The Future for Prison DentistryAn update about changes to the NHS and

NHS dentistry

Sue Gregory OBE

Deputy Chief Dental Officer (England)

NAPDUK: Managing the impossibleBirmingham, 3rd February 2012

Overview

The reformed system

New ways of commissioning

A single operating framework for dentistry

The role of clinicians

Dental contract reform

Contract Pilots, the clinical perspective

IT implications

Background• Equity and Excellence: Liberating the NHS – the Government’s vision for health services:

– Patients are at the heart of everything the NHS does– Healthcare outcomes in England among the best in the world– Clinicians empowered to deliver results

• New Public Health Service

• Liberating the NHS: Commissioning for patients supports the White Paper by setting out a new commissioning architecture for the NHS to drive improvements in healthcare

• ‘Developing the NHS Commissioning Board’, published July 2011, sets out the top structures for the Board

• The new architecture of NHSCB will take on many of the roles and responsibilities currently discharged by the Department of Health, Strategic Health Authorities and Primary Care Trusts

• Responsibility for most commissioning with commissioning consortia, supported and supplemented by the NHS Commissioning BoardThe NHS Commissioning Board will be responsible for commissioning all NHS dental services

Public Health England

Public Health England

Public Health EnglandNHS

Commissioning Board

NHS Commissioning

Board

NHS Commissioning

Board

Dental Professional

Network

Involvement of other clinicians, locally determined and based on local priorities

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ub n

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Nat

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ier

Loca

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horit

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DirPublic Health

Dis

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vel

Loca

l Aut

hori

ty

Fie

ld F

orc

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JSNA

Commissioning priorities

Local DemocraticAccountability

Fie

ld F

orc

e

SoS

Clinical Commissioning

GroupsClinical

CommissioningGroups

Clinical Commissioning

Groups

Health and Wellbeing Board

Effective communication with the wider dental community

Loca

l Den

tal C

omm

ittee

GDS ContractPDS Contract(generalist)

Paediatric

Specialist PracticePDS Contract and

Secondary Care

A&E

NHSDirect

OMFSResto- rative

Special

Care

Ortho

DWSI

NCB Commissioning Responsibilities

Clinical Pathways

Direct Commissioning Workstream

Oversight and delivery of;• Primary care commissioning• Specialised commissioning• Military health and• Offender health

Commissioning of Dentistry

Design a new system of commissioning dentistry as part of the development of the single operating model of the NHS Commissioning Board – the operating model

Have a process of convergence to the new system that ensures a safe and proper transfer of responsibilities in 2013

The direct commissioning work stream has been working to:

Ensure that the new system has the capability to transform the provision of patient care through better commissioning

The board will be a single national organisation with a single operating model and will hold all main primary, community and secondary dental contracts. This requires consistency of policies, procedures, systems and processes for all contractual matters

Some aspects of dental commissioning will continue to be organised nationally but significant aspects will need to be carried out locally to reflect the large number of local providers as well as the need to ensure commissioning decisions reflect local needs and circumstances

The Board will drive implementation of the national strategy at a local level as well as responding to local issues in the development of contracting levers and national strategy

BSA Dental Division and other commissioning support functions will be important to deliver the single operating model

Key features of the operating model

Specific issues for commissioning dentistry

• Basis of reforms is that clinicians already make commissioning decisions

• Opportunity to commission dentistry in an integrated way• Single operating model with consistency where it is required, but

must allow flexibility where it is justified• Transition year 2012/13 hugely important to gain traction• Local relationships with strong system alignment will be key• Dental public health• Primary, CDS and urgent care commissioned and managed on a

field force footprint• Secondary and specialist dental services

HWBs Clinical Commissioning

Groups

Strategy, policy, contract, procedure and assurance of achievement of outcomes

Implementation and development plans to reflect local circumstances

Local intelligence, clinical expertise, innovation and development of integrated care pathways

Peer support, peer review and benchmarking

Maximising performance

NHSCB

national

NHSCB

local

Localprofessional

networks

Informing needs, demand, supply in primary, community and secondary care

Aggregation of need and assurance of performance

HEE local networks

The NHSCB local arms will require close working relationships with CCGs, PHE and HWBs

PHE

Dental Local Professional Networks in focus What are they?

