6.5.1.1 Collaborative working
All external stakeholders, the GMPs and the Consultants in Paediatric Dentistry had a vision to create a ‘holistic patient-centred pathway of care’ free of silos, with effective multiagency working. They described breaking down barriers between professionals to provide a streamlined service with enhanced support for families and ‘feedback loops’. NHS Pathway Management mentioned the role of the specialist in the pathway and that services did not have to always be consultant led.
'It’s not trying to make the child fit round the service ‘cos that is what we tend to do quite often; it is actually trying to think from the other perspective.' (Childsmile)
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Front-line Consultants in Paediatric Dentistry and NHS Pathway Management indicated a necessity to move away from a model of primary/secondary/tertiary care and the mind-set that supporting patients to attend 'is not my job'. The roles and responsibilities described that would need redefined to support engagement (GDP, ‘Named Person’, GMP and DHSW) are outlined below. 6.5.1.1.1 Role of the General Dental Practitioner
Stakeholders described that the role of the GDP should be redefined with wellbeing at the centre. There was an overall feeling that GDPs should be liaising with other agencies as standard practice and must be more accountable for patients they have referred to the DGA pathway, in line with the Children and Young Person’s (Scotland) Act 2014. Several stakeholders thought that GDPs should keep a register of who they have referred in, and should be proactive in tracking what has happened to the patient.
They’ll [GDPs] actually have that responsibility as a health professional in ensuring that they’re following up by letting somebody know at an appropriate time that there is an issue.' (Dental Public Health (Strategic) External Health Board)
'And the whole way you treatment plan needs to be along the lines of am I, as a dentist, able to prevent this disease? And if the answer to that is no, I need other support, then as soon as that little thought process happens, that’s when the multi-agency support should be instigated.' (Cons Paed Dent)
6.5.1.1.2 Role of the ‘Named Person’
For under-5s, the majority of stakeholders foresaw a ‘massive role’ for Health Visitors in this pathway of care in terms of engagement of patients.
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The Health Visiting Strategic stakeholder in particular felt strongly that their teams would want to know about children who ‘were not brought’ in the pathway so this could be added to the child’s 'chronology' and action taken where required. This stakeholder touched on the lack of clarity surrounding the role of the Health Visitor previously, but that the importance of their input is now being fully realised:
'I think Health Visitors have done an enormous job. I think that Health Visitors have a real role to play there [in the pathway] and in relation to dental health.' (Health Visitor (Strategic))
Stakeholders also described the importance of the role of Education being that of the ‘Named Person’, but had less clarity as to how to integrate their role into the pathway of care.
6.5.1.1.3 Role of the General Medical Practitioner
The GMPs thought that any child who was referred for a DGA should be placed on their ‘vulnerable families’ list. They thought they could be more proactive in general with oral health messages and checking if their vulnerable families are registered and participating at the dentist.
6.5.1.1.4 Role of the Dental Health Support Worker
The Dental Public Health (Strategic) GGC stakeholder admitted that Childsmile could be doing more in this pathway as the ‘national prevention programme is
missing these children and we’re not necessarily getting to everybody who needs [Childsmile] most.' A Childsmile strategic stakeholder enquired, ‘Is there any scope for linking [DGA patients] with any support workers?’
The Dental Public Health (Strategic) GGC stakeholder thought there was real potential for DHSWs to assist with patient engagement within the pathway and ensure these patients are receiving preventive care in the aftermath of the DGA.
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'We’re now trying to refine it [Childsmile]. Ensuring all the time that we’re really meeting the needs of those who need it most. And [the dentist] can put them onto a health support worker or whoever, who could follow them up thereafter depending on where they lived...' (Dental Public Health (Strategic) GGC)
When asked about involving DHSWs in the pathway, NHS Pathway Management thought that children in the DGA pathway were ‘past the assistance of a DHSW’, instead considering the role of the DHSW as encouraging registration rather than supporting patients to attend appointments in this pathway of care.
6.5.1.2 The ‘significant event’
Many stakeholders, both internal and external, mentioned that concept of reclassifying a repeat DGA as a ‘significant event’, and considered the importance of having systems in place to investigate why the repeat DGA occurred.
'If we have a child have a second general anaesthetic, we should almost be looking at it as a significant event and actually trying to analyse why.' (NHS Pathway Management)
'It’s got to be the case that we really make the message clear to parents that a general anaesthetic is nothing to take lightly. It’s not just a little whiff of gas and we knock your child out and we take out a couple of teeth.' (Childsmile)
6.5.1.3 The ‘whole family approach’
There was widespread interest in the concept of a ‘whole family approach’, where if one child entered the pathway with poor dental health, that the whole family be supported to engage, in order to change existing health behaviours.
‘Have they got siblings? Because you know if one is like that then chances are the lot will be like that.' (Childsmile)
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It was interesting to note that the only stakeholders who did not mention a vision of a holistic pathway of care, or a ‘whole family approach’ were front-line coal face dentists such as GDPs and PDS clinicians.
6.5.1.4 Early intervention
There was a strong push for an ethos of early intervention for prevention.
Several external stakeholders alluded to the importance of oral health messages in the early years so children do not present in the DGA pathway. Again, the only stakeholders that did not mention this subtheme were GDPs and PDS Dentists:
'I think that there is something about the early prevention, how it makes a big difference around children. The school age child, in terms of their emotional health and wellbeing, in terms of their self-esteem, all of the things that make a massive difference if they happen to have good teeth.' (Health Visiting
(Strategic))
Stakeholders commented on the need to act on low-level pieces of information before the child presents in a ‘crisis’ situation.
'I mean things like the Health Visitors, the school nurses, teachers and Social Workers; there are so many bodies, individuals that work with children….and maybe there are points that they think ‘goodness I should really tell someone about this’. (Childsmile)
6.5.1.5 Tackling health inequalities
All external stakeholders thought that tackling health inequalities would be required at a wider level.
6.5.1.6 A journey of care: The Prevention Pathway
NHS Pathway Management had a vision for a ‘journey of care’ for these children, not simply an ‘episode of care’, and internal hospital-based stakeholders
described their vision of a prevention ‘pathway’ running alongside and integrated with the DGA pathway.
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‘It all should be reinforced, starting at the general practitioner, then the assessment, and carried on at the general anaesthetic.' (PDS Dentist)
6.5.1.6.1 Tailoring prevention
Dental Public Health (Strategic) stakeholders, Scottish Government (GIRFEC) stakeholders, Consultants in Paediatric Dentistry and NHS Pathway Management emphasised the need to ensure tailoring of prevention occurs within this journey of care. In particular, Scottish Government (GIRFEC) stakeholders thought there was a need to understand how these patients got to the point of DGA, and how best to support them through the pathway and beyond. Childsmile stakeholders thought that a new ‘innovative’ prevention method was required.
‘Instead of going through the bog-standard information about
toothbrushing…we need to find another innovative way’ (Childsmile)
Stakeholders thought how prevention is provided for these families should be reassessed.
‘We’ve got oral health information we want to give them and just giving them the ‘Remember, brush your teeth twice a day’… I don’t think the normal process is going to work’. (Childsmile)