Highland NHS Board 3 February 2015 Item 4.3 NHS Highland Plan for rebalancing of Primary Care Dental Services 2015-2020 Report by Dr Ken Proctor Associate Medical Director, Executive Director for Primary Care Dentistry. The Board is asked to: Note the policy context Endorse the proposed changes to service provision Approve the preferred way forward 1 Background and Summary The General Dental Practitioner (GDP) remains the Scottish Government s (SG) preferred provider of Primary Care Dental Services (PCDS) a policy direction which has remained unchanged since 1989. Historically, however, as a result of significant market failure of the GDP sector, notably in Highland from 1993 onwards, NHS Highland responded by developing a Public Dental Service (PDS) network. In this arrangement clinics were staffed by salaried general dental practitioners funded through the General Dental Services (GDS) funding stream. The role of community and salaried dental services in enabling Boards to deliver a comprehensive Public Dental Service to remote and rural areas was acknowledged with a recommendation that the two services were merged (Scottish Executive 2006). The new Public Dental Service was formed in 2013. In 2002, the SG agreed to the planned expansion of a network of PDS clinics throughout Highland. The direction of travel was re-inforced in 2005 and this, coupled with unplanned expansion in the GDP sector has significantly improved availability of NHS dental services in Highland. The PDS has been focusing on developing accessible services for priority groups for some time but capacity pressures do exist in some districts signalling that change is required. The specific issues which need to be considered as part of the reconfiguration in Highland include: NHS Highland s PDS has a significantly greater number of registrations than other Health Boards in Scotland A greater proportion of the PDS registrations in NHS Highland are patients within the most deprived quintiles with the converse trend for Highland GDP registrations Nationally, the split in spend is 83%, GDPs and 17% PDS GDS. In Highland the split is 40% GDPs and 60% for PDS GDS. The only Board that exceeds the NHS Highland proportionate spend on PDS GDS are NHS Orkney and NHS Western Isles. The common factor between all three Health Boards is their shared history of low participation from GDP contractors.
An impact assessment and SWOT analysis (Appendix 1) has been carried out by the Primary Care Dental Strategy Group and from this work the Board is asked to consider three options: Option 1 - Do Nothing Option 2 - Disinvest in all PDS sites (with the exception of where there is no GDP option) or Option 3 - Re-design services to allow PDS presence to meet the needs of 20% of the population In early 2014 NHS Highland submitted to SG its PDS GDS Financial Plan for the three years from 2014/15. The SG has not confirmed the required level of savings for 2014/15 or subsequent years. 1.1 Recommendation All three options carry risks to a greater or lesser extent but taking everything into consideration it is recommended that the Board implements option three by developing a three to five year plan to allow PDS service to be in place for 20% of the population. This will mean: A contraction of the PDS network (currently with 31% of the total Highland registrations) The transfer of some patients to the GDP sector A focus for the PDS on ensuring access for those patients with additional needs 1.2 Planning and key actions to implement option three The Board is asked to support a staged approach to planning the reduction in the PDS as well as seizing opportunities to re-design services as they arise, whilst ensuring oral health inequalities are not widened. Planning at district level will enable the specific characteristics of each district to be reflected in options as they are considered. These characteristics would include availability of GDP services, geography and deprivation profiles. A flow of patients from the PDS into the GDP sector will be required to free up capacity for special care, priority and vulnerable patients. It is acknowledged that this is a difficult area particularly if patients are to be forced to move providers and this will be managed with patients being supported in the move to an alternative provider. The focus would be on those patients, (where NHS registration is also available locally through a GDP provider) who are clinically reviewed as having no complexity in terms of case mix. Actions would also be taken to stem the flow of new patients into the PDS (where family dentistry was available locally through a GDP) as this would be more straightforward than moving existing patients. As Health Boards have very limited control over the GDP sector, their ability to adopt a unified approach to planning is limited. The preferred model in Highland for the provision of sustainable and equitable primary care dental services (PCDS) will include leasing vacant PDS surgeries to GDPs, co-locating PDS and GDP teams where PDS surgeries are surplus to requirements. 2. Overview 2.1. Policy context Successive guidance has emphasised the central role of the general dental practitioner (GDP) as the preferred provider of routine dental services in Scotland. 2
