NHS Dentistry Implementing the new contractual arrangements

1
NHS Dentistry Implementing the new contractual
arrangements

• A Learning Event for PCTs and SHAs

2
Welcome and Introduction
3
Welcome and Introduction

• Housekeeping announcements
• Timetable for change
• Recognise pressures on PCTs and SHAs
• DH Guidance and PCC support to PCTs
• Opportunity to hear about key issues for
  implementation programme locally
• And more interactive work on concerns and
  pressures in breakout sessions

4
Reform of NHS Dentistry
5

Reform of NHS Dentistry (1) Local commissioning,
national framework
From April 2006, PCTs responsible for
commissioning primary care dental services
within national framework of
New system of patient charges
3-year investment guarantee
Contract regulations (GDS PDS)
NICE guidelines (recall intervals)
Oral health plan, including fluoridation
Devolution of budgets to PCTs from April 2006,
based on historic GDS spend 250m net investment
6

Reform of NHS Dentistry (2) Overall objectives
How local commissioning helps, both in the
short term
Stabilise investment at PCT level
Sustain dentists commitment to NHS (off the
treadmill 3-year income guarantee)
Promote less intervention more preventive
approach
Facilitate access improvements (NICE guidelines)
and by establishing a platform for
Influence over where new practices establish
Stronger local relationship with NHS dentists
Commissioning to meet oral health needs of
population
Commissioning to further improve access
7
Reform of NHS Dentistry (3)

• 10 key actions from guidance
• Named PCT leads and contact points
• Engage with dentists and patients groups
• Use information from DPB to agree appropriate
  activity levels
• Benefit from model contracts
• Understand Patients Charges risk

8
Reform of NHS Dentistry (4)

• 10 key actions from guidance cont.
• Make contract offers early and agree by end
  February 2006
• Request support if problems emerge
• Agree out-of-hours/unscheduled care service
• SHA wide approach to commissioning specialised
  services
• Develop new Performers List by April 2006

9
Reform of NHS Dentistry (4)

• NHS performance framework (in development)
• PCT leads (current and new)
• Dental activity expectations (UDA and
• non UDA)
• Forward planning

10
Reform of NHS Dentistry (5)

• Units of Dental Activity (UDAs)
• Key measure reflects 5 reduction in activity
  reduction in treatment within bands
• UDA total at PCT level is a reflection of total
  stability/growth/vfm in dentistry
• to UDA ratio will vary as a result
• Will begin to vary in future according to
  commissioning decisions eg high need groups

11
Contracting
12
Contracting (1) Timetable

• Legislative process due to be completed by end
  November 2005 (patient charges)
• Information to be sent out by end November
• Charge Regulations (subject to Parliament)
• Finalised nGDS nPDS contracts Regulations
• Budgets
• Model Contract
• Statement of Financial Entitlement
• Transitional Order

13
Contracting (2)

• Formal contract negotiations from December
• Contracts can be signed from 1 January 2006
• Aim to have contracts signed by 28 February (to
  enable DPB to process information by end March)

14
Contracting (3) Key Changes to Regs

• Normal surgery hours replaces core hours
• Death in Service
• Irrevocable breakdown of relationship
• Completion of Treatment

15
Contracting (4) Children and Exempt Patients

• PCTs may agree children or exempt only contracts
  if appropriate
• Practices may NOT use parents signing up
  privately as a prerequisite for child registration

16
Contracting (5) Performers List

• Primary dental services only to be provided by
  persons on performers list
• Requirement from 1 April 2006
• Current dentists transfer to new single list
• Only need to be on one list
• CRB Checks

17
Contracting (6)

• There is NO default contract
• no contract in place no NHS work

Dispute resolution
18
Contracting (7) nPDS / nGDS

• nGDS
• Must contain all mandatory services
• Not time limited
• nPDS
• Time limited
• Specialist services
• Available to practices working under existing
  pilot arrangements
• If contains mandatory services cannot pick and mix

19
Contracting (8) Key Points nGDS

• Information sent to providers and PCT - by
  individual contract provider
• Contractors are entitled to an individual
  contract
• PCTs may enter into practice based contracts with
  the agreement of all parties
• Emphasis should be on agreeing like for like
  contracts based on reference period
• Can include undertaking about future discussions

