NHS Dentistry Implementing the new contractual arrangements

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NHS Dentistry Implementing the new contractual
arrangements

• A Learning Event for PCTs and SHAs

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Welcome and Introduction
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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

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Reform of NHS Dentistry
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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
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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
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Reform of NHS Dentistry (3)

• 10 key actions from guidance

1. Make sure there is a named lead within your
PCT, senior sponsorship at Board level, and a
named contact point for the DPB
Letter to SHAs on identifying clear PCT
leadership accountability
2. Engage with dentists and patient
representative groups
Toolkit for communications to dentists
Toolkit for communications to patients and the
public
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Reform of NHS Dentistry (4)

• 10 key actions from guidance cont.

3. Use information provided to you identify
appropriate levels of weighted activity
GDS prescribing profiles (for dentists) and GDS
data set (for PCT)
PDS data set (for PCT)
Statement of Financial Entitlements
Factsheet on PDS contract values and activity
requirements
Factsheet on orthodontic activity requirements
Factsheet on GDS contract values and activity
requirements
BDA advice for LDCs
4.Use model contracts to help agree other
features of new GDS contracts and PDS agreements
GDS and PDS contract regulations
Model GDS contract
Model PDS agreement, including orthodontics
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Reform of NHS Dentistry (5)

• 10 key actions from guidance cont.

5. Make sure that you, your PCT Board and local
dentists understand assumptions about PCR and
minimise financial risks
6. Make contract offers during December and agree
new contracts by 28 February 2006 at the latest
Illustrative timeline for agreeing contracts
7. If there are difficulties agreeing new
contracts, involve your SHA at the earliest
possible opportunity
Factsheet on dispute resolution
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Reform of NHS Dentistry (6)

• 10 key actions from guidance cont

8. Agree arrangements for out-of-hours services
in parallel with local contract negotiation
Factsheet on out-of-hours services
9. Agree SHA-wide approach to commissioning
specialised services
Factsheet on specialist and orthodontic
commissioning
10. Develop the new Performers List for dentists
by April 06
NHS (Performers List) Amendment Regulations
Factsheet on vocational training (VT)
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Reform of NHS Dentistry (7)

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

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Reform of NHS Dentistry (8)

• 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

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Reform of NHS Dentistry (9)

• And finally
• Get to know your practices
• Plan your communications

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Contracting
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Contracting (1) Timetable

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

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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)

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Contracting (3) Key Changes to Regs

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

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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

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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

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Contracting (6)

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

Dispute resolution
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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

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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

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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

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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

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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

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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

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Contracting (13) Handling Change

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

Opportunity to reconfigure services in line with
local plan and priorities
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Finance and Activity
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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
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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

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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

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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

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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

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Commissioning
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Commissioning (1) specialist services

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

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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

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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

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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)

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Commissioning (5) Number of Orthodontic Claims
by Year
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Commissioning (6) Fees authorised for
orthodontic treatment ( millions)
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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

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Commissioning (8) of principal dentists by no
of orthodontic appliance claims 2004-2005
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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

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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

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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)

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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

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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)

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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

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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

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Working with dentists
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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

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Working with Dentists (2)

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

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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

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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

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NHS Dentistry Implementing the new contractual
arrangements

• A Learning Event for PCTs and SHAs