Secondary care orthodontics collaborative programme

Secondary care orthodontics is a highly complex clinical speciality, concerned with the alignment of the jaw and bite as well as the straightening and movement of the teeth. Patients requiring secondary care orthodontics may also access multi-disciplinary specialties alongside their orthodontic treatment, which could include oral surgery or restorative dentistry. Out of 1.8 million people living in Lancashire and South Cumbria around 1,400 patients require the service each year; most of these patients are under the age of 18.

Referral to secondary care is usually for:

• Cases with significant jaw discrepancies or complex tooth misalignments. 
• Orthognathic surgery (when the bite problem requires jaw repositioning surgery). 
• When orthodontic treatment needs to be coordinated with other dental specialties (e.g. restorative dentistry, oral surgery) or medical specialties. 
• Complex cases involving missing teeth, developmental anomalies, or other issues that require a team approach. 
• Patients where additional support is needed. 
• Cases which are not suitable for treatment in a specialist dental practice or where a second opinion is required.

At the present time, secondary care orthodontics is commissioned / delivered from all four acute Trusts in Lancashire and South Cumbria, with clinics delivered out of the eight sites shown below:

• University Hospitals of Morecambe Bay NHS Trust (UHMBT):
  • Royal Lancaster Infirmary
  • Furness General Hospital
  • Queen Victoria Hospital
• Blackpool Teaching Hospitals NHS Trust (BTH):
  • Blackpool Victoria Hospital
• East Lancashire Hospitals NHS Trust (ELHT):
  • Royal Blackburn Hospital
  • Burnley General Hospital
• Lancashire Teaching Hospitals NHS Foundation Trust (LTH):
  • Royal Preston Hospital
  • Chorley and South Ribble Hospital

Both BTH and UHMBT have no permanent consultants and are reliant on temporary / locum consultants to maintain service delivery. In addition to this, BTH is currently not accepting new referrals, with patients having to seek treatment at another provider. These temporary / locum arrangements have led to delays in treatment for new patients and those waiting for follow-up appointments, whilst undergoing orthodontic treatment.

Some of the hospitals have long waiting times for orthodontics from referral to treatment (more than 18 weeks) and extended delays in follow-up appointments for brace adjustments, which should occur every six to eight weeks.

Additionally, the current way of working is not financially sustainable for the NHS because of the need to bring in temporary staff from elsewhere.

Without changes to the orthodontic service as a whole, we will not have a stable, resilient workforce or be able to offer the high-quality and timely care and treatment that patients deserve. At present, due to the configuration of services across Lancashire and South Cumbria, patients are not receiving an equitable service.

The proposal we are currently looking at is split into three main areas:

• Pathway and operational

  • Standardisation of the way services are delivered to maximise capacity across the system such as clinic templates, referral processes and the development of an advice and guidance service to strengthen the links between Primary and Seconday Care.
  • Most of these improvements have already been implemented but due to the configuration of the service, not to maximum efficacy.

• New commissioning model

  • Instead of commissioning (paying) all four hospital Trusts for services, the ICB would pay just one Trust to provide all services in multiple locations across Lancashire and South Cumbria.
  • ELHT would be the lead provider of secondary care orthodontics.
  • All consultants would work for ELHT but in multiple hospital settings.
  • This will strengthen professional infrastructure and create a single accountability for for providing services.

• New location plan

  • This will provide more clinics at fewer sites allowing staff capacity to be maximised.
  • Two main (hub) locations
    • One in East Lanashire (operating out of both Burnley General Hospital and Royal Blackburn Hospital).
    • One in Central Lancashire (operating out of Chorley and South Ribble Hospital).
  • Two satellite (spoke) locations offering clinics one day a week
    • At Blackpool Victoria Hospital.
    • At Furness General Hospital.

The new location plan includes investment of £1.96m into Chorley and South Ribble Hospital for new dental suites and £0.43m investment into Royal Blackburn Hospital.

This proposal should improve the overall service, make recruitment and retention for the workforce more appealing, make the service more sustainable and provide equality of service to all patients.

The new model will require more travel for those who would currently attend Royal Lancaster Hospital, Queen Victoria Hospital (who would now attend either the Furness General satellite site or the Central Lancashire hub) and Royal Preston Hospital (who would now attend the Central Lancashire Hub at Chorley Hospital). However, patients attending either provider currently will benefit from a more effective and reliable service.