In 2013 the Chief Dental Officer emphasised the future challenges for Primary Care Dental Services (PCDS) as Boards plan for an increasingly dentate population, with multiple comorbidities and age related frailty requiring more complex care. The potential impact on demand for domiciliary care is also acknowledged (SG 2013). 2.2 Configuration of services and Dental registrations Services in Highland are delivered by GDPs and directly employed dentists working in the PDS. The PDS operates over 37 sites and employs approximately 400 staff. In addition to the 67,000 registrations it provides a range of outreach, public health and referral services. It also works closely with the Hospital Dental Service in various ways to ensure patients with complex needs receive their care appropriately. There are 46 GDP practices within NHS Highland. Unlike PDS Dentists, GDPs are free to offer private dental treatment as part of an NHS patients treatment plan, provided the patient consents to this and is fully aware of the options available under the NHS. GDPs also have patients for whom they provide only private dental treatment. As with the remainder of Scotland the level of GDS registrations in NHS Highland has increased over the past four years. In December 2009 48% of the Highland population were registered with an NHS dentist and in March 2014 this had increased to 72% of the population. However, registrations continue to be lower than the national average (85.3%) with only two Boards with lower registrations than Highland. Just under one third (31%) of total Highland registrations are with the PDS. The PDS does not actively de-register patients and the continuing care relationship between the clinical team and patient has in many instances been long standing. The PDS also treats patients on referral. 2.3 Drivers for Change 2.3.1 Improved Access Access to NHS dental registration has generally improved for mainstream patients in some localities. GDPs advise NHS Highland on a regular basis, through the dental availability survey where they have capacity for additional registrations. The picture is not uniform throughout Highland and in some localities service pressures continue (waiting lists, selected patient acceptance criteria). Therefore planning of primary care dental services at District level is recommended as we move forwards. There is an increased supply of the dental workforce. In Highland, GDPs in some localities are actively seeking patients for NHS registration and where this is the case, there would be an opportunity to facilitate the transfer of appropriate PDS patients to local providers who are offering family registration. This would immediately start to free up capacity in the PDS for the inequality groups. 2.3.2 Reducing Financial Allocation for the PDS The uncertain financial environment and change in funding arrangements for the PDS GDS allocation requires Boards to ensure they have the capacity within the funded network to meet the needs of the vulnerable and priority groups. In addition the PDS will continue to have a role in providing services in areas where there is no GDP provider / limited availability through this sector. 3
Market forces determine GDP provision. There is a level of financial risk for the Board should this result in a reduction in GDP NHS provision similar to that experienced in the NHS Highland across the Highland Council area during the period 1993 to 2010. 2.3.3 Persistent Oral Health inequalities It is recommended that sustainable and accessible PDS services, delivered by clinical teams who have received appropriate training and awareness raising, will continue to be in place for those with protected characteristics to support the investment in national oral health improvement programmes. Repatriation of appropriate patients from the PDS to GDPs will create capacity for those with more complex needs. 2.3.4 PDS Case Mix The current service has a wide case mix of patients varying from those with complex needs through to patients whose needs could be described as routine. With the increasing pressure for services from those with additional needs, it would be appropriate to optimise capacity within the GDP sector for routine PDS patients. 2.4 Going Forward The strengths and weakness (SWOT) of the different provider models was undertaken by senior clinicians in the PDS and GDP representatives and feedback was sought from the Area Dental Committee (Appendix 1). It is recommended that the planning of sustainable and accessible primary care dental services for all patient groups factors in the strengths of each sector. Taking everything into consideration three options have been considered. Options 2.4.1 Option 1 - Do Nothing Any decision to maintain the status quo would carry the risk of lack of support and funding from SG deferring to the Board to fund the service in totality. Oral health inequalities would persist and widen as some clinics are full and have no additional capacity for the priority groups of vulnerable patients. 2.4.2 Option 2 - Disinvest in all PDS sites (with the exception of where there is no GDP option) Oral health inequalities would widen as mainstreaming patients with additional needs risks their needs being neglected. The Board would have no means of ensuring provision of sustainable and accessible services in localities to meet the needs of the whole population and would rely on market forces to determine the availability of dental services in each local area. 2.4.3 Option 3 - Plan a PDS Service to meet the needs of 20% population Planning would occur at district level to allow for the variations in NHS GDS provision. The plan will require a flow of patients from the PDS into the GDP sector to free up capacity for special care, priority and vulnerable patients. The focus would be on managing the transfer of patients with routine needs into the GDP sector, where NHS GDS registration is also available locally through a GDP provider.. In parallel, the flow of new patients into the PDS (where family dentistry was available locally through a GDP) would be controlled to ensure patients were directed to the appropriate service. This would be more straightforward than moving existing patients. In addition this option would include leasing vacant PDS surgeries to GDPs, co-locating PDS and GDP teams where PDS surgeries are surplus to requirements. Planning a PDS service to meet the needs of 20% of the population is based on an indicative needs assessment and would be reviewed once the planned special dental care needs assessment for the North of Scotland is completed. Basing this assumption on an indicative 4
