The dilemma of commissioning: the isle of wight orthodontic managed clinical network: a 3-year review part 1: patterns of referrals

Managed clinical networks (MCNs) have been defined as ‘linked groups of healthcare professionals and organizations from primary, secondary and tertiary care working in a co-ordinated manner, unconstrained by existing professional and existing [organizational] boundaries to ensure equitable provision of high quality effective services’.¹ The goal is to improve access, quality and appropriateness of treatment, with an emphasis on the patient journey so that the patient has the care he/she needs throughout treatment.² Although a number of medical models have been described,³ they have been slow to develop in dentistry. However, following the implementation of the changed contracting arrangements in April 2006, Primary Care Trusts (PCTs) in England were permitted to commission the dental services they needed locally, which provided the opportunity to develop locally managed clinical networks.

The process of creating the Isle of Wight MCN to improve access has already been described.⁴ One of the key objectives was to create an integrated service measuring the referral patterns and, ultimately, the current orthodontic need on the Isle of Wight. This information could, in turn, inform commissioners and would allow more appropriate manpower planning, thus improving equitable access for all patients. The responsibility to commission dental services locally introduced by the new dental contract in 2006 has many potential advantages, such as addressing local demand and inequality of access. However, many Primary Care Trusts (PCTs) are ill equipped to deal with the problem of orthodontic need as they do not have integrated centralized data. The true measure of orthodontic need in a population has remained elusive because of the lack of integration of primary and secondary care. Theoretical need is complex and the current justification for orthodontic treatment given to PCTs was outlined by the Department of Health in 2006.⁵ Theoretical orthodontic need has been cited in a number of primary sources.^5,6,7 The theories quoted in these sources used to assess orthodontic need are not comparable because of the heterogeneity of their method of calculation.^8,9,10,11