Yes. The satellite clinic proposed for the Barrow site, at Furness General Hospital, has additional capacity to accommodate patients who choose to attend this location, no matter where they live. It is important to note that the travel time from Lancaster and Morecambe to the Central Lancashire Hub, located at Chorley District General Hospital, is shorter than the travel time from Lancaster and Morecambe to Barrow.

The Orthodontic Collaborative Group, made up of both clinical and operational colleagues, has agreed on a few key points to help decide where future orthodontic services should be located:

• The orthodontics service at East Lancashire Hospitals is working well and is stable, so any changes there will be kept to a minimum.
• Satellite clinics will continue at Blackpool Victoria Hospital (for patients in Central Blackpool) and Furness General Hospital (for patients in Barrow).
• Central Lancashire has the second highest number of referrals for specialist orthodontic care – around 36% - so it has been chosen as the location for a second main hub.
• To make sure patients receive safe and high-quality care, there needs to be at least 10 consultant-led clinics each week, ideally 12 if the wider clinical team includes less experienced staff. This also ensures proper supervision for orthodontic therapists.
• Based on these needs, it was agreed that both Royal Preston and Chorley Hospitals cannot continue to offer orthodontic services, and only one will be selected to host the new hub, which has been decided as Chorley Hospital. Chorley Hospital was selected over the Royal Preston Hospital site due to its more central location and its capacity to accommodate the necessary space and infrastructure requirements.

As part of planning future orthodontic services, several options were considered. Below is a summary of each option and why it was not taken forward:

The current number of sites offering secondary care orthodontic services across the region has made it harder to provide extra staffing support when it is needed. This has led to the service being described as fragile. Placing the second hub in Morecambe Bay area e.g. Lancaster, would have made it even more difficult to cover staff absences and maintain consistent care, which would lead to a reduction in patient satisfaction.

To help reduce the impact of longer travel times for some patients, an Early Discharge Scheme has been introduced. This allows patients who are clinically ready to continue their treatment with a more local primary care orthodontist, to be transferred into a primary care practice for continuing care. So far, the scheme has been commissioned for 130 patients across Lancashire and South Cumbria, which is proving to be more than sufficient for what we need. This service is currently being provided in Lancaster and will continue to be so.

There is also a national shortage of consultant orthodontists, with both Blackpool Teaching Hospitals and University Hospitals of Morecambe Bay solely reliant on insourcing and locum support to deliver a service. By creating a more centrally located role it is expected to help attract new staff. This is especially important as the service is currently looking to recruit two additional consultants.

The orthodontic service at East Lancashire Hospitals NHS Trust (ELHT) is currently performing at a high level and is considered both stable and sustainable. As a result, many of the proposed improvements to services across the region are based on replicating the successful model already in place at ELHT.

Introducing a single leadership structure across Lancashire and South Cumbria would help standardise how care is delivered, ensuring all patients receive the same high-quality service regardless of where they live. This approach would also strengthen the professional support available to clinicians and improve how resources are used across the region.

By having one team responsible for overseeing services, we can better address current inequalities in access to orthodontic care and work towards a more consistent and fair experience for all patients.

Within the proposed model, care will be delivered exclusively by permanent staff. This means that temporary staff, such as locum clinicians or insourced providers, will no longer be part of the service.

At the beginning of your treatment, you will be assigned a consultant orthodontist who will oversee your care. However, due to the nature of orthodontic treatment, you may also be seen by other specialist clinicians during your pathway - such as an oral surgeon - if your treatment requires it.

In addition, you may be seen and treated by an orthodontic therapist. Therapists work under the supervision and guidance of a consultant, ensuring that your care remains safe, consistent and of high quality throughout your treatment journey.

In the proposed model, once your brace (also known as an orthodontic appliance) has been fitted, you will need to attend regular appointments to monitor your progress and make any necessary adjustments. These review appointments typically take place every 6 to 8 weeks, although the exact timing will be determined by your consultant based on your individual treatment needs.

In some cases, if it is clinically appropriate, your care may be transferred to a local primary care orthodontist via the Lancashire and South Cumbria Early Discharge Scheme. This would allow you to continue your treatment closer to home, making it more convenient for regular follow-up appointments.

Please be assured that any decision to transfer your care will only be made if it is safe and suitable for your specific treatment plan.

As part of the proposed model, all orthodontic consultants - regardless of where they are based - will have secure access to your orthodontic records. This ensures continuity of care and allows any member of the clinical team involved in your treatment to make informed decisions based on your full clinical history.