Transcript Western LDC
Western LDC 26 March 2013 Donncha O’Carolan Chief Dental Officer
Overview Presentation
• Background to DHSSPS local decontamination guidance & recent changes • GDS budget – structure, allocation & trend • Need for efficiencies &GDS savings proposals • New Contract • Q&A
Local Decontamination Guidance
A Protocol for the Local Decontamination of Surgical Instruments • Issued July 2001, • Health Estates DHSSPS • Key areas • All local decontamination outside of clinical setting where possible • Recommends automated washing • Downward displacement autoclaves- not suitable for processing wrapped instruments or hollow instruments • Do not re-use single use instruments • Described as short term strategy
BDA A12
• Issued February 2003 • Key points • Where possible instruments to be decontaminated in a separate room • Recommends washer disinfector over manual cleaning • Wrapped instruments must be sterilised in a vacuum autoclave • Single use instruments used wherever possible & discarded after use
Hine Review of Decontamination of Endoscopes
• May 2004 problem identified with decontamination of endoscopes/ risk of cross infection with blood bore viruses • Review of effectiveness of arrangements for decontamination of endoscopes & lessons learnt • Service wide review of decontamination of all re-usable medical devices
Audit of Dental Practices
• Letter from CDO issued all GDPs December 2004 • Review current policies & procedures • Complete audit • Conform with recommendations in A12 • Overall compliance 53% amber 47% green • Priority areas: amalgam separators; chart recorders autoclaves; independent water supplies; LDU; WDs; disposable instruments
Audit of Dental Practices – follow up 2005/07
• Series of training workshops across NI (Dr Wil Coulter & Dr Caroline Pankhurst) • Cross Infection Control Manual /CD-ROM • Action plan developed 2006/07 (published annual report 2007/08 ) • Input DHSSPS, HSSB Dental Directors, Dr Wil Coulter, DPAs, ICNs, LDCs, RoI
Policy Position
• Nov 2007 QIS letter; listed priority areas, priority funding, 3-5yr lead in time, advice & support • HTM 01-05 (web) issued DH mid 2009 • PEL(09) 02 issued18 June 2009 • HTM 01-05 & audit tool (hard copy) issued DH Nov 2009 • PEL(10)04 issued 19 Feb 2010
Evidence Base
• •
Advisors HTM01-05
; BDA, MHRA, HPA, Infection Protection Society, Healthcare Commission, Decontamination experts, GDPs, microbiologists, engineers
Evidence base published
: Acts & Regulations; Codes of Practice; British, European & International Stds, research papers, Official Publications
Funding
• • •
QIS
money 2005 - 2010 key priority decontamination (approx £1million recurrent)
Addition QIS
money 2007/2008 £3 million
Practice allowance
Additional £4million (↑ from 5% to 11%) September 2007. Currently £8.6million
– ‘increasing practice requirements in relation to the provision of high quality premises, health & safety, staffing support & information collection & provision
Issue Time scales
PEL(10)04 – Northern Ireland Amendments
[Feb 2010]
Manual cleaning Packaging processed instruments Room layout HTM 01-05 (DH Position)
• Working at or above Essential requirements 1 yr from November 2009; • Detailed plan to move to best practice • Every practice meeting essential requirements ‘validated decontamination cycle’ • Best practice- Washer disinfector
DHSSPS position N. Ireland
• QIS letter 13 November 2007 set the timescale for ‘Best Practice’ • 3 years to start working towards. • 5 years to achieve. • Manual cleaning is not a validated process • Practices to use Washer-Disinfectors by November 2012.
• Permits drying and packing of instruments processed in a type N steriliser (Non-vacuum) and storage for 21 days • This is not a validated process • No evidence base to support this • Instruments processed in a type N steriliser should be stored in covered trays and used in same working day • 3 exemplar room layouts are illustrated • Figure 1 layout is not accepted as a washer disinfector is absent
Review of PEL(10) 04
• DHSSPS reviewed in summer 2011 – Meetings HSCB, RQIA & NIMDTA • DHSSPS further reviewed in summer/autumn 2012 – Meetings BDA, HSCB, RQIA & NIMDTA • Awaiting results of recontamination studies UCL • Awaiting amendments to HTM 01-05
Issue Timescales (Unchanged
)
PEL(12)23
HTM01-05 (DH Position)
• Working at or above Essential requirements 1 yr from November 2009; • Detailed plan to move to best practice
DHSSPS Position
• All practices to have achieved best practice by November 2012
Manual cleaning (Unchanged/clarificati on)
• Every practice meeting essential requirements ‘validated decontamination cycle’ • Best practice- Washer disinfector • Manual cleaning not a validated process; • Require Washer disinfector; (best practice) • Manual cleaning; instruments where manufacturer specifies no WD or WD temporarily unavailable ( written protocol)
LDU Room Layouts (Unchanged/clarificati on) Packaging Instruments processed type N (Changed/Amended) Packaging & Storage of instruments ( New)
• 3 exemplar room layouts • Permits drying & wrapping after processing type N & storage 21 days • 4.26 store with use-by date • 4.29 If stored in clinical area for use on current patients, purpose designed cabinet • Fig 1 unacceptable no WD. • Fig 2 & 3 acceptable.
