Specialist commissioning and 18 weeks Dentistry

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Specialist commissioning and 18 weeks (Dentistry)

• East Midlands SHA
• 12th December 2007

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Commissioning specialist services 18
weeksSETTING THE CONTEXT

• Natasha Dogmetchi

3
Aims of the day
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What are we aiming to do?

• Consider the opportunities for
• Strategic planning
• Service re-design
• Managing demand
• Managing performance
• associated with the specialist services

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What are we aiming to do?

• Linked to top priorities for PCTs
• 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
Understanding dental specialities
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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

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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

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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

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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

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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

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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

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 Surgery (Oral and Maxillofacial Surgery)
• Surgical Dentistry (Minor Oral Surgery)
• Orthodontics
• Dental Public Health
• Paediatric Dentistry
• Restorative Dentistry
• Periodontics
• Endodontics
• Prosthodontics

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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

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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

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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

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Reviewing specific services

• Sedation
• Domiciliary

• Additional service
• Significant variations across PCTs
• DwSI competency framework
• Current competencies should have been assessed
• Significant growing in line with population
  changes
• Referral criteria is key
• Liaison between secondary care services, salaried
  dental services local contractors is essential

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Strategic Commissioning
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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
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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

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System wide approach
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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

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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

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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

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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
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Specialist commissioning and 18 weeks (Dentistry)
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Understanding Specialist Services

• Natasha Dogmetchi

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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

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Conscious Sedation
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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.

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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.

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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

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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

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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.

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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

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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.

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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)

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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.

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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

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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

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Ensuring a safe service

• Collaborative working
• Checklist
• Role of Dental Practice Advisers
• Support from the Dental Reference Service
• Use other external experts

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Future Challenges

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

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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

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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

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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

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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

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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

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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

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Current performance issues

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

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Action Plan

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

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Minor Oral Surgery
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Key facts

• Unable to tell specialist services provided in
  primary care
• Increasing number 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
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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

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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

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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?

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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

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Procuring new servicesCroydon PCT
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• Intermediate Minor Oral Surgery
• (IMOS) Service

60

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

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Referrals to Mayday Hospital for Oral
Maxillofacial Surgery in three year period from
April 2004
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Referrals to Mayday Hospital for Oral
Maxillofacial Surgery in three year period from
April 2004
63

• 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.

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• 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

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• 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.

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• 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).

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• 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.

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Domiciliary Services
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Domiciliary services

• GDS payment system
• Fees in relation to travel to one or more
  patients other than the dentists surgery.
• Fee per circuit
• Less an 10 miles 31.50
• 10 40 miles 43.35
• Over 40 miles 56.90

70
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

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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

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Domiciliary services

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

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Orthodontic services
74
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

75
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)

76
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

77
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

78
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

79
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

80
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

81
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?

82
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)

83
Managing Retiring Practices
84
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
  

85
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

86
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

87
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

88
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

89
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

90
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

91
Applying 18 week rules to dental specialities

• Natasha Dogmetchi

92
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

93
Applying 18 week rule

• What is happening locally
• What data is available?
• RTT data Admitted patients Oral Surgery
• Hospital Waiting Times QM08 outpatient
  referrals all dental specialties

94
RTT Data Oral Surgery
Source RTT Data (www.18weeks.nhs.uk) England
data July 2007
95
RTT Data Oral Surgery
Source RTT Data (www.18weeks.nhs.uk) England
data July 2007
96
QM08 Referrals to Dental Specialties
Outpatients 2006/07
Source Hospital Waiting Times- Outpatient QM08
(http//www.performance.doh.gov.uk/waitingtimes/i
ndex.htm)
97
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

98
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)

99
Applying 18 week rules

• 18 week target does not applies to
• Patients seen by undergraduate dental students
• Referrals from one dental contractor to another

100
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.

101
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 centres
• Specialist dental contractors, DwSI or dentists
  that hold advanced mandatory contracts if they
  are part of dedicated referral management
  arrangements

102
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
• Services provided by undergraduate students in
  dental teaching hospitals or as part of outreach
  teaching

103
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)

104
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 receives the referral later.

