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NHS Contract Reform BDA Views. John Milne GDPC Chair.

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Presentation on theme: "NHS Contract Reform BDA Views. John Milne GDPC Chair."— Presentation transcript:

1 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

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.

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?

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)

7 2006 contract: Its all about control Budget Workforce Location of Services Access to services and growth Workload and output

8 Well documented difficulties with the 2006 contract Slide 8

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

10 Caption here

11 Steele Review Health Select Committee 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!)

12 Caption here Public health Urgent care and pain relief Personalised disease prevention Continuing care Advanced and complex care Treatment of dental disease Reducing priority for public investment What are the priorities of NHS dentistry?

13 13 NHS Dentistry: What could it do? NHS dentistry could lead the world in providing an Oral Health Service Jimmy Steele 2009.

14 Better Not Worse

15 Whats 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

16 Coalition government pledge New Dental Contract Registration Capitation Quality and Outcomes Access still a priority Childrens health particularly important National Steering Group Continued BDA Engagement with vigilance. Registration, capitation, quality and outcomes

17 Caption here Oral Health in 12 year olds


19 Oral health status projections Healthier - low treatment needed Less healthy - high treatment needed No teeth




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

24 Pilot design RAG ratings in each domain. Care Pathways DQOF Safety Patient Experience Clinical effectiveness Early work on complexities and competencies Professional consensus


26 Oral health assessment Treatment & stabilisation (if necessary) Does this patient need to be seen for additional preventive care/advice between now & OHR? When do I need to recall this patient? RAG status Steps in the primary care pathway Date of oral health review Step 1 Step 2 Step 3

27 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 ? yes Offer indirect restoration Pathway in action.........

28 DQOF- clinical effectiveness 60% MeasurePoints – 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 6s improved or maintained 150 Decayed Teeth (DT) reduction in number of carious teeth/dentate adult 75% improved or maintained 150 75% patients with BPE improved or maintained at oral health review75 50% patients with BPE 2 or more with sextant bleeding sites improved at oral health review75 The indicator information will be captured at review and achievement of the indicator is described as either maintaining or improving a patients condition.

29 DQOF Patient Experience Indicators for payment (30%) MeasurePoints - 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 MAX: 30 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 MAX: 30 Level 1 80%-89%= 15 Level 2 90%-100% = 30 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 MAX: 50 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

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: MeasurePoints – MAX:100 90% of patients for whom an up-to-date medical history is recorded at each oral health review MAX: 100



33 Wave 1 Pilots Practioners 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. Patients Valued increased communication and understanding and RAG Valued preventive care

34 Wave 2 Pilots- Responsive Improved IT Some streamlining Override Modified patient charges Access imperative clear Includes salaried service.



37 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) Views about the use of RAG ratings 58% (31%) The traffic light ratings make it easier for me/patients to look after teeth and gums (oral health) 41% (22%) 1% (1%) The traffic light ratings make no difference to how I/patients look after teeth and gums (oral health) The traffic light ratings make it more difficult for me/patients to look after teeth and gums (oral health) 75% 19% 0% N.B. Figures in brackets refer to data based on all patients (3,760) PRACTITIONERSPATIENTS 37

38 RAG status changes Findings relate to patients who had an OHA Sept 2011- 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

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 …Its a very, very beneficial system for patients because were finding it much, much easier to explain to them Well, this is what weve 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

40 Pilots so far.............................. Best thing Ive ever done, free from UDAs at last. Can deliver proper care. Worst thing possible, no way this system can work!

41 Slide 41 What about Associates? Falling incomes Uncertain futures Replacement with DCPs Concern about de-skilling Anxious about pensions They too deserve a good career and a secure future UDA U A

42 We need some honesty in the debate. Access NHS Offer Scope of advanced care. Elderly Population Existing inequalities

43 Capital Risk v Reward. Buildings Equipment Future investment Returns

44 The pilots are not the finished article

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)

46 UDA Distribution.

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

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

52 Where to now? Evaluation (ongoing by BDA and DH) Learning what does and doesnt work Listening to pilots and patients Practical framework design Negotiation Big Bang or Phase roll out

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

54 When will it all change?

55 Caption here Lets 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?

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