NHS Contract Reform

BDA Views.

John Milne

GDPC Chair.

How we got here

• Options for Change• PDS pilots• 2006 contract• Steele Review• Coalition Pledge• Context of changing

demographics of disease• Wave 1 Pilots• Wave 2 Pilots• Implementation

Options for change (2002-3)

• Recognised problems of IOS• Recognised need for prevention• Collaborative working- DH and BDA• Clinical Pathways• Changing skill mix• Different remuneration schemes.

PDS (pilots)

• Positive start?• Sidetracked as a route for new access as NHS access

was falling• Few controls• Reduced PCR• Better working conditions for dentists?• Gaming• Neglect?

2006 contract

• Imposed• Talks with profession broke down• Confusion over currency of contract

• Introduction of UDA (not conceived originally as a currency, more a reflection of differing workloads related to oral health of practice population)

2006 contract: It’s all about control

• Budget• Workforce• Location of Services• Access to services and

growth• Workload and output

Well documented difficulties with the 2006 contract

Slide 8

2006 problems

• No incentive to maintain access

• No guarantee of NHS care for patients

• Pension problems for some providers

• Difficult to grow successful practices

• Gaming behaviours (dentists)

• Gaming behaviours (PCTs ATs)

• Few checks on clinical quality

• Inconsistencies in practice sales,

incorporation.

• Unreasonable and bullying PCT behaviour

• No flexibility eg snow, flu.

• Increased referrals to Salaried and hospital

services

• Deskilling

• Less advanced care

• PCT Variations

• And and and and.................

• Inequity in contract values• No reward for prevention• Discrimination of high needs• Professional jeopardy with claims

interpretation• Clawback and targets• Inaccurate calculation of contract values• Practice contract may have disadvantaged

associates• Difficulty of hitting targets whilst treating pts

ethically• No reward for additional work• UDA being used as a currency to drive

contract prices down.• Variable levels of care• Lack of clarity what NHS care means• Inequality of contract values in an area

Caption here

Steele Review

• Health Select Committee• Widespread criticism from all

sides of 2006 contract.

• Steele Review• Hierarchy of provision• Assessment and control of

disease risks• Level of care dependant on risk

control and likely success.

• Workshops: BDA “Engagement with extreme vigilance” Recognition of “Big Challenge”

• Early pilots

(needed brave PCTs!)

Caption herePublic health

Urgent care and pain relief

Personalised disease prevention

Continuing care

Advanced and complex care

Treatment of dental disease

Reducing priority for public investment

What are the priorities of NHS dentistry?

13

NHS Dentistry: What could it do?

“NHS dentistry could lead the world in providing an

Oral Health Service”Jimmy Steele 2009.

Better Not Worse

What’s important?

For the profession• Improved patient

outcomes• Fair remuneration• Job security• Current benefits

preserved• Ability to transfer

contracts (goodwill)• Financial stability in

transition stage.

For the public• Access to quality care

• And urgent care• Improved oral health

outcomes• Good experience• Clarity of what the NHS

will provide• Simple charging system

Coalition government pledge

• New Dental Contract• Registration• Capitation• Quality and Outcomes

• Access still a priority• Children’s health

particularly important

• National Steering Group• Continued BDA

Engagement with vigilance.

Registration, capitation, quality and outcomes

Caption here

Oral Health in 12 year olds

Oral health status projections2010

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

16-24 25-34 35-44 45-54 55-64 65-74 75-84

1998

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

16-24 25-34 35-44 45-54 55-64 65-74 75-84

2020

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

16-24 25-34 35-44 45-54 55-64 65-74 75-84

2030

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

16-24 25-34 35-44 45-54 55-64 65-74 75-84

Healthier - low treatment needed

Less healthy - high treatment needed

No teeth

Oral Health Assessment: leads to homecare plan and professional care plan.

• Medical History• Alcohol and tobacco• Social History

• Family caries history

• Diet and tooth-brushing• Full chart of restorations• Full chart of carious

lesions

• BPE• Bleeding• Pocket chart

• Tooth surface loss (relative to age)

• Soft tissues

Pilot design

• RAG ratings in each domain.• Care Pathways• DQOF

• Safety• Patient Experience• Clinical effectiveness

• Early work on complexities and competencies• Professional consensus

Oral health

assessment

Treatment & stabilisation (if necessary)

Does this patient need to be seen for additional preventive care/advice between now & OHR?

When do I need to recall this patient?

RAG status

Steps in the primary care pathway

Date of oral health review

Step 1

Step 2

Step 3

PREVENTION

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

Pathway in action.........

