1. BDA Views. John Milne GDPC Chair.
NHS Contract Reform
BDA Views.
John Milne
GDPC Chair.

3. How we got here Options for Change PDS pilots 2006 contract
Steele Review
Coalition Pledge
Context of changing demographics of disease
Wave 1 Pilots
Wave 2 Pilots
Implementation
The need for change within the NHS dental service has been long recognised. Some would say that the 1990 contract was introduced against the wishes of the profession and things have been going wrong ever since!

4. Options for change (2002-3) Recognised problems of IOS
Recognised need for prevention
Collaborative working- DH and BDA
Clinical Pathways
Changing skill mix
Different remuneration schemes.
IOS was seen by many as a perverse incentive that operated against health improvement and brought with it the temptation to over-treat to maximise income despite the safety mechanisms of DRO inspections and prior approval.
Prevention has always been seen as desirable, but IOS payment schemes did not incentivise it.
Options for change came about by collaboration between government and DH with the profession.
Introduced some of the concepts that are now being considered again for contract reform, such as clinical pathways, utilising the wider skill mix available and changing the payment systems.

5. PDS (pilots) Positive start?
Sidetracked as a route for new access as NHS access was falling
Few controls
Reduced PCR
Better working conditions for dentists?
Gaming
Neglect?
Effectively the PDS pilots were a capitation system, practices were given a budget and the freedom to deliver whatever care was necessary for their patient base. It enabled prevention to be embraced, many practices involved broadened their skill mix.
There were very few controls and output and patient charge revenue fell. There was some evidence of gaming and providing care privately which could have been provided through the NHS. As there was a bulk payment, effectively a double payment was being made.
Working conditions for dentists were undoubtedly better, but the lack of controls and policing made PDS seem poor value for money and unworkable.
The process of contract reform so far has been to re-visit some of the principles of options for change and PDS and design safeguards and controls to enable better outcomes for patients and value for money for the taxpayer. Our stance has been that this is OK, but professional incomes should not be undermined.

6. 2006 contract Imposed Talks with profession broke down
Confusion over currency of contract
Introduction of UDA (not conceived originally as a currency, more a reflection of differing workloads related to oral health of practice population)
Discussions with DH were positive and constructive until 2005 when they broke down over unacceptable conditions.
Discussions about just what the NHS would provide were difficult to pin down.

7. 2006 contract: It’s all about control
Budget
Workforce
Location of Services
Access to services and growth
Workload and output
Prior to 2006 non cash limited service, and if the whole population attended then the bill would have to be met. The 1992 fee cut was a result of more people than were expected accessing the service.
Registration (introduced in 1990) became something dentists could control, and queues outside dentists accepting NHS patients made embarrassing headlines.
After the 1992 fee cut a significant number of dentists reduced their NHS commitment and the private dental sector began to grow. However, to government the non cash limited system presented both risk of spiralling costs and no control over where services were delivered.

8. Well documented difficulties with the 2006 contract

9. 2006 problems No incentive to maintain access
No guarantee of NHS care for patients
Pension problems for some providers
Difficult to grow successful practices
Gaming behaviours (dentists)
Gaming behaviours (PCTs ATs)
Few checks on clinical quality
Inconsistencies in practice sales, incorporation.
Unreasonable and bullying PCT behaviour
No flexibility eg snow, flu.
Increased referrals to Salaried and hospital services
Deskilling
Less advanced care
PCT Variations
And and and and
Inequity in contract values
No reward for prevention
Discrimination of high needs
Professional jeopardy with claims interpretation
Clawback and targets
Inaccurate calculation of contract values
Practice contract may have disadvantaged associates
Difficulty of hitting targets whilst treating pts ethically
No reward for additional work
UDA being used as a currency to drive contract prices down.
Variable levels of care
Lack of clarity what NHS care means
Inequality of contract values in an area
Give time to look at list.
Pick out some damaging examples.....Bullying, retrospective extrapolation and clawback based on new interpretation of claiming regs with hindsight.
Accept faults on all sides
This list shows huge need for change as soon as practicable

10. Continue to build on case for change, particularly with regard to patient care as a long term possibility within capitation.

