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Specialist commissioning and 18 weeks (Dentistry)

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Title: Specialist commissioning and 18 weeks (Dentistry)


1
Specialist commissioning and 18 weeks (Dentistry)
  • West Midlands SHA
  • 16th January 2008

2
Commissioning specialist services 18
weeks SETTING THE CONTEXT
  • Natasha Dogmetchi

3
Aims of the day
4
What are we aiming to do?
  • Consider the opportunities for
  • Strategic planning
  • Service re-design
  • Managing demand
  • Managing performance
  • associated with the specialist services

5
What are we aiming to do?
  • Linked to top priorities for PCTs 2007/08
  • Achieving a maximum wait of 18 weeks from GP
    referral to start of treatment of patients
  • Reducing rates of MRSA and other healthcare
    associated infections
  • Reducing health inequalities and promoting health
    and well-being
  • Achieving financial health
  • Source The NHS in England the operating
    framework for 2007/08
  • Note First 18 weeks milestone is March 2008

6
What are we aiming to do?
  • Operating Framework 2008/09 national priorities
    are 5 key areas
  • Improving cleanliness reducing HCAls
  • Improving access through achievement of the
    18-week referral to treatment pledge, improving
    access (including at evenings weekends) to GP
    services
  • Keeping adults children well, improving their
    health reducing health inequalities
  • Improving patient experience, staff satisfaction
    and engagement and
  • Preparing to respond in a state of emergency,
    such as an outbreak of pandemic flu.

7
What are we aiming to do?
  • Operating Framework for 2008/09 (13 Dec 07)
  • Dentistry featured in para 2.35
  • PCTs also need to secure robust commissioning
    strategies for primary dental services, based on
    assessments of local needs and with the objective
    of ensuring year-on-year improvements in the
    number of patients accessing NHS dental services
    (as measured by quarterly data published by the
    Information Centre on the number of people
    receiving primary dental services within the most
    recent two year period.)'

8
What are we aiming to do?
  • Operating Framework for 2008/09
  • In addition, para 1.10 states that
  • '2008/2009 is the start of the next three period
    planning round. In this context, we are
    clarifying the priorities for the next three
    years.'
  • Positions dental services as a key priority over
    the longer term.

9
What are we aiming to do?
  • Operating Framework for 2008/09
  • refers to an overall increase in dental
    allocations, with each PCT receiving 9 and each
    SHA receiving an additional 2 with which to
    target local areas or issues under pressure.

10
Understanding dental specialities
11
What are Specialist Areas in Dentistry?
  • Distinctive specialist titles for branches of
    dentistry identified by the General Dental
    Council under the European primary and Specialist
    Dental Qualifications Regulations (1998)
  • Key aim of protecting patients from unwarranted
    claims of specialist expertise

12
The Dental Specialties
  • Oral Surgery (Oral and Maxillofacial Surgery
    Medical Specialty)
  • Surgical Dentistry (Minor Oral Surgery)
  • Orthodontics
  • Dental Public Health
  • Paediatric Dentistry
  • Restorative Dentistry
  • Periodontics
  • Endodontics
  • Prosthodontics
  • Oral medicine
  • Oral Microbiology
  • Oral Pathology
  • Dental and Maxillofacial Radiology
  • Special Care Dentistry yet to be
    formalised

13
What do they do?
  • Oral Surgery/Oral and Maxillofacial Surgery
  • Surgical Dentistry (Minor Oral Surgery)
  • Orthodontics
  • Dental Public Health
  • Paediatric Dentistry
  • Restorative Dentistry
  • Periodontics
  • Endodontics
  • Prosthodontics

14
What do they do?
  • Oral and Maxillofacial Surgery/Oral Surgery
  • Surgical Dentistry (Minor Oral Surgery)
  • Orthodontics
  • Dental Public Health
  • Paediatric Dentistry
  • Restorative Dentistry
  • Periodontics
  • Endodontics
  • Prosthodontics

15
What do they do?
  • Oral Surgery (Oral and Maxillofacial Surgery)
  • Surgical Dentistry (Minor Oral Surgery)
  • Orthodontics
  • Dental Public Health
  • Paediatric Dentistry
  • Restorative Dentistry
  • Periodontics
  • Endodontics
  • Prosthodontics

16
What do they do?
  • Oral Surgery (Oral and Maxillofacial Surgery)
  • Surgical Dentistry (Minor Oral Surgery)
  • Orthodontics
  • Dental Public Health
  • Paediatric Dentistry
  • Restorative Dentistry
  • Periodontics
  • Endodontics
  • Prosthodontics

17
What do they do?
  • Oral Surgery (Oral and Maxillofacial Surgery)
  • Surgical Dentistry (Minor Oral Surgery)
  • Orthodontics
  • Dental Public Health
  • Paediatric Dentistry
  • Restorative Dentistry
  • Periodontics
  • Endodontics
  • Prosthodontics

