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
Clu
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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
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hori
ty
Fie
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JSNA
Commissioning priorities
Local DemocraticAccountability
Fie
ld F
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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