3How we got here Options for Change PDS pilots 2006 contract Steele ReviewCoalition PledgeContext of changing demographics of diseaseWave 1 PilotsWave 2 PilotsImplementationThe 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!
4Options for change (2002-3) Recognised problems of IOS Recognised need for preventionCollaborative working- DH and BDAClinical PathwaysChanging skill mixDifferent 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.
5PDS (pilots) Positive start? Sidetracked as a route for new access as NHS access was fallingFew controlsReduced PCRBetter working conditions for dentists?GamingNeglect?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.
62006 contract Imposed Talks with profession broke down Confusion over currency of contractIntroduction 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.
72006 contract: It’s all about control BudgetWorkforceLocation of ServicesAccess to services and growthWorkload and outputPrior 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.
8Well documented difficulties with the 2006 contract
92006 problems No incentive to maintain access No guarantee of NHS care for patientsPension problems for some providersDifficult to grow successful practicesGaming behaviours (dentists)Gaming behaviours (PCTs ATs)Few checks on clinical qualityInconsistencies in practice sales, incorporation.Unreasonable and bullying PCT behaviourNo flexibility eg snow, flu.Increased referrals to Salaried and hospital servicesDeskillingLess advanced carePCT VariationsAnd and and andInequity in contract valuesNo reward for preventionDiscrimination of high needsProfessional jeopardy with claims interpretationClawback and targetsInaccurate calculation of contract valuesPractice contract may have disadvantaged associatesDifficulty of hitting targets whilst treating pts ethicallyNo reward for additional workUDA being used as a currency to drive contract prices down.Variable levels of careLack of clarity what NHS care meansInequality of contract values in an areaGive 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 sidesThis list shows huge need for change as soon as practicable
10Continue to build on case for change, particularly with regard to patient care as a long term possibility within capitation.
11Steele Review Health Select Committee Steele Review Widespread criticism from all sides of 2006 contract.Steele ReviewHierarchy of provisionAssessment and control of disease risksLevel 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.
12What are the priorities of NHS dentistry? Advanced and complex careReducing priority for public investmentContinuing careTreatment of dental diseaseBasic 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 successDo it once and do it well.Personalised disease preventionUrgent care and pain reliefPublic health
13NHS 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
14Better Not WorseThe 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.
15What’s important? For the profession Improved patient outcomes Fair remunerationJob securityCurrent benefits preservedAbility to transfer contracts (goodwill)Financial stability in transition stage.For the publicAccess to quality careAnd urgent careImproved oral health outcomesGood experienceClarity of what the NHS will provideSimple charging systemMost will agree with these lists.
16Coalition government pledge New Dental ContractRegistrationCapitationQuality and OutcomesAccess still a priorityChildren’s health particularly importantNational Steering GroupContinued BDA Engagement with vigilance.Registration, capitation, quality and outcomesAfter 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.
17Oral 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.
18However, 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?
19Oral health status projections Healthier - low treatment neededLess healthy - high treatment neededNo teethThese 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.
20This 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.
21Perhaps 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.
22Wide involvement with interested parties, not least the 90 or so pilot practices. BDA has 4 places on steering group
23Oral Health Assessment: leads to homecare plan and professional care plan. Medical HistoryAlcohol and tobaccoSocial HistoryFamily caries historyDiet and tooth-brushingFull chart of restorationsFull chart of carious lesionsBPEBleedingPocket chartTooth surface loss (relative to age)Soft tissuesOHA reflects current good practice.
24Pilot design RAG ratings in each domain. Care Pathways DQOF SafetyPatient ExperienceClinical effectivenessEarly work on complexities and competenciesProfessional consensusThe elements that are being tested are largely uncontroversial in terms of the OHA and care pathways.Maybe mention freedom to overideDQOF as a possible tool to minimise neglect
26Steps in the primary care pathway PREVENTIONOralhealth assessmentRAGstatusTreatment & stabilisation(if necessary)Step 1When do I need to recall this patient?Date of oral health reviewStep 2Does 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 appointmentsStep 3
27Pathway in action......... Are the general principles for Are the general patientfactors supportive ?Are the relevant oral healthrisks controlledIs the proposed restorationclinically feasible andbeneficialyesAre the general principles forindirect restorations satisfied ?Offer indirectrestorationThis pathway looks at the decision making for an indirect restoration such as a crown.Might be worth discussing override scenario here?
28DQOF- clinical effectiveness 60% MeasurePoints – MAX:600Decayed teeth (dt) aged 5 years old and under, reduction in number of carious teeth/child50% Under 5s active decay (dt) improved or maintained150Decayed Teeth (DT) aged 6 years old and over, reduction in number of carious teeth/child75% over 6’s improved or maintainedDecayed Teeth (DT) reduction in number of carious teeth/dentate adult75% improved or maintained75% patients with BPE improved or maintained at oral health review7550% patients with BPE 2 or more with sextant bleeding sites improved at oral health reviewDQOF 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.