DQOF- clinical effectiveness 60%

Measure Points – MAX:600

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

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

75% over 6’s improved or maintained

150

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

75% improved or maintained

150

75% patients with BPE improved or maintained at oral health review 75

50% patients with BPE 2 or more with sextant bleeding sites improved at oral health review 75

The indicator information will be captured at review and achievement of the indicator is described as either maintaining or improving a patient’s condition.

DQOF 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

DQOF 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:

Measure Points – MAX:100

90% of patients for whom an up-to-date medical history is recorded at each oral health review

MAX: 100

Wave 1 Pilots

Practioners

• Liked philosophy and approach• Appointment book problems

and time pressure• Paying associates?• Interim Care• IT problems• Time• Access• Skill-mix +ve and -ve• Clawback if access drop.

Patients

• Valued increased communication and understanding and RAG

• Valued preventive care

Wave 2 Pilots- Responsive

• Improved IT• Some streamlining• Override

• Modified patient charges• Access imperative clear• Includes salaried service.

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)

Views about the use of RAG ratings

58%

(31%)

The ‘traffic light’ ratings make it easier for me/patients to look after teeth and gums (oral health)

41%

(22%)

1%(1%)

The ‘traffic light’ ratings make no difference to how I/patients look after teeth and gums (oral health)

The ‘traffic light’ ratings make it more difficult for me/patients to look after teeth and gums (oral health)

75%

19%

0%

N.B. Figures in brackets refer to data based on all patients (3,760)

PRACTITIONERSPATIENTS

37

RAG status changes

26% 24%

67%65%

6% 11%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OHA OHR

RAG status change in adults, from OHA to latest OHR

Green

Amber

Red

11% 9%

32% 31%

57% 59%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OHA OHR

RAG status change in children, from OHA to latest OHR

Green

Amber

Red

• Findings relate to patients who had an OHA Sept 2011- Mar 2012 who returned for an OHR by Mar ’13

• Net improvement where there is complete data• Adults: 2% reduction in red patients and 4% increase in green• Children: 2% increase in green patients and 2% reduction in red

Is disease risk consistently capturedand communicated to patients?

• Yes, and RAG ratings are being generated • Distribution of the ratings is broadly as would be

expected from the epidemiology, particularly for those at greatest risk

• Some 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”

Pilots so far..............................

Best thing I’ve ever done, free from UDAs at

last. Can deliver proper

care.

Worst thing possible, no way this system can

work!

Slide 41

What about Associates?

• Falling incomes•Uncertain futures•Replacement with DCPs• Concern about de-skilling• Anxious about pensions

•They too deserve a good career and a secure future

UDA

UDA

UDAU

A

We need some honesty in the debate.

• Access• NHS Offer• Scope of advanced care.• Elderly Population• Existing inequalities

Capital

• Risk v Reward.• Buildings• Equipment• Future investment• Returns

The pilots are not the finished

article

Issues to solve

• Practice viability and sustainability• Avoiding supervised neglect• NHS Offer• Mixing and private care• Incentivising Quality and Access• Transitional arrangements ? MPIG• PCR• Growth• Contract Management• Capitation payment mechanisms (full or partial)

UDA Distribution.

Capitation 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 and• assuming that the patients have the same age and sex profile

as the practice population and• using the patient capitation values from the pilots• It is clear that the required patient numbers could change for

many practices

Small practice in London

• 4,500 patients• £350,000 contract value• Higher than average £/UDA• Would have to take on 490 new patients

Large practice in West Sussex

• 11,000 patients• £800,000 contract value• Lower than average £/UDA• Practice will need to see 790 fewer patients

Average size practice in the North West

• £570,000 contract value• 11,000 patients• Just below average £/UDA value• Practice can lose 2,000 patients

Capitation

• Transitional protection is needed to manage changes in patient numbers or potential cuts in contract value

• There might be additional weighting to capitation amounts to take account of factors such as rurality or staff pay factors

• The DH is currently modelling capitation scenarios and there is no information yet about how it is going to work

Where to now?

• Evaluation (ongoing by BDA and DH)• Learning what does and doesn’t work

• Listening to pilots and patients

• Practical framework design• Negotiation• Big Bang or Phase roll out

What do we want?

• Improved oral health• Sustainability of practice

• Long term future.

• Career pathway for dentists• Practice ownership and

equity

• Realistic workforce planning

• Proper remuneration

When will it all change?

Caption here

Let’s hope so!

Will this have a happy ending?

Some 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?