The Future for Prison Dentistry An update about changes to the NHS and NHS dentistry

1. NAPDUK: Managing the impossible Birmingham, 3rd February 2012 The Future for Prison DentistryAn update about changes to the NHS and NHS dentistry Sue Gregory OBE Deputy Chief Dental Officer (England)

2. Overview • The reformed system • New ways of commissioning • A single operating framework for dentistry • The role of clinicians • Dental contract reform • Contract Pilots, the clinical perspective • IT implications

3. Background • Equity and Excellence: Liberating the NHS – the Government’s vision for health services: • Patients are at the heart of everything the NHS does • Healthcare outcomes in England among the best in the world • Clinicians empowered to deliver results • New Public Health Service • Liberating the NHS: Commissioning for patients supports the White Paper by setting out a new commissioning architecture for the NHS to drive improvements in healthcare • ‘Developing the NHS Commissioning Board’, published July 2011, sets out the top structures for the Board • The new architecture of NHSCB will take on many of the roles and responsibilities currently discharged by the Department of Health, Strategic Health Authorities and Primary Care Trusts • Responsibility for most commissioning with commissioning consortia, supported and supplemented by the NHS Commissioning BoardThe NHS Commissioning Board will be responsible for commissioning all NHS dental services

4. SoS National Public Health England NHS Commissioning Board Public Health England NHS Commissioning Board Sub national Field Force Local Democratic Accountability Public Health England NHS Commissioning Board Dir Public Health Clinical Commissioning Groups Health and Wellbeing Board Dental Professional Network Clinical Commissioning Groups Clinical Commissioning Groups JSNA Upper Tier Local Authority level Field Force Cluster level Local Dental Committee Commissioning priorities Involvement of other clinicians, locally determined and based on local priorities District level Local Authority Effective communication with the wider dental community

5. NCB Commissioning Responsibilities Secondary Care Resto- rative Clinical Pathways OMFS Specialist Practice PDS Contract and GDS Contract PDS Contract (generalist) Special Care A&E NHS Direct DWSI Paediatric Ortho

6. Direct Commissioning Workstream Oversight and delivery of; • Primary care commissioning • Specialised commissioning • Military health and • Offender health

7. Commissioning of Dentistry The direct commissioning work stream has been working to: Design a new system of commissioning dentistry as part of the development of the single operating model of the NHS Commissioning Board – the operating model Have a process of convergence to the new system that ensures a safe and proper transfer of responsibilities in 2013 Ensure that the new system has the capability to transform the provision of patient care through better commissioning

8. The board will be a single national organisation with asingle operating model and will hold all main primary, community and secondary dental contracts. This requires consistency of policies, procedures, systems and processes for all contractual matters Some aspects of dental commissioning will continue to be organised nationally butsignificant aspects will need to be carried out locallyto reflect the large number of local providers as well as the need to ensure commissioning decisions reflect local needs and circumstances The Board will drive implementation of the national strategy at a local levelas well asresponding to localissues in the development of contracting levers and national strategy BSA Dental Division and other commissioning support functions will be important to deliver the single operating model Key features of the operating model

9. Specific issues for commissioning dentistry • Basis of reforms is that clinicians already make commissioning decisions • Opportunity to commission dentistry in an integrated way • Single operating model with consistency where it is required, but must allow flexibility where it is justified • Transition year 2012/13 hugely important to gain traction • Local relationships with strong system alignment will be key • Dental public health • Primary, CDS and urgent care commissioned and managed on a field force footprint • Secondary and specialist dental services

10. The NHSCB local arms will require close working relationships with CCGs, PHE and HWBs Clinical Commissioning Groups HEE local networks HWBs PHE Informing needs, demand, supply in primary, community and secondary care Peer support, peer review and benchmarking Local professional networks Maximising performance Local intelligence, clinical expertise, innovation and development of integrated care pathways NHSCB local Implementation and development plans to reflect local circumstances NHSCB national Aggregation of need and assurance of performance Strategy, policy, contract, procedure and assurance of achievement of outcomes

