practice’.
The GDPs did not explicitly state that they were undertaking enhanced
prevention at the point of referral for DGA. Internal stakeholders postulated that preventive messages were most likely not being given at the point of referral by GDPs, and indeed the PDS Dentists described first hand experiences of patients at Paediatric Assessment clinic reporting no previous preventive input from GDPs.
The PDS Dentists often did provide prevention at the point of referral. Those referring from a solitary ‘satellite’ paediatric assessment site in the PDS detailed the type of prevention provided at referral by the PDS:
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‘I would just give them as much information as I could: diet, oral hygiene and I would do Duraphat sometimes, for certain patients …if they’re just going straight to a general anaesthetic’. (PDS Dentist)
6.1.1.2 Stage 2: Electronic vetting of referral letters
Stage 2 was an electronic vetting process conducted by Consultants in Paediatric Dentistry with no direct contact with patients and thus will not be included in this section.
6.1.1.3 Stage 3: Paediatric assessment clinic
On the whole, internal stakeholders described little or no direct clinical
prevention activity at the paediatric assessment clinic appointment at Glasgow Dental Hospital and School. There was no explicit mention by internal
stakeholders of fluoride varnish application, oral hygiene advice, or dietary advice being given as standard practice. One PDS Dentist stated ‘there’s not
time for us to do prevention with them’.
Consultants in Paediatric Dentistry mentioned that a ‘Triplicate pad’ had been constructed (Appendix 8) to aid the prevention information and guidance being sent from GDHS to primary care. One copy of this form was posted to the GDP to highlight the patient as high caries risk and advise the appropriate enhanced prevention regime. Parents signed a second copy to show that they understood the need for prevention and ongoing care at the GDP. Another copy was kept in the patient case notes at GDHS. Some PDS Dentists mentioned that the triplicate pad was no longer being used in the clinic.
The PDS Dentists described one pre-existing ‘satellite paediatric assessment site’ in NHS GGC. The PDS Dentist stationed here can refer directly from this clinic onto the ‘extraction-only’ DGA list and there are necessary orthopantomogram radiography facilities to aid treatment planning that not all PDS sites have. The clinician based at this site thought this ‘satellite site’ approach to the paediatric assessment clinic allowed time to provide preventive information on the day (longer slots for patients) and reduced the overall amount of onward referral for DGA as inhalation sedation at that site is offered if required. This practitioner
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provided diet advice, oral hygiene and placed fluoride varnish at the assessment appointment.
6.1.1.4 Stage 4: Day of treatment
Internal stakeholders thought that there was a lack of standardised prevention information given to patients and families on the day of DGA treatment. The PDS Dentists mentioned that they may individually endeavour to give some ‘ad hoc’ preventive advice on the day but that time constraints usually precluded this. They thought that parents may not be amenable to preventive advice at this stage of the pathway. Fluoride varnish was not mentioned as being applied at the time of DGA.
One PDS staff member gives ad-hoc advice to patients about attending their GDP 6-8 weeks post-DGA for review and prevention, but this stakeholder is unable to ascertain if they have actually attended, leaving the onus on the patient.
It is up to the individual clinician to decide if they wish to review the patient in the PDS post-treatment, otherwise the patients are routinely discharged back to the GDP. One PDS staff member actively allocates a PDS follow-up appointment on the day of the DGA itself but again, ‘failure rate is high’.
6.1.1.5 Stage 5: Follow-up period post-general anaesthetic
The two main groups reviewing patients’ post-DGA were the GDPs and PDS Dentists.
Overall, there was no agreed standardised follow-up prevention protocol for the patients in this pathway of care post-DGA.
Internal stakeholders were unsure if children were actually attending a follow-up appointment post-DGA with the initial referrer to access enhanced prevention. Dental Public Health (Strategic) stakeholders described that this was a ‘grey area’ of the pathway.
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There was a generalised concern that GDPs were not proactive in the follow-up period contributing to a lack of engagement and prevention in the post-
operative period.
'The carious teeth are removed, and a 6-month appointment will be sent out. And if they don’t attend then they don’t attend’. (NHS Pathway Management)
The GDPs, whom the pathway clinicians are relying to undertake prevention, did not feel ‘chasing-up’ patients to provide prevention was a part of their role. They generally thought that they were capable of providing prevention should the patients attend:
'And if we know they’ve been seen, we can follow-up at the end in the fifth stage. To see them back, to counsel them and say to them, ‘we’ve kind of got this thing sorted out’. (GDP)
The GDPs described that sending out a letter to arrange a follow-up was where they ‘drew the line’ and that despite sending out a letter ‘some patients still don't turn up’.
‘They’ll suddenly turn up again with sixes all messed up... I don’t really know what you can do. ‘Cause we could send them letters, texts. But they just don’t turn up'. (GDP)
‘Where does your responsibility stop? Where does it start? Somebody’s got to be blamed for everything.' (GDP)
PDS Dentists thought they were more active in capturing these children within the PDS and that many then received enhanced prevention including fluoride varnish application there (although again the ‘WNB’ rate was generally high).
'We do the entire gambit of following the guidelines of fluoride varnishing and fissure sealing. And we will fissure seal primary molars as well. Fluoride varnish, diet advice and oral hygiene advice as well.' (PDS Dentist)
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The PDS Dentists following these children up post-DGA mentioned that receiving the triplicate pad from the paediatric assessment clinic aided with specific advice on prevention. These stakeholders described the process of chasing up of patients who require prevention and who do not attend within the pathway as running on ‘goodwill’.
The PDS staff did mention that there may be an underreporting of prevention activity undertaken in the PDS as some ‘extra’ prevention activity, such as sealing palatal pits of lateral incisors, goes unregistered on GP17 forms.
6.1.2 Need for action to improve prevention in the pathway of
care
Based on the above mentioned lack of prevention, internal stakeholders were in agreement that there was a ‘need for action’ in the pathway of care to improve prevention and facilitate engagement of patients. Many described incredulity at the lack of linkages to prevention in the pathway and saw a real opportunity for change:
‘Childsmile hasn’t managed to get them ‘cause they are hard to reach children and, in fact, this could be the key turning point for these children.' (Cons Paed Dent)
'If we have a good understanding of the reasons of them getting there, we can perhaps provide better support while they’re within that pathway. It’s a huge opportunity within that period of a child coming in.’ (Cons Dental Public Health (Strategic) GGC)
'This is the highest risk cohort of children, from both a child protection point of view and from a dental health point of view. And we do nothing.' (Cons Paed Dent)
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The PDS Dentists described a desire for change, but collectively portrayed a feeling of isolation, helplessness and not being heard:
'You can highlight problems in that system of care. And then nothing gets changed. You’re only one individual.' (PDS Dentist)
Stakeholders involved in following these patients up after the DGA (GDPs, PDS Dentists) were in agreement that improved links with prevention are required for these children, certainly in the period following the DGA, and within the pathway where appropriate.
6.1.3 Key findings
There is little-to-no prevention incorporated in the RHCG pathway of care, simply ad-hoc preventive advice ‘if and when’ the clinician has time on
paediatric assessment and on the day of DGA. Some PDS Dentists are providing oral hygiene, diet advice and fluoride varnish at the point of referral for DGA. Stakeholders do not think GDPs are providing prevention and engaging these families at the time of referral and follow-up. PDS Dentists describe that there is not sufficient time at paediatric assessment clinic or on the day of DGA to provide any prevention at present. Stakeholders thought there was a need for action to ‘capture’ these children for prevention whilst they were attending the pathway of care.