Transcript PPT Unbranded presentation template V1

Oral Care Conference: 23rd September 2011
The Node Conference Centre
Tackling Inequalities,
Meeting Real Needs
Sue Gregory OBE
Deputy Chief Dental Officer
(England)
Overview
 Oral health and inequalities in England
 Changing context of the NHS
 Commissioning changes
 Government commitments to oral health
 Dental Contract Reform and prevention in practice
 OHA and pathways
 Dental Quality and Outcomes Framework
 Collaborative/Community approaches
 What’s in it for you?
Oral Health in 12 year olds
Average number of dentinally
decayed, missing and filled
teeth in 12 year old children
2008/09 by PCT
Lowest:
0.23
England mean:
0.74
Highest:
1.48
BUT: 66.7% of children had
no experience
Average of those affected: 2.21
Average number of dentinally
decayed, missing and filled
teeth in 5 year old children
2007/08 by PCT
Lowest:
0.48
England mean:
1.1
Highest:
2.5
BUT: 69.1% of children
had no experience
Average of those affected: 3.45
Mean Number of Teeth
Mean Number of Teeth with Obvious Decay
Experience by Socio-Ecomonic Status of
Household in the UK, 2003
3
Managerial and
Professional
2.5
2
Intermediate
1.5
1
Routine and Manual
0.5
0
8 year olds
12 year olds
15 year olds
Source: Children’s Dental Health in the United Kingdom – Social factors and oral
health in children. Office for National Statistics
Adult Oral Health
Source: Adult Dental Health Survey 2009- Executive Summary, NHS Information Centre
Adult Dental Health Survey 2009 headline figures

86% of dentate adults had 21 or more natural
teeth

72% adults had no visible coronal caries

The average number of decayed or unsound
teeth was 1.0, with only small variations across
the age ranges

