Brian Kelly

1
Orthodontic Commissioning

• Brian Kelly
• Senior Orthodontic Adviser
• Dental Reference Service

2
Future Orthodontic Provision

• NHS Dentistry - Options for Change
• Published August 2002
• Drawn up by three task groups representing a wide
  range of dentists and other stakeholders
• Set out proposals for the modernisation of NHS
  dental services

3
Future Orthodontic Provision

• NHS Dentistry - Options for Change
• Proposals
• Devolved resources
• PCT led local commissioning
• Responsive to local need
• Integrated primary dental service
  (GDS/PDS/CDS/HDS)

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Future Orthodontic Provision

• Health and Social Care Act 2003
• The legislative vehicle for O4C
• Each PCT will have a statutory duty to secure or
  provide primary dental services to the extent
  that it considers reasonable within its area

6
Future Orthodontic Provision

• What is reasonable?
• The definition for reasonable could be similar
  to what is understood in other NHS services - for
  local decision against national benchmarking

7
Future Orthodontic Provision

• National benchmarking for orthodontics?
• Index of Orthodontic Treatment Need
• IOTN
• Dental Health Component (DHC)
• Aesthetic Component (AC)

8
IOTN Dental Health Component (DHC)

• Grade 5 Need treatment
• Grade 4 Need treatment
• Grade 3 Borderline need
• Grade 2 Little need
• Grade 1 No need

9
IOTN Dental Health Component (DHC)

• Grade 5 Need treatment / eligible
• Grade 4 Need treatment / eligible
• Grade 3 Borderline need / eligibility
• Grade 2 Little need / ineligible
• Grade 1 No need / ineligible

10
Commissioning Orthodontic Services
11
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
12
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
13
Strategic Planning Needs assessment

• What proportion of the population is eligible for
  NHS treatment?

14
IOTN Distribution in the Population(Brook and
Shaw 1989)

• Dental Health Need (DHC)
• Great (Grades 4 and 5) 32.7
• Moderate (Grade 3) 32.1
• None (Grades 1 and 2) 35.1
• Aesthetic Need (AC) .

15
Strategic Planning Needs assessment

• Based on this evidence
• 66 of population could reasonably be referred
  (IOTN DHC 5, 4 and 3)
• 44 of population eligible for treatment
• (IOTN DHC 3 AC5)
• But..
• Significant numbers are unsuitable or unwilling
  to proceed
• (Child Dental Health Survey 2003)

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Strategic Planning Needs assessment

• What is reasonable provision?
• 60 of 12 year-olds to receive assessments
• 30 of 12 year-olds to receive treatment

17
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
18
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
19
Strategic Planning Review Current Service
Provision

• Current levels of orthodontic provision are
  largely determined by GDS provision in 2005/2006

20
Strategic Planning Review Current Service
Provision

• Patterns of orthodontic treatment prior to the
  new contract on 1st April 2006
• What was being treated?
• What resources are necessary to maintain or
  improve upon 2005/2006 levels of provision?

21
Strategic Planning Review Current Service
Provision

• Patterns of orthodontic treatment prior to the
  new contract on 1st April 2006
• What was being treated?
• What resources are necessary to maintain or
  improve upon 2005/2006 levels of provision?

22
Patterns of NHS orthodontic provision prior to
local commissioning..

• Increasing

23
Number of Orthodontic Claims by Year
24
Rate of orthodontic claims per 1,000
registrations and population by year
25
Number of principal dentists who made 100
orthodontic appliance claims by year
26
Patterns of NHS orthodontic provision prior to
local commissioning

• Increasingly specialised

27
Percentage of Principal Dentists by the Number of
Orthodontic Appliance Claims they made in
2005-2006
28
Percentage of Principal Dentists by the Number of
Orthodontic Claims they made in 1996-1997 and
2005-2006
29
Orthodontic appliance claims by orthodontists and
general dentists
280
260
240
220
(000s)
200
Orthodontists
180
160
140
Number of claims
120
General
100
80
60
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year to March
30
Patterns of NHS orthodontic provision prior to
local commissioning..

• Increasingly complex

31
Removable spring and multiband appliance by
orthodontists and general dentists
32
Number of appliances in England and Wales in
years to March 1996 and 2006
160
1996
140
2006
120
(000s)
100
80
60
Number of appliances
40
20
0
Multi (upper)
Multi (lower)
Removable spring
33
Number of appliances in England and Wales by year
180
Fixed multiband upper
160
140
(000s)
120
Fixed multiband lower
100
Number of appliances
80
60
Removable spring upper
40
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year to March
34
Number of appliances in England and Wales by year
18
16
Functional
14
12
Simple fixed upper
(000s)
10
8
Biteplane
6
Number of appliances
4
Removable spring lower
2
Simple fixed lower
0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year to March
35
Patterns ofNHS orthodontic provision prior to
local commissioning.