18
What do they do?
  • Oral Surgery (Oral and Maxillofacial Surgery)
  • Surgical Dentistry (Minor Oral Surgery)
  • Orthodontics
  • Dental Public Health
  • Paediatric Dentistry
  • Restorative Dentistry
  • Periodontics
  • Endodontics
  • Prosthodontics

19
Mandatory, Advanced Mandatory Specialist
Services
  • Mandatory Services
  • The normal range of primary care dental
    services provided by a generalist dental
    practitioner
  • Specialist Services
  • Services provided on referral by a
    practitioner who is listed by the GDC as a
    specialist
  • Advanced Mandatory Services
  • Additional primary care dental services on
    referral that by virtue of the high level of
    facilities, experience or expertise required is
    above the level provided by a generalist dental
    practitioner

20
Specialist services
  • Most common specialist service in primary care
  • Orthodontics
  • Others in primary care setting, but can also be
    provided as part of mandatory services as
    advanced mandatory services
  • Endodontics
  • Paediatric dentistry
  • Periodontics
  • Prosthodontics
  • restorative
  • Minor oral surgery
  • Other key non mandatory services - additional
    services
  • Sedation
  • domiciliary

21
Reviewing specific services
  • Orthodontics
  • Minor oral surgery
  • Domiciliary services
  • Sedation services
  • Contracting process
  • Key developments since the new contract
  • Hints tips regarding performance

22
Reviewing specific services
  • Orthodontics
  • Minor oral surgery
  • Largest primary care specialist services
  • 175 million (POL System Mar 07)
  • DwSI competency framework
  • 18 weeks waiting list issues
  • Service tendering
  • Largest volume of secondary care referrals
    531,590 referral to outpatients (QM08 data
    2006/07)
  • DwSI competency framework
  • Tendering beginning

23
Reviewing specific services
  • Sedation
  • Domiciliary
  • Significant variations across PCTs
  • DwSI competency now available
  • Have PCT reviewed current services?
  • Significant growing in line with population
    changes
  • Referral criteria is key
  • Liaison between is essential

24
Strategic Commissioning
25
The Commissioning Cycle
Review current service provision
Assess needs
Decide priorities
Design service
Patient and public feedback
Strategic planning Service redesign Managing
demand Managing performance
Shape structure of supply
Managing Performance (quality, performance,
outcomes)
Manage Demand and ensure appropriate access
to care
Clinical decision making
26
Contracting to commissioning
  • Is this now possible?
  • Total budgets for dentistry
  • Local contracts service redesign in line with
    local needs
  • New work force opportunities
  • But.
  • Is dentistry on the PCTs agenda?
  • PCT capacity issues?
  • Budgets under delivery of UDAs

27
System wide approach
28
System wide approach
  • Assessing need unmet demand
  • Considering current capacity (both ST LT)
  • Setting priorities board support
  • Being clear what treatment can be provided in
    primary care in secondary care only
  • VFM
  • Quality frameworks

29
System wide approach
  • Developing capacity in primary care
  • Tendering procurement
  • Developing/supporting clinical networks
  • Improving patients experience managing their
    expectations
  • Opportunities for changing the pattern of
    provision in the ST

30
System wide approach
  • Joint initiatives across PCTs
  • Developing more effective referrals from the
    beginning of the patient pathway
  • Improving throughput of secondary care
  • Optimising workforce productivity
  • Appointing DwSI?

31
The Commissioning Cycle
Review current service provision
Assess needs
Decide priorities
Design service
Patient and public feedback
Strategic planning Service redesign Managing
demand Managing performance
Shape structure of supply
Managing Performance (quality, performance,
outcomes)
Manage Demand and ensure appropriate access
to care
Clinical decision making
32
Understanding Specialist Services
  • Natasha Dogmetchi

33
Service transformation
  • Merely doing things faster will not
  • achieve the 18 weeks target for
  • consultant-led dental services

34
Understanding specialist services
  • Conscious sedation
  • Minor oral surgery advanced mandatory service
  • Domiciliary services
  • Orthodontics
  • One year on key lessons
  • New developments
  • Looking to the future

35
Conscious Sedation
36
What is sedation?
  • The procedure of relaxing patients with the use
    of drugs without inducing complete loss of
    consciousness. Verbal contact with the patient is
    maintained and local anaesthesia is usually also
    maintained.

37
NHS (GDS contracts) and PDS Agreements
Regulations 2005
  • Sedation services defined as meaning
  • a course of treatment provided to a patient
    during which the contractor administers one or
    more drugs to a patient, which produce a state of
    depression of the central nervous system to
    enable treatment to be carried out, and during
    and in respect of that period of sedation-
  • the drugs and techniques used to provide the
    sedation are deployed by the contractor in a
    manner that ensures loss of consciousness is
    rendered unlikely and
  • verbal contact with the patient is maintained in
    so far as is reasonably practicable.

