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DENTAL CONTRACT REFORM

 

The remit for dental contract reform in the engagement exercise was:

 

Neutral over all expenditure

Maintain present scope of NHS care

Capped contract remuneration

Metrics for measuring delivery and financial recovery

The ability to flex the levels of service.

Patient charges to raise a similar proportion of costs

Allow appropriate mixing of NHS and private care

 

We would also add the following:

 

Core prevention commissioned in the contract

Improved care for patients

Sustainable business model for practices

Support for quality care and treatment through greater time

Introduce the concept of peer review, education and self regulation.

Establish a culture of we rather than them and us.

 

 

Firstly the DOH basket of requirements leaves very little room for maneuver. Indeed as the pilots have demonstrated satisfying all these requirements is difficult and indeed requires a series of compromises.

 

 

Secondly let us look at what really worked well with the pilots.

 

1. The care pathways approach has received universal support across Dentistry. There is a requirement for more work on linking some medical history / pharmacological / social history with risk status. In addition as up to 70% of recall intervals are being over ridden by pilot practitioners there is clearly a need to look closely at the soft ware drivers for recalls. On the whole though the care pathway approach is seen as very positive by practitioners and patients.

 

2. The prevention aspects of the pilots are excellent. For too long now prevention has been ignored in terms of funding. The pilots were able to place prevention at the centre of their practice. This means that targeted, individualized prevention can be delivered. The concept of Interim Care is an excellent one. The development of this concept, particularly in terms of using DCP’s to deliver this aspect of the care pathway is important.

 

3. Practices felt “liberated “by the removal of UDA targets. Practitioners felt more relaxed about spending more time with patients to deliver treatments. As a result they felt tat the quality of care increased.

 

 

Where possible we would propose retaining these elements of the pilots within contract reform.

 

 

Thirdly let’s look at what did not go so well.

 

  1. 1.The P.C.R levels were reduced resulting in the service becoming more expensive.

 

  1. 2.The access levels dropped resulting in fewer patients being treated and fewer new patients getting access to care.

 

 

  1. 3.The list sizes of practices were difficult to maintain and as a result even though the practitioners were working longer hours than under the UDA contract practice claw back was taking place.

 

4. Recall intervals were routinely over ridden. We propose that           more soft ware work is done to find out why this was happening.

 

We propose strategies that will hopefully reduce the impact of the above within contract reform.

 

 

 

 

 

 

 

 

In summary

 

Include care pathways

 

 

Look at ways of incentivizing:

 

Access and patient retention.

Quality of care

Prevention.

Activity

Urgent care

Education and self regulation.

Up-skilling – to provide additional/specialist care

 

Establish a culture of problem solving rather than problem acceptance and associated frustration.

 

 

Look at ways of disincentivising:

 

Inappropriate referrals

Inappropriate care

 

We support the idea of a Blended Contract Reform. The key drivers for remuneration to be centered around:

 

ACCESS

 

ACTIVITY

 

QUALITY

 

 

 

 

 

The framework for remuneration to be around the following:

 

ACCESS - 40%

Broken down in to;

35% list size dependant

5% patient turn over/growth.

 

ACTIVITY – 45%

UDA scored and managed – but with more sensitive banding encouraging prevention and hopefully reducing referral rates.

 

 

QUALITY - 15%

Based on:

Patient experience -4%

Patient safety-2%

Clinical Effectiveness – 4%

QOF-3%

SCORED PEER REVIEW PRACTICE VISIT – 2%

 

 

ACCESS                    40%

 

In real terms the success of a provider can usually be measured by the numbers of patients choosing to access care. In simple terms if access is a driver for provider remuneration and therefore performer remuneration this system should result in greater quality of care for patients and greater patient retention. Currently the driver is mainly activity which may be remaining on target in spite of reduced patient numbers and falling access. Remunerating access should drive up standards of care across the board and also stimulate competition within the NHS dental care market which in turn will result in improved services for patients.

 

The Access payments are made up of:

Patient list – 35% of contract value

Patient turnover -5% of contract value

 

 

ACCESS 1           35%

This part of the re            formed contract needs to support the development of a philosophy of payment in return for caring for a geographically sensitive number of patients. If we assume that current levels express a reasonable average list size then this average can be applied. Providing a practice supports 90%-110% of this average list size 35% of the existing contract value will be accrued.

 

Some work is required around the average list size and the values applied to various age groups and areas.

