dcr engagement event

1 DH Leading the nations health and care

Dental Contract ReformEngagement Events

January and February 2017


Dental Contract ReformEngagement EventsIntroduction and overview

3 DH Leading the nations health and careDH Leading the nations health and care

Why Change?

Activity systems fit well with high disease and high treatment need (e.g. post-war Heavy Metal generation).

But oral health has been transformed in last 60 years. Now need system focussed on prevention as well as treating disease.

Tooth decay is largely preventable

Current system: Is not keeping pace with improvements in oral health

Does not meet the changing pattern of dental treatment needs across different generations/patient groups

Is not perceived by dentists as recognising time/resources used by dental teams in advising/supporting individual patients to improve and then maintain good oral health

Dental Contract Reform


Contract Reform to date

The need for a new clinical approach and a remuneration system which reflects the developing focus on prevention were set out in Professor Jimmy Steeles Independent Review in 2009

The 2010 coalition government committed to introducing a new NHS dental contract with the aim of improving oral health and increasing access to NHS dentistry and to pilot any potential new contract before making any changes.

The principles of the reformed system are:

A preventative clinical approach (the patient pathway)

Measurement and remuneration for quality of care; and

Remuneration that supports prevention as well as treatment

Piloting began in 2011 in order to test the key elements of reform needed to design a new system.

There has been cross-party support for the need to reform the current system.



What did the Pilots tell us?

The dental pilots ran from April 2011 to 31 March 2016.

Learning from the pilots included:

That the prevention focused pathway has been welcomed by both patients and dentists

Some pilots were able to maintain access

Switching from full activity to full capitation would be too radical a shift

That we need a remuneration system that supports prevention and delivery of treatment (the prototype system)


Piloting showed potential for change and the current Government support the need for the next stage of testing (Prototyping)


Prototypes the current stage

The learning from piloting enabled the prototype system to be designed

Prototype practices:

Are continuing to test the patient pathway

Are continuing to be measured against clinical and patient indicators in the Dental Quality and Outcomes Framework (DQOF)

Are testing two blends of remuneration. The majority of remuneration in both blends are for capitated ongoing and preventative care.



Contract Reform Principles Patient Pathway


* RAG = The patients oral health marked as red, amber or green


Prototypes Remuneration

Dentists receive a proportion of their remuneration as capitation and a proportion for measured activity.

To determine the most appropriate mix of capitation and activity, two blends are being tested in which capitation and activity cover different proportions of care.

Blend A approx. 60% capitation Blend B approx. 83% capitation

Capitation forms the majority of payment in both blends.


All band 1 and band 2 activity included in capitation Band 3 included in activity

All band 1 activity included in capitation band 2 and 3 included in activity


What are the characteristics of the prototypes?

Total of 82 prototypes

79 high street

3 Community Dental Services

21 new sites (ex UDA)

58 former pilots

Of the 79 high street practices

40 Blend A ( 29 former pilot 11 new prototypes)

39 Blend B (29 former pilot 10 new prototypes)



How will we measure success?

3 high level measures of success have to be captured before any new system can be rolled out:

1. Appropriate, high quality care: outcomes will be measured (tooth decay and gum disease) and treatment volumes to check appropriate care has been delivered

2. Access: prototypes will need to be able to provide care for at least the same number of patients as the current system

3. Value for money: that care to patients can be delivered within the existing dental budget



From 2018 2019 it may be possible to begin nation-wide roll out

Proposed remuneration system finalised for CDS, domiciliary services etc.

Learning from prototypes

2016/17

Prototyping new system

2017/18

Further development and

evaluation

2018-2019 and beyond

High level timeline for reformDental Contract Reform

Initial Evaluation

Decision on timing of full roll out

Full Evaluation



Interim Evaluation


Evaluation prototype scheme

Evaluation and Learning Sub Group:

Chaired by Eric Rooney, deputy CDO

Representatives from BDA and CQC

Key themes

Quality and appropriateness of care;

Improvements in oral health;

Access and accessibility

Value for money

Sustainability for roll out

Pro

fess

ion

Pati

ents

Co

mm

issi

on

ers


Evaluation continued

Quality and appropriateness of care

Patients getting the treatment they need

Compliance with the pathway / all bits of the pathway adding value

Professional satisfaction with the approach

Patient journey / resources going to patients with the highest need

Oral Health

Were the improvements seen at the pilot stage maintained / improved further



Can practices provide care to the same number of patients

Are patients able to get an appointment (both new patients and existing patients)

Value for money

Can the reformed contract be delivered within the same financial budget





Is it scalable?

Does it work for all practice types?

What tweaks are required?

Does the contract structure have the flexibility to evolve over time?


The purpose of the interim evaluation

To assist the National Dental Steering Group and the Programme Board in their consideration of the next stage of the programme.