An integral part of the NHS CB field team with links to national clinical networks and clinical senates

A vehicle for clinically led and clinically owned delivery of;• Quality improvement – CQC, LPN, field team• Best outcomes for patients that reflects local need – JSNA, oral health strategy• Best use of NHS resources – clinically owned commissioning• Planning and designing integrated care pathways – leverage in commissioning• Leadership and engagement – ensuring

To ensure clinical leadership at the heart of the local operating model

Design proposals for LPNs describe those functions where clinical expertise and leadership can add most value within local commissioning operating model

Commissioning managers and clinicians delivering NHS CB vision together

Common purpose

Core Clinical Commissioning Team

(commissioning managers, clinical

quality and network leaders, public health)

Local clinicians

(clinical expertise for ‘task and finish’ projects, quality

improvement, pathway re-design, strategic development

and planning)

All primary care providers (influence, communications,

roll out, embedding)

Local Professional Networks Operating Model

Relationship with the NHS CB through local teams

clinical engagement and leadership

Local variation where justified by health needs

Consistency in approach to commissioning

In addition to the core LPN team and network arrangements, there will be mechanisms to draw on specific areas of expertise

•Leadership and accountability for LPNs would come from within their core teams and link closely to senior commissioners within the field force

• Discussions so far have suggested that LPNs would include the following clinical and professional input from an identified ‘pool’ of clinicians to feed into their work;

• Primary and Secondary Care Commissioners• Dental Public Health (resourced from LA/PHE) • Quality and Performance Improvement Leads •Clinical and Professional Expertise Input – primary care clinicians• Specialist Clinical Input – secondary care• PC clinicians with a specialist interest

•Health and Wellbeing Board representation •Clinical Skill Mix (e.g. dental nurses)• Local Dental Committees • Workforce and Development – deaneries, CPPE• Patient and the Public Representation• CCG Representation • Interdependencies to support as appropriate – e.g. Informatics, Finance, PC regulatory experts

LPNs and their clinicians

• Fundamental change in thinking, culture and behaviour • Desire to improve quality and services for patients• Population view - public health specialists• Evidence – based approach• Strategic and operational skills• Objective decision making• Willingness to take action and responsibility• Carrying the local profession with the NHS CB and LPN• Ensuring success in new relationships, behaviour and culture

Leadership

Management

Advice

Move towards leadership for clinicians

Relationships

• InternallyNHSCB – local and national

Wider local and national clinical networks & senates

• ExternallyLocal authorities - HWBs

Patients – healthwatch Clinical Commissioning GroupsPublic Health England - CDPHsProviders/performers (primary, community and secondary)LDCs

• Managing conflicts of interest

Challenges and Opportunities

• Shift in culture – ownership within ‘corporate’ model

• The right incentives to be involved

• Governance – conflicts of interest/self interest

• Delivery within the challenges of financial austerity and national operating model

• Demonstrating the design proposals are worth the investment – testing LPNs

• Clinical capacity to provide robust quality improvement and patient outcomes – level playing field

• Clinicians in a leadership role within the system that commissions their services – shift from clinical advisory role to commissioning leadership

• Enabling clinicians to design care pathways that best meet patient needs

• Expertise where best adds value

• Consistency in approach to commissioning and relationship between NHS dental providers and NHSCB

• Local relationship with the NHSCB through local teams, but economies of scale where leverage can add value

• Local variation where justified by health needs

• Local clinical engagement and leadership across dental professions

• Opportunity to have all dental services commissioned in an integrated way

• Clinically led and clinically owned service improvement and transformation

The reforms for dentistry…

Dental Contract Reform Pilots

Pilots are testing several components:

The oral health assessment and risk screening

A capitation approach

An outcomes approach

…………to assess whether they provide the basis for a dental contract and contribute to improving oral health.

Type 3Weighted capitation &

quality model, with separate budget for higher cost

treatments

Pilot Contract TypesType 1

Simulation Model

Pilot practices will be guaranteed their contract value (their remuneration in the current contract year) and required to deliver the same NHS commitment whilst adhering to the new pathway.

Type 2

Weighted capitation & quality model

These pilots will test the implications of applying a national weighted capitation model where capitation payments vary for different patients depending on the factors on which the national capitation model is based.

These pilots will test the implications of applying a national weighted capitation model but the capitation payment will be for preventative and routine care only and complex care will be funded separately.