• Need separate room • 21 days storage type N wrapped instruments • 60 days storage type B wrapped instruments • Non wrapped stored & used in working day • Clearly dated ‘use by’ • Stored in clinical area for use on patients within clinical session – dedicated storage cabinet
PEL(12)23
• Refer to full HTM 01-05 document • DH reviewing storage times – DHSSPS will review guidance as appropriate • Dental hand-pieces –advice from manufacturers as to which sterilisation cycle most suitable (4.5 HTM 01-05) • Advice from Health Estates Investment Group – John Singh
Minimum Standards for Dental Care and Treatment
• RQIA will inspect against • HSCB will commission against •
Std 13.4:’Prevention & Control of Infection
’ ‘
Your dental service meets current best practice on the decontamination of reusable dental & medical instruments
’.
• RQIA will inspect 13.4 in 2013/14 • DHSSPS/RQIA: Agreed inspection criteria
GDS Budget Structure/Trend/Savings Proposals
CDO
DHSSPS Structure
Minister
Permanent Secretary & Deputy Secretaries HEIG • Local decontamination • Capital planning SQS • Regulation of private dentistry • Dental standards • RQIA Primary Care • GDS contract • CDS Public Health • Oral health improvement • Health protection HRD • Workforce • Occupational health • Dental school • School of hygiene
New HSC structures
Department HSCB (Including LCGs) PHA RQIA GDS Trusts BSO Agencies NDPBs Key Stakeholders
Independent Assurance Performance Management
PCC
GDS Budget – Structure
GDS Budget – Allocation Mechanism
GDS Budget – Structure
Net Patient Pressure
GDS Budget – Investments
• £4 million (recurrent) into practice allowance ( total approx £8.6 million) • £3 million (non-recurrent) into QIS • £500k (recurrent) into VT grants • £2.33m (recurrent) into extending registration period • £400k (recurrent) salaried dental services • £5.7 million Improve access via dental tender • £1.1 (recurrent) into commitment payments
Dentistry: other investments
• Capitation fees
(deprived)
↑ 100% 0-5 yo;↑ 50% 6 17yo • Continuing Care
(all)
↑ 15% & ↑ 50%
(deprived)
• £120k CPD for DCPs • £300k for 5 additional dental students • £3 million re-equip school of dentistry • £100k additional registrar posts • Occupational health services for the whole dental team
GDS Budget: Proportion of Earnings
2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 Items of Service
65.6% 62.3% 58.3% 59.5% 59.3% 58.4%
Capitation & Continuing Care
21.6% 21.0% 21.9% 23.2% 22.6% 23.4%
Block Payments (allowances)
12.7% 16.8% 19.8% 17.3% 18.1% 18.2%
GDP – Taxable Income
net income* 2007/08 2008/09 2009/10 2010/11
Principal £121,200 £129,600 £122,900 £114,200 Associate £66,100 £66,700 £62,700 £59,400 *
Estimates of taxable income are not affected by flows of money between principals and associates
GDS Budget – increased provision
Patients (000s) Dentists Practices 1200 1000 800 600 400 200 0 2007 2008 2009 2010 2011 2012
GDS Budget
GDS Budget: Market Changes
GDS Budget: Market Changes
GDS Budget: Proposals for Savings- Principles
• Must have potential to realise savings for GDS budget • Can be implemented within existing GDS contract or with minor regulatory change • Can be implemented within coming financial year • Must be consistent with direction of new GDS contract • Comply with equality legislation & other regulatory requirements.
