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DHSSPS Structure
CDO
Minister
Permanent Secretary & Deputy Secretaries
HEIG SQSPrimary
CarePublic Health
HRD
• Local decontamination
• Capital planning
• Regulation of private dentistry
• Dental standards• RQIA
• GDS contract• CDS
• Oral health improvement
• Health protection
• Workforce• Occupational
health• Dental school• School of hygiene
GDS Budget – Investments
• £4 million (recurrent) into practice allowance• £3 million (non-recurrent) into QIS• £500k (recurrent) into VT grants• >£500k (recurrent) into extending registration
period• £400k (recurrent) salaried dental services• £5.7 million Improve access via dental tender• £1.1 (recurrent) into commitment payments
GDS Budget: other investments
• £120k CPD for DCPs• £300k for 5 additional dental students• £3 million re-equip school of dentistry• £100k additional registrar posts• Occupational health services for the whole
dental team
GDS Budget: Proportion of Earnings
2006/07 2007/08 2008/09 2009/10 2010/11
Items of Service 65.6% 62.3% 58.3% 59.5% 59.3%
Capitation & Continuing Care 21.6% 21.0% 21.9% 23.2% 22.6%
Block Payments (allowances) 12.7% 16.8% 19.8% 17.3% 18.1%
GDS budget – Overall Earnings & Expenses
net income 2007/08 2008/09 2009/10
Principal £121,200 £129,600 £122,900
Associate £66,100 £66,700 £62,700
GDS Budget – increased provision
2007 2008 2009 2010 20110
200
400
600
800
1000
1200
Patients (000s) Dentists Practices89
873
536
1
1001
10
98
381
GDS Budget
2006/07 2007/08 2008/09 2009/10 2010/11 2011/120
20
40
60
80
100
120
Patient charges
Over spend
Net
GDS Budget: Proposals for Savings- Principles
• Must have potential to realise savings for GDS budget
• Can be implemented within existing GDS contract or with minor regulatory change
• Can be implemented within coming financial year
• Must be consistent with direction of new GDS contract
• Comply with equality legislation & other regulatory requirements.
GDS Budget – Proposals for Savings
• QIS- £1.16m transfer to GDS budget• Core service
• Molar endo – prior approval• Co/Cr – prior approval• Bridgework – posterior/large; prior approval• Veneers -all prior approval
• Alter time bar on S&P
GDS Budget – Proposals for Savings
• Orthodontic treatment – IOTN 3.6, all other ortho prior approval
• Practice allowance –new criteria• Average of 750 patients/DS, with average 200
fee paying• Removal of commitment payments
GDS Budget: Potential Savings
• QIS funding transfer to the GDS budget - £1.161m
• Move to a core service under the SDR: ~ £2m; • Altering claims conditions on S&P: ~ £1m • Changes to the practice allowance: ~£344k• Ceasing commitment payment: ~ £3m• Restricting orthodontic treatment to IOTN 3.6:
~£1.5m (full year effect realised over a 24 month period)
Process & timeline• Restrict orthodontic treatment
• This will require amendments to the GDS Regulations and the SDR
• Consultation with BDA/PCC/ wider dental profession and public
• Subject to the consultation/approval of the Assembly, could be implemented from summer 2012.
• QIS funding to transfer to GDS budget• No changes to regulations or the SDR are necessary• The HSCB could action this with effect from 1 April
2012.
Process & timeline• Move to a core service under the SDR
• This will require amendments to the SDR• consultation with BDA/PCC/ wider dental profession
and public• Subject to the consultation this could be implemented
from summer 2012.
• Alter S&P time-bar• Will require amendments to the SDR• Consultation with BDA/PCC/ wider dental profession
and public• Subject to the consultation, could be implemented
from summer 2012
Process & timeline• Removal Commitment payment
• will require amendment to both the GDS regs and SDR
• Practice Allowance amendments to criteria• will require amendment of the SDR
• Consultation with BDA/PCC/ wider dental profession and public
• Subject to the consultation/ approval of the Assembly, could be implemented from summer 2012.