• Increasingly expensive

36
Fees authorised for orthodontic treatment (
millions)

• Year Child Adult Total
• 1992 29.6 1.0 30.6
• 1993 34.5 1.3 35.8
• 1994 40.5 1.5 42.0
• 1995 44.5 1.5 46.0
• 1996 50.6 1.4 52.0
• 1997 57.2 1.5 58.7
• 1998 66.6 1.6 68.2
• 1999 77.9 1.8 79.7
• 2000 83.2 2.0 85.2
• 2001 94.3 2.2 96.5
• 2002 107.7 2.2 109.9
• 2003 114.8 2.3 117.1
• 2004 132.1 2.7 134.8
• 2005 143.1 3.2 146.3
• 2006 156.6 2.8 159.4

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Fees authorised for orthodontic treatment (
millions)
38
Orthodontic treatment (Item 32) as a proportion
of total item of service fees (excluding patient
charges)

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

• 2005/2006
• GDS expenditure 1,012,357,143
• Orthodontic treatment 159,415,365
• 15.75

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Orthodontic treatment (Item 32) as a percentage
of total item of service fees (excluding patient
charges)
1992 2.95 2006 15.75 As a proportion of
GDS expenditure orthodontic expenditure trebled
in the 10 years prior to the abolition of the GDS
40
Patterns ofNHS orthodontic provision prior to
local commissioning..

• Inequitable access

41
Orthodontic appliance claims per 1,000
registered patients aged 10-17 in2001-2002 by
former area health authority
The classification of low, medium and high is
defined by the quartiles. Low refers to the 25
health authorities with the lowest values,
medium the next 50, and high the 25 health
authorities with the highest values.
42
Number of principal dentists who made 200
appliance claims in the year 2001-2002 by former
area health authority
The classification of low, medium and high is
defined by the quartiles. Low refers to the 25
health authorities with the lowest values,
medium the next 50, and high the 25 health
authorities with the highest values.
43
Former Strategic Health Authorities
Q01 Norfolk, Suffolk and Cambridgeshire Q02 Bedfor
dshire and Hertfordshire Q03 Essex
Q09
Q09 Northumberland, Tyne Wear Q10 County Durham
and Tees Valley Q11 North And East Yorks and
Northern Lincs Q12 West Yorkshire Q13 Cumbria and
Lancashire Q14 Greater Manchester Q15 Cheshire
Merseyside
Q10
Q13
Q11
Q12
Q14
Q23
Q16 Thames Valley Q17 Hampshire and Isle of
Wight Q18 Kent and Medway Q19 Surrey and
Sussex Q20 Avon, Gloucestershire and
Wiltshire Q21 South West Peninsula Q22 Dorset and
Somerset Q23 South Yorkshire Q24 Trent
Q24
Q26
Q27
Q25
Q01
W00
Q28
Q02
Q03
Q16
Q20
Q18
Q25 Leics, Northamptonshire and
Rutland Q26 Shropshire and Staffordshire Q27 Birmi
ngham and The Black Country Q28 West Midlands
South W00 Wales NHS area
Q17
Q19
Q22
Q21
Q04 North West London Q05 North Central
London Q06 North East London Q07 South East
London Q08 South West London
44
Orthodontic appliance claims per 1,000 registered
patients aged 10-17 in 2005-2006 by former
strategic health authority
152
95
57
Medium
High
Low
The classification of low, medium and high is
defined by the quartiles. Low refers to the 7
strategic health authorities values with the
lowest values high to the 7 strategic health
authorities with the highest, medium the 15
strategic health authorities of the interquartile
range
45
Number of principal dentists who made 200
appliance claims in the year 2005-2006 by former
strategic health authority
39
Upper outlier 32
21
14
High
Medium
Low
The classification of low, medium and high is
defined by the quartiles. Low refers to the 7
strategic health authorities values with the
lowest values high to the 7 strategic health
authorities with the highest, medium the 15
strategic health authorities of the interquartile
range
46
Patterns ofNHS orthodontic provision prior to
local commissioning

• Increasing
• Increasingly specialised
• Increasingly complex
• Increasingly expensive
• Inequitable access

47
Strategic Planning Review Current Service
Provision

• Patterns of orthodontic treatment prior to the
  new contract on 1st April 2006
• What was being treated?
• What resources are necessary to maintain or
  improve upon 2005/2006 levels of provision?