38
Contracting sedation services
  • CACV schedules set out the number of NHS claims
    that included sedation during the reference
    period.
  • PCTs now contracting for number of courses of
    treatment that include sedation
  • Additional Services section of contracts
    should have been completed

39
Contracting sedation services
  • Provided as an entire course of treatment by
    one contractor. Contractor credited with UDAs
    for the banded course of treatment.
  • Dental charges are those appropriate to the
    banded course of treatment.
  • There is no charge for the administration of
    sedation.
  • Contractor cannot provide sedation privately
    as part of an NHS courses of treatment.

40
Indications for use of conscious sedation
  • Include
  • Anxious or phobic patients
  • Patients with physical or mental disability who
    may otherwise be unlikely to allow safe
    completion of dental care
  • To enable an unpleasant procedure, such as more
    complex extractions to be carried out without
    distress to the patient
  • To avoid the need for general anaesthesia

41
ASA Classification
  • Normally only ASA I or II treated in primary care
  • Class I No organic, physiological,
    biochemical or psychiatric
  • disease
  • Class II Mild to moderate systemic
    disturbance eg. Mild diabetes,
  • moderate anaemia,
    well-controlled asthma, not disabling
  • Class III Severe systemic disease, eg. Severe
    diabetes with
  • vascular complications, severe
    pulmonary insufficiency,
  • disabling
  • Class IV Severe systemic disorders that are
    already life threatening,
  • eg. Signs of cardiac
    insufficiency
  • Class V The moribund patient who has little
    chance of survival
  • without operative intervention

42
Standard Conscious Sedation Techniques
  • Inhalational sedation using nitrous oxide/oxygen
  • Intravenous sedation using midazolam alone
  • Oral/transmucosal benzodiazepine (provided
    adequate competence in intravenous techniques
    have been demonstrated
  • In primary dental care majority will be
    inhalation
  • or intravenous sedation using a single agent.

43
Key guidelines to date
  • Conscious Sedation in the Provision of Dental
    Care, Report of an Expert Group on Sedation for
    Dentistry. The Standing Dental Advisory
    Committee, Department of Health 2003(1)
  • Standards for Conscious Sedation in Dentistry
    Alternative techniques. Faculty of Dental Surgery
    of the Royal College of Surgeons of England and
    the Royal College of Anaesthetists, 2007(6)
  • Commissioning Conscious Sedation Services in
    Primary Dental Care, Department of Health,
    2007(5)

44
New DwSI in Conscious Sedation
  • Guidelines for the appointment of Dentists with
    Special Interests (DwSIs) in Conscious Sedation
  • Read in conjunction with previous guidance
  • Document acknowledges that basic (or standard)
    conscious sedation can be carried out by all
    primary care dentists who are competent to do so
    and is not designed to reduce widespread access.

45
New DwSI in Conscious Sedation
  • Definition of a DwSI in Conscious Sedation is a
    primary care dentist who
  • Is able to demonstrate a continuing level of
    competence in standard conscious sedation
    techniques as defined in Standards for Conscious
    Sedation in Dentistry Alternative Techniques
    including
  • Any form of conscious sedation for patients under
    the age of 12 years other than nitrous
    oxide/oxygen inhalation sedation

46
New DwSI in Conscious Sedation
  • In addition to the standard sedation techniques,
    expected that DwSI may be able to
  • Accept referrals from other practices, clinics,
    hospitals
  • Offer more advanced or alternative conscious
    sedation techniques
  • Provide conscious sedation for patients with more
    complex medical histories and/or dental treatment
    needs
  • Provide conscious sedation for patients under 12
    years of age using techniques other than inhaled
    nitrous oxide and oxygen

47
Ensuring a safe service
  • Collaborative working
  • Checklist
  • Role of Dental Practice Advisers
  • Support from the Dental Reference Service
  • Use other external experts

48
Future Challenges
  • Determining capacity/ service levels
  • Considering needs v demands
  • Considering care pathways and referrals?

49
Future Challenges
  • Determining capacity/ service levels
  • What is being provided locally
  • Primary care
  • Optimum service levels?
  • Conscious sedation techniques
  • Who is administering treating
  • Secondary care available information?
  • Patient flows referral patterns
  • Joint commissioning opportunities

50
Future Challenges
  • Considering need v demand - Can PCTs quantify
    the need for sedation?
  • Salford, Manchester Oldham PCTs 3 month
    pilot
  • Providers capture the following information
  • Age
  • Referring practitioner
  • Reason for sedation
  • Dental request
  • Anxiety scale
  • Patient view from the DSD questionnaire

51
Future Challenges
  • Dental Anxiety Scale
  • (not, slightly, fairly, very extremely)
  • Went for treatment
  • Sitting in waiting room
  • About to have teeth drilled
  • Teeth scaled polished
  • Local anaesthetic injection

52
Future Challenges
  • Considering care pathways referrals
  • Clinical indications that may justify a need
    for the use of conscious sedation?
  • Patients that are anxious or phobic
  • Individuals with physical or mental disability
    who are otherwise unlikely to complete treatment
    safety
  • Unpleasant or complicated procedure to be carried
    out without distress
  • Avoid need for GA, such as patients with long
    standing dental phobia

