Tackling Inequalities, Meeting Real Needs

1
Tackling Inequalities,Meeting Real Needs
Oral Care Conference 23rd September 2011 The
Node Conference Centre

• Sue Gregory OBE
• Deputy Chief Dental Officer (England)

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Overview

• Oral health and inequalities in England
• Changing context of the NHS
• Commissioning changes
• Government commitments to oral health
• Dental Contract Reform and prevention in practice
• OHA and pathways
• Dental Quality and Outcomes Framework
• Collaborative/Community approaches
• Whats in it for you?

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Oral Health in 12 year olds
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Average number of dentinally decayed, missing and
filled teeth in 12 year old children 2008/09 by
PCT
Lowest 0.23 England mean 0.74 Highest
1.48 BUT 66.7 of children had no
experience Average of those affected 2.21
5
Average number of dentinally decayed, missing and
filled teeth in 5 year old children 2007/08 by
PCT Lowest 0.48 England mean 1.1 Highest
2.5 BUT 69.1 of children had no
experience Average of those affected 3.45
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Source Childrens Dental Health in the United
Kingdom Social factors and oral health in
children. Office for National Statistics
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Adult Oral Health
Source Adult Dental Health Survey 2009-
Executive Summary, NHS Information Centre
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Adult Dental Health Survey 2009 headline figures

• 86 of dentate adults had 21 or more natural
  teeth
• 72 adults had no visible coronal caries
• The average number of decayed or unsound teeth
  was 1.0, with only small variations across the
  age ranges
• Only 6 of adults were edentate

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Source NHS Information Centre Outcome and
impact a report from the Adult Dental Health
Survey 2009
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• Oral Health Impacts
• Just under two-fifths of all adults (39 per cent)
  experienced one or more of the problems included
  in OHIP-14 (Oral Health Impact Profile-14 scale)
  occasionally or more often in the previous 12
  months.
• Most commonly reported OHIP-14 problems physical
  pain (30 per cent) and psychological discomfort
  (19 per cent)
• Between 1998 and 2009 the proportion of dentate
  adults in England who reported having experienced
  one or more problem on the OHIP-14 scale
  occasionally or more often in the previous 12
  months, fell by 12 percentage points 51 per cent
  in 1998 to 39 per cent in 2009.
• A third of all adults (33 per cent) said they had
  difficulty performing at least one element of the
  OIDP (Oral Impacts on Daily Performance).
  Overall, the more prevalent oral impacts among
  adults were difficulty eating (21 per cent),
  smiling (15 per cent), cleaning teeth (13 per
  cent) and relaxing (10 per cent).

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Reform of the NHS

• White Paper published July 2010 for
  consultation
• Places patients at the heart of services, enabled
  by easy access to the information they need and
  want, and involved in decisions about their care
• Places a focus on relentlessly improving the
  clinical outcomes of care moving away from
  measurement of process
• Empowers professionals and trusts in their
  clinical judgment, and
• Achieves efficiency gains and reduces bureaucracy

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Supporting consultative papers

• Local democratic legitimacy in health
• Transparency in outcomes a framework for the
  NHS
• Regulating healthcare providers
• Commissioning for patients
• Developing the healthcare workforce

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Public Health White Paper

• Publication 30th November 2010
• A coherent national framework across Government
  with outcome goals
• National Public Health Service, with strong
  evaluation strategy, to be fully operational by
  April 2012
• Directors of Public Health in LAs
• Ring-fenced public health budget
• Empowering individuals, families and local
  communities a new relationship between
  government and people

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Reference to dental public health

• the dental public health workforce will increase
  its focus on effective health promotion and
  prevention of oral disease, provision of
  evidence-based oral care and effective dental
  clinical governance. It will concentrate
  particularly on improving childrens oral health,
  because those who have healthy teeth in childhood
  have every chance of keeping good oral health
  throughout their lives. It will also make a vital
  contribution to implementation of a new contract
  for primary care dentistry, which the Government
  is to introduce to increase emphasis on
  prevention while meeting patients treatment
  needs more effectively.

