1. Presentation to Northern LDC
Donncha O’Carolan
Chief Dental Officer
5 April 2012

2. Overview of Presentation
GDS Budget & Pressures
New GDS Contract
Local Decontamination Guidance

3. Permanent Secretary & Deputy Secretaries
DHSSPS Structure
CDO
Minister
Permanent Secretary & Deputy Secretaries
HEIG
SQS
Primary Care
Public Health
HRD
Local decontamination
Capital planning
Regulation of private dentistry
Dental standards
RQIA
GDS contract
CDS
Oral health improvement
Health protection
Workforce
Occupational health
Dental school
School of hygiene

4. GDS Budget

5. GDS Budget – Structure

6. GDS Budget – Structure

7. GDS Budget – Structure

8. GDS Budget – Structure
 Net
 Patient
 Pressure

9. GDS Budget – Investments
£4 million (recurrent) into practice allowance
£3 million (non-recurrent) into QIS
£500k (recurrent) into VT grants
>£500k (recurrent) into extending registration period
£400k (recurrent) salaried dental services
£5.7 million Improve access via dental tender
£1.1 (recurrent) into commitment payments

10. GDS Budget: other investments
£120k CPD for DCPs
£300k for 5 additional dental students
£3 million re-equip school of dentistry
£100k additional registrar posts
Occupational health services for the whole dental team

11. GDS Budget: Proportion of Earnings
2006/07
2007/08
2008/09
2009/10
2010/11
Items of Service
65.6%
62.3%
58.3%
59.5%
59.3%
Capitation & Continuing Care
21.6%
21.0%
21.9%
23.2%
22.6%
Block Payments (allowances)
12.7%
16.8%
19.8%
17.3%
18.1%

12. GDS budget – Overall Earnings & Expenses
net income
2007/08
2008/09
2009/10
Principal
£121,200
£129,600
£122,900
Associate
£66,100
£66,700
£62,700
6.8% earn £50-100K
5.2% earn OVER £100K

13. GDS Budget – increased provision

14. GDS Budget

15. GDS Budget: Market Changes

16. GDS Budget: Market Changes

17. GDS Budget: Proposals for Savings- Principles
Must have potential to realise savings for GDS budget
Can be implemented within existing GDS contract or with minor regulatory change
Can be implemented within coming financial year
Must be consistent with direction of new GDS contract
Comply with equality legislation & other regulatory requirements.

18. GDS Budget – Proposals for Savings
QIS- £1.16m transfer to GDS budget
Core service
Molar endo – prior approval
Co/Cr – prior approval
Bridgework – posterior/large; prior approval
Veneers -all prior approval
Alter time bar on S&P

19. GDS Budget – Proposals for Savings
Orthodontic treatment – IOTN 3.6, all other ortho prior approval
Practice allowance –new criteria
Average of 750 patients/DS, with average 200 fee paying
Removal of commitment payments

20. GDS Budget: Potential Savings
QIS funding transfer to the GDS budget - £1.161m
Move to a core service under the SDR: ~ £2m;
Altering claims conditions on S&P: ~ £1m
Changes to the practice allowance: ~£344k
Ceasing commitment payment: ~ £3m
Restricting orthodontic treatment to IOTN 3.6: ~£1.5m (full year effect realised over a 24 month period)

21. Process & timeline Restrict orthodontic treatment
This will require amendments to the GDS Regulations and the SDR
Consultation with BDA/PCC/ wider dental profession and public
Subject to the consultation/approval of the Assembly, could be implemented from summer 2012.
QIS funding to transfer to GDS budget
No changes to regulations or the SDR are necessary
The HSCB could action this with effect from 1 April 2012.

22. Process & timeline Move to a core service under the SDR
This will require amendments to the SDR
consultation with BDA/PCC/ wider dental profession and public
Subject to the consultation this could be implemented from summer 2012.
Alter S&P time-bar
Will require amendments to the SDR
Consultation with BDA/PCC/ wider dental profession and public
Subject to the consultation, could be implemented from summer 2012

23. Process & timeline Removal Commitment payment
will require amendment to both the GDS regs and SDR
Practice Allowance amendments to criteria
will require amendment of the SDR
Consultation with BDA/PCC/ wider dental profession and public
Subject to the consultation/ approval of the Assembly, could be implemented from summer

24. New Dental Contract

25. Primary Dental Care Strategy 2006
Local commissioning of services;
Access to appropriate dental care for everyone who needs it;
A clear definition of treatments available under the health service;
A greater emphasis on disease prevention;
Guaranteed out-of-hours services;
A revised remuneration system, which rewards dentists fairly for operating the new arrangements.