105
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

106
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)

107
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 is fitting of a dental
  brace

108
Applying 18 week rules

• Does not stop the clock
• A first or subsequent outpatient appointment or
  assessment that does not involve treatment or the
  fitting of a dental device
• 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

109
Service transformation whole system review
110
Service transformation

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

111
Assessing needs demands
112
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

113
Service planning
114
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

115
Developing capacity in primary care
116
Service transformation

• Developing capacity in primary care
• Growth in specialist care particularly
  orthodontics
• Feedback 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
• Tendering exercises
• Orthodontics
• Minor oral surgery

117
Establishing clinical networks
118
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

119
Managing patients expectations patients
public involvement
120
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

121
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)

122
Patient Public Involvement

• Key Changes
• Introduction of LINks
• Replacement of Patient Forums CPPIH
• Patient initiated petitions
• Patient Prospectuses
• Overview Scrutiny Committees

123
Patient Public Involvement

• Some Implications
• Consultation and involvement will become a
  standard requirement.
• PPI mechanisms need to be built into
  decision-making processes
• Greater feedback
• Joint Strategic Needs Assessment

124
Patient Public Involvement

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

125
Changing the pattern of provision
126
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

127
Effective refferrals
128
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

129
Service transformation

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

130
Improving secondary care throughput
131
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

132
Recruitment skill mixRole of DwSI
133
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

134
Role of Dentists With a Special Interest
135
Summary

• Practitioners with a Special Interest the
  policy and principles
• Accrediting Dentists with a Special Interest
  (DwSIs)
• The role of the PCT
• Commissioning for DwSI services

136
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

137
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.

138
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.

139
Advantages of DwSIs in a Patientled NHS

• Greater convenience
• Faster access
• More choice
• Avoidance of inappropriate referrals

140
Advantages for Dentists

• Formal recognition by the NHS of special skills
  obtained through experience and/or training
• Development of a recognised referral pathway for
  their patients within NHS primary dental care.

141
Advantages for the NHS

• Close strategic fit with the NHS Dentistry
  Agenda by
• Providing PCTs with greater flexibility in terms
  of local commissioning of dental services
• Encouraging dentists to develop their practice
  within the NHS.

142
DwSIs Next Steps

• Clinical Competency Frameworks and appointment
  guidelines published-2006
• Step by step guide for PCTs published -2006
• Model Patient leaflet published- 2006
• Appointment of DwSIs
• Second wave competencies to follow

143
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144
DWSIs First Areas for Development

• Orthodontics
• Minor Oral Surgery
• Periodontics
• Endodontics

145
DWSIs Second Wave
Competencies in Development

• Conscious Sedation- Chair David Craig
• Prison Dentistry- Chair Helen Falcon
• Dental Public Health ?
• (Awaiting review of capacity and
  capability)

146
Commissioning DwSI services

• Reviewing current services
• Identifying what is needed
• Designing the service
• Establishing Clinical Governance
• Putting Audit Evaluation in place.

147
Step 1 review current services

• Health needs assessment
• Engage variety of stakeholders
• Involve patients public (PPI)
• Examine existing referral patterns
• Be clear of objectives of setting up DwSI

148
Step 2 What you will need

• Establish commissioning group
• Impact assessment
• How will service fit integrated commissioning
  strategy
• Identify resource needs and locations.

149
Step 3 Design the Service

• Scope of service
• Clarify range of care type of conditions to be
  treated by DwSIs
• Administration arrangements
• Clinical Network
• Consider suitable contract arrangements including
  remuneration method of payment.

150
Step 4 Clinical Governance

• Lines of accountability
• Continuing professional development
• Accreditation
• Risk assessment
• Maintaining records

151
Step 5 Audit Evaluation

• Service specification
• Monitoring arrangements
• Performance
• Outcomes

152
Commissioning for Additional DwSI Services

• Commissioning must be contestable
• - specification of service required
• - tender
• Contract for completed cases on referral
• Patients charge levied by referring dentist
• Enhanced data set

153
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