53
Future Challenges
  • Considering care pathways referrals
  • Other methods of pain and anxiety control
    including behaviour management techniques
  • for some patients is a one-off episode (i.e. oral
    surgery procedure)
  • Intermediate stage as part of graduated into to
    treatment under local anaesthesia
  • for some conscious sedation may be a long-term
    requirement such those with physical or mental
    disabilities

54
Future Challenges
  • Considering care pathways referrals
  • Central referral management systems
  • Assessment and treatment process must be
    robust
  • Prioritisation of patients
  • Opportunities for
  • Reviewing other methods of pain of anxiety
    control
  • Reducing common referral problems such as
    patient referred with advanced restorative
    treatment with periodontal disease

55
Current performance issues
  • Referrals increases both to secondary and primary
    care
  • Referrals within practices by providers
  • Competency checks by PCTs

56
Action Plan
  • Practice assessments
  • Review of service capacity
  • Needs assessment
  • Developing strategic care pathways

57
Minor Oral Surgery
58
Key facts
  • Unable to tell specialist services provided in
    primary care
  • Handful of new services being commissioned in
    primary care
  • Appointment process of DwSI now beginning
  • Largest volume of referrals to secondary care

Source Hospital Waiting Data Outpatient
referrals QM08 2006/07
59
Accreditation of UDAs PCR
  • Patients referred for an entire course of
    treatment
  • Sedation
  • Domiciliary services
  • Orthodontic services
  • Referring practitioner credited with associated
    UDAs for treatment up to point of referral, plus
    the collection of associated PCR
  • Practitioner carrying out new course of the
    treatment will be credited with appropriate
    UDAs/UOAs for that course of treatment, plus the
    collection of associated PCR

60
Accreditation of UDAs PCR
  • Accreditation of UDAs PCR
  • Patients referred for part course of treatment
  • minor oral surgery
  • restorative
  • Periodontics
  • Referring practitioner sets out the patients
    entire treatment plan and collects patient
    charges associated with overall COT.
  • Referring will be credited with UDAs associated
    with the overall COT
  • The dentist providing treatment on referral
    collects no PCR and will be credited with the
    UDAs associated with the banded course of
    treatment provided as the additional service

61
Minor oral surgery
  • Why are such high volume of patients being
    referred to secondary care
  • Not practice builders
  • Practitioners competencies
  • Simple v more difficult UDAs?
  • Are PCTs liaising with Trust to review the number
    of referrals and from whom?
  • Are there opportunities for transferring services
    across to primary care managing referrals?

62
Minor oral surgery
  • April 2008 FP17s will record where contractors
    have referred patients for split courses of
    treatment and where contractors have provided COT
    on referral.
  • These will be counted as well as shown a of COT
    undertaken.
  • Enable PCTs to monitor advanced mandatory
    services more closely
  • Are inappropriate referrals being sent back

63
Procuring new services Derby City Derbyshire
County PCTs Croydon PCTs
64
PDS Minor Oral Surgery Pilot
  • Commenced November 1998 (after pre-pilot)
  • Recurrent funding patient charge
  • Long waiting times for MOS in secondary care
    esp 3rd molars
  • Unattractive GDS fee scale / MOS not a practice
    builder
  • Initially 2 (later 3) GDPs with specialist
    skills in MOS
  • Major issue - vicarious liability clinical
    standards
  • Admission to specialist list a defined surgical
    standard
  • SAAD independent audit used to define sedation
    standards
  • Worked closely with specialists to develop and
    refine process that reflects NICE guidance

65
PDS Minor Oral Surgery Pilot (2)
  • Referral made directly to PDS practice by GDP
  • Patients aged 18 and over
  • Initially 3rd molar surgery apicectomies on
    previously root filled canines and incisors
  • Treatment under LA with or without sedation
  • Medically compromised patients - ASA categories 1
    2 only

66
PDS Minor Oral Surgery Pilot (3)
  • Range of procedures increased in 2002
  • Locally administered system
  • Protocol
  • Case audit form / invoice for each patient
  • Patient satisfaction questionnaire (70 response)

67
PDS Minor Oral Surgery Pilot (4)
  • Simple cost per case used initially for pre-pilot
  • 1998 - Simple fee scale in place
  • Core fee
  • Sedation fee
  • Supplementary fee
  • Made more complex by having to use the SDR to
    calculate the patients charge
  • In old system - Cost per case to the pilot
    budget, depends on patients contribution
    sedation rate.