Care Pathway Approach Principles

Oral health assessment with a standardised approach

Focus on promoting health, not just on repair and treatment

Stronger focus on outcomes and effectiveness

Recognises potential of clinical engagement and using whole team to deliver care pathway

Clinical pathways in primary dental care

Patient Assessment

Risk Screening

Care Pathways

Recall intervals

Patient self-care plan

Patient Assessment

Patient self-care plan

Entry criteria Complexity Assessments

Quality Indicators

Overview of risk screening processRisk

screening

-

-

-

-

-

-

-

-

Domains Risk Category

Prevention

Patient actions……………

Dentist actions……………

T1

Self care plan, preventive and treatment plans

Caries

Perio

Soft tissue

TSL

P

C

C

P

= Clinical Factors

= Patient Factors

KEY

= Time intervalT

P

C

P

C

P

C

Patient Assessment

-

-

-

-

-

-

-

-

Recall

T2T3

Patient actions……………

Dentist actions……………

T1T2

T3

Patient actions……………

Dentist actions……………

T1T2

T3

Patient actions……………

Dentist actions……………

T1T2

T3

Determining the clinical and patient factors for CARIES

Domain

Risk

Teeth with carious lesions

Caries

Sibling experience

Diet

Excess sugar

Frequent sugar

Poor plaque controlNo teeth with

carious lesions

Patient factors

+ =

Actions

(pathways)

Professional Patient

Patient Communication

Age

Clinical factors

Symptoms

Red risk status

Amber risk status

Green risk status

Assigning riskThe patient’s risk status for each domain is determined as follows:

Allocated if there is a red clinical factor, this cannot be modified by patient factors.

Amber risk status is allocated if there is an amber clinical factor, or if there is a green clinical factor but a co-existing patient factor which increases risk e.g. a patient with no caries would still be classed amber if there was poor plaque control

Green risk status is allocated to those with green clinical factors and no patient factors which increase risk.

Pilot Dental Quality & Outcomes FrameworkQuality is a necessary part of future dental contracts and it will take time to get a quality system that is solely outcome based. Quality is defined as covering three domains:

Clinical effectiveness

Patient experience

Safety

Measures ready for contract

pilots

Measures ready for contract

implementation

Longer term development of

quality indicators

Continual development

and raising the bar

Pathway Development

Work on quality indicators, and in particular outcome indicators, is relatively new in the NHS and even more so in dentistry. The DQOF will therefore continue to be developed over the coming years. The framework will be underpinned by the development of a comprehensive set of accredited clinical pathways.

The DQOF working group followed the process outlined below working back from first principles to define indicators that support the consensus within dentistry that good oral health is the ideal clinical outcome:

The Development of DQOF

For a patient to be in good oral health, we mean;

They are free from pain

They have good functionality and aesthetic form to their teeth – They can “eat, speak and socialise”*

They have clinically assessed good oral health now and we are confident that this will continue into the future

Principles

The patient’s view of being free from pain and good functionality should be covered by patient experience and PROMS domain rather than clinical effectiveness

Outcomes (patient view)

The clinical view is covered in this domainand focuses on:Improvement in oral healthMaintenance of good oral health

Outcomes (clinical view)

*(World Health Organisation 1982)

MeasuresClinical components of the OHA:

Improvement Maintenance

Caries

Perio

Elements of PDCPA for DQOFClinical

Domains

Measured at Review

Caries

Perio

Soft tissue

TSL

P

C

C P= Clinical Factors = Patient Factors

Key

P

C

P

C

P

C

Patient Assessment

-

-

-

-

-

-

-

Utility of PDCPA for DQOF measure

x

x

x

x

x

x

Maintenance/improvement3 categories

Maintenance/improvement2 categories

Clinical Effectiveness Outcome Indicators for payment (60%)

MeasurePoints –

MAX:600 Active 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

Active Decayed Teeth (DT) aged 6 years old and over, reduction in number of carious teeth/child

75% over 6’s improved or maintained

150

Active Decayed Teeth (DT) reduction in number of carious teeth/dentate adult

75% improved or maintained150

75% patients with BPE improved or maintained at oral health review 7550% patients with BPE 2 or more with sextant bleeding sites improved at oral health review

75

The following outcome indicators are derived from the clinical elements of the assessment based on the standardised NHS primary dental care patient assessment (PDCPA) and the associated risk screening process. The indicator information will be captured at review and achievement of the indicator is described as either maintaining or improving a patient’s condition.

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% =15Level 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% = 15Level 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%= 15Level 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% = 25Level 2 85%-100% = 50

Would you recommend this practice to a friend?

% of patients who would recommend the dental practice to a friend

MAX: 100Level 1 70%-79% = 50Level 2 80%-89%= 75Level 3 90%-100%=100

How satisfied are you with the NHS dentistry received?