26. Problems with existing system
Quantity not quality is rewarded;
Treatment rather than prevention is rewarded;
Demand led rather than needs led;
SDR > 400 items is administratively complex;
Patient charges are difficult for the public to understand

27. Problems with existing system
Dentists incomes directly related to the volume of treatment provided causes remuneration treadmill;
HSCB lacks control over targeting services at areas and patients with greatest need.
50 year old system no longer meets the needs of patients, oral health care professionals or society at large.

28. Options for New System
Prof Ciaran O’Neill looked at range of remuneration systems
Retrospective Fee for Service (Item of service);
Prospective Payment System (Full capitation);
Salaried/Sessional system
Advised blended service

32. Essential Services Periodontal treatment Restorations
Endodontics (except molars)
Crown work
Extractions & surgical
Dentures –acrylic
Children’s treatment
Miscellaneous items

33. Exceptional Treatments
Molar endodontics
Co/Cr dentures
Bridgework
Veneers

35. Care Payments Quality care payments (QCPs)
Practice environment indicators
Practice inspection
Recognised charter-mark
Practitioner indicators
Peer review / clinical audit
Higher qualification

37. Patient Care Payment Weighted Capitation formula Adjusted for Age
Adjusted gender
Adjusted for additional needs
Adjusted for ‘new patients’
Adjusted for list turnover

38. Orthodontics

39. Oral Surgery Band Examples of complexity Patient charge A Charge A B
Assessment, radiographs, non surgical exts,
Charge A B
Multiple exts, surgical exts, fraenectomy, biopsies
Charge B C
Apicectomy, exposure, periodontal surgery
Charge C D
Multiple surgical exts, multiple apicectomies
Charge D

40. Pilots Use Pilot PDS Consultation October 2010 – March 2011
Responses very supportive
Oral Surgery pilot well advanced
Orthodontic contract will be phased in
GDS will follow oral surgery

41. Progress on New Contract
Essential services
complete
Exceptional treatments
Quality care Payments
Patient Care Payments
(weighted capitation formula)
Patient charges
Model developed
Oral surgery PDS
current phase with HSCB
Orthodontics
Phase 1 – 2012 & further phasing
Pilot group
ICT
Business case approved - ongoing
Contract & Regulations
ongoing

42. Why has it taken so long? Resources Addressing access issue
IT system at BSO
GDS budget – controlling pressures
Legislative problems – e.g. pensions, performers lists
Proposals from BDA?

43. How will new contract impact on profession?
Local commissioning – HSCB will target resource at need.
Control of entry –performers lists
Fixed GDS budget and global sum formula
Focus on prevention
Out of hours responsibility of HSCB

44. What’s in for Profession?
Limits number of dental practices
Increase value of practices?
Can opt out of Out of Hours
Work-life balance?
Performer/provider contracts
Career structure?
Capitation payments
Improved cash flow
Global sum
More stable budgetary position?

45. Local Decontamination Guidance

46. Content
Policy Background
Funding
Current Position
Regulation

47. Policy Background

48. A Protocol for the Local Decontamination of Surgical Instruments
Issued July 2001,
Health Estates DHSSPS
Key areas
All local decontamination outside of clinical setting where possible
Recommends automated washing
Downward displacement autoclaves- not suitable for processing wrapped instruments or hollow instruments
Do not re-use single use instruments
Described as short term strategy

49. BDA A12 Issued February 2003 Key points
Where possible instruments to be decontaminated in a separate room
Recommends washer disinfector over manual cleaning
Wrapped instruments must be sterilised in a vacuum autoclave
Single use instruments used wherever possible & discarded after use

50. Hine Review of Decontamination of Endoscopes
May 2004 problem identified with decontamination of endoscopes/ risk of cross infection with blood bore viruses
Review of effectiveness of arrangements for decontamination of endoscopes & lessons learnt
Service wide review of decontamination of all re-usable medical devices

51. Audit of Dental Practices
Letter issued to GDPs August 2004 re quality assurance of decontamination processes
Protocol for the local decontamination of Surgical Instruments (July 2001) reissued & dentists asked to comply
Letter from CDO issued all GDPs December 2004
Review current policies & procedures
Complete audit
Conform with recommendations in A12

52. Audit of Dental Practices - Outcomes
Overall compliance good (53% amber, 47% green)
Priority areas
Amalgam separators
Chart recorders for autoclaves
Independent water bottles
Dedicated rooms for decontamination
Washer disinfectors
Disposable instruments

53. Audit of Dental Practices – follow up 2005/06
Series of training workshops across NI (Dr Wil Coulter & Dr Caroline Pankhurst)
Cross Infection Control Manual
Cross Infection Control CD-ROM
Launched 2 May 2006

