Dental contract reform: Overview of prototyping Policy background on dental contract reform 1. The reform of the current dental contract to increase dental access and improve oral health is a well established aim of this and successive Governments. It was repeated as a 2017 manifesto commitment. 2. Primary care dentistry requires a remuneration system that supports dentists to deliver appropriate care to a number of patients. Crucially, recognising the changing oral health needs of the population that has emerged over recent decades, the system needs to support prevention based care as well as providing appropriate treatment, and retreatment where necessary for current disease. 3. The overall need for reform and the core principles it tries to work towards were set out in Professor Jimmy Steele s 2009 Independent Review of NHS Dentistry which can be accessed on this link https://tinyurl.com/2009independentreview 4. The principles of the reformed system proposed are: a clinical approach focussed on thorough assessment and prevention, as well as treatment, and which supports a pathway approach to care measurement and focus on quality of care remuneration that supports continuing care as well as a focus on prevention in addition to any necessary treatment Further information on each of these can be found in Annex A. 5. The principles of contract reform align with NHS England s strategic direction of travel in the Five Year Forward View, which emphasises the need to focus on prevention and access to empower patients to take control of their own oral health and to make the most efficient use of NHS resources. 6. Piloting of the clinical approach ran from 2011-2015 and the learning from this was captured in a series of reports which can be found on the link below. https://tinyurl.com/pilotlearning The pilots tested delivery of the clinical pathway but not a remuneration system proposed for any future system. The clinical approach is well accepted by patients and dental professionals alike. Patients reported an increase in selfmanagement and clinicians reported improvements in patients oral health.
7. On the basis of the learning from the pilot stage in 2015 the Government published proposals for a prototype system testing the key elements of a proposed new remuneration system. This system was launched in December 2015 and 75 high street dental practices are currently part of this testing. 8. The success criteria for the Dental Contract Reform programme is to maintain or improve access, ensure quality and appropriateness of care and improve oral health, within the current financial envelope, in a way that is sustainable for dental practices, patients and commissioners. 9. The prototypes continue to test and refine the pathway approach established in 2011 and, with some changes to individual metrics, the same broad set of quality measures. The prototypes remuneration system is majority capitation but with an element of activity. The aim is to align as far as possible the financial drivers with the clinical approach. Capitation ensures a focus on maintaining or improving access, and for the individual patient supports prevention, continuing care and to an extent treatment. The remuneration for activity supports treatment, and in blending this with capitation, balances the two incentives. Further information on remuneration can be found in Annex A. 10. The learning from the first full year of prototyping confirmed that the clinical approach is widely accepted by clinicians and patients. The elements that remain to be fully proved are the detailed remuneration model. A decision has been taken to continue testing the approach for up to a further two years (to March 2020) while simultaneously focusing on the practical learning needed to manage any subsequent roll out effectively. The aim in now taking on additional sites is both to increase the overall learning and specifically as a dry run for any future roll out. 2
Annex A Key elements for prototypes 11. The prototype model consists of the following key elements: a clinical approach focussed on thorough assessment and prevention, as well as treatment, and which supports a pathway approach to care measurement and focus on quality of care remuneration that supports continuing care as well as a focus on prevention in addition to any necessary treatment The clinical pathway a preventive care pathway 12. The preventive care pathway approach is about providing high quality clinical care, based on: a more holistic approach to planning care for patients promoting a long term preventive approach based on individual need and risk focussing on outcomes and effectiveness encouraging patients to take responsibility for protecting and maintaining their own oral health, with support from the practice dental team 13. The care pathway is comprised of the following elements: Oral health assessment (OHA) and Red Amber Green (RAG) status 14. The pathway starts with a standardised assessment of a patient s oral health. Information collected is used to assign risk in four clinical areas including any patient factors that could contribute to current or future problems: dental caries (tooth decay) periodontal disease (gum disease) tooth surface loss (worn down teeth) conditions affecting the soft tissues of the mouth, for example oral cancer 15. From this assessment each patient is given an individual RAG status which along with the clinical judgement informs the recall interval (ie date of oral health review), and preventive appointments (if needed) for each patient. Treatment and stabilisation 16. Any necessary treatment identified at the OHA is provided. However, in some cases it may be appropriate to stabilise the patient s oral health before undertaking this treatment. Stabilisation can be supported by the preventive interim care appointment(s). 3