Its prime purpose is to consider whether there are any serious difficulties with the current prototype versions of the contract, that cast doubt on moving to the next planned stage



Interim Evaluation

Oral Health


High level question

Oral Health

Were the improvements seen at the pilot stage maintained / improved further?


Oral health Patients with a series of OHA - OHRsP

erc

enta

ge


Sustainability Practice survey results

The Pathway helps to deliver appropriate care for all patients

0%

10%

20%

30%

40%

50%

60%

Strongly agree Agree Neither agree nordisagree

Disagree Strongly disagree

Percentage of responses

Wave 1 and 2 practices

in terms of preventative care

in terms of treatment




0%

10%

20%

30%

40%

50%

60%

Strongly agree Agree Neither agree nordisagree

Disagree Strongly disagree


Former UDA Practices

in terms of preventative care

in terms of treatment



Have flexibility to use clinical judgement

0%

10%

20%

30%

40%

50%

60%

Stronglyagree

Agree Neitheragree nordisagree

Disagree Stronglydisagree


Wave 1 and 2

0%

10%

20%

30%

40%

50%

60%

Stronglyagree



Notapplicable


Former UDA practices



Flexibility to use clinical judgement compared to during pilot

0%

10%

20%

30%

40%

50%

60%

Much better Slightly better No difference Slightly worse Much worse


Wave 1 and 2


Summary

Oral Health: Recognising that the aim of the reform program is to achieve long term improvement in oral health, reports from the pilot phase have shown that over a relatively short timescale oral heath improved through use of the clinical pathway in the pilots. Further monitoring over time is required to assess the stability of this. There is some evidence that this improvement is being maintained by the ex pilots in the prototype phase and no significant evidence at this stage that oral health is deteriorating as a result of the prototype arrangements. The analysis does not cover the former UDA prototype nor any influence that may be associated with Blend A or B as there has been insufficient time for a fully representative sample across the range of times between assessments and reviews. This will be picked up in the full report


Workshop questions and discussions

Sense check the data:

What data provided was as you expected?

What data was a surprise ?

What questions for further analysis does it raise for you?

For the problems identified, what are your suggestions for improving oral health?



Interim Evaluation




Can practices provide care to the same number of patients?

Are patients able to get an appointment (both new patients and existing patients)?

High level questions


Capitated numbers

86%

88%

90%

92%

94%

96%

98%

100%

102%

Change in capitated numbers from start of pilot/ prototype (November 16 data)

former UDApractices

wave 2 pilots

wave 1 pilots


Wave 1 spread

0%

20%

40%

60%

80%

100%

120%

% of expected capitated patients - 10 highest and lowest Wave 1 pilots from start to Nov 16


Wave 2 spread

0%

20%

40%

60%

80%

100%

120%

% of expected capitated patients - all Wave 2 pilots from start to Nov 16


Former UDA practices spread

0%

20%

40%

60%

80%

100%

120%

% of expected capitated patients - all former UDA practices from start to Nov 16


Access falls and recovery

0.8

0.85

0.9

0.95

1

1.05

% of expected capitated patients by blend and wave, from pilot/prototype start (November 2016 data)

Blend B, former UDApractices

Blend A, former UDApractices

Blend B, Wave 1 practices

Blend B, Wave 2 practices

Blend A, Wave 2 practices

Blend A, Wave 1 practices


Access analysis

Practice Profile

Analysis has taken place to establish if there is any relationship existsbetween the drop in patient numbers and age profile of practicepopulations or the index of multiple deprivation. No clear relationship hasbeen found at this stage and this will be investigated more deeply in thefinal report.

Practice operating procedures

The length of time for taken for the oral health assessment OHA hasanecdotally been considered as something which is likely to affect the abilityto maintain patient numbers. Appointment time data collected as part ofthe programme has been analysed together with the capitated patientnumbers and no correlation of significance has been found. There does notappear to be evidence that longer median OHA appointment durationsexplain the decline in the number of capitated patients in any of the wavesof the programme.


Accessibility

% of patients responding that they

were quite or very satisfied with NHS

dentistry received (PE.06)

% of patients responding that the

length of time it took to get an

appointment was as soon as was

necessary (PE.07)

2015/16 2016/17 (to Oct 2016) 2015/16 2016/17 (to Oct 2016)

Wave 1 pilots 97.0% 96.8% 87.8% 89.8%

Wave 2 pilots 97.5% 97.4% 86.6% 88.7%

Former UDA

practices 97.5% 97.5% 93.2% 89.2%

Total 97.2% 97.1% 88.8% 89.4%

Current UDA

practices

95.9% 91.0%


Accessibility

0

5

10

15

20

25

30

35

Feb Mar Apr May Jun Jul Aug Sep Oct Nov

Day

s

Time in days until 3rd next available appointment for an OHA/OHR with any dentist (based on responses from 46 pilot and 10 former UDA practices)

Wave 1 & 2pilots 2016

Wave 1 & 2pilots 2015

Former UDApractices 2016


Summary

Access: The majority (63%) of practices are delivering the level of access expected within the parameters of the contract. For the practices that joined the programme in Spring 2016, the initial impact on access has been less than in the pilot phase. For the ex-pilot practices, there is evidence of improving access towards the expected level, and some evidence that the rate of this is greater for blend B practices. There is no evidence at this stage of a significant relationship between access levels and either the age or deprivation profile of the practices, or the appointment length for Oral Health Assessments. These factors will be explored in more detail for the final report.