needs assessment runs the risk of over or under provision. Workforce profile recommendations would be made as part of the special dental care needs assessment. There would be a risk of a disconnect between the skill base of existing staff and future requirements as the service develops and an uncertain transition for staff if patients with mainstream needs are moved out of the service too quickly and the take up of service by the inequality groups has reduced momentum. 2.5 Assessment of Options. Active reduction of the GDS funded PDS workforce would require movement of mainstream patients into the GDP sector where there is availability. The emphasis on ensuring provision for vulnerable groups builds on work that had been started previously within NHS Highland and it is recommended that capacity within the PDS would be required for approximately 20% population recognising there will be a spectrum of needs and a range of service models to meet those needs, including shared care. Re-balancing of providers would involve change for patients, a reduction in the size of the PDS, reduced ability for the Board to plan services and a greater reliance on market forces to ensure PCDS are sustained. Where market forces fail NHS Highland will be reliant on the contingency of a reduced PDS network to provide services. A PDS presence will be required in each locality as the Board does not have the power to adopt a unified approach to planning primary care dental services. Controls over the GDP sector are limited to formal lease agreements with the Board with conditions to incentivise NHS commitment (80% gross income to be derived from NHS) or grant assistance through the Scottish Dental Access Initiative (SDAI) with a 7 year tie in. 2.6 Recommendation Taking everything into consideration it is recommended that the Board implements option three by developing a three to five year plan to allow a PDS presence for 20% population.. This will mean; a contraction of the PDS network, the transfer of patients to the GDP sector and a focus for the PDS on ensuring access for those patients with additional needs.. Planning at district level will enable the characteristics of each district to be reflected in options as they are applied and assessed to ensure sustainable and equitable services are in place. 3 Contribution to Board Objectives A set of guiding principles have been developed and these would provide a framework to ensure the planning of services are equitable, sustainable, affordable in line with the NHS Scotland s Quality Strategy: Safe, Effective and Person Centred delivery. This encompasses Planning for Fairness and NHS Highland s Better heath; better care; better value approach. Full implementation of the National Oral Health Improvement Programmes will support a proactive and increased emphasis on the inequality groups who have the most to gain in terms of improved oral health. 3.1 Governance Implications Staff Governance SG Planning Guidance for PDS (March 2013) directs Boards to actively manage a reduction in their salaried GDS workforce where access improves. 5
Updated planning guidance issued later in 2013 further stated that Boards should only be providing routine dental care through the PDS where there is a gap in independent contractor provision. While there is a recognition that the GDP contractor model will not always be sustainable in rural areas Boards were reminded of their responsibility to ensure that NHS dental services are available for those who wish to access them in their area including vulnerable groups of people and that the PDS should continue to reduce such inequalities. SG Dec.2014 Active management of a reduction in the PDS workforce presents some staff governance risks. Due to the dimensions of the service, it is recommended that change is therefore broadly opportunistic and proportionate. Staff will be supported in their conversations with patients through a framework and clinical assessment. Complexities have been identified with the active disinvestment in the PDS in particular related to TUPE implications of service transfer to GDP providers. The NHS Highland Organisational Change process, requiring full involvement of staff and their representatives, will be used, and the SG policy of no compulsory redundancies still applies. Clinical Governance A confirmed strength of the PDS highlighted in the SWOT analysis (Appendix1) is the organisational approach to clinical governance and the proactive management of risk, review and shared learning from adverse events and feedback from patients. Clinical concerns are investigated early to ensure patient safety is not at risk and performance issues managed within the appropriate policies and procedures. The Board is asked to note the weaknesses within the national framework for GDP governance. Financial Governance (Appendix 2) The PDS is funded through two funding streams Board allocation and PDS General Dental Services (PDS GDS) allocation from SG. The current spend in Highland is 40% GDPs and 60% PDS GDS. Nationally the split is 83% GDPs and 17% PDS. NHS Highland has very limited control over planning where new GDP practices are set up or which patients are seen. Control is limited to formalising lease agreements with GDP partners in return for an 80% gross income to be derived from NHS or supporting the award of Scottish Dental Access Initiative Grants with a seven year tie in to delivering NHS. The introduction of a new financial framework for the PDS involves the submission of an integrated service and financial plan on which a PDS GDS allocation is made. Any shortfall in funding of the PDS GDS allocation will become a cost pressure for the Board. In addition there are a number of support staff vacancies that have been either re-designed or delayed where there has been an opportunity to do so with no adverse impact on services for patients. At the same time the service continues to deliver efficiency savings in non pay through the review of procurement. As Boards actively manage a reduction in the size of their salaried GDS workforce as directed by SG, savings will be released. This work is already underway. 6