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Outcomes Frameworks

• NHS Outcomes framework 3 domains- effectiveness
  of treatment and care, measured by clinical and
  patient reported outcomes- safety of treatment
  and care- broader patient experienceAvailable
  from April 2011, implementation April 2012
• Separate public health outcomes
  frameworkincluding
• Rate of dental caries in children aged 5 years
  (decayed, missing or filled teeth)

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The Reformed System

• The White Paper envisages that power and
  responsibility for commissioning most services
  will be devolved to local consortia of GP
  practices.
• NHS dentistry will be one of a number of services
  that will not be devolved.
• An autonomous NHS Commissioning Board will be
  established

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Functions of NHS Commissioning Board

• Providing national leadership on commissioning
  for quality improvement
• Promoting and extending public and patient
  involvement and choice
• Ensuring the development of GP commissioning
  consortia
• Commissioning certain services that cannot solely
  be commissioned by consortia, including dentistry
• Hosting of clinical networks and clinical senates
• Allocating and accounting for NHS resources

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Timeline

• The Board will be established in shadow form as a
  Special Health Authority from October 2011
• It will go live in October 2012 as a separate
  statutory body, taking on full functions April
  2013
• It is anticipated that all consortia will be
  fully functioning by 2013
• SHAs and PCTs will be abolished by April 2013
• The sub national arrangements of the Board will
  reflect the SHA and PCT clusters

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Changes to Dental Commissioning

• Currently PCTs commission Primary Secondary
  Care Dentistry using a number of contract types.
  From 2013 these services will be commissioned by
  the NHS Commissioning Board. The benefits of a
  nationally commissioned dental service include
• The ability to address overlap between the
  primary secondary care sectors
• The opportunity to move care from secondary to
  primary sectors
• The opportunity to develop centralised
  commissioning dental expertise
• The opportunity to share clinical best practice
  more widely.

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Emerging proposals Dental, Pharms, Optoms
Health and well being boards
Provider skills networks
Consortia
Informing needs, demand, supply in primary,
community and secondary care
Peer support, peer review and benchmarking
Local professional networks
Maximising performance
Local intelligence, clinical expertise,
innovation and development of integrated care
pathways
NHS CB field force
Implementation and development plans to reflect
local circumstances
NHSCB national
Aggregation of need and assurance of performance
Strategy, policy, contract, procedure and
assurance of achievement of outcomes
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central
central
central
outsourced
outsourced/central
field
place
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Local v national

• If contract management was undertaken once
  nationally, with agreed standard approaches to
  common issues and routine contract monitoring and
  performance management done centrally what key
  tasks would need to be undertaken locally?
• What are the key clinical/professional elements
  that could be undertaken once nationally and what
  would need to be undertaken locally?

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What is local?

• Identifying health needs of local communities
• Ensuring patient choice and patient involvement
• Identifying gaps in access to services
• Producing oral health strategies for local
  communities
• Preventive programmes
• Enabling/supporting democratic/community input
  and accountability in commissioning decisions
• Forum for clinicians
• Local face to face interaction in contract
  management
• Development of local professional networks?

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Strength of local professional networks?

• Local knowledge and expertise, enables-
• - meaningful, intelligent interpretation of
  data
• - local investigation
• - local action
• - local relationships

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Government Commitments on Oral Health

• In the Coalition Agreement the government stated
  their intention to
• Introduce a new contract based on registration,
  capitation and quality
• Increase access to primary dental services
• Improve the oral health of the population,
  particularly children.

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Steele Review- NHS Dental Services in England

• 22nd June 2009
• Just as health is the desired outcome of the rest
  of the NHS, so health should now be the desired
  outcome for NHS dentistry

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What does a public health approach in practice
mean to you?

