Practitioner Services dental clinical team – peer review of prior approval cases

Each year, Practitioner Services receives a considerable volume of prior approval requests for assessment. Whilst many of those requests are assessed by our team of trained Prior Approval Officers, our Dental Advisers, who are all registered dentists with significant experience of NHS general dental practice, review complex or extensive treatment plans, including orthodontic treatment plans and requests for discretionary fees.  Criteria set by the Scottish Dental Practice Board determine which types of case can be reviewed by a Prior Approval Officer, and which require a review to be carried out by a clinician.

Prior approval requests are reviewed by our Dental Advisers on a case by case basis to assess whether the care and treatment proposed is in accordance with the Statement of Dental Remuneration, in compliance with the Regulations and appears to be in the patient’s best interests having regard to a risk versus benefit analysis based on the information supplied by the dentist proposing the treatment. Decisions are made with patients’ best interests in mind and not on grounds of cost.

In cases where further information or clarification is needed, our Dental Advisers discuss the treatment plan with the dentist, providing advice and support to ensure that treatment proposals are appropriate and that patients receive treatment that is in their best interests. A Dental Reference Officer’s opinion is sought in cases where this would help to establish the most appropriate treatment pathway for a patient.

Members of the dental clinical team (Dental Advisers and Dental Reference Officers), with over 200 years experience of NHS general dental practice collectively, are all aware that there is often more than one correct approach to the management of a patient’s treatment needs, and that treatment which would be entirely appropriate for one patient might be unsuitable for another.

All members of the clinical team are keen to demonstrate that clinical decisions they make would be supported by a reasonable body of clinical opinion and for this reason a programme of internal and external  peer review is in place, as described below:

The dental clinical team regularly carries out peer review of cases submitted for prior approval.  In addition to informal peer review, where the Dental Advisers, including our Orthodontic Advisers, discuss cases together during the course of their day-to-day work, we also carry out formal peer review, both internally and externally, as described below:

Internal Peer review

In addition to informal peer review, where the Dental Advisers, including our Orthodontic Advisers, discuss cases together during the course of their day-to-day work, we also carry out formal peer review.

Our electronic prior approval review system (PARS) allows a Dental Adviser to request peer review, by one or more Dental Adviser colleagues, of any case s/he has been assigned. In addition, PARS is configured to require, on the basis of random selection, a proportion of cases to be peer reviewed by at least two Dental Advisers before a decision can be made on whether the case can be approved as submitted or whether some other action is appropriate. PARS also requires a proportion of cases capable of being approved by Prior Approval Officers to be reviewed by Dental Advisers.

Peer review meetings, involving the whole clinical team, are held approximately every two months, where more challenging cases are selected for review and discussion, and notes of the discussions recorded.

During the year to 31 March 2019 49 such cases were reviewed at peer review meetings and a wide range of issues were discussed.

External Peer Review

In addition to the internal peer review activities described above, external peer review meetings are held, normally on a quarterly basis, separately with representatives of the BDA Scottish Dental Practice Committee (SDPC) and the Scottish Orthodontic Specialist Practitioners’ Group (SOSPG).  The majority of cases are selected for review by our prior approval administrative staff, with the remainder being selected by Dental Advisers where they consider that a particular example or clinical scenario would benefit from discussion with SDPC or SOSPG.  All prior approval proposals, with patient and contractor identities redacted, are reviewed together with all available supporting information.
The results of external peer review with both groups consistently demonstrate a high level of agreement with the decisions made by the Dental Advisers.

During the year to 31 March 2019, Dental Advisers met with representatives of SDPC  on  three occasions. A total of 29 prior approval submissions were reviewed. The SDPC representative agreed with the Dental Advisers’ decisions in all cases.

During the same period our Orthodontic Advisers met with representatives of SOSPG on four occasions, reviewing a total of 40 prior approval submissions. On each occasion, 10 submissions were selected at random for review. Each attendee was asked to grade the IOTN of the cases presented. The results demonstrate a high degree of consistency of IOTN grading among our prior approval team, orthodontic advisers and the SOSPG representatives.

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