68
Cases Treated 2002 - 2005
69
Costs
70
Cost per case
71
  • 05/06 national tariff costs
  • Inpatient
  • 730 Planned procedure
  • 1271 Emergency procedure
  • Outpatient
  • 1st visit
  • Adult - 116
  • Child lt17 - 156
  • Follow up visits
  • Adult - 60
  • Child lt17 - 81

72
Conclusions
  • MOS service is a success!
  • Is in the public interest.
  • Provides a tool that can be used elsewhere in the
    right circumstances
  • Needs to be taken forward in a spirit of
    partnership
  • 10 and 20 care are different parts of spectrum of
    services funded by the public for the public
    need to look at total resource
  • CPD of the primary care dental workforce role
    for specialist practices?
  • PCTs need to consider the best framework locally
    for delivering services on referral in primary
    care

73
  • Intermediate Minor Oral Surgery
  • (IMOS) Service

74
  • IMOS Background
  • Increasing referrals
  • Case mix referred
  • Effects of Payment by Results (national tariff).

75
Referrals to Mayday Hospital for Oral
Maxillofacial Surgery in three year period from
April 2004
76
Referrals to Mayday Hospital for Oral
Maxillofacial Surgery in three year period from
April 2004
77
  • Payment By Results
  • Maxillofacial surgery, Code 144
  • Adult First Attendance - 127
  • Adult Follow Up - 66
  • HRG C04 minor mouth - 543
  • HRG C58 intermediate mouth - 785.

78
  • Payment By Results 07/08
  • Minor oral surgery hospital case
  • OP FA procedure no follow up
  • 670-912
  • Primary care setting e.g PDS
  • Local anaesthesia /- sedation
  • 150-200

79
  • IMOS Waiting List Initiatives
  • Waiting list initiatives 3 phases to date
  • Restricted tendering exercise involving all
    Croydon providers
  • Oral surgeons to be included on GDCs specialist
    list
  • Two providers selected (South Croydon Norbury)
  • Oral surgeons triaged 584 patients appropriately
  • To date, 151 patients treated in primary care.

80
  • IMOS Service (1)
  • Business plan approved by PCTs board in April
    2007
  • Tendering exercise national tender
  • Expressions of interest over August 07
  • Providers shortlisted interviews 19/10/07
  • Activity reduction in Mayday SLA of 50 cases
    per month (conservative estimate).

81
  • IMOS Service (2)
  • Referrals triaged by PCTs CST staffed by MOS
    surgeon (weekly triage session)
  • Produce new referral protocols referral form
  • Patients triaged appropriately to IMOS, secondary
    care or back to GDP
  • X-rays must be of suitable diagnostic quality
  • Effect on secondary care career pathways.

82
Domiciliary Services
83
Domiciliary services
  • Domiciliary visit fee no UDA
  • Clinical care provided to patients UDAs
  • DPB info includes
  • number of claims for domiciliary visits and NOT
    the number of domiciliary visits

84
Domiciliary services
  • Who is being seen?
  • Patients at home
  • Specific residential or nursing homes?
  • Ongoing or one off arrangement
  • Geographical area
  • Mix between domiciliary fee and clinical care
  • Dentures only
  • Little treatment

85
Domiciliary services
  • Reporting and performance issues
  • Old world - number of claims
  • New world number of courses of treatment
  • Defining services in more detail

86
Orthodontic services
87
Orthodontic services
  • Review of the transition to the new contract
  • More than one year on where are we now
  • Clarifying contractual process
  • Retiring orthodontic contractors

88
Transition to the new contract
  • Early misunderstanding regarding transitional
    payments for patients transferring across from
    the GDS
  • Far fewer growing practices than anticipated
  • Inability for PCTs to separate mandatory/orthodont
    ic elements of contractual agreements on DSD
  • High number of cases referred to the NHSLA
    (mainly associated with close down payments)

89
Transition to the new contract
  • Mixed practices - orthodontic elements
    translated into UDAs
  • Few specialist contractor opted out of the NHS
    (formally)
  • 175m on commissioning orthodontic contractors
  • Huge geographical variation in orthodontic
    provision
  • Significant variations in v population

90
Transition to the new contract
  • Greatest noise from MPs patients regarding
    specialist services
  • Ineligibility to treatment PCTs established
    patient appeals processes
  • Private v NHS waiting lists
  • Fall in national UOA values due to
  • Transitional commissioning errors corrected
  • Ability to separate out orthodontics on POL
  • Tendering additional services at lower UOA

91
One year on - v
  • Local assessment of needs
  • Short and longer term commissioning intentions
    agreed at Board level communicated to
    contractors
  • Tendering of new services
  • Joint commissioning being explored
  • Clinical networks being established
  • New referral management arrangements

92
One year on X
  • Misunderstanding patient flow data by some PCTs
  • Wasted activity
  • Ineligible IOTN case starts
  • High of failed to returns
  • High volume of assessments v case starts
  • Private v NHS
  • Waiting times games
  • Not considering the whole patient pathway
    links with secondary care colleagues 18 weeks

93
Contractual misunderstandings
  • nGDS mixed contracts
  • notice by PCTs to remove orthodontic elements and
    convert to UDAs
  • Contract variations, including change in UOA
    value must be agreed by both parties
  • nPDS specialist contracts
  • 5 year contracts
  • Contract variations, including change in UOA
    value must be agreed by both parties

94
Contractual misunderstandings
  • nGDS/nPDS contract variations
  • Contract variations not agreed can be forwarded
    by either the PCT or the provider to the NHSLA
    who will take into account
  • Has the PCT followed the correct process
  • Is what is being proposed by the PCT reasonable
  • Local benchmarks i.e. disproportionately high
    unit rate with no reasonable explanation
  • Under performing?