11. Dental Local Professional Networks in focus What are they? An integral part of the NHS CB field teamwith links to nationalclinical networksandclinical senates A vehicle for clinically ledandclinically owned delivery of; Quality improvement – CQC, LPN, field team Best outcomes for patients that reflects local need – JSNA, oral health strategy Best use of NHS resources – clinically owned commissioning Planning and designing integrated care pathways – leverage in commissioning Leadership and engagement – ensuring To ensure clinical leadership at the heart of the local operating model Design proposals for LPNs describe those functions where clinical expertise and leadership can add most value within local commissioning operating model Commissioningmanagers and clinicians delivering NHS CB vision together Common purpose

12. Local Professional Networks Operating Model All primary care providers (influence, communications, roll out, embedding) Relationship with the NHS CB through local teams Local clinicians (clinical expertise for ‘task and finish’ projects, quality improvement, pathway re-design, strategic development and planning) clinical engagement and leadership Local variation where justified by health needs Core Clinical Commissioning Team (commissioning managers, clinical quality and network leaders, public health) Consistency in approach to commissioning

13. In addition to the core LPN team and network arrangements, there will be mechanisms to draw on specific areas of expertise • Leadership and accountability for LPNs would come from within their core teams and link closely to senior commissioners within the field force • Discussions so far have suggested that LPNs would include the following clinical and professional input from an identified ‘pool’ of clinicians to feed into their work; • Primary and Secondary Care Commissioners • Dental Public Health (resourced from LA/PHE) • Quality and Performance Improvement Leads • Clinical and Professional Expertise Input – primary care clinicians • Specialist Clinical Input – secondary care • PC clinicians with a specialist interest • Health and Wellbeing Board representation • Clinical Skill Mix (e.g. dental nurses) • Local Dental Committees • Workforce and Development – deaneries, CPPE • Patient and the Public Representation • CCG Representation • Interdependencies to support as appropriate – e.g. Informatics, Finance, PC regulatory experts

14. LPNs and their clinicians • Fundamental change in thinking, culture and behaviour • Desire to improve quality and services for patients • Population view - public health specialists • Evidence – based approach • Strategic and operational skills • Objective decision making • Willingness to take action and responsibility • Carrying the local profession with the NHS CB and LPN • Ensuring success in new relationships, behaviour and culture

15. Move towards leadership for clinicians Leadership Management Advice

16. Relationships • Internally • NHSCB – local and national • Wider local and national clinical networks & senates • Externally • Local authorities - HWBs • Patients – healthwatch • Clinical Commissioning Groups • Public Health England - CDPHs • Providers/performers (primary, community and secondary) • LDCs • Managing conflicts of interest

17. Challenges and Opportunities Shift in culture – ownership within ‘corporate’ model The right incentives to be involved Governance – conflicts of interest/self interest Delivery within the challenges of financial austerity and national operating model Demonstrating the design proposals are worth the investment – testing LPNs Clinical capacity to provide robust quality improvement and patient outcomes – level playing field Clinicians in a leadership role within the system that commissions their services – shift from clinical advisory role to commissioning leadership Enabling clinicians to design care pathways that best meet patient needs Expertise where best adds value

18. Consistency in approach to commissioning and relationship between NHS dental providers and NHSCB Local relationship with the NHSCB through local teams, but economies of scale where leverage can add value Local variation where justified by health needs Local clinical engagement and leadership across dental professions Opportunity to have all dental services commissioned in an integrated way Clinically led and clinically owned service improvement and transformation The reforms for dentistry…

19. Dental Contract Reform Pilots Pilots are testing several components: • The oral health assessment and risk screening • A capitation approach • An outcomes approach …………to assess whether they provide the basis for a dental contract and contribute to improving oral health.

20. Pilot Contract Types Type 1 Simulation Model Type 2 Weighted capitation & quality model Type 3 Weighted capitation & quality model, with separate budget for higher cost treatments Pilot practices will be guaranteed their contract value (their remuneration in the current contract year) and required to deliver the same NHS commitment whilst adhering to the new pathway. These pilots will test the implications of applying a national weighted capitation model where capitation payments vary for different patients depending on the factors on which the national capitation model is based. These pilots will test the implications of applying a national weighted capitation model but the capitation payment will be for preventative and routine care only and complex care will be funded separately.

