Assessing the provision of prevention in the care pathway for children undergoing dental extractions under general anaesthetic at the Royal Hospital for Children, Glasgow: a qualitative systems-level needs assessment.

Abstract

Introduction Although Scotland has made advances in the last decade in dental prevention and in tackling oral health inequalities, many children still develop dental caries, and many subsequently require a Dental General Anaesthetic (DGA) for extractions. These DGAs are undesirable given the impact on the patient, family and NHS. National guidelines recommend that a DGA is undertaken only if there are no other options for treatment. When children require a second ‘repeat’ DGA, or siblings consequently require a DGA, it suggests that current prevention protocols are not working. These children are slipping through the net. Both strategic and front-line stakeholders raised concerns that the care pathway for children undergoing general anaesthetics (GAs) for dental extractions at the Royal Hospital for Children, NHS Greater Glasgow and Clyde (RHCG) was not aligned to prevention, and was not best supporting these vulnerable families to improve and maintain oral health. Aims and Objectives The overarching aim of this study was to assess provision of dental prevention in the RHCG DGA care pathway, with a view to making recommendations at a local level on how to optimise prevention. The objectives were (i) to assess the pathway of care in relation to prevention and, if required, to investigate what opportunities existed to integrate further prevention into the pathway; (ii) to explore the pathway’s wider context including national policies and programmes which may support prevention, and (iii) to explore some examples of good preventive practice for DGA pathways locally and in other Scottish NHS boards. Methods This work was undertaken in two phases. An initial scoping exercise mapped the existing pathway of care and any child health policy or programme which could support prevention. A qualitative systems-level needs assessment subsequently explored both the views of stakeholders involved in providing care for these children, and individuals in wider child health policy and programmes, to ascertain how prevention could be better integrated into the pathway. Results Key findings illustrated minimal prevention currently being provided in the pathway of care and limited linkages with wider policy and programmes. Stakeholders recognised a need for change. Good preventive practice was highlighted in two external NHS Health Boards and one DGA pathway of care within NHS GGC. Suggestions for integrating prevention focused on transforming the pathway ethos towards multi-agency, tailored prevention and a whole-family approach. Clinical prevention suggestions were made within a proposed ‘Prevention Pathway’ model of tailored care. Potential strategies were suggested as to how to maximise patient engagement including local access clinics and liaising with support workers and the ‘Named Person’. Anticipated barriers to change included challenges with collaborative working, stakeholder attitudes, service pressures and board-level challenges such as the size of NHS GGC. Suggestions to overcome these challenges included training and education of stakeholders, consideration of an Early Years Collaborative pilot to assess changes within a local setting, improved communication and the development of a multi-agency working group to lead and affect change in the ‘Prevention Pathway’. Conclusion This study found that prevention was not currently embedded within the pathway of care, particularly at paediatric assessment and on the day of DGA, but that many positive steps could be taken to improve the provision of prevention at all stages; from direct clinical prevention to the wider multi-agency response. Wider health inequalities must not be forgotten in efforts to engage these vulnerable families, and an ethos of prevention and early intervention must be entrenched in current practice to reduce the number of children requiring preventable general anaesthetics