95
Managing retiring practices
  • Provider retiring
  • Existing provider contracted to complete patients
  • No UOAs
  • Short term fixed contract
  • Incentive to start cases prior to notice period
  • This is likely to most expenses option for PCT
  • Sliding down scale contract, based on a
    completion rate (look at historical rate)

96
Managing Retiring Practices
97
Managing retiring practices
  • Former GDS orthodontists paid fees after
    treatment was completed
  • nPDS/nGDS no payment for completing cases,
    monthly payments for continuing treatment
  • Units of activity awarded at assessment case
    starts
  • Minimum 3 months notice (nGD/nPDS)
  • Orthodontic treatment can last up 18 36 months
  • Each month some cases are started other
    finished, vary from one contractor to another
  • New problem ensuring the completion of patients

98
Managing retiring practices
  • Guiding principles?
  • Treatment of all patients should be completed
  • Contractor should cease starting new cases
  • The PCTs should not be financially disadvantaged
  • PCTs should be able to commission the same level
    of service
  • Note Responsibility of PCT to ensure completion
    of patients once the contract period ends

99
Managing retiring practices
  • Scenarios
  • Performer leaving a practice based contracts
  • Provider retiring and
  • New provider to take on contracts
  • No new provider to take on contracts

100
Managing retiring practices
  • Performer leaving a practice based contracts
  • Responsibility for completing the outstanding
    care of patients and delivering the contracted
    number of UOAs remains with the provider.
  • Should be a seamless transfer
  • Provider may seek to deliver the contract via
    expansion of existing capacity within practice or
    new performer to be employed

101
Managing retiring practices
  • Provider retiring
  • Contract not being transferred, but agreement
    reached with PCT for extended notice period to
    enable to planned completion of all patients
    prior to retirement.
  • Notice period depending on number and pattern of
    completing patients (need to look at history of
    completion)
  • PCTs could consider flexible approach regarding
    carrying over UOAs to reduce contract payment
    reductions whilst no new UOAs are being
    attributed

102
Managing retiring practices
  • Provider retiring
  • New provider identified to take on contract
  • Tripartite agreement (where required) between
    PCT, new and retiring practice regarding
  • notice period
  • completion start up of new cases across the two
    providers.
  • Principle remains that no financial loss to the
    PCT

103
Managing retiring practices
  • Provider retiring
  • New provider identified to complete patients only
  • Short term fixed contract
  • May be some reluctance by contractor to complete
    patients only
  • Best option only where PCT does not wish to
    commit resources on a recurring basis to
    orthodontics

104
Applying 18 week rules to dental specialities
  • Natasha Dogmetchi

105
Applying 18 weeks rule
  • Principles of 18 week clock rules apply equally
    to pathways that involve, or could potentially
    involve care led by a dental consultant
  • A maximum 18 weeks from point of initial referral
    up to the start of any necessary treatment
    includes referrals to clinical consultant-led
    services in dental specialities, ie
  • Oral surgery, orthodontics, paediatric dentistry,
    restorative dentistry, periodontics,
    prosthodontics, endodontics, oral medicince and
    dental and maxillofacial radiology

106
Applying 18 week rule
  • What is happening locally
  • What data is available?
  • RTT data Admitted patients Oral Surgery
  • Hospital Waiting Times QM08 non-admitted all
    dental specialties
  • New RTT data for non-admitted patients Sep 07
    only counts oral surgery

107
RTT Data Oral Surgery
Source RTT Data (www.18weeks.nhs.uk) England
data July 2007
108
RTT Data Oral Surgery
Source RTT Data (www.18weeks.nhs.uk) England
data July 2007
109
QM08 Referrals to Dental Specialties
Outpatients 2006/07
Source Hospital Waiting Times- Outpatient QM08
(http//www.performance.doh.gov.uk/waitingtimes/i
ndex.htm)
110
Applying 18 week rule
  • Consultant-led dental services
  • Consultant retains overall responsibility for the
    patient, but does not mean
  • that they are present for each appointment
  • Setting in which care is provided in necessarily
    the secondary care

111
Applying 18 week rule
  • 18 week target applies to
  • Consultant-led hospital services
  • Consultant-led services provided in the primary
    care setting
  • General anaesthesia services
  • Patients under the care of all postgraduate
    dental students, including specialist registrars
    (SpRs)

112
Applying 18 week rules
  • 18 week target does not applies to
  • Patients seen by undergraduate dental students
  • Referrals from one dental contractor to another
    in primary care