11. Steele Review Health Select Committee Steele Review
Widespread criticism from all sides of 2006 contract.
Steele Review
Hierarchy of provision
Assessment and control of disease risks
Level of care dependant on risk control and likely success.
Workshops: BDA “Engagement with extreme vigilance” Recognition of “Big Challenge”
Early pilots
(needed brave PCTs!)
Health select committee reacted to criticism of the 2006 contract from the BDA and many others by looking at the effects of the changes in 2006 and concluding that government needed to look again. The result was that the Labour govt commissioned Prof Jimmy Steele to conduct a review which was accepted by the secretary of state and work began on contract reform.

12. What are the priorities of NHS dentistry?
Advanced and complex care
Reducing priority for public investment
Continuing care
Treatment of dental disease
Basic principles were that prevention should be given more prominence and that treatment should be based on whether the risks of disease were being controlled, as that gives the long term prospect of successful outcomes.
Do it when it will have a good chance of success
Do it once and do it well.
Personalised disease prevention
Urgent care and pain relief
Public health

13. NHS Dentistry: What could it do?
“NHS dentistry could lead the world in providing an Oral Health Service”
Jimmy Steele 2009.
Note the word Could!! 13

14. Better Not Worse
The aim of improving oral health is not really controversial and the Steele Review suggests that any changed system should incentivise prevention and care rather than simply reward treatment. Capitation payments are seen as spreading the risks and costs across the population as in other areas of healthcare provision.

15. What’s important? For the profession Improved patient outcomes
Fair remuneration
Job security
Current benefits preserved
Ability to transfer contracts (goodwill)
Financial stability in transition stage.
For the public
Access to quality care
And urgent care
Improved oral health outcomes
Good experience
Clarity of what the NHS will provide
Simple charging system
Most will agree with these lists.

16. Coalition government pledge
New Dental Contract
Registration
Capitation
Quality and Outcomes
Access still a priority
Children’s health particularly important
National Steering Group
Continued BDA Engagement with vigilance.
Registration, capitation, quality and outcomes
After change of govt to coalition, the health ministers met with BDA and agreed that their pre- election commitment to change dentistry could be worked into the Steele Review process and work continued to set up pilots.

17. Oral Health in 12 year olds
Reform is being considered at a time when oral health in children is generally improving. We might argue about how much, but there is no doubt that the burden of restoration, repair and replacement in the under 40s is much less. Todays 12 year olds will need far fewer fillings, endodontics, crowns and bridgework as they get older than their parents did.
Disease tends to be greater in socially deprived areas, but even there there have been vast improvements over the last 20 years. Extracting 4x 6s is relatively rare now- thank goodness!
Practitioners looking back wistfully at IOS might consider just how much fee income would be available as the proportion of healthy individuals has risen so much.

18. However, the “heavy metal” brigade of the 50+ present a severe challenge to our skill as the heavily restored dentitions built through the 60s 70s and 80s begin to fail. That’s why changes in the workforce need to be thought about rationally and carefully, because this sector of the population take time and resources to treat. And skilled dentists who are able to do this. There is also a moral and ethical consideration as to how far the NHS funding should be spent in this regard?

19. Oral health status projections
Healthier - low treatment needed
Less healthy - high treatment needed
No teeth
These DH slides show the treatment need of the heavy metal generation moving over the next 20 years, and give us much cause for reflection about workforce planning.

20. This is a cover slide and can be found on the DH web-site as an interactive document explaining the principles of reform.
Encourage people to have a look and respond.

21. Perhaps the fact that DH have published GDPCs thoughts here is at least an acknowledgement of the size of the task which confronts us if we are to develop a better way of the NHS providing dental care.

22. Wide involvement with interested parties, not least the 90 or so pilot practices.
BDA has 4 places on steering group

23. Oral Health Assessment: leads to homecare plan and professional care plan.
Medical History
Alcohol and tobacco
Social History
Family caries history
Diet and tooth-brushing
Full chart of restorations
Full chart of carious lesions
BPE
Bleeding
Pocket chart
Tooth surface loss (relative to age)
Soft tissues
OHA reflects current good practice.