48
IOTN DHCGDS cases receiving treatment (pre-April
2006)(Sample of 1575 cases from 170
practitioners)

• IOTN ? 2.2
• IOTN 2 3.2
• IOTN 3
• IOTN 35 26.5
• IOTN 4 47.0
• IOTN 5 12.5

i
49

• IOTN DHC
• Based on this sample 14 of patients treated
  prior to April 2006 are no longer be eligible for
  NHS treatment following the introduction of the
  new contract.

50
Strategic Planning Review Current Service
Provision

• Patterns of orthodontic treatment prior to the
  new contract on 1st April 2006
• What was being treated?
• What resources are necessary to maintain or
  improve upon 2005/2006 levels of provision?

51
What resources are necessary?

• Up to 44 of 12 year-olds remain eligible for NHS
  orthodontic treatment
• Up to 60 will require assessment
• Up to 30 will require treatment

52
What resources are necessary?

• 12 year-old population in 2005/06 625,000
  (Office for National Statistics)
• 2005/2006 expenditure 160 million
• 200,000 courses of treatment were provided ( 32
  of 12 year-olds)
• Mean cost per course 800
• 170,000 fixed appliance cases
  ( 27 of 12 year-olds)
• Mean cost per case 941

53
What resources are necessary?

• At 55/UOA
• Cost per case 1210 (22 UOA _at_ 55/UOA)
• 160m would commission 132,000 cases
• 38,000 fewer patients than were treated with
  fixed appliances in 2005/2006
• 21 of 12 yr-olds
• 30 of 12 yr-olds would require 227m
• Potential shortfall of 9 or 67m?

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What resources are necessary?

• But
• Up to 28,000 cases treated in 2005/06 were
  probably below IOTN 3.6 (4.5 of 12 yr-olds)
• Number of 12 year-olds nationally is falling at
  10,000 per year (1.6 per annum)
• Estimated 12,500 cases p.a. are treated in
  hospital / salaried services (2 of 12 yr-olds)
• Estimated 10,000 cases will choose the private
  sector (1.6 of 12 yr olds)

55
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
56
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
57
IOTN Distribution GDS treated cases (Pre-April
2006)
58
IOTN Dental Health Component (DHC)

• Grade 5 Need treatment / eligible
• Grade 4 Need treatment / eligible
• Grade 3 Borderline need / eligibility
• Grade 2 Little need / ineligible
• Grade 1 No need / ineligible

59
IOTN Dental Health Component (DHC)

• But is eligibility entitlement ?
• Yes

60
IOTN Dental Health Component (DHC)

• Grade 5 Need treatment / entitled
• Grade 4 Need treatment / entitled
• Grade 3 Borderline need / entitlement Grade 2
  Little need / ineligible
• Grade 1 No need / ineligible

61
Strategic Planning Decide Priorities

• Suggested IOTN Targeting / Prioritisation
• Grade 5 Need treatment ?
• Grade 4 Need treatment ?
• Grade 3 Borderline need ?
• PCTs / LHBs CANNOT DENY TREATMENT TO
  ELIGIBLE PATIENTS

62
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
63
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
64
Orthodontic CommissioningService redesign /
Managing demand

• Design Service
• Shape structure
• Ensure appropriate access
• Clinical decision making

65
Orthodontic CommissioningService redesign /
Managing demand

• Potential providers
• Dentists with Special Interest (DwSI)
• Salaried Services / PCTDS Specialists
• Independent Specialists
• Hospital Consultant-led service

66
Traditional Model of Orthodontic Provision
General Dental Practitioner
No treatment
Treatment
Specialist Practice
DwSI
Treatment
Treatment
Hospital Consultant
Treatment of IOTN DHC 4 and 5
Treatment planning for DwSIs
Multidisciplinary treatment
Advice for GDPs
Teaching / Training
Audit / Research
67
Orthodontic CommissioningService redesign /
Managing demand

• Disadvantages of traditional model
• Lack of NHS (PCT/LHB) control
• Lack of patient choice
• Inequitable access
• Service driven by demand not need
• Very variable waiting times
• Very variable quality / value for money

68
Orthodontic Commissioning Service redesign
Future Model?

• PCT/LHB wish-list
• NHS (PCT/LHB) control
• Patient choice
• Improve access
• Prioritise to the most needy
• Reduce waiting times
• Meet 18 weeks target (secondary care)
• Increase value for money (Increased activity
  without compromising quality)