As at month eight an under-spend of 680k was forecasted against the allocation of 14.173m. This under-spend has arisen due to a combination of factors including SG with holding approval to recruit to vacant Dentist posts and instances of long term sick leave. The symbiotic relationship between the PDS and GDPs and wide ranging stakeholder groups will continue to be developed, ensuring appropriate use of resource. 4 Risk Assessment The proposed way forward is based on an indicative needs assessment. This runs the risk of over or under provision. Workforce profile recommendations would be made as part of the special dental care needs assessment. There would be a risk of a disconnect between the skill base of existing staff and future requirements as the service develops and an uncertain transition for staff if patients with mainstream needs are moved out of the service too quickly and the take up of service by the inequality groups has reduced momentum. The potential is for both Dentists and support staff to find themselves in a redeployment situation. This could be managed by adopting a phased and opportunistic approach. SG has not confirmed the level of funding reduction or timescales that they are going to apply to the PDS GDS budget. At present SG are not approving the recruitment to any Dentists posts and as a consequence this requires the transfer of patients without local consultation. In localities where there is no GDP option available this will result in waiting lists being re-introduced pending the marketing of premises leasing opportunities for new GDP providers. The alternative would be for NHS Highland to fund these posts as an interim position to maintain services to patients. It is recommended that clarification is sought from SG as to the expected level of savings and associated timescale to assist with a planned approach. 5 Planning for Fairness Special Care Dentistry provides preventive and treatment oral care services for people who are unable to accept routine dental care because of some physical, intellectual, medical, emotional, sensory, mental or social impairment, or a combination of these factors. Special Care Dentistry is concerned with the improvement of oral health of individuals and groups in society who fall within these categories. It requires a holistic approach that is specialist led in order to meet the complex requirements of people with impairments. (Royal College of Surgeons of England 2012) A Planning for Fairness assessment has been completed. Going forward this will be continually refreshed to ensure that, as dental services develop, those with additional support needs have equitable access to primary care dental services integrated around their own particular needs. This should minimise the risks associated with the concerns expressed by Dougall and Fisk (2008), that mainstreaming people with a disability could result in dental neglect. 6 Engagement and Communication Service change will be supported by an overarching communication and engagement plan for all stakeholders including patients. In terms of the work carried out to date, staff side have been involved as members of the review group and staff have been routinely updated by letter after each meeting of the group. Patients will be provided with information on the role of the PDS and options available to them for the transfer of their care. 7
7 Conclusion The substantial expansion of the NHS Highland PDS over the past decade now sees the Board managing the largest PDS system in Scotland. While this has greatly assisted in addressing the previous access problems, other factors now mean the PDS has to adapt. In most (but not all) districts, GDPs are available and the role of the PDS as provider of all dental care is no longer required. The careful preparatory work already undertaken by the Primary Care Dental Strategy Group will help support the work now required to rebalance the PDS activity whilst ensuring all patients continue to be able to access primary care dental services regardless of their needs or which part of the Board area they live in. It is proposed that this work is taken forwards in Highland through the establishment of a Project Board to monitor and report on implementation. Dr Ken Proctor Associate Medical Director January 2015 8