113
Applying 18 week rules
  • Clock starts when referral is made to a
    consultant on the basis that
  • the patient is to be assessed and then if
    appropriate treated, before being referred back
    and
  • the patient will, or could potentially receive
    treatment from a consultant-led services.
  • Note Referrals to consultant-led dental services
    for treatment planning and/or advice also start
    the clock

114
Applying 18 week rules
  • Referrals to following start the 18 week clock
  • Consultant-led dental services (in secondary or
    other setting)
  • Oral cancer services (62 day cancer clock also
    for urgent suspected cancer cases)
  • Diagnostic services, on basis that if
    appropriate, will be treated by a consultant-led
    service before referred back
  • Referral management arrangements/interface
    services
  • Specialist dental contractors, DwSI or dentists
    that hold advanced mandatory contracts if they
    are part of dedicated referral management
    arrangements

115
Applying 18 week rules
  • Referrals to following does not start the 18 week
    clock
  • Services provided primary care dentists
  • Salaried primary dental care services
  • Services provided by specialist dental
    contractors, DwSI or dentists that hold advanced
    mandatory contracts where they are not part of
    dedicated referral management arrangements/interfa
    ce services
  • Services provided by undergraduate students in
    dental teaching hospitals or as part of outreach
    teaching

116
Applying 18 week rules
  • Whose referrals start the clock
  • 18 week pathway can begin with a referral by an
  • health professional or health body authorised to
  • make referrals, including
  • GDPs, specialist dental contractors, DwSI or
    dentists with advanced mandatory contracts
  • Salaried primary dental care services
  • Prison dental services
  • Consultants (or consultant-led services)

117
Applying 18 week rules
  • What defines the clock-start date
  • Date on which the provider to whom the initial
    referral is made
  • (including management centres) receives notice of
    the patients
  • referral. Referrals using Choose Book, is date
    on which the patients
  • unique booking reference number (UBRN) is
    converted.
  • For dentistry, most likely to be referrals by
    letter and therefore is the date on which the
    provider (where the clock starts) receives the
    referral letter NOT the date the patient is
    assessed.

118
Applying 18 week rules
  • Clock stops
  • The clock stops when a clinical decision is
    made that no treatment is required, or when first
    definitive treatment begins.
  • First definitive treatment (with our without
    discharge)
  • A decision not to treat
  • A decision to embark on a period of watchful
    waiting or active monitoring
  • A decision to refer patient for treatment in
    primary care (not consultant-led)
  • Patient declines treatment offered to them

119
Applying 18 week rules
  • Clock stops
  • First definitive treatment can be
  • Inpatient treatment - date of admission
  • Out patient or day-case treatment - date of
    attendance treatment
  • Fitting of a dental device date on which
    definitive fitting or trial fitting begins
  • First-line treatment ie dental treatment or
    management provided with the aim of avoiding the
    need for more invasive treatment. (new clock
    starts is a later decision is taken for more
    invasive treatment)

120
Applying 18 week rules
  • Clock stops
  • Dental examples - outpatient
  • Orthodontic treatment clock stops when
  • Patient referred back to the dentist in primary
    care for removal of a tooth
  • Patient needs to be referred when older (clock
    stops when clinical decision made and referring
    dentist informed to commence waiting)
  • First definitive treatment such as the fitting of
    a dental brace

121
Applying 18 week rules
  • Does not stop the clock
  • A first or subsequent outpatient appointment or
    assessment that does not involve treatment
  • Pain relief treatment or other steps to manage a
    patients condition in advance of definitive
    treatment
  • Consultant-to-consultant referrals were the
    underlying condition remains unchanged

122
Service transformation whole system review
123
Service transformation
  • Merely doing things faster will not
  • achieve the 18 weeks target for
  • consultant-led dental services

124
Assessing needs demands
125
Service transformation
  • Assessing needs demand
  • Important relationship between provision in
    primary care dental services (not subject to 18
    weeks) and consultant-led services (subject to 18
    weeks)
  • Through assessing oral health needs, PCTs should
    have set agreed relative priorities, in both
    short long terms across primary secondary
    care
  • Priorities should be considered in relation to
    current capacity, in both short long term
    across primary secondary care

126
Service planning
127
Service transformation
  • Service planning
  • Redirecting resources may be essential locally
  • Shifting work that has traditionally taken place
    in hospitals to specialist or DwSI in primary
    care
  • Treatment reviews what can only be done in
    secondary care
  • Whole system approach involves considering
    referrals and quality frameworks across primary
    and secondary care
  • Capacity v workload should be assessed in
    relation to referral patterns and types

128
Developing capacity in primary care
129
Service transformation
  • Developing capacity in primary care
  • Is there a need for growth in specialist care
    particularly orthodontics
  • Feedback overall that no shortage of contractors
    seeking new/extended contracts, although local
    capacity is not always readily available
  • Tendering and new contracts provides the
    opportunity to tailor services in line with local
    needs