21. Care Pathway Approach Principles • Oral health assessment with a standardised approach • Focus on promoting health, not just on repair and treatment • Stronger focus on outcomes and effectiveness • Recognises potential of clinical engagement and using whole team to deliver care pathway

22. Clinical pathways in primary dental care Quality Indicators Patient Assessment Patient Assessment Risk Screening Patient self-care plan Patient self-care plan Care Pathways Recall intervals Entry criteria Complexity Assessments

23. Overview of risk screening process Patient Assessment Risk screening Risk Category Recall Prevention Domains - - - - - - - - - - - - - - - - C T1 Patient actions…………… Caries T2 P Dentist actions…………… T3 C T1 Patient actions…………… Perio T2 Dentist actions…………… P T3 C T1 Patient actions…………… Soft tissue T2 Dentist actions…………… P T3 C T1 Patient actions…………… T2 TSL P Dentist actions…………… T3 Self care plan, preventive and treatment plans KEY C = Clinical Factors P = Patient Factors T = Time interval

24. Determining the clinical and patient factors for CARIES Domain Caries Actions (pathways) Clinicalfactors Patientfactors Risk Patient Professional Age Teeth with carious lesions Symptoms = + Diet Excess sugar Frequent sugar No teeth with carious lesions Poor plaque control Sibling experience Patient Communication

25. Assigning risk The patient’s risk status for each domain is determined as follows: Allocated if there is a red clinical factor, this cannot be modified by patient factors. Red risk status Amber risk status is allocated if there is an amber clinical factor, or if there is a green clinical factor but a co-existing patient factor which increases risk e.g. a patient with no caries would still be classed amber if there was poor plaque control Amber risk status Green risk status is allocated to those with green clinical factors and no patient factors which increase risk. Green risk status

26. Pilot Dental Quality & Outcomes Framework Quality is a necessary part of future dental contracts and it will take time to get a quality system that is solely outcome based. Quality is defined as covering three domains: Clinical effectiveness Patient experience Safety Continual development and raising the bar Measures ready for contract pilots Measures ready for contract implementation Longer term development of quality indicators Pathway Development Work on quality indicators, and in particular outcome indicators, is relatively new in the NHS and even more so in dentistry. The DQOF will therefore continue to be developed over the coming years. The framework will be underpinned by the development of a comprehensive set of accredited clinical pathways.

27. The Development of DQOF For a patient to be in good oral health, we mean; • They are free from pain • They have good functionality and aesthetic form to their teeth – They can “eat, speak and socialise”* • They have clinically assessed good oral health now and we are confident that this will continue into the future Principles The DQOF working group followed the process outlined below working back from first principles to define indicators that support the consensus within dentistry that good oral health is the ideal clinical outcome: The patient’s view of being free from pain and good functionality should be covered by patient experience and PROMS domain rather than clinical effectiveness Outcomes (patient view) Measures Clinicalcomponentsof the OHA: Maintenance Improvement The clinical view is covered in this domain and focuses on: • Improvement in oral health • Maintenance of good oral health Caries Perio Outcomes (clinical view) *(World Health Organisation 1982)

28. Elements of PDCPA for DQOF Utility of PDCPA for DQOF measure Patient Assessment Measured at Review Clinical Domains Maintenance/improvement 3 categories  C - - - - - - - x Caries P Maintenance/improvement 2 categories  C Perio x P x C Soft tissue x P x C TSL x P Key C P = Patient Factors = Clinical Factors

29. Clinical Effectiveness Outcome Indicators for payment (60%) The following outcome indicators are derived from the clinical elements of the assessmentbased on the standardised NHS primary dental care patient assessment (PDCPA) and the associated risk screening process. The indicator information will be captured at review and achievement of the indicator is described as either maintaining or improving a patient’s condition.