Appendix 1 SWOT Analysis Of Different Dental Provider Sectors In NHS Highland The following SWOT analysis was undertaken during the Dental Service Planning Performance meeting on 26 th February 2014. It includes input from the Primary Care Strategy Group. The Strengths and Weaknesses outlined in the document are internal to NHS Highland and are therefore under their control however difficult that may be. The Opportunities and Threats are external to the organisation and are therefore only able to be influenced by NHS Highland. STRENGTHS Public Dental Service (PDS) Service provided to those who GDPs are unwilling or unable to treat Respond to needs of whole population Filling a gap geographically Ensures access to scheduled & unscheduled care Balance contingency and specialist role Established PDS Teams, some co-located with health & social care teams, working as part of a wider support network. Established relationships with health, social care & third sector teams encouraging integrated working. Public money has provided enhanced provision. Patient needs met in a not for profit business model enabling equity of service provision Optimise use of specialist staff & skills across network Service wholly NHS (full range of services) no ambiguity for patients Organisational led clinical governance policies & procedures NHS Highland s control over direct primary care dental services provision allows alignment with the clinical strategy of the Board. It can be monitored and changed in response to circumstances. Targeted training, development & CPD in place for a staff aligned to service needs Networked clinical system & sharing of information General Dental Practitioners (GDP) Higher volumes of patient registrations Lower cost to Scottish Government Potential for greater choice for patients as able to choose NHS, mixed or private option Potential for greater flexibility to optimise use of premises as not constrained by nationally negotiated terms & conditions & staff governance framework Clearer management & decision making response times Able to access specialist staff and skills via Referral Hub Increasing number of GDP s provides ability for expansion Practices available throughout the Board area
WEAKNESSES Higher cost to Scottish Government Lower volumes patients seen Activity and case mix not easily reported Reporting does not capture nature of activity and case-mix Loss of staff whose working or career expectations cannot be met. De-skilling of staff Organisational structure impacts on response times & reduces flexibility Service wholly NHS limited choice for patients Scottish Government holds PDS/GDS budget Potential for patient confusion (private vs. NHS treatment/cost) NHS Highland cannot guarantee to each patient indefinite access to NHS dental services through a GDP The GDP business model does not support equity of access & is therefore not universal. Board has no med/long-term control over independent practice business model except where SDAIs or lease agreements are in place Training needs aligned with Practice priorities rather than Board. Board s ability to plan GDP services restricted to lease agreements & SDAI. This reduces further with reduced SDAI availability. Limited opportunities for co-ordination between clinical services and health improvement work
OPPORTUNITIES THREATS Public Dental Service (PDS) Align development of service with the needs of priority groups and national strategies with the focus on addressing inequalities. Further develop link with co-located allied health & social professionals and GDP colleagues to ensure patient centred approach. Optimise benefits to patients of co-location with other health and community care providers Further aligning staff training with service priorities Enables planning to target areas and groups with greatest need. Career progression & varied programmes of work Development of skill mix Development of performance indicators which reflect case mix, inequalities & deprivation. Nationally agreed frameworks provide certainty Expanded available workforce projected to be maintained in future Cash limiting. Uncertain financial allocation. Lack of flexibility due to nationally agreed terms & conditions & staff governance framework Perceived value of service by stakeholders and understanding of role of PDS General Dental Practitioners (GDP) Availability survey confirms GDPs have additional capacity in some localities. Service duplication can be reduced in some areas to free up capacity in the PDS to address the needs of the priority groups. This would enhance profitability & sustainability of GDP model. The flexibilities of not being constrained by nationally negotiated terms & conditions would enable opening hours to be extended in areas where there is demand. Increased availability of workforce may improve access to NHS dental Services Expanded available workforce projected to be maintained in future GDPs have no control over market forces - overprovision Business model poses additional barriers to service accessibility Financial uncertainty will disproportionately penalise vulnerable groups Weaknesses within the national framework for GDP governance leads to Board losing confidence in robustness of Governance practice
Appendix 2 2014/15 2014/15 2014/15 2014/15 2014/15 2015/16 2016/17 General Dental Services Allocation Forecast Variance Plan Plan Plan Plan Salaried dental services - Unified Staff costs WTE WTE Dentists' salaries 61.50 5,071 4,727 344 63.49 5,173 5,331 5,528 Chairside assistants and receptionists 225.18 6,083 5,913 170 246.00 6,222 6,371 6,570 Total pay costs 286.68 11,154 10,640 514 309.49 11,395 11,702 12,098 Non-pay costs 3,903 3,726 177 4,094 4,107 4,121 Total expenditure on salaried dental services 15,057 14,366 691 15,489 15,809 16,219 Less: Patient charges (884) (873) (11) (906) (906) (906) Net unified spend on salaried dental services 14,173 13,493 680 14,583 14,903 15,313 As at month 8 we were forecasting an underspend of 680k against this years allocation of 14.173m. The most significant factor contributing to this underspend is the high volume of vacancies within the Service which account for almost 2/3rds of the total underspend. There has also been ongoing work within the Service to reduce spend on consumables and lab work which has also contributed.