Primary Dental CareStrategy 2006
• Local commissioning of services;• Access to appropriate dental care for everyone who
needs it;• A clear definition of treatments available under the health
service;• A greater emphasis on disease prevention;• Guaranteed out-of-hours services;• A revised remuneration system, which rewards dentists
fairly for operating the new arrangements.
Problems with existing system
• Quantity not quality is rewarded;
• Treatment rather than prevention is rewarded;
• Demand led rather than needs led;
• SDR > 400 items is administratively complex;
• Patient charges are difficult for the public to understand
Problems with existing system
• Dentists incomes directly related to the volume of
treatment provided causes remuneration treadmill;
• HSCB lacks control over targeting services at areas and
patients with greatest need.
• 50 year old system no longer meets the needs of
patients, oral health care professionals or society at
large.
Options for New System
• Prof Ciaran O’Neill looked at range of remuneration systems• Retrospective Fee for Service (Item of
service);• Prospective Payment System (Full capitation);• Salaried/Sessional system
• Advised blended service
Blended System of Remuneration
Care Payments Item of Service
Patient Care Payment For Registration, Examination, Patient Appraisal, & Prevention
Quality Care Payment Practice Practitioner
Essential Services & EXCEPTIONAL
TREATMENTS
Occasional Services
IN
PARALLEL:
Private care (M
ixed E
con
om
y) • 1° Sp
ecialist care • 2° C
are
History- taking By Dental team
Clinical Examination E.O. & I.O. (dental/perio)
Risk-Based Patient Appraisal
Preventive Services
CCAA
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Essential Services
Exceptional Treatments
ASSOCIATED PROCEDURES e.g. Radiographs (IF INDICATED)
Recall Interval
II ooSS
PPAA
YYMM
EENN
TT
Simple Perio Care
Blended System of Remuneration
Care Payments Item of Service
Patient Care Payment For Registration, Examination, Patient Appraisal, & Prevention
Quality Care Payment Practice Practitioner
Essential Services & EXCEPTIONAL
TREATMENTS
Occasional Services
Essential Services
• Periodontal treatment• Restorations• Endodontics (except molars)• Crown work• Extractions & surgical• Dentures –acrylic• Children’s treatment• Miscellaneous items
Blended System of Remuneration
Care Payments Item of Service
Patient Care Payment For Registration, Examination, Patient Appraisal, & Prevention
Quality Care Payment Practice Practitioner
Essential Services & EXCEPTIONAL
TREATMENTS
Occasional Services
Care PaymentsQuality care payments (QCPs) • Practice environment indicators
• Practice inspection• Recognised charter-mark
• Practitioner indicators• Peer review / clinical audit• Higher qualification
Blended System of Remuneration
Care Payments Item of Service
Patient Care Payment For Registration, Examination, Patient Appraisal, & Prevention
Quality Care Payment Practice Practitioner
Essential Services & EXCEPTIONAL
TREATMENTS
Occasional Services
Patient Care Payment
• Weighted Capitation formula• Adjusted for Age• Adjusted gender• Adjusted for additional needs• Adjusted for ‘new patients’• Adjusted for list turnover
Orthodontics
ORTHODONTIC ASSESSMENT Examination Assessment Charting
ASSOCIATED PROCEDURES (if indicated) Radiographs Photographs Models
P
rivate Sp
ecialist Orth
od
on
tic Care
REVIEW FOR TREATMENT
GDP
TREATMENT COMMENCING
SIM
PL
E A
PP
LIA
NC
ES
SIN
GL
E A
RC
H F
UL
L
FIX
ED
AP
PL
IAN
CE
S
DO
UB
LE
AR
CH
FU
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IXE
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TREATMENT ABANDONED
TREATMENT DISCONTINUED
INCLUDING: PRE & POST-OP MODELS ANY OTHER STAGES REPAIRS RETENTION
2º Specialist Orthodontic Care
REFER FOR TREATMENT
REFERRAL (Guidelines)
TREATMENT DECLINED
TREATMENT NOT INDICATED
Exceptional Treatments
Process
NOT ACCEPTED
ACCEPTED
ORTHODONTIC TREATMENT
OPTION
DH1/10/69575
Oral Surgery
Band Examples of complexity Patient charge
A Assessment, radiographs, non surgical exts, Charge A
B Multiple exts, surgical exts, fraenectomy, biopsies Charge B
C Apicectomy, exposure, periodontal surgery Charge C
D Multiple surgical exts, multiple apicectomies Charge D
Pilots
• Use Pilot PDS• Consultation October 2010 – March 2011
• Responses very supportive• Oral Surgery pilot well advanced• Orthodontic contract will be phased in• GDS will follow oral surgery
Progress on New ContractEssential services complete
Exceptional treatments complete
Quality care Payments complete
Patient Care Payments(weighted capitation formula)
complete
Patient charges Model developed
Oral surgery PDS current phase with HSCB
Orthodontics Phase 1 – 2012 & further phasing
Pilot group current phase with HSCB
ICT Business case approved - ongoing
Contract & Regulations ongoing
Why has it taken so long?