20
Contracting (9) Key Points nPDS

• Information to PCTs by individual contract
  provider
• PDS reference period activity converted to UDAs
  forms basis for contract activity
• Current PDS pilots can agree a substantive nPDS
• or nGDS contract
• If moving to nPDS
• new contract duration should be at least
  unexpired part of the pilot
• value must be at least the value of the pilot
• negotiate UDA values
• If moving to nGDS
• entitled to contract value
• negotiate UDA values - could be agreed based on
  local nGDS levels

21
Contracting (10) Activity

• For nGDS, CACV UDAs in reference period less 5
  to allow dentists to get off IoS treadmill
• For existing PDS pilot practices, activity levels
  should allow practices to work in new ways and
  achieve PCR
• Flexibility to include non-UDA activity in
  contract BUT cannot assign UDAs to that activity
• Any non-UDA activity must be clearly defined in
  the contract and should include appropriate
  milestones

22
Contracting (11) Out of Hours

• PCTs responsible for all residents visitors
• Key national principles
• Dental OOH services may be integrated with
  medical OOH services
• Triage (form is up to PCTs)
• Patient should have access to telephone advice,
  and face to face contact when appropriate
• Genuine dental emergencies are rare, so
• OOH advice can be provided for a large area by
  telephone triage a dentist on call with access
  to facilities
• OOH service is not a substitute for urgent
  treatment

23
Contracting (12) New practices

• Practices setting up without complete 12 month
  CACV
• are entitled to contract if in practice on 31
  March 2006, but
• Negotiate full year value level of service to
  be provided
• Can base additional activity on local needs
  benchmarking
• Funding for any additional activity comes from
  PCT 2006/7 budget
• Dentists moving to a new practice
• Within PCT
• Outside PCT

24
Contracting (13) Handling Change

• Turnover
• Retirements, workforce mobility
• Practices leaving NHS
• Reduced NHS commitment
• Funds remain within PCT budget
• Ensure continuity of patient service
• PCT (quick) interim response

Opportunity to reconfigure services in line with
local plan and priorities
25
Finance and Activity
26
Finance and Activity (1) Overview
INVESTMENT
Current gross NHS income
Uprated by 06/07 prices
Calculated Annual Contract Value (CACV)
n GDS ACTIVITY
Current activity (item of service)
Weighted courses of treatment (units of dental
activity) less 5
Activity to be delivered in return for CACV
Indicative comparison of GDS/PDS using new
currency of weighted activity
Former GDS activity
PCT uses as basis for re-setting PDS agreements
n PDS ACTIVITY

New PDS activity
CHARGE INCOME
Charge income under GDS
New charging system (Bands 1, 2, 3) reduction
in activity
Designed to deliver same level of income in future
27
Finance and Activity (2)
National resources earmarked by PCT

• 2004/05
• 2005/06
• 2006/07
• 2007/09

• verification in progress
• budgets produced
• RLA / CLA imminent
• RLA / CLA adjustments Jan 2006
• growth and handling imminent
• budgets issued end November 2005
• PCT Budgets reset each year

28
Finance and Activity (3)

• PDS pilots approved and live will be funded
• but
• gt3 months will only be funded exceptionally
  (where good reasons for delay)
• lt3 months will only be funded with an agreed go
  live date
• PCT variations above approved sums not funded
  within devolved budget

29
Finance and Activity (4)

• Patient Charges Revenue
• 2005/06 risk covered up to 20
• Risk above 20 needs PCT justification to SHA
  then recommendation to DH
• 2006/07 PCR risk if UDAs are delivered then
  normally PCR will be delivered

30
Finance and Activity (5)

• Business rates - direct reimbursement
• Seniority payments - for dentists transferring
  from GDS
• Employers superannuation included in the
  allocation but is not part of the CACV
• Maternity / paternity leave long term sickness
  funded from allocation
• VT Funding arrangements to be facilitated by
  SHAs and distributed in accordance to location of
  VTs
• CPD / Clinical Audit included within CACV

31
Commissioning
32
Commissioning (1) specialist services

• Key areas covered
• Specialist commissioning
• Orthodontic contract currency
• General lessons

33
Commissioning (2) Specialist services

• PCTs will be expected to commission specialist as
  well as general services from April 2006
• Most common specialist services include
  orthodontics minor oral surgery (info on
  sedation domiciliary care)
• Those accessing services often come from wide
  geographical area
• Funding within baseline of where service based