Accessibility: Patients in the prototype practices were slightly less satisfied with the length of time to get an appointment than those in normal NHS general dental practices, but slightly more satisfied with the NHS dental care received.







For the problems identified, what are your suggestions for maintaining access or accessibility?


Lunch

Please be ready to start again in 45 minutes



Interim Evaluation



High level question


Is it scalable?

Does it work for all practice types?

What tweaks are required?

Does the contract structure have the flexibility to evolve over time?


Sustainability delivering the contract


Sustainability delivering the contract

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

% of wave 1,blend A

% of wave 1,blend B

% of wave 2,blend A

% of wave 2,blend B

% of UDA pracs,blend A

% of UDA pracs,blend B

Overall achievement by blend and wave (Nov 16)

>100%

96%-100%

90%-96%


Sustainability Delivering the contract UDA element

0%

20%

40%

60%

80%

100%

120%

140%

160%

% of 16/17 expected prototype UDAs achieved, 3-month moving average

All Wave 1

All Wave 2

All former UDA


0%

20%

40%

60%

80%

100%

120%

140%

160%

% of 16/17 expected prototype UDAs achieved, 3-month moving average

Former UDA Blend B

Former UDA Blend A

Wave 2 Blend A

Wave 1 Blend A

Wave 2 Blend B

Wave 1 Blend B

Sustainability Delivering the contract UDA Element


Sustainability Offset of activity for capitated patients

Blend Wave TypeCapitation

achievement %

Activity

achievement (%)

Overall

achievement (%)

B wave 1 1 105% 72% 100%

A former UDA - 104% 86% 97%

A wave 2 3 104% 85% 97%

B wave 1 1 103% 63% 99%

B former UDA - 103% 85% 99%

B wave 1 2 99% 89% 98%



Is 20 minutes enough for OHA?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Much toolong

Slightly toolong

Right lengthof time

Slightly tooshort

Much tooshort


Wave 1 and 2

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Much too long Slightly toolong

Right length oftime

Slightly tooshort

Much tooshort





Is 15 minutes enough for OHR?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Much toolong

Slightly toolong

Right lengthof time

Slightly tooshort

Much tooshort


Wave 1 and 2

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Much too long Slightly toolong

Right length oftime

Slightly tooshort

Much tooshort





Skill mix has changed to deliver pathway

0%

10%

20%

30%

40%

50%

60%

Stronglyagree

Agree Neither agreenor disagree



Wave 1 and 2

0%

10%

20%

30%

40%

50%

60%

Strongly agree Agree Neither agreenor disagree






Skill mix has reverted back

0%

10%

20%

30%

40%

50%

60%




Wave 1 and 2



Blended contract better than UDA system

0%

10%

20%

30%

40%

50%

60%

Stronglyagree




Wave 1 and 2

0%

10%

20%

30%

40%

50%

60%







Stress compared to under UDA system

0%

10%

20%

30%

40%

50%

60%




personal stress stress across practice



Stress compared to under UDA system

0%

10%

20%

30%

40%

50%

60%



personal stress stress across practice



How well the practice is managing overall under prototype scheme

0%

10%

20%

30%

40%

50%

60%

Very well Well Neither wellnor poorly

Poorly Very poorly


Wave 1 and 2

0%

10%

20%

30%

40%

50%

60%

Very well Well Neither wellnor poorly

Poorly Very poorly

Number of responses



Summary

Sustainability for Practices: Currently 46% of practices are achieving their contract requirements. This figure is skewed by Wave 1 and 2 pilot practices who are transitioning from the pilot phase. In general they have been required to increase their patient numbers and activity as measured by UDAs from the level delivered in the pilot phase. It is clear that loss of access it is difficult to recover and achieve the overall contract requirements.

For the new joiners who entered the prototypes in the spring of 2016 from the current 2006 contract, their expected patient numbers have remained the same as those seen in the previous year, and their expected activity as measured by UDAs has been reduced in recognition of the focus on prevention. Simple linear projections suggest that 62% are projected to meet their contractual requirements by year-end, based on the latest 6 months achievement.

It is important to remember that in any further roll out of the prototype programme, practices will be entering in the same manner as the new joiner practices.







For the problems identified, what are your suggestions for improving sustainability for practices?


Refreshment break

Please be ready to start again in 15 minutes



Panel questions


Panel questions

Please wait for microphone before asking your question



Next steps for evaluation and programme



Close


Close

Thank you for your participation today

Please complete your evaluation forms

Have a safe journey home

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