Only 6% of adults were edentate
Source: NHS Information Centre: Outcome and impact – a report from the Adult Dental Health Survey 2009
Oral Health Impacts
 Just under two-fifths of all adults (39 per cent) experienced one or more of
the problems included in OHIP-14 (Oral Health Impact Profile-14 scale)
occasionally or more often in the previous 12 months.
 Most commonly reported OHIP-14 problems physical pain (30 per cent) and
psychological discomfort (19 per cent)
 Between 1998 and 2009 the proportion of dentate adults in England who
reported having experienced one or more problem on the OHIP-14 scale
occasionally or more often in the previous 12 months, fell by 12 percentage
points; 51 per cent in 1998 to 39 per cent in 2009.
 A third of all adults (33 per cent) said they had difficulty performing at least
one element of the OIDP (Oral Impacts on Daily Performance). Overall, the
more prevalent oral impacts among adults were difficulty eating (21 per
cent), smiling (15 per cent), cleaning teeth (13 per cent) and relaxing (10
per cent).
Reform of the NHS
White Paper published July 2010
– for consultation
 Places patients at the heart of services,
enabled by easy access to the information
they need and want, and involved in
decisions about their care
 Places a focus on relentlessly improving the
clinical outcomes of care – moving away
from measurement of process
 Empowers professionals and trusts in their
clinical judgment, and
 Achieves efficiency gains and reduces
bureaucracy
Supporting consultative papers
 Local democratic legitimacy
in health
 Transparency in outcomes
– a framework for the NHS
 Regulating healthcare
providers
 Commissioning for patients
 Developing the healthcare
workforce
Public Health White Paper
Publication 30th November 2010
A coherent national framework across
Government with outcome goals
National Public Health Service, with
strong evaluation strategy, to be fully
operational by April 2012
Directors of Public Health in LAs
Ring-fenced public health budget
Empowering individuals, families and
local communities: a new relationship
between government and people
Reference to dental public health
 the dental public health workforce will increase its
focus on effective health promotion and prevention of
oral disease, provision of evidence-based oral care
and effective dental clinical governance. It will
concentrate particularly on improving children’s
oral health, because those who have healthy teeth
in childhood have every chance of keeping good
oral health throughout their lives. It will also make a
vital contribution to implementation of a new contract
for primary care dentistry, which the Government is to
introduce to increase emphasis on prevention while
meeting patients’ treatment needs more effectively.
Outcomes Frameworks
NHS Outcomes framework: 3 domains
- effectiveness of treatment and care, measured by
clinical and patient reported outcomes
- safety of treatment and care
- broader patient experience
Available from April 2011, implementation April 2012
Separate public health outcomes framework
including:
 “Rate of dental caries in children aged 5
years (decayed, missing or filled teeth)”
The Reformed System
 The White Paper envisages that power and
responsibility for commissioning most services will
be devolved to local consortia of GP practices.
 NHS dentistry will be one of a number of services
that will not be devolved.
 An autonomous NHS Commissioning Board will be
established
Functions of NHS Commissioning Board
 Providing national leadership on commissioning for
quality improvement
 Promoting and extending public and patient
involvement and choice
 Ensuring the development of GP commissioning
consortia
 Commissioning certain services that cannot solely
be commissioned by consortia, including dentistry
 Hosting of clinical networks and clinical senates
 Allocating and accounting for NHS resources
Timeline
 The Board will be established in shadow form as a
Special Health Authority from October 2011
 It will go live in October 2012 as a separate statutory
body, taking on full functions April 2013
 It is anticipated that all consortia will be fully
functioning by 2013
 SHAs and PCTs will be abolished by April 2013
 The sub national arrangements of the Board will
reflect the SHA and PCT clusters
Changes to Dental Commissioning
Currently PCTs commission Primary & Secondary Care Dentistry
using a number of contract types. From 2013 these services will
be commissioned by the NHS Commissioning Board. The benefits
of a nationally commissioned dental service include:
The ability to address overlap between the primary &
secondary care sectors
The opportunity to move care from secondary to primary
sectors
The opportunity to develop centralised commissioning dental
expertise
The opportunity to share clinical best practice more widely.
Emerging proposals: Dental, Pharms, Optoms
Provider skills
networks
Informing needs,
demand, supply in
primary, community
and secondary care
Local intelligence, clinical
expertise, innovation and
development of
integrated care pathways
Aggregation of need
and assurance of
performance
Health and well
being boards
Local
professional
networks
NHS CB
Consortia
Peer support, peer
review and
benchmarking
Maximising
performance
field force
NHSCB
national
Strategy, policy, contract,
procedure and assurance of
achievement of outcomes
COMMISSIONING DEVELOPMENT PROGRAMME
Implementation and
development plans to
reflect local
circumstances
Clinicians in the proposed model
Clinical
advice
central
Clinical input to
risk
stratification
central
central
outsourced/central
outsourced
Clinical management – sharing
good practice, managing
poor performance and
assurance of quality
Clinical practitioners supporting the
implementation of strategy and engaging in
peer review and benchmarking
COMMISSIONING DEVELOPMENT PROGRAMME
field
place
Local v national

If contract management was undertaken once
nationally, with agreed standard approaches to
common issues and routine contract monitoring and
performance management done centrally what key
tasks would need to be undertaken locally?

