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Reforming The NHS Dental Contract

Amit Rai, LPN Chair

on behalf of

Elizabeth Lynam, Head of Dental Policy

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A quick recap...

• Coalition government: A commitment to developing a new contract and piloting aspects of it before introduction

• Proposed a contract based on quality, capitation and registration

• 70 pilot practices began trialling 3 different versions of capitation, but all using same care pathway, in summer of 2011

• 24 more pilot sites added in 2013

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Learning from the Pilots

First report was published in October 2012:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212999/NHS-dental-contract-pilots-early-findings.pdf

Second Evidence and learning Group Report published on 7 February: https://www.gov.uk/government/publications/dental-contract-pilots-evidence-and-learning

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Focus on Prevention

Demonstrated in the pilots that a primary care prevention focus is improving the OH of patients.

3rd Edition anticipated.

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Dental Contract Reform

Focus on quality and outcomes

Patients

ContractorsNHS

Strategic fit with overall direction for NHS England

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Patient

NHS Contractors

• what it is trying to achieve for them

• their responsibilities when not in the dental practice

• their relationship with their practice is changing

• affordability • access • commissionable –

to ensure appropriate high quality services

• Principles/ethos understood

• staff development • good patient

experience• business

The Aims of the Reforms

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An approach that aligns contractual incentives with clinical outcomes whilst maintaining access

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Patients

ContractorsCommissioners

OH Gains

WorkableCommissionable

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A Pathway Approach

‘Focus on commissioning the entire dental pathway as an integrated model of service delivery’.

‘A care pathway approach is proposed for all dental services to align with the NHS CB single operating model’.

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A Pathway Approach

This allows clarity, consistency and equity in service delivery.

Increase integration across primary, community and hospital settings.

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What is the Primary Care Pathway?

The planning of the journey that the patient would experience in continuing care and includes:

– Oral health assessment and risk assignment– Advice and oral health promotion– A personalised self care plan– Interim care– Referral to other services where necessary– Date of oral health review

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Primary Care Pathway• Greater focus on prevention – but not at the

expense of necessary treatment.• Pathway approach is a way of ensuring

consistency and focus on delivering evidence-based care.

• Software is decision-supporting, not decision-making – clinical judgement must be in the lead.

• The aim is to improve outcomes for patients.

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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

Primary Care Pathway

Date of oral health review

Step 1

Step 2

Step 3

PR

EV

EN

TIO

N

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• Patients and dentists continue to like the concept of a

pathway.

• Risks are being managed and reduced through the

pathway.

• Routine treatment for disease is being provided and

oral health is improving - although there is variation.

• Different dentists use RAG rating in very different ways.

• Findings to date tell us little about advanced care.

How has it worked in the pilots?

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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.

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Is disease risk consistently capturedand communicated to patients?

“…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”

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Big Themes from the Pilots

• Access• Shared understanding of the pathway

approach• Practice diversity• Quality measures

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Shared Understanding

• The population will only receive benefit as a whole if all dental clinicians are supportive.

• This involves:– Communication– Clarity of message– Culture – Change to be embraced– Consistency

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Practice Diversity

Finding ways to be fair to all:

• Different types of practice• Different types of contract• Skill mix Practice cultures

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Quality Measures

• First version of the DFOQ did not turn out as expected.

• The different combinations of measures did not hang well together.

• How to monitor a capitation based system?

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Remuneration

• Moving away from UDAs is a major change.

• Wide range of factors – very complex.• Needs careful analysis to avoid

unfairness and potential destabilisation.

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Next stages

• There is no plan for a wholesale move to a

reformed contract in 2015-16 .

• Earl Howe – the Minister responsible for dentistry

has said that the next stage would be to test out

whole variants of a potential new system. Trial

contract testing.

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Next stages

• DH recognise that there is a need for a wider debate with

dentists for their feedback.

• An engagement exercise will begin in June. This will help to

inform the shape of what is tested in 2015-16.

• It will set out thoughts and invite comments on:

– Pathway philosophy

– Quality measures

– Remuneration models