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

Presentation to Northern LDC

Donncha O’Carolan

Chief Dental Officer

5 April 2012

Overview of Presentation

• GDS Budget & Pressures• New GDS Contract• Local Decontamination

Guidance

DHSSPS Structure

CDO

Minister

Permanent Secretary & Deputy Secretaries

HEIG SQSPrimary

CarePublic 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

GDS Budget

GDS Budget – Structure Net

Patient

GDS Budget – Structure

Net Patient


Under spend

Patient


Patient

Pressure

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

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

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%

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

GDS Budget – increased provision

2007 2008 2009 2010 20110

200

400

600

800

1000

1200

Patients (000s) Dentists Practices89

873

536

1

1001

10

98

381

GDS Budget

2006/07 2007/08 2008/09 2009/10 2010/11 2011/120

20

40

60

80

100

120

Patient charges

Over spend

Net

GDS Budget: Market Changes

GDS Budget: Market Changes

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.

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

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

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)

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.

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

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 2012.

New Dental Contract

Primary Dental CareStrategy 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.

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

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.

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

Blended System of Remuneration

Care Payments Item of Service

Patient Care Payment For Registration, Examination, Patient Appraisal, & Prevention

Quality Care Payment Practice Practitioner

Essential Services & EXCEPTIONAL

TREATMENTS

Occasional Services

IN

PARALLEL:

Private care (M

ixed E

con

om

y) • 1° Sp

ecialist care • 2° C

are

History- taking By Dental team

Clinical Examination E.O. & I.O. (dental/perio)

Risk-Based Patient Appraisal

Preventive Services

CCAA

RREE

PPAA

YYMM

EENN

TTSS

[[ PPaa t

t iiee n

ntt

CCaa r

r ee &&

QQuu

aa ll ii tt

yy CC

aa rr ee

]]

Essential Services

Exceptional Treatments

ASSOCIATED PROCEDURES e.g. Radiographs (IF INDICATED)

Recall Interval

II ooSS

PPAA

YYMM

EENN

TT

Simple Perio Care






TREATMENTS

Occasional Services

Essential Services

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


• Molar endodontics• Co/Cr dentures• Bridgework• Veneers






TREATMENTS

Occasional Services

Care PaymentsQuality care payments (QCPs) • Practice environment indicators

• Practice inspection• Recognised charter-mark

• Practitioner indicators• Peer review / clinical audit• Higher qualification






TREATMENTS

Occasional Services

Patient Care Payment

• Weighted Capitation formula• Adjusted for Age• Adjusted gender• Adjusted for additional needs• Adjusted for ‘new patients’• Adjusted for list turnover

Orthodontics

ORTHODONTIC ASSESSMENT Examination Assessment Charting

ASSOCIATED PROCEDURES (if indicated) Radiographs Photographs Models

P

rivate Sp

ecialist Orth

od

on

tic Care

REVIEW FOR TREATMENT

GDP

TREATMENT COMMENCING

SIM

PL

E A

PP

LIA

NC

ES

SIN

GL

E A

RC

H F

UL

L

FIX

ED

AP

PL

IAN

CE

S

DO

UB

LE

AR

CH

FU

LL

F

IXE

D A

PP

LIA

NC

ES

FU

NC

TIO

NA

L A

PP

LIA

NC

E

TREATMENT ABANDONED

TREATMENT DISCONTINUED

INCLUDING: PRE & POST-OP MODELS ANY OTHER STAGES REPAIRS RETENTION

2º Specialist Orthodontic Care

REFER FOR TREATMENT

REFERRAL (Guidelines)

TREATMENT DECLINED

TREATMENT NOT INDICATED


Process

NOT ACCEPTED

ACCEPTED

ORTHODONTIC TREATMENT

OPTION

DH1/10/69575

Oral Surgery

Band Examples of complexity Patient charge

A 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

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

Progress on New ContractEssential services complete

Exceptional treatments complete

Quality care Payments complete

Patient Care Payments(weighted capitation formula)

complete

Patient charges Model developed

Oral surgery PDS current phase with HSCB

Orthodontics Phase 1 – 2012 & further phasing

Pilot group current phase with HSCB

ICT Business case approved - ongoing

Contract & Regulations ongoing

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?

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

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?

Local Decontamination Guidance

Content

• Policy Background

• Funding

• Current Position

• Regulation

Policy Background

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

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

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

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

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

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

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

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

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 01-05 & Scotland

• Nov 2007 QIS letter; Policy position; funding for priority areas; Advice & support; 3-5 year lead in time.

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

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

Funding

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)

Funding• Profits: 07/08 £121,200: 09/10 £129,900:10/11

£122,900

• QIS money 2005 - 2010 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

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 - 1948

Current Position

• 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 2010-12– 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)

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

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

Other Guidance sincePEL (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

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

Non-compliance

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

What’s next?

• Direct Access• Amalgam

Contacts & References

• CDO website for Newsletters, annual reports & other publications

http://www.dhsspsni.gov.uk/pgroups/dental/dental.asp

• PEL (10) 04 on HE website

http://www.dhsspsni.gov.uk/index/hea/decontamination-general-dental-practices.htm

• Dental Standards

http://www.dhsspsni.gov.uk/index/dental/dental-pubs.htm

• HE contact number for advice

028 90 523802

Thank You

Documents

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