What are the key clinical/professional elements that
could be undertaken once nationally and what
would need to be undertaken locally?
What is local?
 Identifying health needs of local communities
 Ensuring patient choice and patient involvement
 Identifying gaps in access to services
 Producing oral health strategies for local communities
 Preventive programmes
 Enabling/supporting democratic/community input and
accountability in commissioning decisions
 Forum for clinicians
 Local face to face interaction in contract management
 Development of local professional networks?
Strength of local professional networks?
Local knowledge and expertise, enables:-
- meaningful, intelligent interpretation of
data
- local investigation
- local action
- local relationships
Government Commitments on Oral Health
In the Coalition Agreement the government stated their
intention to:
 Introduce a new contract based on registration,
capitation and quality
 Increase access to primary dental services
 Improve the oral health of the population, particularly
children.
Steele Review- NHS Dental Services
in England
22nd June 2009
 Just as health is the
desired outcome of the
rest of the NHS, so
health should now be
the desired outcome
for NHS dentistry
What does a public health approach in
practice mean to you?
 A sandal wearing
prevention agent of a
nanny state?
Dental Contract Reform
•
•
Unmet Need
Met Need
Appropriate
Use
Avoidable
Use
NEED
•
•
Need to achieve met need &
Appropriate use of services
DEMAND
I can’t sleep!
ILLNESS
FACTORIES
Manufacturers of
poor oral health
Oh my tooth!.
Sugar, smoking, lack of
Fluoride, poor plaque
control ……
Tobacco
Sweets
Beer
Help!
Help!
Adapted from Mc Kinley (1979) by Makiko Nishi
F THE 8760 HURS IN NE YEAR
…
HUR BY HUR CARE F a Chronic Condition
Re-orientating dental services towards prevention
using evidence-based guidelines 1257
C. Bridgeman, R. Singh, S. Saleem, S. Taylor, R. Harris
NHS Manchester, NHS Salford, NHS Oldham
School of Dental Sciences
Aim
Introduction
Care pathways are ‘a methodology for the mutual decision making
and organisation of care for a well-defined group of patients during a
well-defined period.’
• ‘Care
To evaluate the use of care pathways in general dental practice
based on a structured assessment of disease and risk and
monitoring compliance to care protocols for prevention.
pathways’ is a concept adapted from
industry which itemises the steps in a patients’
journey, based on accepted summaries of ‘best
practice’ as identified by available evidence.
Methods
A standardised assessment tool measuring active
disease and risk was developed based on: Medical
history, social history/ self care habits and Clinical
examination. The assessment tool included a decision
making section to classify patients into one of three
care pathway groups, Red, Amber and Green. The care
pathway protocols were based on Delivering Better Oral
Health Guidance (Department of Health, 2007).
• In the UK, the dental remuneration system has
shifted from a fee-per-item to one based on a
contract between the dental practice and the
commissioner.
• Commissioners
are looking towards using
measures of adherence to care pathways for
prevention, as part of a mix of contract
currencies which define both quantity and
quality of care.
Key performance indicators were developed to capture
and report on the needs of the practice population,
clinicians adherence to protocols and oral health
outcomes for patients. Clinical information systems
were used.
Results
Care pathways are usually monitored by looking
Types of procedures
currencies which
quality of care.
define
both
quantity
and
outcomes for patients. Clinical information systems
were used.
Results
Care pathways are usually monitored by looking
at process and outcome indicators.
•
Types of procedures
Numbers of
procedures
Clinical information systems could be adapted
to identify 3 broad types of patients and any
transfer between pathways.
•
Data on process outcomes was more readily
available and showed relatively high numbers of
preventive procedures when benchmarked.
•
Health outcome indicators were harder to
measure, although some movement between
pathways was seen.
In Practice 1 between April 2009 and March 2010 only 171 (24%) Red patients were reviewed out of the 713
scheduled to be reviewed.
Measuring performance on the basis of health outcomes of patients following care pathways may be
unreasonable.
•IEF 7cm pI 3-10
•SDS 12%
•Silver stain
Green at review
Amber at Review
Red at review
Green at
assessment
2
1
0
Amber at
assessment
1
5
1
Red at
assessment
4
56
118
Of the 178 Red patients
re-assessed, 31.4% had
shifted from a Red to
Amber category
E mail: [email protected]
Conclusions
Care pathways appear to have the potential to provide a structured approach to re-orientation of dental services towards prevention.
Considerable challenges were identified in bringing high risk patients to successful conclusions in their patient journey.
Public Health in Clinical Practice
 Understand practice population and identify
individual need
 Think upstream and pathway interventions