54. Development of Action Plan
October 2006; DHSSPS, Health Estates, Dental Directors, Dr Wil Coulter
Looked at priority areas from audit
Amalgam separators, chart recorders autoclaves & independent water bottles largely achieved & funding provided through QIS 2005 & 2006
Separate decontamination room, washer disinfectors & disposables logistically & financially more difficult to achieve
Needed to develop an action plan listing priorities

55. Workshop February 2007 & Publication of Action Plan
CDO, Dental Directors, Dental Practice Advisers, Infection Control nurses, LDCs, representatives RoI
Action plan agreed, developed & published (annual report 2007/08)
Washer disinfectors
Quality of water supply
Improved surgery layouts
Use vacuum autoclaves
Appropriate testing equipment
Procurement of equipment

56. Other Policy Influences
DH England working on HTM 01-05
Health Estates had observer status
BDA developing new A12
Working drafts shared with DH, subsequently withdrawn
Scotland
Glennie Group
Top ten tips
Ensured DHSSPS action plan consistent with working drafts HTM & Scotland
Nov 2007 QIS letter; Policy position; funding for priority areas; Advice & support; 3-5 year lead in time.

57. Evidence Base
Advisors HTM01-05; BDA, MHRA, HPA, Infection Protection Society, Healthcare Commission, Decontamination experts, GDPs, microbiologists, engineers
Evidence base published: Acts & Regulations; Codes of Practice; British, European & International Stds, research papers, Official Publications

58. Further Support
Supported Labour Government, Coalition Government, Minister DHSSPS.
NI, Scotland, England – all moving to similar standards but on different timetable.
ROI; New National stds for Prevention & Control of Health Care Associated Infections

59. Funding

60. Investments into GDS Practice Allowance: £4million additional (2007)
QIS: £3million additional (2007/08)
Commitment payments: £1.1million additional (2009)
Registration: £500k additional (2009)
Vocational training: £500k additional (2007)

61. Funding Profits: 07/08 £121,200: 09/10 £129,900:10/11 £122,900
QIS money key priority decontamination (approx £1million recurrent)
Addition QIS money 2007/2008 £3 million
Practice allowance ↑ from 5% to 11% September 2007
‘increasing practice requirements in relation to the provision of high quality premises, health & safety, staffing support & information collection & provision

62. The Health Service - 60 Years old
“We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving – it must always appear inadequate.”
Aneurin Bevan

63. Current Position

64. Nov 2009 DH publish HTM 01-05 (Hard Copy)
10 Feb 2010 DHSSPS issue NI position, accept HTM01-05 with modifications (PEL(10)04):
Washer disinfector – manual cleaning not a validated process
Timescale: must have achieved best practice by
Instruments processed in a type N autoclave cannot be subsequently wrapped & stored – use within working day
Exemplar room layout; fig 1 does not apply (no WD)

65. Minimum Standards for Dental Care and Treatment
Primary Care Private & HS
RQIA will inspect against
HSCB will commission against
Std 13:’Prevention & Control of Infection’
‘Your dental service meets current best practice on the decontamination of reusable dental & medical instruments’.
Issued March 2011

66. RQIA -Regulation Private Dentistry
Legislation – HPSS (QIR) NI Order 2003
Amend Order through regulations to permit regulation of all private dentistry
Regulation commenced 1 April 2011
RQIA; Register & annual inspection
Any dental practice which provides any private dentistry
Inspect against dental standards
Inspection Reports published on the RQIA web-site

67. Other Guidance since PEL (10) 04
Scottish Health Technologies Group Advice Statements
Wrapping Dental Instruments
Benchtop steam sterilisers
Sterilization of Dental Instruments (SDCEP)
BDJ: Time-dependent recontamination rates of sterilised instruments
IDJ: Three Steps to Decontamination Heaven

68. Review of PEL(10) 04 DHSSPS reviewed PEL (10) 04 in summer 2011
HSCB
RQIA
NIMDTA
Await results of recontamination studies UCL
Offered meeting with BDA

69. Non-compliance

70. Compliance DHSSPS has provided significant funding
Minister will be held accountable for delivery
Profession will be expected to deliver
All 14 Oasis practices are compliant (230 across UK)
Do not report significant problems
Other NI practices have already complied or are close to compliance
DHSSPS, NIMDTA & HSCB considerable resource into training to aid compliance

71. What’s next?
Direct Access
Amalgam

72. Contacts & References
CDO website for Newsletters, annual reports & other publications
PEL (10) 04 on HE website
Dental Standards
HE contact number for advice

73. Thank You