24. Pilot design RAG ratings in each domain. Care Pathways DQOF
Safety
Patient Experience
Clinical effectiveness
Early work on complexities and competencies
Professional consensus
The elements that are being tested are largely uncontroversial in terms of the OHA and care pathways.
Maybe mention freedom to overide
DQOF as a possible tool to minimise neglect

26. Steps in the primary care pathway
PREVENTION
Oral
health assessment
RAG
status
Treatment & stabilisation
(if necessary)
Step 1
When do I need to recall this patient?
Date of oral health review
Step 2
Does this patient need to be seen for additional preventive care/advice between now & OHR?
And so, in the pilots, the first stage is a comprehensive oral health assessment, looking at several disease areas.
Steps 1 & 2 would be done by the dentist.
Step 3: If the patient needs additional prevention care/advice, then would expect DCP to deliver these appointments
Step 3

27. Pathway in action......... Are the general principles for
Are the general patient
factors supportive ?
Are the relevant oral health
risks controlled
Is the proposed restoration
clinically feasible and
beneficial
yes
Are the general principles for
indirect restorations satisfied ?
Offer indirect
restoration
This pathway looks at the decision making for an indirect restoration such as a crown.
Might be worth discussing override scenario here?

28. DQOF- clinical effectiveness 60%
Measure
Points – MAX:600
Decayed teeth (dt) aged 5 years old and under, reduction in number of carious teeth/child
50% Under 5s active decay (dt) improved or maintained
150
Decayed Teeth (DT) aged 6 years old and over, reduction in number of carious teeth/child
75% over 6’s improved or maintained
Decayed Teeth (DT) reduction in number of carious teeth/dentate adult
75% improved or maintained
75% patients with BPE improved or maintained at oral health review 75
50% patients with BPE 2 or more with sextant bleeding sites improved at oral health review
DQOF represents 10% of contract value.
Pick an example and explain.
Thresholds acknowledge that not all patients will improve- whatever we do!
The indicator information will be captured at review and achievement of the indicator is described as either maintaining or improving a patient’s condition.

29. DQOF Patient Experience Indicators for payment (30%)
Measure
Points - Max:300
Are you able to speak and eat comfortably?
% of patients reporting that they are able to speak & eat comfortably
MAX: 30
Level 1 45%-54% =15
Level 2 55%-100% =30
How satisfied were you with the cleanliness of the practice?
% of patients satisfied with the cleanliness of the dental practice
Level 1 80%-89% = 15
Level 2 90%-100% = 30
How helpful were the staff at the practice?
% of patients satisfied with the helpfulness of practice staff
Level 1 80%-89%= 15
Did you feel sufficiently involved in decisions about your care?
% of patients reporting that they felt sufficiently involved in decisions about their care
MAX: 50
Level 1 70%-84% = 25
Level 2 85%-100% = 50
Would you recommend this practice to a friend?
% of patients who would recommend the dental practice to a friend
MAX: 100
Level 1 70%-79% = 50
Level 2 80%-89%= 75
Level 3 90%-100%=100
How satisfied are you with the NHS dentistry received?
% of patients reporting satisfaction with NHS dentistry received
Level 1 80%-84% = 20
Level 2 85%-89% = 40
Level 3 90%-100% =50
How do you feel about the length of time taken to get appointment?
% of patients satisfied with the time to get an appointment
MAX: 10
Level 1 70%- 84% = 5
Level 2 85%-100% =10
Risks of only the disgruntled filling in surveys and so need for large samples of patients to be used.
Currently only a dozen or so in GDS and PDS, but 100+ used in pilots.

30. DQOF Safety Indicators for payment (10%)
Clinical aspects of patient safety can be monitored and rewarded through payment and payment will be made on the following indicator:
Measure
Points – MAX:100
90% of patients for whom an up-to-date medical history is recorded at each oral health review
MAX: 100
Should basic safety be rewarded in this way?