130
Establishing clinical networks
131
Service transformation
  • Establishing clinical networks
  • Establishing networking of GDPs, specialists
    across primary and secondary care key. Is there a
    need to review it in light of
  • Need to include all local stakeholders
  • Attaining 18 week requirement
  • Latest good practice information
  • PCT/SHA benchmarking information
  • Latest information regarding referral patterns
    patient flows
  • Capacity implications
  • To consider effective referrals and treatment
    criteria across the system

132
Managing patients expectations patients
public involvement
133
Service transformation
  • Managing patients expectations
  • Need to communicate to patients what they can
    expect and entitlement to treatment
  • Clarity about referral criteria and service
    delivery will support this
  • Responsibility of PCTs to actively engage with
    patients and the public during the course of
    their decision-making process

134
Patient and Public Involvement
  • A Stronger Local Voice (2006)
  • PPI to form central role in future
  • commissioning decision-making
  • Will apply to health social care
  • sectors
  • Local Government Public
  • Involvement in Health Act (2007)

135
Patient Public Involvement
  • Key Changes
  • Introduction of LINks
  • Replacement of Patient Forums CPPIH
  • Consultation and involvement will become a
    standard requirement.
  • PPI mechanisms need to be built into
    decision-making processes

136
Patient Public Involvement
  • Useful Information
  • PCC website
  • DH website
  • NHS Centre for Involvement
  • PPI Exchange Network (PPIX)
  • Workshops and Seminars

137
Changing the pattern of provision
138
Service transformation
  • Changing the pattern of provision
  • May be a need to implement short term action
    whilst considering a longer term vision
  • Short term actions may include
  • Commissioning short term contracts to take
    patients off existing waiting lists
  • Agreeing joint commissioning strategy with
    neighbouring PCTs
  • Validating secondary care waiting lists
  • Putting in place
  • Changing capacity may be longer term,
    particularly where there this cannot be procured
    locally

139
Effective referrals
140
Service transformation
  • Effective referrals
  • Referral patterns significant effect waiting
    lists for secondary care dentistry
  • Need to have local communication strategy with
    primary care contractors that sets out referral
    process criteria
  • Training should be offered by PCT or both primary
    secondary care referrals

141
Service transformation
  • Effective referrals
  • Number of referral management systems
  • Referrals to secondary care via primary care
    specialists first
  • Dedicated primary care referral management
    arrangements/processes (18 weeks rule)
  • Standardising local referral protocols

142
Improving secondary care throughput
143
Service transformation
  • Improving throughput of secondary care
  • Feedback from Trusts, that PCTs are not willing
    to engage in discussions on dentistry
  • Is local data being reviewed
  • Process mapping support identifying limiting
    steps without causing unanticipated consequences
  • Important to note that not all referrals will be
    for treatment ie treatment planning advice

144
Recruitment skill mix Role of DwSI
145
Service transformation
  • Tackling recruitment changing skill mix
  • Difficulties in recruitment of specialist
    clinical staff in secondary care
  • Primary care feedback is that less of an issue
  • Need to assess workforce recruitment plans
    across both and consider in context of service
    reconfiguration and skill mix
  • New skill mix opportunities in primary care
  • Therapists
  • DwSI

146
Role of Dentists With a Special Interest
147
PwSIs - Common Principles
  • Draws on generalist skills as a gatekeeper to
    more specialised services
  • Must be able to work without supervision
  • Competences required will always be greater than
    a generalist
  • Appropriate qualification may be one way of
    demonstrating competence but must not be the only
    way
  • Accreditation essential
  • Local Ts Cs agreed with PCT

148
DWSIs - General Principles
  • Used in clinical areas where delivery and health
    needs require a local solution
  • Contractual arrangement between PCTs and primary
    dental care practitioners to provide specialised
    skills within the PCT area
  • PCT appointment to nationally agreed selection
    criterion
  • Ideally part of a consultant led clinical network
  • Type of contract to be decided locally normally
    by number of cases seen.

149
DwSIs the key concepts
  • DwSI concept of enhanced practitioner,
    sub-speciality level but retaining primary care
    generalist profile
  • Recognition of existing levels of special skills
    through portfolio of evidence and/or taught
    diplomas and certificates
  • Appointed by PCTs after assessment of competency.

150
(No Transcript)
151
DWSIs First Areas for Development
  • Orthodontics
  • Minor Oral Surgery
  • Periodontics
  • Endodontics
  • New Conscious sedation

152
DwSI - Selected examples of competency criteria
for Orthodontics
  • Requirement Sources of Evidence
  • Understanding of occlusion BDS, DVT, GPT
  • its development
  • Diagnose malocclusion Clinical Assistant
    training
  • know when to intervene scheme or clinical
    attachment
  • Understand limits of Peer group assessment,
  • appliance therapy present treated cases
  • Maintain quality of treatment verifiable CPD,
    attendance
  • standards at orthodontic courses
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