• Resources• Addressing access issue• IT system at BSO• GDS budget – controlling pressures• Legislative problems – e.g. pensions,
performers lists• Proposals from BDA?
How will new contract impact on profession?
• Local commissioning – HSCB will target resource at need.
• Control of entry –performers lists• Fixed GDS budget and global sum formula• Focus on prevention• Out of hours responsibility of HSCB
What’s in for Profession?
• Limits number of dental practices• Increase value of practices?
• Can opt out of Out of Hours– Work-life balance?
• Performer/provider contracts• Career structure?
• Capitation payments• Improved cash flow
• Global sum• More stable budgetary position?
A Protocol for the Local Decontamination of Surgical Instruments
• Issued July 2001, • Health Estates DHSSPS • Key areas
• All local decontamination outside of clinical setting where possible
• Recommends automated washing• Downward displacement autoclaves- not suitable for processing
wrapped instruments or hollow instruments• Do not re-use single use instruments
• Described as short term strategy
BDA A12
• Issued February 2003• Key points
• Where possible instruments to be decontaminated in a separate room
• Recommends washer disinfector over manual cleaning
• Wrapped instruments must be sterilised in a vacuum autoclave
• Single use instruments used wherever possible & discarded after use
Hine Review of Decontamination of Endoscopes
• May 2004 problem identified with decontamination of endoscopes/ risk of cross infection with blood bore viruses
• Review of effectiveness of arrangements for decontamination of endoscopes & lessons learnt
• Service wide review of decontamination of all re-usable medical devices
Audit of Dental Practices
• Letter issued to GDPs August 2004 re quality assurance of decontamination processes
• Protocol for the local decontamination of Surgical Instruments (July 2001) reissued & dentists asked to comply
• Letter from CDO issued all GDPs December 2004
• Review current policies & procedures
• Complete audit
• Conform with recommendations in A12
Audit of Dental Practices- Outcomes
• Overall compliance good (53% amber, 47% green)
• Priority areas• Amalgam separators
• Chart recorders for autoclaves
• Independent water bottles
• Dedicated rooms for decontamination
• Washer disinfectors
• Disposable instruments
Audit of Dental Practices – follow up 2005/06
• Series of training workshops across NI(Dr Wil Coulter & Dr Caroline Pankhurst)
• Cross Infection Control Manual • Cross Infection Control CD-ROM
– Launched 2 May 2006
Development of Action Plan
• October 2006; DHSSPS, Health Estates, Dental Directors, Dr Wil Coulter
• Looked at priority areas from audit
• Amalgam separators, chart recorders autoclaves & independent water bottles largely achieved & funding provided through QIS 2005 & 2006
• Separate decontamination room, washer disinfectors & disposables logistically & financially more difficult to achieve
• Needed to develop an action plan listing priorities
Workshop February 2007 & Publication of Action Plan
• CDO, Dental Directors, Dental Practice Advisers, Infection Control nurses, LDCs, representatives RoI
• Action plan agreed, developed & published (annual report 2007/08)– Washer disinfectors– Quality of water supply– Improved surgery layouts– Use vacuum autoclaves– Appropriate testing equipment– Procurement of equipment
Other Policy Influences• DH England working on HTM 01-05
– Health Estates had observer status• BDA developing new A12
– Working drafts shared with DH, subsequently withdrawn• Scotland
– Glennie Group– Top ten tips
• Ensured DHSSPS action plan consistent with working drafts HTM 01-05 & Scotland
• Nov 2007 QIS letter; Policy position; funding for priority areas; Advice & support; 3-5 year lead in time.