31. GDPC believe that the improvement in health should be rewarded as an additional payment- above the line- a carrot. Whilst the other DQOF measures might be more of a stick.
Additional funding for quality could be provided via the funding allocated to seniority pay, but not currently being spent. This principle was first raised in 2004 with GDPC when the abolition of seniority pay was first considered by DH. Views?

32. Current weightings being looked at in the pilots are age, gender and social deprivation.

33. Wave 1 Pilots Practioners Patients
Valued increased communication and understanding and RAG
Valued preventive care
Liked philosophy and approach
Appointment book problems and time pressure
Paying associates?
Interim Care
IT problems
Time
Access
Skill-mix +ve and -ve
Clawback if access drop.
Some likes and dislikes that became evident in the first year.

34. Wave 2 Pilots- Responsive
Improved IT
Some streamlining
Override
Modified patient charges
Access imperative clear
Includes salaried service.
The importance of access made clear, some potential clawback if access falls. Limited to 2% at insistence of BDA as we did not wish to see practices damaged by testing a system that it is hoped will improve care.
Need to look at profitability of pilot practices.
However, the pilots are being responsive to practical concerns and attempting to solve the problems that are becoming evident.

36. Acknowledges difficulties and change of culture.

37. Views about the use of RAG ratings
PATIENTS
PRACTITIONERS 1%
(1%) 0%
The ‘traffic light’ ratings make it more difficult for me/patients to look after teeth and gums (oral health)
41%
(22%)
The ‘traffic light’ ratings make no difference to how I/patients look after teeth and gums (oral health)
19%
58%
(31%)
75%
The ‘traffic light’ ratings make it easier for me/patients to look after teeth and gums (oral health)
General approval of this system by dentists and patients
N.B. Figures in brackets refer to data based on all patients (3,760)
Patients: Q14. Which of the following best describes your view about the use of ‘traffic light’ ratings?
Base: All patients and carers/guardian/parents of patients who can remember using traffic light ratings (2,011)
Practitioners: Q10. Which of the following statements best describes your view about red/amber/green status?
Base: All respondents (320)

38. RAG status changes
Findings relate to patients who had an OHA Sept Mar 2012 who returned for an OHR by Mar ’13
Net improvement where there is complete data
Adults: 2% reduction in red patients and 4% increase in green
Children: 2% increase in green patients and 2% reduction in red
findings relate to patients who had an OHA Sept Mar 2012 who returned for an OHR by Mar ’13
Net improvement where there is complete data
Adults: 2% reduction in red patients and 4% increase in green patients
Children: 2% increase in green patients and 2% reduction in red patients
Proportion of green patients in this subset of “reviewed” patients is lower than the proportion seen at OHA across all pilots, possibly reflecting longer review periods

39. Is disease risk consistently captured and communicated to patients?
Yes, and RAG ratings are being generated
Distribution of the ratings is broadly as would be expected from the epidemiology, particularly for those at greatest risk
Some anomalies around the boundaries of the amber ratings
“…It’s a very, very beneficial system for patients because we’re finding it much, much easier to explain to them ‘Well, this is what we’ve assessed. This is the situation now and this is where we need to get to. And for you to be there, we need you to follow this path, the aftercare, the prevention you need to carry out at home to get you to green”
[E & L report page 31] Many practitioners acknowledged that the RAG score was a useful tool to assist patients in understanding their risk status. Some felt that the RAG score acted as an incentive for some patients and the concept was deemed useful in demonstrating improvement (or an increase in risk status) over time.
However, despite these positive comments about its utility as a motivational tool, a number of practitioners reported that they neither used nor referred to the RAG score with patients.

40. Worst thing possible, no way this system can work!
Pilots so far
Worst thing possible, no way this system can work!
Best thing I’ve ever done, free from UDAs at last. Can deliver proper care.
Not a surprise given different motivations of those applying to be pilot practices.

41. What about Associates? Uncertain futures Replacement with DCPs
Falling incomes
Uncertain futures
Replacement with DCPs
Concern about de-skilling
Anxious about pensions
They too deserve a good career and a secure future A
UDA U
UDA
UDA
It’s important to remember that the vast majority of dentists working in the NHS are associates. Any change must not hinder their professional development and their ability to increase their skills and knowledge throughout their careers.