 

Some work has been done within the pilots with post codes to place an added value on a patient living in an area associated with high treatment needs. This would lead to practices in areas of high need having to register a factored reduction in the number of patients. This seems fair.

 

Once the system is implemented for any given area with a given contract value it will be clear what the target patient list size is. The practices will be able to assess what their recruitment priorities are during the lead in period.

 

Access 1 – will support 35% of contract value

Practices will have a THREE YEAR LEAD IN PERIOD in which to stabilize list size.

After the lead in period financial recovery will operate if the practice has a 10% variance.

Less than 10% may be held over through to the following year and be balanced by additional activity/ list size growth. Financial recovery/ roll over will be based on a percentage of the 40% of contract value attributed to Access.

 

For example if a practice has a negative of 12% on list size, the claw back would be 12% of 35%.

 

To avoid a situation where a practice misses the target by greater than 20% the practice will be required to provide a written explanation and risks contract reduction the following year if this is repeated.

 

ACCESS 2          5%

It is anticipated that this concept will drive access. However in order to further drive access each provider will have an access target of registering a number of new patients equaling 2.5% of their average list size. This will effectively be patient turn over as it is expected that at least this number of patients will leave the list “naturally” during the course of a year.

On a list of 2,000 this would be a turn over of 50 patients per year.

 

The Access 2 payment will not be enforceable if the practice already has 110% of the list size registered.

This can be measured and will allow for financial recovery.

If a practice does not achieve this level of “growth/ patient turnover” it will face financial claw back of 5% of contract value.

 

Within the NHS there is some philosophical opposition to child only NHS contracts where the parents are treated privately.

The proposal includes stipulating that where there is an imbalance between adults and children the commissioners in any given locality may request that the practice concerns register turn over patients at average levels. This will slowly change this situation.

 

 

 

 

ACTIVITY               45%

 

The requirement for metrics to allow measurement of activity and to support financial recovery probably mean that some form of activity

Unit is required.

The UDA has been universally derided as a poor method of delivering quality care. This is mainly because the three bands are not sensitive enough and do not support more complex care. Plus the variation in UDA value has been seen as unfair and divisive.

 

We propose an extended band scheme with EIGHT BANDS. Whilst we acknowledge that this introduces a change in terms of increased complexity we believe that the additional bands allow a fairer way of measuring activity. The additional UDA’s attached to more complex restorative care should reflect the time required for the procedure and not disincentivise more complex care. This approach goes some way to achieving this. In addition improving the funding of more complex care should reduce the numbers of referrals to secondary care for procedures that can be treated in primary care leading to cost savings. This is a difficult and sensitive process – the proposal seeks to support more complex care like endo, crown and bridge, surgical exodontia without incentivizing it.

 

We also propose that the UDA is valued around the national average taking in to consideration the dental health status and treatment needs of the relevant community and the demography of the patient lists. We understand that some work has already been done with regard to this. This will mean that a practice working in a fluoridated area within a high socio economic area will be required to register a larger number of patients to achieve a given income level. This seems to be reasonable. There is an argument that making the Access list size and UDA levels geographically sensitive is “over the top” in respect that the proposal provides a double compensation. However if we acknowledge that NHS care first and foremost needs to be more available to the patients that need it, it is hard to argue with making those patients more valuable.

 

Band 0 is for the Interim care appointment for at risk groups of patients or patients with a red oral health status. It is expected that this service will be delivered in general by trained DCP’s. The excellent P.C.C. prevention course could be used to train DCP’s to the correct standard and license them for this kind of care. Continued support of licensed DCP’s will be required through education. We recognize that this element of our reformed contract will require monitoring to ensure that the prevention element is delivered appropriately. We will look at this in the QUALITY section of the reformed contract proposal. In any event the maximum proportion of the contract value that can be used to support this service provision is 7%.

 

The service provision in band 0 will include:

 

Topical fluoride application for at risk groups at 3/12 intervals

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002279.pub2/abstract

 

Diet advice based on a personal diet record

Tooth brushing instruction

Plaque removal

TBI and ID aids for patients with high risk of periodontal disease.

 

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002279.pub2/abstract.