Evidence Base
• Advisors HTM01-05; BDA, MHRA, HPA, Infection Protection Society, Healthcare Commission, Decontamination experts, GDPs, microbiologists, engineers
• Evidence base published: Acts & Regulations; Codes of Practice; British, European & International Stds, research papers, Official Publications
Further Support
• Supported Labour Government, Coalition Government, Minister DHSSPS.
• NI, Scotland, England – all moving to similar standards but on different timetable.
• ROI; New National stds for Prevention & Control of Health Care Associated Infections
Investments into GDS
• Practice Allowance: £4million additional (2007)• QIS: £3million additional (2007/08)• Commitment payments: £1.1million additional
(2009)• Registration: £500k additional (2009)• Vocational training: £500k additional (2007)
Funding• Profits: 07/08 £121,200: 09/10 £129,900:10/11
£122,900
• QIS money 2005 - 2010 key priority decontamination (approx £1million recurrent)
• Addition QIS money 2007/2008 £3 million
• Practice allowance ↑ from 5% to 11% September 2007– ‘increasing practice requirements in relation to the provision of
high quality premises, health & safety, staffing support & information collection & provision
The Health Service - 60 Years old
“We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving – it must always appear inadequate.”
Aneurin Bevan - 1948
• Nov 2009 DH publish HTM 01-05 (Hard Copy)• 10 Feb 2010 DHSSPS issue NI position, accept HTM01-
05 with modifications (PEL(10)04):– Washer disinfector – manual cleaning not a validated process– Timescale: must have achieved best practice by 2010-12– Instruments processed in a type N autoclave cannot be
subsequently wrapped & stored – use within working day– Exemplar room layout; fig 1 does not apply (no WD)
Minimum Standards for Dental Care and Treatment
• Primary Care Private & HS
• RQIA will inspect against
• HSCB will commission against
• Std 13:’Prevention & Control of Infection’
‘Your dental service meets current best practice on the decontamination of reusable dental & medical instruments’.
• Issued March 2011
RQIA -Regulation Private Dentistry
• Legislation – HPSS (QIR) NI Order 2003 • Amend Order through regulations to permit regulation
of all private dentistry• Regulation commenced 1 April 2011• RQIA; Register & annual inspection• Any dental practice which provides any private dentistry• Inspect against dental standards• Inspection Reports published on the RQIA web-site
Other Guidance sincePEL (10) 04
• Scottish Health Technologies Group Advice Statements• Wrapping Dental Instruments• Benchtop steam sterilisers
• Sterilization of Dental Instruments (SDCEP)• BDJ: Time-dependent recontamination rates of
sterilised instruments• IDJ: Three Steps to Decontamination Heaven
Review of PEL(10) 04
• DHSSPS reviewed PEL (10) 04 in summer 2011• HSCB• RQIA• NIMDTA
• Await results of recontamination studies UCL
• Offered meeting with BDA
Compliance
• DHSSPS has provided significant funding• Minister will be held accountable for delivery• Profession will be expected to deliver• All 14 Oasis practices are compliant (230 across UK)
• Do not report significant problems
• Other NI practices have already complied or are close to compliance
• DHSSPS, NIMDTA & HSCB considerable resource into training to aid compliance
Contacts & References
• CDO website for Newsletters, annual reports & other publications
http://www.dhsspsni.gov.uk/pgroups/dental/dental.asp
• PEL (10) 04 on HE website
http://www.dhsspsni.gov.uk/index/hea/decontamination-general-dental-practices.htm
• Dental Standards
http://www.dhsspsni.gov.uk/index/dental/dental-pubs.htm
• HE contact number for advice
028 90 523802