Dental Pilot update – Wednesday 18th September 2013
During October 2012 Barry Cockcroft announced that there were plans for a second wave of pilots to test out elements of the new proposed NHS dental contract. I managed to secure one of these pilots, which commenced 1st August 2013.
I own a single handed practice in East Hull, which is 100% NHS.I was aiming for a rather hefty 10500 UDA’s per year. As we all now know, the 2006 contract provides a finite income for an infinite amount of work. With Practice overheads are rising sharply over the last few years, I felt this contract was too uncompromising and, ultimately, unfair.
Background
The eventual new contract will be based on registration, capitation and quality. The existing pilots are testing:
• A pilot patient pathway
• A pilot dental quality and outcomes framework (DQOF)
There are three remuneration models:
o Type 1 (fixed remuneration)
o Type 2 (a simulation of capitation)
o Type 3 (a simulation of capitation for routine treatment and fixed income
identified for complex treatment)
I secured a Type 2 pilot. With this scheme 90% of the practice income is via capitation, the remaining 10% from the Dental Quality Outcome Framework (DQOF). The DQOF covers clinical effectiveness, patient experience, and patient safety. The clinical effectiveness elements will measure the maintenance or improvement in oral health in respect of dental caries – the number of teeth with carious lesions – and periodontal health.
Practices are expected as a minimum to maintain (or ideally increase) their patient list size.
All pilot sites are required to perform a standard Oral Health Assessment (OHA) for each patient electronically so that the new computer software can score the patient as red, amber or green, based on individual risk. This is known as the RAG score. The OHA involves taking a full patient history, a full dental examination including periodontal records, soft tissues and tooth surface loss. An extra oral examination is also carried out, and patients are issued with initial preventive advice. The system then automatically produces a care plan for the patient (known as the care pathway). This should be followed by the dentist but can be over-ridden.
The software also generates a suggested recall interval, based on risk factors. Again, this can be overridden.
There is an emphasis on prevention, and it is hoped that other team members (therapists, hygienists, DCP’s etc) will be able to support the patient in improving their oral health.
Our Journey so far
We were offered a place on the pilot scheme mid January 2013, but due to IT problems did not go live until 1st August. Trying to obtain an expected UDA delivery figure for the period 1st April to end of July proved to be incredibly difficult. This resulted in my contract over-performing by over 2 weeks of UDA’s, for which there was no financial return.
When the new contract is rolled out, this is something that will really need to be addressed.
The OHA appointment
Medical and Social History Forms must be completed on paper and then entered onto the computer. For patients with an extensive medication list this can take over 10 minutes. The Social History form includes sections on tobacco and alcohol use. One patient has refused to complete this, claiming that the government are ‘spying like Big Brother.’
Computerisation
The care pathway is generated by software in the surgery. The pilot team are trying to produce a paper version of the pathway, but it is so complicated that I can’t possibly see how this would work. The Oral Health Assessment involves a huge amount of data being fed into the computer. There are several advantages to this. It ensures that the patient receives a very thorough examination (the software will not let you move on until all information is collected) and Medico-legally, it also helps produce a very robust set of notes. The obvious down side to this is the amount time it takes.
We have found that both the dentist and DCP need to be able to see a screen, so this has involved the purchase and fitting of extra monitors.
Patient Examination
The computer software almost guides the dentist through this. After a full dental charting has been recorded, information is inputted regarding periodontal health, the soft tissues and tooth surface loss.
At this point the computer generates the RAG score, and a suggested recall interval.
Recall intervals are based on active disease.
For example
52 year old gentleman. Non Smoker. Drinks around 10 units per week. Heavily restored dentition. 2 bridges, 4 crowns and many large amalgams. Good standard of oral hygiene. Small amount of calculus deposits around lower anteriors. No bleeding on probing. Recent bitewing radiographs suggestion everything ok. Soft tissues healthy. Suggested recall – 24 months!
I have been overriding many of these. If I had a heavily restored mouth, I would prefer a check more than once every two years.
Diary Clogging
We were advised to book 30 minutes for an OHA for every adult. Under the UDA system, we were seeing patients every ten minutes. This has really clogged the patient diary. With time, we have found that most (but not all) OHA’s can be done in around twenty minutes. We are now trying to re-arrange hundreds of appointments, which has resulted in numerous annoying ten minute gaps. End of day appointments have been very popular. On the UDA system I would try to see a family of four in 30 minutes. Under the new pilot, we were advised to book 30 minutes for adults and 20 minutes for children. A family of four would therefore take 1 hour and 40 minutes. We have re-arranged this down to one hour. Late appointments on a Friday which have always been a popular slot have turned into the golden time of the week. We are that fully booked that a family of four are now waiting until April for their Oral Health Assessments.
Other pilot sites have reported a loss of patients to neighbouring practices as (understandably), patients get frustrated at increased waiting times for appointments. We have not noticed this as yet.
FTA’s and Late Arrivals
FTA’s are having a massive and devastating effect on the practice. These we annoying enough under the UDA system – if Mr and Mrs Smith don’t arrive for their appointments, it was 20 minutes lost. Under the new system timings, that becomes 40 minutes lost. You can imagine the loss of time when a family doesn’t come to their appointments. Fortunately these have been few and far between.
Patients turning up late for their appointment can create problems too. If the patient arrives ten minutes late and then takes another ten minutes to fill their forms in, their appointment has gone before they have even sat in the chair.
Finances
Due to the decreased number of patients seen in a day we have noticed a huge drop in Patient Charge Revenue – in the region of about 40%. Admittedly this is with the current charging model, but how this will be corrected is yet to be determined.
Some Positives!
ü It is great to be allowed time to teach prevention – just like we were all taught at dental school.
ü Dentistry feels a lot more rewarding
ü The care pathway provides a very structured approach for the provision of treatment.
ü The software providers (Pearl) have been very helpful and patient with all of the staff during the learning curve.
Finally
There are still few uncertainties as to how certain parts of the new contact will work and there are a lot of things that need addressing/correcting. However, it is nice not to have to worry about UDA targets!