34
Commissioning (3) Specialist services

• Need to
• Determine patients flows
• ensure that PCTs work together across SHA and SHA
  boundaries
• Local commissioning plans set priorities assess
  need for specialist services

35
Commissioning (4) Specialist services

• Information being made available to PCTs
• Specialist practitioners
• Dentists limited to orthodontics - activity
  income translated into Units of Orthodontic
  Activity - transfer into nPDS
• Mixed practices
• Orthodontic activity summary - activity income
  - agree future UOA
• Number of domiciliary visits (cost per case)
• Number of sedations provided (cost per case)
• Transfer into nGDS (with addendum)

36
Commissioning (5) Number of Orthodontic Claims
by Year
37
Commissioning (6) Fees authorised for
orthodontic treatment ( millions)
38
Commissioning (7) Orthodontic treatment (Item
32) as a proportion of total item of service fees

• 1991/1992
• GDS expenditure 1,041,289,918
• Orthodontic treatment 30,692,000
• 2.95

• 2004/2005
• GDS expenditure 1,228,917,668
• Orthodontic treatment 146,354,413
• 11.91

39
Commissioning (8) of principal dentists by no
of orthodontic appliance claims 2004-2005
40
Commissioning (9) Orthodontic trend

• Proportion of GDS expenditure risen significantly
  now 12
• But - 72 of dentists provide no orthodontic
  treatment
• 19 provide lt10 appliances per year
• Move to more specialist activity
• Rise in orthodontic activity may account for GDS
  growth in some areas

41
Commissioning (10) Orthodontic services

• Planning - 30 of 12 year olds as initial guide
  (DPH Consultants) patient flows
• Contracting currency based on the provision of
  annual number of Units of Orthodontic Activity
  (UOAs) - 2 main activities
• Case assessment 1 UOA
• Case start 20 UOA (included all necessary
• treatment)
• Proportion of case assessments versus starts
  depends on local circumstances

42
Commissioning (11) Orthodontic services

• Index of Treatment Need (IOTN)
• 3 with an aesthetic component of 6
• 4 and 5
• 14 of current activity falls outside these
• Commissioning for population under 18 at the time
  of assessment
• Adults - by negotiation (currently 2.2)

43
Commissioning (12) Orthodontic services

• Dentists with a Special Interest (DwSI)
• PCTs should ensure
• Dentists have the skills for accurate diagnosis
  treatment planning, or
• Mechanisms for diagnostic treatment planning
  element (or verified) by specialist or hospital
  consultant
• Continued level of competency in orthodontics

44
Commissioning (13) Orthodontics services

• When practitioner transfers into new contracting
• arrangement, all incomplete GDS courses of
• treatment will be paid by DPB at
• 70 of total fees for ongoing treatment (less any
  interim payments made)
• 50 for incomplete supervised retention
• Fees paid under practitioners GDS schedules -
  not be include as part of the nPDS/GDS contract
  value.
• Performance monitoring - outcome measure Peer
  Assessment Rating (PAR) Index (min 10 cases to
  DRS)

45
Commissioning (14) Lessons learned

• PCTs need to access expertise
• Local plans need to set relative priorities
• Growing specialties in primary care look at
  secondary care context
• Be clear about activity

46
Commissioning (15) Lessons learned

• Do not leave initiative and expertise to the
  provider
• Then providers will respond to vfm requirements
• Changing UOA value in response to active
  commissioning

47
Working with dentists
48
Working with Dentists (1)

• What worries dentists and how to reassure them
• Myths and misconceptions and how to dispel them
• Loss of autonomy
• Back on the treadmill
• Mixing private and NHS

49
Working with Dentists (2)

• Working with LDCs
• BDA document
• Building on PDS
• Role of DROs and dental advisors

50
Breakout Sessions (1)

• Each session twice 1 hour long
• Facilitators will record key points
• Format
• Short presentation (focus on current local issues
  pragmatic ways forward)
• Discussion groups (issues ways forward)
• Report back from groups discussion/reaction
  from presenters

51
Breakout Sessions (2)

• Working with dentists and LDCs
• Contingency Planning
• Agreeing Contracts and Activity
• Specialist contracting including Orthodontics
• DPB information for contracting
• Contract and regulations surgery

52
NHS Dentistry Implementing the new contractual
arrangements

• A Learning Event for PCTs and SHAs