Transcript Presentation to Northern LDC

Presentation to Northern LDC
Donncha O’Carolan
Chief Dental Officer
5 April 2012
Overview of Presentation
• GDS Budget & Pressures
• New GDS Contract
• Local Decontamination
Guidance
DHSSPS Structure
Minister
Permanent Secretary & Deputy Secretaries
CDO
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
GDS Budget
GDS Budget – Structure
Net
Patient
GDS Budget – Structure
Net
Patient
GDS Budget – Structure
Net
Under spend
Patient
GDS Budget – Structure
 Net
 Patient
 Pressure
GDS Budget – Investments
•
•
•
•
£4 million (recurrent) into practice allowance
£3 million (non-recurrent) into QIS
£500k (recurrent) into VT grants
>£500k (recurrent) into extending registration
period
• £400k (recurrent) salaried dental services
• £5.7 million Improve access via dental tender
• £1.1 (recurrent) into commitment payments
GDS Budget: other investments
•
•
•
•
•
£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
Items of Service
65.6%
62.3%
58.3%
59.5%
59.3%
Capitation & Continuing Care
21.6%
21.0%
21.9%
23.2%
22.6%
Block Payments (allowances)
12.7%
16.8%
19.8%
17.3%
18.1%
GDS budget – Overall Earnings &
Expenses
net income
2007/08
2008/09
2009/10
Principal
£121,200
£129,600
£122,900
Associate
£66,100
£66,700
£62,700
GDS Budget – increased provision
Patients (000s)
Dentists
Practices
1200
1000
800
600
898
735
361
200
1001
1098
381
400
0
2007
2008
2009
2010
2011
GDS Budget
120
Patient charges
100
Over spend
80
Net
60
40
20
0
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
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
• Core service
•
•
•
•
Molar endo – prior approval
Co/Cr – prior approval
Bridgework – posterior/large; prior approval
Veneers -all prior approval
• Alter time bar on S&P
GDS Budget – Proposals for
Savings
• Orthodontic treatment – IOTN 3.6, all other
ortho prior approval
• Practice allowance –new criteria
• Average of 750 patients/DS, with average 200
fee paying
• Removal of commitment payments
GDS Budget: Potential Savings
• QIS funding transfer to the GDS budget £1.161m
• Move to a core service under the SDR: ~ £2m;
• Altering claims conditions on S&P: ~ £1m
• Changes to the practice allowance: ~£344k
• Ceasing commitment payment: ~ £3m
• Restricting orthodontic treatment to IOTN 3.6:
~£1.5m (full year effect realised over a 24 month
period)
Process & timeline
• Restrict orthodontic treatment
• This will require amendments to the GDS Regulations
and the SDR
• Consultation with BDA/PCC/ wider dental profession
and public
• Subject to the consultation/approval of the Assembly,
could be implemented from summer 2012.
• QIS funding to transfer to GDS budget
• No changes to regulations or the SDR are necessary
• The HSCB could action this with effect from 1 April
2012.
Process & timeline
• Move to a core service under the SDR
• This will require amendments to the SDR
• consultation with BDA/PCC/ wider dental profession
and public
• Subject to the consultation this could be implemented
from summer 2012.
• Alter S&P time-bar
• Will require amendments to the SDR
• Consultation with BDA/PCC/ wider dental profession
and public
• Subject to the consultation, could be implemented
from summer 2012
Process & timeline
• Removal Commitment payment
• will require amendment to both the GDS regs and
SDR
• Practice Allowance amendments to criteria
• will require amendment of the SDR
• Consultation with BDA/PCC/ wider dental
profession and public
• Subject to the consultation/ approval of the
Assembly, could be implemented from summer
2012.
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.
Options for New System
• Prof Ciaran O’Neill looked at range of
remuneration systems
• Retrospective Fee for Service (Item of
service);
• Prospective Payment System (Full capitation);
• Salaried/Sessional system
• Advised blended service
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
Occasional
Services
& EXCEPTIONAL
TREATMENTS

Clinical Examination
E.O. & I.O. (dental/perio)
Recall
Interval
ASSOCIATED
PROCEDURES
e.g.
Radiographs
(IF INDICATED)
Risk-Based
Patient Appraisal
• 1° Specialist care • 2° Care
Preventive
Services
Simple Perio Care
Essential
Services
Exceptional
Treatments
CARE PAYMENTS [Patient Care & Quality Care]
Private care (Mixed Economy)
History- taking
By Dental team
IoS PAYMENT
IN
PARALLEL:
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
Occasional
Services
& EXCEPTIONAL
TREATMENTS