% of patients reporting satisfaction with NHS dentistry received

MAX: 50Level 1 80%-84% = 20Level 2 85%-89% = 40Level 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: 10Level 1 70%- 84% = 5Level 2 85%-100% =10

Safety Indicators for payment (10%)

Safety quality measures will fall under the remit of CQC and work with professional bodies such as the GDC. The dental profession and commissioners are committed to ensuring that clinical practice remains safe and that safety is a fundamental part of the service that is delivered.

Consequently, patient safety overall is not something that should be rewarded through a quality payment as all dentists should adhere to safe practices. However 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

Indicators for monitoring overall quality (no payment)

Measure Domain

% of children aged 11 who have had an assessment of unerupted canines Clinical effectiveness

% of children aged 18 and under who have had fluoride varnish in the last year.

Clinical effectiveness

Was the cost of treatment explained to you before your treatment started? Patient Experience

Do you understand what you personally need to do to maintain and improve your oral health?

Patient Experience

Do you understand how healthy your teeth and gums are? Patient Experience

It is proposed that the following quality indicators are monitored throughout the pilots to understand the impact of the change of system on clinical behaviour and patient perception.

Advanced care pathways

Indirect restorations

Metal based partial dentures

Endodontic treatment

Advanced periodontal care

Now starting work on minor oral surgery and intend then to look at paedodontics

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

yes

yes Offer indirect restoration

Decision making cascade

Ongoing support

Regional Support Leads and PCC Advisors regular contact with PCTs and Pilot Practices

Twice weekly clinical telephone calls

Pilot Perspective Newsletter

Future events for both PCTs and Practices

Peer Support Groups for Practices

Information Portal (NHSDS)

Electronic Information network

Overview of the Pilots Selection process – sampling to ensure variability

Ran from December to January500+ expressions of interestPCT and SHA involvement

150 pilots initially considered

Reviewed down to 72, with some substitutes

Pilot Type identified for each practice

Support to PCTs and Pilots via national pilot team and identified Regional Support Leads

Overview of the Pilots, contdFebruary to September was contract implementation

New SFE

Contract Variation Notice

Working with PCTs and Pilots for baseline data

- Contract values

- Skill Mix

- NHS Hours

70 practices now “live” as o f 1st September

Overview of the Pilots, contd Practice staff attended Clinical and Software

Training

Software support from the suppliers involved- Software of Excellence, Carestream and Dentsys

Beta testing of pilot software

NHS BSA DSD continues to pay pilots and provide management information

PCTs remain the commissioner and contract holder

Ongoing support/Ongoing listening

Regional Support Leads and PCC Advisors regular contact with PCTs and Pilot Practices

Twice weekly clinical telephone calls

Pilot Perspective Newsletter

Future events for both PCTs and Practices

Peer Support Groups for Practices

Information Portal (NHSDS)

Electronic Information network

DCDO practice visits

Learning from the Pilots

Qualitative

the experiences and impact on

– Dentists

– PCTs

– Patients

Quantitative

Clinical data set from Oral Health Assessment

DQOF

Feedback on OHA and care pathway

Generally positive from both dental team and patients

OHA appointment length

Important to manage appointment book

IT is being beta tested during roll out – no major crashes

Skill Mix Issues

Hygienist

Smoking cessation adviser

Extended duties dental nurse

Therapists

Computer Software

Designed to collect and transmit:

Entirety of oral health needs assessment- including complexity of care and referral information

Entirety of treatment delivered information

Inbuilt matrices to support:

Individual risk assessment by clinical domain

Evidence based prevention plan for both patient and dental team

Hardware

Requirement for in-surgery data collection

Hardware specifications vary by supplier, dependent on the overall platform on which they have built the pilot software

Patient self-care plans need printing

Computer Systems

3 software suppliers

Beta testing as we go

Weekly conferences calls with suppliers

Regional support leads logging issues

Currently developing a transmission guide for practices

Electronic transmission 2 separate transmission streams:

- oral health assessment and treatment delivery- FP17 and course of treatment, PCR

Separate functionality to transmit both streams

Variation in transmission reports, even within software suppliers: - some practices successfully transmitting both- some transmitting peripatetically both- some one stream no the other

Too many error messages of no relevance

? Training issue rather than functionality

Pilot software review and refinement

November to February review and refine software in light of flaws and issues raised in beta testing and early piloting

Steering group and focus groups

Technical and clinical issues included

NOT reviewing care pathways

Next steps

Pilot will help inform the proposals for a new dental contract

Policy team at DH to develop proposals for the new contract, and for reforms to the patient charging system to fit in with the new contract.

The changes will require legislation, which will be introduced to Parliament in a Bill – timing to be confirmed.

Public consultation on the changes……

Leading to……Legislation to introduce new contract