• A sandal wearing prevention agent of a nanny
  state?

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Dental Contract Reform
Unmet Need Met Need
Appropriate Use Avoidable Use

•  
•  
•  
•  

NEED
Need to achieve met need Appropriate use of
services
DEMAND
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I cant sleep!
Manufacturers of poor oral health Sugar,
smoking, lack of Fluoride, poor plaque control
ILLNESS FACTORIES
Oh my tooth!.
Tobacco Sweets Beer
Help!
Help!
Adapted from Mc Kinley (1979) by Makiko Nishi
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?F THE 8760 H?URS IN ?NE YEAR
H?UR BY H?UR CARE ?F a Chronic Condition
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Public Health in Clinical Practice

• Understand practice population and identify
  individual need
• Think upstream and pathway interventions
• - like following a musical score!
• Communicate risk transfer responsibility
• Celebrate and record improved outcomes

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Benefits of Outcomes Focus

• Key development in NHS reform agenda
• Focus on promoting health and well being not on
  repair and treatment
• Stronger focus on outcomes to reduce
  inequalities and prevent disease
• Emphasises on effectiveness
• Recognises potential of clinical engagement and
  using whole team to deliver care pathway

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Pilot Contract Types

• Type 3
• Weighted capitation quality model, with
  separate budget for higher cost treatments

• Type 1
• Simulation Model

Type 2 Weighted capitation quality model
Pilot practices will be guaranteed their contract
value (their remuneration in the current contract
year) and required to deliver the same NHS
commitment whilst adhering to the new pathway.
These pilots will test the implications of
applying a national weighted capitation model
where capitation payments vary for different
patients depending on the factors on which the
national capitation model is based.
These pilots will test the implications of
applying a national weighted capitation model but
the capitation payment will be for preventative
and routine care only and complex care will be
funded separately.
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Capitation potential variables
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New patient visits dentist
Routine care
Urgent care
Definitive care relief
Assessment of oral health
Accept
Recommend assessment of oral health
Disease prevention and management
Decline
Continuity of care and routine management
Proposed patient Pathway (Steele)
Advanced care
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Clinical pathways in primary dental care
Quality Indicators
Patient Assessment
Patient Assessment
Risk Screening
Patient self-care plan
Patient self-care plan
Care Pathways
Recall intervals
Entry criteria
Complexity Assessments
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Overview of risk screening process
Risk screening
Patient Assessment
Risk Category
Prevention
Recall
Domains

- - - - - - - -
- - - - - - - -
C
Patient actions
T1
Caries
T2
P
Dentist actions
T3
C
Patient actions
T1
Perio
T2
Dentist actions
P
T3
C
Patient actions
T1
Soft tissue
T2
P
Dentist actions
T3
C
Patient actions
T1
T2
TSL
P
Dentist actions
T3
Self care plan, preventive and treatment plans
C
Clinical Factors
KEY
P
Patient Factors
Time interval
T
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Determining the clinical and patient
factors for CARIES
Domain

Caries
Actions (pathways)
Clinical factors
Patient factors
Risk
Professional
Patient
Age
Teeth with carious lesions
Symptoms


Diet Excess sugar Frequent sugar
No teeth with carious lesions
Poor plaque control
Sibling experience
Patient Communication
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Assigning risk The patients risk status for each
domain is determined as follows
Allocated if there is a red clinical factor,
this cannot be modified by patient factors.
Red risk status
Amber risk status is allocated if there is an
amber clinical factor, or if there is a green
clinical factor but a co-existing patient factor
which increases risk e.g. a patient with no
caries would still be classed amber if there was
poor plaque control
Amber risk status
Green risk status is allocated to those with
green clinical factors and no patient factors
which increase risk.
Green risk status
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Prevention in practice

• Simple messages
• Concise advice
• Evidence based with strength of evidence
• Practical and easy to use
• Good reference for sugar free medicines and
  fluoride concentration in toothpaste
• Links with healthy eating