 

 

 

 

URGENT CARE

 

The provision of urgent care will be discussed later in our proposal however it is clear that driving an access agenda will result in practices being more open to accepting urgent care patients. In addition we propose that providers demarcate urgent care slots within clinical care sessions to provide care for emergency patients who are registered with the practice or un-registered. A session of 30 minutes per day per performer would seem reasonable. Where these slots are not filled 24 hrs before the session is planned the time can be used by the practice as required. The numbers of urgent care patients treated will form part of reporting and these reports will

form part of the Scored Peer Review Practice Visit.

The Urgent Band of Band 2 / 2.5 UDA’s, patient charge of £27 will require some work. We propose that this includes the use of a care pathway that includes diagnosis, radiography and relevant treatment. This would allow comprehensive treatment of the urgent issue. It would seem reasonable to place a maximum contract value on this element of activity at an average regional level.

We believe this incentivizes the treatment of Urgent cases with obvious benefits. Capping of the contract value for this activity at 7% regulates the use/misuse.

 

FISSURE SEALANTS

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001830.pub4/abstract

 

The Cochrane Review on Fissure Sealants found that:

The review revealed that sealants are effective in high risk children but information on the magnitude of the benefit of sealing in other conditions is scarce.

 

For this reason the proposal is that fissure sealants are placed in high risk children (as defined by the O.H.A Care Pathway approach) between the ages of six and sixteen.

 

The cap for Fissure sealants in terms of contract value is 5%

 

 

 

P.C.R

 

We have also introduced additional P/C/R band charges. We recognize that this will not be universally popular with consumer groups. However a maximum charge of over £300 was in place prior to the 2006 contract.

 

We would also suggest that we examine the evidence behind the exemption of pregnant and nursing Mothers for dental charges. This is historical and has very little supporting evidence base.

Additionally we support the removal of the exemption form charges for patients returning for equal banding treatment within two months. Whilst we understand the philosophy behind this exemption it is a naïve regulation and should be withdrawn.

We also support the re-introduction of failed to attend (F.T.A) fees. Activity targets in the absence of any sanction for F.T.A’s is poor regulation. We propose an F.T.A fee of £10 for each ten minute slot is appropriate. This fee would be split between the provider and the B.S.A. In this way collection of the FTA fee is incentivized at practice level.

 

Perhaps we also need to consider a £5 annual registration fee for adults. This would raise substantial fees. However this may prove problematic and may cost more to administer than the £5 fee.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACTIVITY BANDS

GEOGRAPHICALLY SENSITIVE UDA VALUE

 

 

BAND O – (up to a maximum of 7% of contract value).

Targeted prevention appointment provided by DCP or GDP. –

0.75 UDA’s

P/C/R           £19

 

 

 

BAND 1 –

Recall examination following initial Oral Health Assessment.

1 UDA

P/C/R           £19

 

 

 

 

BAND 2 –

Initial Oral Health Assessment / Urgent care including active treatment. /placement of three or more fissure sealants – for patients under 16 yrs. Fissure sealants have an established evidence base and as a result should form part of the prevention agenda. Work will be required on a care pathway approach to the use of sealants. The use of sealants will be capped at a level of 5% of contract value. Fissure sealant stats will also form part of the QOF Quality remuneration. Any sealants placed subsequent to the 5% level being breached will be paid at Band 1.

 

 

2.5 UDA

P/C/R           £27     fissure sealants capped at 5%

                                    Urgent care capped at geographical average %

                        Approx 7% of a 36 hr fte working week at 30                         minutes per day.

                  

 

 

 

 

 

 

 

 

BAND 3-

Simple restorative care / exodontia/ perio tx of cases with 1 sextant of 3.

3 UDA

P/C/R           £50

 

 

 

BAND 4

As above but including more endodontics / complex exodontia/ treatment of TMJ problems using a soft acrylic splint. Also to ensure that the reformed contract provides care of high needs cases where there are 6 carious lesions present the case will receive band 4 remuneration. These cases will be monitored electronically to assess

Prescribing behavior against regional averages and will be assessed in the PEER REVIEW VISIT

 

5 UDA

P/C/R           £85                

 

 

 

 

BAND 5

As above but inc. molar endodontics/ More than 2 sextants with a B.P.E of 3 or over. It is expected that a clear care pathway is developed for advanced periodontal care involving plaque scores/ pre treatment charts/ RSD under la/ post tx charts.

6 UDA

P/C/R           £99

 

 

 

 

BAND 6

As above but inc. acrylic dentures/ up to two crowns, inlays, veneers/ single chrome denture.

12 UDA’s

P/C/R           £225

 

 

BAND 7

As above inc upper and lower chrome dentures / more than two crowns, inlays, veneers.