Essential Services
•
•
•
•
•
•
•
•
Periodontal treatment
Restorations
Endodontics (except molars)
Crown work
Extractions & surgical
Dentures –acrylic
Children’s treatment
Miscellaneous items
Exceptional Treatments
•
•
•
•
Molar endodontics
Co/Cr dentures
Bridgework
Veneers
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
Occasional
Services
& EXCEPTIONAL
TREATMENTS

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
Occasional
Services
& EXCEPTIONAL
TREATMENTS

Patient Care Payment
•
•
•
•
•
•
Weighted Capitation formula
Adjusted for Age
Adjusted gender
Adjusted for additional needs
Adjusted for ‘new patients’
Adjusted for list turnover
2º Specialist Orthodontic Care
GDP
REFERRAL
(Guidelines)
ORTHODONTIC
ASSESSMENT
 Examination
 Assessment
 Charting
TREATMENT
NOT INDICATED
ASSOCIATED
PROCEDURES
(if indicated)
 Radiographs
 Photographs
 Models
OPTION
TREATMENT
DECLINED
REVIEW FOR
TREATMENT
NOT
ACCEPTED
Exceptional
Treatments
Process
Private Specialist Orthodontic Care
REFER FOR
TREATMENT
Orthodontics
TREATMENT
COMMENCING
ACCEPTED