GDS Budget – Proposals for Savings
• QIS- £1.16m transfer to GDS budget (done) • Core service ( consistent with PDCS) • Molar endo – prior approval • Co/Cr – prior approval • Bridgework – posterior/large; prior approval • Veneers -all prior approval • Alter time bar on S&P (evidence base absent)
GDS Budget – Proposals for Savings
• Orthodontic treatment – IOTN 3.6, all other ortho prior approval (consistent with PDCS & rest UK) • Practice allowance –new criteria • Average of 750 patients/DS, with average 200 fee paying • Removal of commitment payments
Scale & Polish
• No evidence to support the clinical effectiveness of single S&P, nor frequency of provision – Cochrane Collaboration (Beirne, Worthington & Clarkson, 2008) – Clinical Outcomes of Single-Visit Oral Prophylaxis (Jones; Milsolm et al 2011) • Item 10c number claims = 813 • Item 10a number claims = 602,743 • Item 10b number claims = 47,760 • Perio SOD number contacts = 4,800
ADHS (2009)
• 15% periodontally healthy (no bleeding or calculus/LOA <4mm) • 41% periodontally healthy( LOA <4mm) but had calculus bleeding • 44% LOA>4mm would require 10c or perio department SOD • Adult registration 55% = 645,480 patients • Approx 284,000 patients need item 10c?
GDS Budget: Potential Savings
• Move to a core service under the SDR: ~ £840k • Altering claims conditions on S&P: ~ £744.5k • Changes to the practice allowance: ~£500k • Ceasing commitment payment: ~ £3.1m
• Restricting orthodontic treatment to IOTN 3.6: ~£1.7m ( realised over a 24 month period) • Total = £6.8million (approx)
Process & Timelines
• Consultation closes 3 April 2013 • Consideration stage • Minister signs off • IOTN & commitment payment –regulatory change – Health committee • Core service, S&P, practice allowance – SDR changes;
The Health Service - 65 Years old
“We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving – it must always appear inadequate.”
Aneurin Bevan - 1948
New Dental Contract
Primary Dental Care Strategy 2006
• Local commissioning of services; • Access to appropriate dental care for everyone who needs it; • A clear definition of treatments available under the health service; • A greater emphasis on disease prevention; • Guaranteed out-of-hours services; • A revised remuneration system, which rewards dentists fairly for operating the new arrangements.
Problems with existing system
• Quantity not quality is rewarded; • Treatment rather than prevention is rewarded; • Demand led rather than needs led; • SDR > 400 items is administratively complex; • Patient charges are difficult for the public to understand
Problems with existing system
• Dentists incomes directly related to the volume of treatment provided causes remuneration treadmill; • HSCB lacks control over targeting services at areas and patients with greatest need.
• 50 year old system no longer meets the needs of patients, oral health care professionals or society at large.
Blended System of Remuneration Care Payments Patient Care Payment
For Registration, Examination, Patient Appraisal, & Prevention
Quality Care Payment
Practice Practitioner
Item of Service Essential Services
& EXCEPTIONAL TREATMENTS
Occasional Services
Care Payments
Quality care payments (QCPs)
• Practice environment indicators • Practice inspection • Recognised charter-mark • Practitioner indicators • Peer review / clinical audit • Higher qualification
Blended System of Remuneration Care Payments Patient Care Payment
For Registration, Examination, Patient Appraisal, & Prevention
Quality Care Payment
Practice Practitioner
Item of Service Essential Services
& EXCEPTIONAL TREATMENTS
Occasional Services
Patient Care Payment
•
Weighted Capitation formula
• Adjusted for Age • Adjusted gender • Adjusted for additional needs • Adjusted for ‘new patients’ • Adjusted for list turnover
Capitation and Quality Payment Model
Care Payments Payment Patient Care Payment Quality Care Payment
Practice Practitioner Prevention & Necessary Treatment
Quality Care Payment
Practice Practitioner
Why has it taken so long?
• Resources • Addressing access issue • IT system at BSO • GDS budget – controlling pressures • Legislative problems – e.g. pensions, performers lists • Proposals from BDA?
How will new contract impact on profession?
• Local commissioning – HSCB will target resource at need.
• Control of entry – commissioning /performers lists • Fixed GDS budget and global sum formula • Focus on prevention • Out of hours responsibility of HSCB
What’s in for Profession?
• Limits number of dental practices • Increase value of practices?
• Can opt out of Out of Hours – Work-life balance?
• Performer/provider contracts • Career structure? • Capitation payments • Improved cash flow • Global sum • More stable budgetary position ?
More information
Visit www.dhsspsni.gov.uk/pgroups/dental/dental.asp
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