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Pilot Dental Quality Outcomes Framework

• Quality is a necessary part of future dental
  contracts and it will take time to get a quality
  system that is solely outcome based. Quality is
  defined as covering three domains
• Clinical effectiveness
• Patient experience
• Safety

Continual development and raising the bar
Measures ready for contract pilots
Measures ready for contract implementation
Longer term development of quality indicators
Pathway Development
Work on quality indicators, and in particular
outcome indicators, is relatively new in the NHS
and even more so in dentistry. The DQOF will
therefore continue to be developed over the
coming years. The framework will be underpinned
by the development of a comprehensive set of
accredited clinical pathways.
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The Development of DQOF
The DQOF working group followed the process
outlined below working back from first principles
to define indicators that support the consensus
within dentistry that good oral health is the
ideal clinical outcome
The patients view of being free from pain and
good functionality should be covered by patient
experience and PROMS domain rather than clinical
effectiveness
Outcomes (patient view)
Measures
Clinical components of the OHA
Improvement
Maintenance

• The clinical view is covered in this domain
• and focuses on
• Improvement in oral health
• Maintenance of good oral health

Caries Perio
Outcomes (clinical view)
(World Health Organisation 1982)
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Elements of PDCPA for DQOF
Patient Assessment
Utility of PDCPA for DQOF measure
Measured at Review

Clinical Domains
Maintenance/improvement 3 categories
?
C
- - - - - - -
x
Caries
P
Maintenance/improvement 2 categories
?
C
Perio
x
P
x
C
Soft tissue
x
P
x
C
TSL
x
P
Key
C
P
Patient Factors
Clinical Factors
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Clinical Effectiveness Outcome Indicators for
payment (60)
The following outcome indicators are derived from
the clinical elements of the assessment based on
the standardised NHS primary dental care patient
assessment (PDCPA) and the associated risk
screening process. The indicator information will
be captured at review and achievement of the
indicator is described as either maintaining or
improving a patients condition.
Measure Points MAX600
Active decayed teeth (dt) aged 5 years old and under, reduction in number of carious teeth/child 50 Under 5s active decay (dt) improved or maintained 150
Active Decayed Teeth (DT) aged 6 years old and over, reduction in number of carious teeth/child 75 over 6s improved or maintained 150
Active Decayed Teeth (DT) reduction in number of carious teeth/dentate adult 75 improved or maintained 150
75 patients with BPE improved or maintained at oral health review 75
50 patients with BPE 2 or more with sextant bleeding sites improved at oral health review 75
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Patient Experience Indicators for payment (30)
Measure Points - Max300
Are you able to speak and eat comfortably? of patients reporting that they are able to speak eat comfortably MAX 30 Level 1 45-54 15 Level 2 55-100 30
How satisfied were you with the cleanliness of the practice? of patients satisfied with the cleanliness of the dental practice MAX 30 Level 1 80-89 15 Level 2 90-100 30
How helpful were the staff at the practice? of patients satisfied with the helpfulness of practice staff MAX 30 Level 1 80-89 15 Level 2 90-100 30
Did you feel sufficiently involved in decisions about your care? of patients reporting that they felt sufficiently involved in decisions about their care MAX 50 Level 1 70-84 25 Level 2 85-100 50
Would you recommend this practice to a friend? of patients who would recommend the dental practice to a friend MAX 100 Level 1 70-79 50 Level 2 80-89 75 Level 3 90-100100
How satisfied are you with the NHS dentistry received? of patients reporting satisfaction with NHS dentistry received MAX 50 Level 1 80-84 20 Level 2 85-89 40 Level 3 90-100 50
How do you feel about the length of time taken to get appointment? of patients satisfied with the time to get an appointment MAX 10 Level 1 70- 84 5 Level 2 85-100 10
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Safety Indicators for payment (10)