42. We need some honesty in the debate.
Access
NHS Offer
Scope of advanced care.
Elderly Population
Existing inequalities
Which brings me back to the question of honesty. We can’t increase access without additional funding, we have to recognise that the needs of the elderly patients cannot be ignored, and neither can government ignore the real costs of that care if it is to be provided within General Practice. And if much of it is to be provided by our salaried service colleagues then they too need adequate resources. The existing inequalities in funding need sorting without destabilising practices.
The pilots will, if the oral health assessments are accurate, reveal the needs that exist out there, and it is governments responsibility to decide whether to meet that need or whether to ration care. But at the moment, we don’t really know the answer.
Core service= core money- the money for advanced care would be stripped out.

43. Capital Risk v Reward. Buildings Equipment Future investment Returns
The NHS gets a fantastic deal from the profession in that we meet the capital costs of service provision and take the financial risk. It is only right that we should be able to get a return on that investment both through an adequate income, and the ability to sell the business and transfer any NHS contract.

44. The pilots are not the finished article
Really important to understand that the pilots are a testing ground. We are seeing what does and doesn’t work and that will hopefully enable a workable reform to be designed that is acceptable all round.

45. Issues to solve Practice viability and sustainability
Avoiding supervised neglect
NHS Offer
Mixing and private care
Incentivising Quality and Access
Transitional arrangements ? MPIG
PCR
Growth
Contract Management
Capitation payment mechanisms (full or partial)
Go through each briefly.

46. UDA Distribution.
Might be worth mentioning that any harmonisation of values needs to be done after a thorough examination of what is provided per UDA across the piece. For example- some low UDA practices only do perio and s/p privately. Equally, some high UDA practices might do very little endo or advanced work.
Transitional arrangements will be needed to protect viability.

47. Capitation examples Taking three actual contracts chosen at random and
assuming that all of the patients seen in the previous two years live in the practice postcode area and
assuming that the patients have the same age and sex profile as the practice population and
using the patient capitation values from the pilots
It is clear that the required patient numbers could change for many practices
The following examples need to bear in mind the point made previously about the work done per UDA.
This is a simple example of what may need consideration.

48. Small practice in London
4,500 patients
£350,000 contract value
Higher than average £/UDA
Would have to take on 490 new patients

49. Large practice in West Sussex
11,000 patients
£800,000 contract value
Lower than average £/UDA
Practice will need to see 790 fewer patients

50. Average size practice in the North West
£570,000 contract value
11,000 patients
Just below average £/UDA value
Practice can lose 2,000 patients

51. Capitation
Transitional protection is needed to manage changes in patient numbers or potential cuts in contract value
There might be additional weighting to capitation amounts to take account of factors such as rurality or staff pay factors
The DH is currently modelling capitation scenarios and there is no information yet about how it is going to work
This is an area that needs more work, but is probably the key to practice viability. There is a lot at stake here- get it wrong and practices will not want to accept NHS contracts and access will fall as dentists move to the private sector. We are stressing this risk to Govt, DH and NHS England.

52. Where to now? Evaluation (ongoing by BDA and DH)
Learning what does and doesn’t work
Listening to pilots and patients
Practical framework design
Negotiation
Big Bang or Phase roll out
A heavy year in prospect for GDPC!

53. What do we want? Improved oral health Sustainability of practice
Long term future.
Career pathway for dentists
Practice ownership and equity
Realistic workforce planning
Proper remuneration
Check with audience that these are OK!

54. When will it all change?
In the hands of politicians, but remind of case for change due to current useless system.
Advantages and disadvantages of phased roll out- suggest commitment to say 33% pts get OHA each year?

55. Will this have a happy ending?
Let’s hope so!
Will this have a happy ending?

56. Some Questions to consider........ And your questions?
Are there any dangers in seeking clarity of NHS offer?
Should “mixing” still be possible?
Should there be a cap on a list size?
Will capitation work for the elderly?
Should the money “follow the patient”?
How can that work within a fixed budget?
Is the profession ethical enough for this type of system?