16 UDA’s

P/C/R           £350

 

 

 

Using this system activity can be measured.

Using this method underperformance can be measured allowing for financial recovery.

Financial recovery however should only be as a percentage of the activity element of the contract value. So for example if a practice under delivers by 12 %

Only 12% of 45% is clawed back.

 

 

 

 

QUALITY                 15%

 

We support the Quality agenda of the reformed contract. However quality is a difficult thing to measure. As Einstein famously stated “Not everything that counts can be counted and not everything that can be counted counts”

The Outcome indicators used in the pilot reform seem reasonable. Our ideas broadly support these.

 

 

 

PATIENT EXPERIENCE           4%

With the possible exception of PE.01 we are happy to support the patient experience indicators. P.E.01 does not adequately take in to consideration the level of complexity or invasiveness of the procedures undertaken and so it could be misleading. For example following difficult exodontia or in a situation where a denture patient has unrealistic expectations. PE .06 appears to cover the general issue of satisfactory treatment.

The sample size must be large for it to be a valid interpretation of quality – at least 20% of C.O.T.

Indicator

PE.01

Patients reporting that they are able to speak & eat comfortably

PE.02

Patients satisfied with the cleanliness of the dental practice

PE.03

Patients satisfied with the helpfulness of practice staff

PE.04

Patients reporting that they felt sufficiently involved in decisions about their care

PE.05

Patients who would recommend the dental practice to a friend

PE.06

Patients reporting satisfaction with NHS dentistry received

PE.07

Patients satisfied with the time to get an appointment

 

TARGET: This should be monitored in the pilot period and a reasonable target agreed that is reasonably achievable. In addition PE.07 Values must also represent a change in service levels with regard to appointment time expectation due to appt book clogging with OHA.

 

The remuneration of the Patient Experience element of the Quality Framework will be 4% of contract value. The levels will be on a scale and will require planning.

 

 

 

PATIENT SAFTEY               2%

We are supportive of this measurement of patient safety. The Patient Safety element will provide 2% of remuneration.

Indicator

SA.01

Recording an up-to-date medical history at each oral health assessment/review

 

 

CLINICAL EFFECTIVENESS.   4%

We recognize the sense of including these indicators of clinical effectiveness within the contract reform. We have some reservations with regards to the accuracy of the data in the pilots. It is very important that this data is accurate as the data will be useful in terms of delivering targeted care to certain communities. For example in communities where a larger proportion of children are identified as red an increased proportion of contract value devoted to prevention may be indicated. As such the remuneration attached should not bias scoring and this should be balanced within contract reform. At the very maximum level remuneration should initially be based around maintaining RAG scores or very small improvements. In real terms it is in the provider’s interests within this system to improve the oral health of it’s patient base as this will allow the patient base to remain stable and to register 5% of new patients annually.

We propose that the remuneration is as follows:

Caries indicators – 2% of contract value for a 2% improvement.

Periodontal Indicators – 2% of contract value for a 2% improvement.

These targets will require assessment during the pilot period

Indicator

OI.01

Decayed teeth (DT) for patients aged under 6 years old

OI.02

Decayed teeth (DT) for patients aged 6 years old to 18 years old

OI.03

Decayed teeth (DT) for patients aged 19 years old and over

OI.04

BPE score for patients aged 19 years old and over

OI.05

Number of sextant bleeding sites for patients aged 19 years old and over

 

 

QUALITY AND OUTCOME FRAMEWORK        3%

We propose that the following indictors are assessed within the Q.O.F.

Both sets of indicators combined are worth 3% of contract value.

 

The first group are simply policies that are in place.           1%

1. Smoking Cessation – on-line training certificate / log of referrals to smoking cessation services. Numbers of smoking cessation referrals to be within average numbers. This can be transmitted with the C.O.T as;

SMOKER – BUT NO INTEREST IN CESSATION

SMOKER –INTERESTED IN CESSATION – (COULD THESE PATIENTS BE AUTO REFERRED BY SELECTING THIS RESPONSE ON THE SOFT WARE?)

2. Referral log – Numbers of referrals to be logged and transmitted. Referrals to be within average numbers.

3. Provision of urgent care slots – Average values to reflect remuneration.

4. DCP training for prevention services. Where a DCP is used for this service certification of training and C.P.D is required.