30. Patient Experience Indicators for payment (30%)

31. Safety Indicators for payment (10%) Safety quality measures will fall under the remit of CQC and work with professional bodies such as the GDC. The dental profession and commissioners are committed to ensuring that clinical practice remains safe and that safety is a fundamental part of the service that is delivered. Consequently, patient safety overall is not something that should be rewarded through a quality payment as all dentists should adhere to safe practices. However clinical aspects of patient safety can be monitored and rewarded through payment and payment will be made on the following indicator:

32. Indicators for monitoring overall quality (no payment) It is proposed that the following quality indicators are monitored throughout the pilots to understand the impact of the change of system on clinical behaviour and patient perception.

33. Advanced care pathways Indirect restorations Metal based partial dentures Endodontic treatment Advanced periodontal careNow starting work on minor oral surgery and intend then to look at paedodontics

34. Are the general principles for indirect restorations satisfied ? yes Are the general patient factors supportive ? yes Are the relevant oral health risks controlled yes Is the proposed restoration clinically feasible and beneficial Offer indirect yes restoration Decision making cascade

35. Ongoing support Regional Support Leads and PCC Advisors regular contact with PCTs and Pilot Practices Twice weekly clinical telephone calls Pilot Perspective Newsletter Future events for both PCTs and Practices Peer Support Groups for Practices Information Portal (NHSDS) Electronic Information network

36. Overview of the Pilots Selection process – sampling to ensure variability Ran from December to January 500+ expressions of interest PCT and SHA involvement 150 pilots initially considered Reviewed down to 72, with some substitutes Pilot Type identified for each practice Support to PCTs and Pilots via national pilot team and identified Regional Support Leads

37. Overview of the Pilots, contd February to September was contract implementation New SFE Contract Variation Notice Working with PCTs and Pilots for baseline data - Contract values - Skill Mix - NHS Hours 70 practices now “live” as o f 1st September

38. Overview of the Pilots, contd • Practice staff attended Clinical and Software Training • Software support from the suppliers involved- Software of Excellence, Carestream and Dentsys • Beta testing of pilot software • NHS BSA DSD continues to pay pilots and provide management information • PCTs remain the commissioner and contract holder

39. Ongoing support/Ongoing listening Regional Support Leads and PCC Advisors regular contact with PCTs and Pilot Practices Twice weekly clinical telephone calls Pilot Perspective Newsletter Future events for both PCTs and Practices Peer Support Groups for Practices Information Portal (NHSDS) Electronic Information network DCDO practice visits

40. Learning from the Pilots Qualitative • the experiences and impact on • Dentists • PCTs • Patients Quantitative • Clinical data set from Oral Health Assessment • DQOF

41. Feedback on OHA and care pathway • Generally positive from both dental team and patients • OHA appointment length • Important to manage appointment book • IT is being beta tested during roll out – no major crashes

42. Skill Mix Issues Extended duties dental nurse Hygienist Smoking cessation adviser Therapists

43. Computer Software Designed to collect and transmit: • Entirety of oral health needs assessment- including complexity of care and referral information • Entirety of treatment delivered information Inbuilt matrices to support: • Individual risk assessment by clinical domain • Evidence based prevention plan for both patient and dental team

44. Hardware • Requirement for in-surgery data collection • Hardware specifications vary by supplier, dependent on the overall platform on which they have built the pilot software • Patient self-care plans need printing

45. Computer Systems • 3 software suppliers • Beta testing as we go • Weekly conferences calls with suppliers • Regional support leads logging issues • Currently developing a transmission guide for practices

46. Electronic transmission • 2 separate transmission streams:- oral health assessment and treatment delivery- FP17 and course of treatment, PCR • Separate functionality to transmit both streams • Variation in transmission reports, even within software suppliers: - some practices successfully transmitting both- some transmitting peripatetically both- some one stream no the other • Too many error messages of no relevance • ? Training issue rather than functionality

47. Pilot software review and refinement • November to February review and refine software in light of flaws and issues raised in beta testing and early piloting • Steering group and focus groups • Technical and clinical issues included • NOT reviewing care pathways

48. Next steps Pilot will help inform the proposals for a new dental contract Policy team at DH to develop proposals for the new contract, and for reforms to the patient charging system to fit in with the new contract. The changes will require legislation, which will be introduced to Parliament in a Bill – timing to be confirmed. Public consultation on the changes…… Leading to……Legislation to introduce new contract