Self-care plan 17. Some modifying factors (e.g. diet, smoking) can be influenced and altered through changes in patient behaviour. The self-care plan provides patient specific information using a red/amber/green (RAG) traffic light system and is a useful platform for communication with patients, including awareness of their responsibility for self-care. Oral health review (OHR) 18. The OHR is a refresh or updating of the original oral health assessment, and restarts the pathway cycle. The recall interval for this review is set at the completion of the OHA. Preventive actions and advice 19. Throughout the pathway preventive actions and advice are given, there may be patients who would benefit from additional preventive support which can be provided by interim care appointments. Software support 20. The clinical pathway is supported by the practice s dental software systems. Dental quality and outcomes framework (DQOF) 21. Under piloting and prototyping practices have been submitting data to inform achievement against a set of quality measures. The current indicators and how they are used to inform the quality of the services delivered is being reviewed by the dental contract reform programme with a stakeholder group. 22. It is under consideration whether DQOF should be applied as a financial adjustment or whether measurement only is more appropriate. In the interim a decision has been taken by the dental contract reform programme that for the period 2018-2020 there will be no financial adjustments associated with DQOF, prototype practices will still continue to collect data and will still receive information on their achievement against the indicators. 23. For prototypes quality is defined as covering five domains: Clinical effectiveness Best practice Patient experience Safety Data Quality 4
Remuneration 24. The prototypes are based on a blended remuneration system where a practice s contract value and remuneration for mandatory services will be split between: a capitation element for which the practice would be expected to have a minimum number of capitated patients on their list an activity element for which the practice would be expected to deliver a minimum level of activity Further information on the remuneration system can be found on the DCR webpages which can be found at www.pcc-cic.org.uk/article/remuneration 25. There are two blends of remuneration tested in the prototypes: blend A - capitation is used as the basis of remuneration for oral health assessment and reviews and preventive care (current Band 1 type care and include Band 1A) and activity payments are used for all treatment (current Band 2 and Band 3 type care) blend B - capitation is used as the basis of remuneration for oral health assessment and reviews, preventive care and routine treatment (current Band 1, include Band 1A and Band 2 type care) and activity payments are used for more complex treatment (current Band 3 type care) 26. Overall achievement is a combination of both capitation and activity. How capitated patient numbers are measured 27. A patient will count towards a practice s capitated patient numbers if they have had an oral health assessment or review with the practice in the previous three years and have not subsequently triggered capitation at another practice (attended for routine care). For the purpose of any financial adjustments, a practice s capitated patient numbers for the year will be measured at year-end. How activity is measured 28. Whilst in a future roll-out we may wish to move away from measuring activity in terms of Units of Dental Activity (UDAs) and the current banding system, for the prototypes we continue to measure activity in UDAs and depending on your blend the amount of activity associated with bands will vary (known as prototype UDAs). 29. Within the prototype system as well as the current 3 bands there is an additional Band 1A for preventive actions, which is funded under capitation. 30. Urgent patients - where a patient is a capitated patient with the practice, an urgent course of treatment will not count towards a practice s activity levels. Where a patient is not a capitated patient with the practice, an urgent course of treatment will count as 1.2 UDAs. This will allow for the scenario where a patient attends a practice for urgent care away from their usual practice. 5
31. Patients seen on referral - where a patient is treated on referral at a practice and does not trigger capitation at the practice through having an oral health assessment or review, the course of treatment will count towards a practice s activity levels. Switching between the capitation and activity elements of the contract in terms of remuneration 32. With the emphasis on prevention, as patient treatment needs change over time the prototype system allows for a prototype practice to see additional patients to offset under-delivery of activity, this is not available the other way around. Tolerance on delivery of contract achievement 33. Prototype practices are able to carry forward under-delivery up to 4% of their contract achievement. The financial risk associated with the prototype arrangement will be limited to 10% of contract value (for mandatory services). Practices will also be allowed to over-deliver up to 2% of contract value. Additional services within contracts 34. Additional services are not being tested in the prototype arrangements, therefore the contract value associated with these services are removed from the prototype remuneration calculations. These services will continue to be managed by local offices. Other areas to note Registration/Capitation 35. Under the prototype regulations, while a patient is on a practice capitation list the patient is entitled to continuing care from the practice. This reflects the fact that the practice is receiving a payment for the patient s on going care through capitation. Patient charges 36. The prototypes use the same patient charge system as the current 3-band system but with the addition of Band 1A for preventive only care. Prototype management 37. The prototype practice contract continues to be held by NHS England and management of the prototype arrangements will be managed by their commissioners with input and support from the dental contract reform programme which will include direct contact with practices from the programme team. 6
38. Both prototype practices and their commissioners have the right of exit/to exit practices from the scheme. Individual practices will be judged on capitation and activity performance. Community dental services (CDS) 39. The pathway and DQOF is currently being tested in three CDS. These services are working under the Pilot type 1 remuneration arrangements. The intention is to continue this through the prototype stage rather than expand numbers or move CDS services on to the prototype remuneration arrangements. 40. We need to test the pathway approach with vulnerable patients who are concentrated typically in the CDS but we are clear that the CDS and high street services may well need different forms of remuneration. This is why we intend for the prototype stage to stay with the existing numbers and approach. Further information 41. Additional information on all aspects of the prototype arrangements can be found on the DCR webpages at the link below. www.pcc-cic.org.uk/resources/dental-contract-reform 7