29DQOF Patient Experience Indicators for payment (30%) MeasurePoints - Max:300Are you able to speak and eat comfortably?% of patients reporting that they are able to speak & eat comfortablyMAX: 30Level 1 45%-54% =15Level 2 55%-100% =30How satisfied were you with the cleanliness of the practice?% of patients satisfied with the cleanliness of the dental practiceLevel 1 80%-89% = 15Level 2 90%-100% = 30How helpful were the staff at the practice?% of patients satisfied with the helpfulness of practice staffLevel 1 80%-89%= 15Did you feel sufficiently involved in decisions about your care?% of patients reporting that they felt sufficiently involved in decisions about their careMAX: 50Level 1 70%-84% = 25Level 2 85%-100% = 50Would you recommend this practice to a friend?% of patients who would recommend the dental practice to a friendMAX: 100Level 1 70%-79% = 50Level 2 80%-89%= 75Level 3 90%-100%=100How satisfied are you with the NHS dentistry received?% of patients reporting satisfaction with NHS dentistry receivedLevel 1 80%-84% = 20Level 2 85%-89% = 40Level 3 90%-100% =50How do you feel about the length of time taken to get appointment?% of patients satisfied with the time to get an appointmentMAX: 10Level 1 70%- 84% = 5Level 2 85%-100% =10Risks 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.
30DQOF 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:10090% of patients for whom an up-to-date medical history is recorded at each oral health reviewMAX: 100Should basic safety be rewarded in this way?
31GDPC 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?
32Current weightings being looked at in the pilots are age, gender and social deprivation.
33Wave 1 Pilots Practioners Patients Valued increased communication and understanding and RAGValued preventive careLiked philosophy and approachAppointment book problems and time pressurePaying associates?Interim CareIT problemsTimeAccessSkill-mix +ve and -veClawback if access drop.Some likes and dislikes that became evident in the first year.
34Wave 2 Pilots- Responsive Improved ITSome streamliningOverrideModified patient chargesAccess imperative clearIncludes 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.
36Acknowledges difficulties and change of culture.
37Views about the use of RAG ratings PATIENTSPRACTITIONERS1%(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 patientsN.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)
38RAG status changesFindings relate to patients who had an OHA Sept Mar 2012 who returned for an OHR by Mar ’13Net improvement where there is complete dataAdults: 2% reduction in red patients and 4% increase in greenChildren: 2% increase in green patients and 2% reduction in redfindings relate to patients who had an OHA Sept Mar 2012 who returned for an OHR by Mar ’13Net improvement where there is complete dataAdults: 2% reduction in red patients and 4% increase in green patientsChildren: 2% increase in green patients and 2% reduction in red patientsProportion 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
39Is disease risk consistently captured and communicated to patients? Yes, and RAG ratings are being generatedDistribution of the ratings is broadly as would be expected from the epidemiology, particularly for those at greatest riskSome 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.
40Worst thing possible, no way this system can work! Pilots so farWorst 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.
41What about Associates? Uncertain futures Replacement with DCPs Falling incomesUncertain futuresReplacement with DCPsConcern about de-skillingAnxious about pensionsThey too deserve a good career and a secure futureAUDAUUDAUDAIt’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.
42We need some honesty in the debate. AccessNHS OfferScope of advanced care.Elderly PopulationExisting inequalitiesWhich 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.
43Capital 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.
44The 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.
45Issues to solve Practice viability and sustainability Avoiding supervised neglectNHS OfferMixing and private careIncentivising Quality and AccessTransitional arrangements ? MPIGPCRGrowthContract ManagementCapitation payment mechanisms (full or partial)Go through each briefly.
46UDA 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.
47Capitation 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 andassuming that the patients have the same age and sex profile as the practice population andusing the patient capitation values from the pilotsIt is clear that the required patient numbers could change for many practicesThe 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.
48Small practice in London 4,500 patients£350,000 contract valueHigher than average £/UDAWould have to take on 490 new patients
49Large practice in West Sussex 11,000 patients£800,000 contract valueLower than average £/UDAPractice will need to see 790 fewer patients
50Average size practice in the North West £570,000 contract value11,000 patientsJust below average £/UDA valuePractice can lose 2,000 patients
51CapitationTransitional protection is needed to manage changes in patient numbers or potential cuts in contract valueThere might be additional weighting to capitation amounts to take account of factors such as rurality or staff pay factorsThe DH is currently modelling capitation scenarios and there is no information yet about how it is going to workThis 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.
52Where to now? Evaluation (ongoing by BDA and DH) Learning what does and doesn’t workListening to pilots and patientsPractical framework designNegotiationBig Bang or Phase roll outA heavy year in prospect for GDPC!
53What do we want? Improved oral health Sustainability of practice Long term future.Career pathway for dentistsPractice ownership and equityRealistic workforce planningProper remunerationCheck with audience that these are OK!
54When 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?
55Will this have a happy ending? Let’s hope so!Will this have a happy ending?
56Some 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?