5. Satisfactory CQC report.

6. Completion of audits on clinical notes/ radiography/referrals. (These will form part of the Scored Peer Reviewed Practice Visit).

The value of these in total will be 1% of contract value.

The following will be scored. Payment of 2% of contract value providing the practice achieves the regional average value +/- 10%.

3. NICE guidelines for recalls. As previously stated, the majority of the recall intervals generated by the care pathway software were over ridden by the clinicians in the pilots. Some re-design is required to allow practitioners to develop full confidence in the system. Providing this is achieved at reasonable intervals a QOF indicator within regional averages would be a sensible measure.

4. Numbers of free replacement restorations provided. Average values to reflect remuneration.

7. Fluoride Varnish applications

8. Fissure sealants

 

 

SCORED PEER REVIEWED PRACTICE VISIT          2%

This element of the Quality matrix is time consuming and expensive but in our opinion there is no substitute for a practice visit in relation to assessing quality of care for patients.

We propose a practice visit is made to all practices. This will assess:

General practice accommodation

Assessment of prevention clinics

Assessment of referral audits by the specialist providers in primary and secondary care – see below.

Assessment of audits – in this case the peer review group will look at the audits produced by the provider and discuss them.

Random clinical notes assessment and to also include:

Cases including endo/ perio/ simple restorative care/ complex restorative care

The value of the scored QOF elements is 2% of contract value.

 

The Scored Practice Visit will require development to ensure that it is seen as both a quality measure and also a driver for education and development. If a practice scores highly a visit will not be required for at least three years unless there is a significant change in ownership. If a practice score poorly an early second visit will be triggered.

We propose that the Scored Practice Visit is funded through a process of paying sessional fees to a group of trained active NHS GDS practitioners. The costs to be exchanged for normal activity within the existing capped remuneration.

 

Reducing Inappropriate Referrals

There is anecdotal evidence that following the introduction of the contract in 2006 referrals to secondary care have increased. The increased bands and UDA reward for more complex care should help to reverse this trend. In addition we propose a referral audit of all referrals to be undertaken by specialist provider which will indicate whether a referral is appropriate or not. Some work is required on this to ensure that the grading is reasonable. Inappropriate referral may indicate a number of things, misunderstanding, poor knowledge of mandatory services, and an educational requirement. All these issues require exploration in situations where inappropriate referrals are higher than average.

This report will form part of the Peer Reviewed Practice Visit.

The Peer reviewed Practice Visit would be triggered where this is highlighted. Greater communication between Area Teams and Health Education England will be required to ensure that where necessary educational supervision is provided.

 

COMMISSIONED SPECIALIST /ADDITIONAL CARE

The reformed contract needs to have the potential to be flexible in order to meet individual communities’ requirements and to reduce referrals to secondary care where necessary.

This can be achieved at no increased cost by exchanging a block of normal activity for a block of specialist activity.

For example for Oral Surgery where a provider demonstrates that they can deliver a service an agreed level of service can be struck around sessional payments or payments per case. In this case the provider concerned would be asked to audit referrals as per the arrangements discussed above.

 

URGENT CARE

The access component of the contract should increase access for urgent care treatment. In general in-hours emergency care can be provide by providers within a strict criteria agreement of what constitutes an emergency care situation. These patients can be sign posted by And E, 111 etc and media advertising could be used to make patients aware that urgent care sessions in all NHS practices are available.

Where additional urgent care sessions are required during the day or in to the evening care could be commissioned through the commissioned specialist/additional care route.

LEAD IN TIME

We propose an initial pilot period of at least two years to assess data. We recognize the requirement for some practices to increase patient numbers in the early part of the reformed contract and the requirement to prepare properly for the introduction of the QOF and clinical effectiveness framework and so in view of this we propose a three year lead in time where access and quality payments are guaranteed at 100% providing activity levels of 80% are met.

CLAW BACK FUNDS

If practices fail to reach 80% of target for three consecutive years contract value appraisal may result in a contract value being reduced permanently. In this case the funds should be re-commissioned within the framework of a transparent and fair process. This may lead to contract value enhancement or when/where required the creation of new practices. This could lead to the introduction of new practices to the market place.

Any claw back funds between 10% and 20% to be accounted for and ring fenced for dental commissioning. This could take the form of commissioned additional care/ specialist care as described above in the following financial year.

Any performance between 90 and 100% can be rolled in to the following year and a practice can elect to make this up as activity or increased access.

 

 

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