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

Measure Points MAX100
90 of patients for whom an up-to-date medical history is recorded at each oral health review MAX 100
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Indicators for monitoring overall quality (no
payment)
It is proposed that the following quality
indicators are monitored throughout the pilots to
understand the impact of the change of system on
clinical behaviour and patient perception.
Measure Domain
of children aged 11 who have had an assessment of unerupted canines Clinical effectiveness
of children aged 18 and under who have had fluoride varnish in the last year. Clinical effectiveness
Was the cost of treatment explained to you before your treatment started? Patient Experience
Do you understand what you personally need to do to maintain and improve your oral health? Patient Experience
Do you understand how healthy your teeth and gums are? Patient Experience
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Advanced care pathways

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

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Decision making cascade
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Indirect Restorations (Veneers, Inlays, Crowns
Bridges)

Teeth that can be restored and made functional
Risk Screening

Teeth with good prognosis
and entry

Patients co
operation does not preclude indirect restorations
criteria to be
determined

The patients Medical History does not preclude
crown and/or bridge work i
Level 1
Level 2
Level 3
Restorations not involved in anterior Guidance,
where there are adequate Sound or restored teeth
to predictably Maintain the existing
occlusion (conformative approach)
Restorations that contribute to anterior guidance
where there are sufficient sound or restored
teeth to predictably maintain the existing
occlusion (conformative approach)

Extra coronal restoration of the complete
anterior guidance including pontic units



Extra coronal restoration of opposing sextants
(all teeth)

Extra coronal restoration of any one posterior
sextant (all teeth), not involved in anterior
guidance where a terminal unit is involved
Restoration that are supported by osseointegrated
implants



No more than 3 units of crown or bridge work

Significant re
-
organisation of occlusion

More than 3 units of crown or bridge work

Evidence of significant parafunction

Slight limitation of mouth opening

Significant/severe limitation of mouth opening
Work to be carried out by a GDP who
Work to be carried out by GDP
has additional competencies
Work to be referred to Specialist Services
(
-
crowns which are produced in a lab)
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5
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Learning from the Pilots

• Qualitative
• the experiences and impact on
• Dentists
• PCTs
• Patients
• Quantitative
• Clinical data set from Oral Health Assessment
• PCR ??

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Next steps

• Develop proposals for the new contract, and for
  reforms to the patient charging system to fit in
  with the new contract.
• The changes will require legislation, which will
  be introduced to Parliament in a Bill timing to
  be confirmed.
• Public consultation on the changes
• Leading toLegislation to introduce new contract

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Windsor Dental Practice, Salford
Extended duties dental nurse
Hygienist
Smoking cessation adviser
Therapists
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Specialisation and the Workforce

• Need to look at those areas of care outside of
  mandatory services, including-- orthodontics-
  domiciliary- sedation
• Piloting within salaried services
• Impact of skill-mix

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Background

• Local Area Agreement (LAA) identified
• childrens oral health as a local priority
• Lancashire County Council funded a LAA Oral
  Health Lead to work with NHS colleagues
• Children and Young Peoples Oral Health Strategy
  developed and approved by the LA/NHS partnership
  Be Healthy Theme Group

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and enables Early Years Foundation Stage settings
to demonstrate and be recognised for their oral
health improvement activity through the
Smile4Life Award Scheme
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Politics of the Smile4Life Programme

• Is consistent with the Coalition direction of
  travel
• Focus on public health and prevention
• Focus on encouraging healthy behaviours
• Focus on collaboration with local authorities
  responsibility for outcomes
• Focus on oral health
• of school children and
• increased access

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Implementation of Smile4Life Programme

• Salaried Service OHI team to act as experts and
  advisors
• Local Childrens Centres to identify Oral Health
  Champion
• Dental practice staff to link with local settings

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Whats in it for you?

• Primary/Secondary care interface
• Clinical leadership
• Networks
• Training and development
• QIPP