DH1/10/69575
INCLUDING:
PRE & POST-OP MODELS
ANY OTHER STAGES
REPAIRS
RETENTION
FUNCTIONAL APPLIANCE
DOUBLE ARCH FULL
FIXED APPLIANCES
TREATMENT
DISCONTINUED
SINGLE ARCH FULL
FIXED APPLIANCES
TREATMENT
ABANDONED
SIMPLE APPLIANCES
ORTHODONTIC
TREATMENT
Oral Surgery
Band Examples of complexity
Patient charge
A
Assessment, radiographs, non
surgical exts,
Charge A
B
Multiple exts, surgical exts,
fraenectomy, biopsies
Charge B
C
Apicectomy, exposure,
periodontal surgery
Charge C
D
Multiple surgical exts, multiple
apicectomies
Charge D
Pilots
• Use Pilot PDS
• Consultation October 2010 – March 2011
• Responses very supportive
• Oral Surgery pilot well advanced
• Orthodontic contract will be phased in
• GDS will follow oral surgery
Progress on New Contract
Essential services
complete
Exceptional treatments
complete
Quality care Payments
complete
Patient Care Payments
complete
(weighted capitation formula)
Patient charges
Oral surgery PDS
Orthodontics
Pilot group
ICT
Contract & Regulations
Model developed
current phase with HSCB
Phase 1 – 2012 & further phasing
current phase with HSCB
Business case approved - ongoing
ongoing
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 –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?
Local Decontamination
Guidance
Content
• Policy Background
• Funding
• Current Position
• Regulation
Policy Background
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 issued to GDPs August 2004 re quality assurance
of decontamination processes
• Protocol for the local decontamination of Surgical
Instruments (July 2001) reissued & dentists asked to
comply
• Letter from CDO issued all GDPs December 2004
• Review current policies & procedures
• Complete audit
• Conform with recommendations in A12
Audit of Dental Practices
- Outcomes
• Overall compliance good
(53% amber, 47% green)
• Priority areas
• Amalgam separators
• Chart recorders for autoclaves
• Independent water bottles
• Dedicated rooms for decontamination
• Washer disinfectors
• Disposable instruments
Audit of Dental Practices
– follow up 2005/06
• Series of training workshops across NI
(Dr Wil Coulter & Dr Caroline Pankhurst)
• Cross Infection Control Manual
• Cross Infection Control CD-ROM
– Launched 2 May 2006
Development of Action Plan
• October 2006; DHSSPS, Health Estates, Dental Directors, Dr Wil
Coulter
• Looked at priority areas from audit
• Amalgam separators, chart recorders autoclaves &
independent water bottles largely achieved & funding provided
through QIS 2005 & 2006
• Separate decontamination room, washer disinfectors &
disposables logistically & financially more difficult to achieve
• Needed to develop an action plan listing priorities
Workshop February 2007 &
Publication of Action Plan
• CDO, Dental Directors, Dental Practice Advisers,
Infection Control nurses, LDCs, representatives RoI
• Action plan agreed, developed & published (annual report
2007/08)
–
–
–
–
–
–
Washer disinfectors
Quality of water supply
Improved surgery layouts
Use vacuum autoclaves
Appropriate testing equipment
Procurement of equipment
Other Policy Influences
• DH England working on HTM 01-05
– Health Estates had observer status
• BDA developing new A12
– Working drafts shared with DH, subsequently withdrawn
• Scotland
– Glennie Group
– Top ten tips
• Ensured DHSSPS action plan consistent with working
drafts HTM 01-05 & Scotland
• Nov 2007 QIS letter; Policy position; funding for priority
areas; Advice & support; 3-5 year lead in time.
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
Further Support
• Supported Labour Government, Coalition
Government, Minister DHSSPS.
• NI, Scotland, England – all moving to similar
standards but on different timetable.
• ROI; New National stds for Prevention & Control
of Health Care Associated Infections
Funding
Investments into GDS
• Practice Allowance: £4million additional (2007)
• QIS: £3million additional (2007/08)
• Commitment payments: £1.1million additional
(2009)
• Registration: £500k additional (2009)
• Vocational training: £500k additional (2007)
Funding
• Profits: 07/08 £121,200: 09/10 £129,900:10/11
£122,900
• QIS money 2005 - 2010 key priority
decontamination (approx £1million recurrent)
• Addition QIS money 2007/2008 £3 million
• Practice allowance ↑ from 5% to 11%
September 2007
– ‘increasing practice requirements in relation to the provision of
high quality premises, health & safety, staffing support &
information collection & provision
The Health Service - 60 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
Current Position
• Nov 2009 DH publish HTM 01-05 (Hard Copy)
• 10 Feb 2010 DHSSPS issue NI position, accept HTM0105 with modifications (PEL(10)04):
– Washer disinfector – manual cleaning not a validated process
– Timescale: must have achieved best practice by 2010-12
– Instruments processed in a type N autoclave cannot be
subsequently wrapped & stored – use within working day
– Exemplar room layout; fig 1 does not apply (no WD)
Minimum Standards for Dental
Care and Treatment
• Primary Care Private & HS
• RQIA will inspect against
• HSCB will commission against
• Std 13:’Prevention & Control of
Infection’
‘Your dental service meets current best
practice on the decontamination of
reusable dental & medical instruments’.
• Issued March 2011
RQIA -Regulation Private
Dentistry
• Legislation – HPSS (QIR) NI Order 2003
• Amend Order through regulations to permit regulation
of all private dentistry
• Regulation commenced 1 April 2011
• RQIA; Register & annual inspection
• Any dental practice which provides any private dentistry
• Inspect against dental standards
• Inspection Reports published on the RQIA web-site
Other Guidance since
PEL (10) 04
• Scottish Health Technologies Group Advice
Statements
• Wrapping Dental Instruments
• Benchtop steam sterilisers
• Sterilization of Dental Instruments (SDCEP)
• BDJ: Time-dependent recontamination rates of
sterilised instruments
• IDJ: Three Steps to Decontamination Heaven
Review of PEL(10) 04
• DHSSPS reviewed PEL (10) 04 in summer
2011
• HSCB
• RQIA
• NIMDTA
• Await results of recontamination studies
UCL
• Offered meeting with BDA
Non-compliance
Compliance
•
•
•
•
DHSSPS has provided significant funding
Minister will be held accountable for delivery
Profession will be expected to deliver
All 14 Oasis practices are compliant (230 across UK)
• Do not report significant problems
• Other NI practices have already complied or are close to
compliance
• DHSSPS, NIMDTA & HSCB considerable resource into
training to aid compliance
What’s next?
• Direct Access
• Amalgam
Contacts & References
• CDO website for Newsletters, annual reports & other publications
http://www.dhsspsni.gov.uk/pgroups/dental/dental.asp
• PEL (10) 04 on HE website
http://www.dhsspsni.gov.uk/index/hea/decontamination-general-dental-practices.htm
• Dental Standards
http://www.dhsspsni.gov.uk/index/dental/dental-pubs.htm
• HE contact number for advice
028 90 523802
Thank You