- like following a musical score!
 Communicate risk & transfer responsibility
 Celebrate and record improved outcomes
Benefits of Outcomes Focus
 Key development in NHS reform agenda
 Focus on promoting health and well being not on
repair and treatment
 Stronger focus on outcomes to reduce inequalities
and prevent disease
 Emphasises on effectiveness
 Recognises potential of clinical engagement and
using whole team to deliver care pathway
Pilot Contract Types
Type 1
Simulation Model
Pilot practices will be
guaranteed their
contract value (their
remuneration in the
current contract year)
and required to
deliver the same
NHS commitment
whilst adhering to the
new pathway.
Type 2
Weighted capitation &
quality model
These pilots will test the
implications of
applying a national
weighted capitation
model where
capitation payments
vary for different
patients depending
on the factors on
which the national
capitation model is
based.
Type 3
Weighted capitation &
quality model, with separate
budget for higher cost
treatments
These pilots will test the
implications of
applying a national
weighted capitation
model but the
capitation payment
will be for
preventative and
routine care only and
complex care will be
funded separately.
Capitation – potential variables
£ / head
Oral health status
Age
Deprivation
New or existing
patient
Gender
Adjusted £ / head
Capitation £
New patient visits dentist
Routine care
Urgent care
Definitive care relief
Assessment of
oral health
Disease prevention
and management
Continuity of care and
routine management
Advanced care
Accept
Recommend assessment
of oral health
Decline
Proposed patient
Pathway (Steele)
Clinical pathways in primary dental care
Quality Indicators
Patient Assessment
Patient Assessment
Risk Screening
Patient self-care plan
Patient self-care plan
Care Pathways
Recall intervals
Entry criteria
Complexity Assessments
Overview of risk screening process
Patient
Assessment
-
Risk
screening
Caries
-
-
-
-
Risk
Category
Domains
Perio
C
Patient actions……………
P
Dentist actions……………
C
Patient actions……………
-
P
-
-
C
Patient actions……………
-
-
P
Dentist actions……………
-
-
C
Patient actions……………
-
-
P
Dentist actions……………
TSL
T1
T2
T3
T1
T2
Dentist actions……………
-
Soft tissue
Recall
Prevention
T3
T1
T2
T3
T1
T2
T3
Self care plan, preventive and treatment plans
KEY
C
= Clinical Factors
P
T
= Time interval
= Patient Factors
Determining the clinical and patient
factors for CARIES
Domain
Caries
Actions
(pathways)
Clinical factors
Patient factors
Risk
Age
Teeth with carious
lesions
Symptoms
+
Diet
Excess sugar
=
Frequent sugar
No teeth with
carious lesions
Poor plaque control
Sibling experience
Patient
Communication
Professional
Patient
Assigning risk
The patient’s risk status for each domain is determined
as follows:
Red risk
status
Allocated if there is a red clinical factor, this cannot be
modified by patient factors.
Amber
risk
status
Amber risk status is allocated if there is an amber clinical
factor, or if there is a green clinical factor but a co-existing
patient factor which increases risk e.g. a patient with no
caries would still be classed amber if there was poor
plaque control
Green
risk
status
Green risk status is allocated to those with green clinical
factors and no patient factors which increase risk.
Prevention in practice
Simple messages
Concise advice
Evidence based with strength
of evidence
Practical and easy to use
Good reference for sugar free
medicines and fluoride
concentration in toothpaste
Links with healthy eating
Pilot Dental Quality & Outcomes Framework
Quality is a necessary part of future dental contracts and it will take time to get a quality
system that is solely outcome based. Quality is defined as covering three domains:
 Clinical effectiveness
 Patient experience
 Safety
Measures ready
for contract
pilots
Measures ready
for contract
implementation
Longer term
development of
quality indicators
Continual
development
and raising the
bar
Pathway Development
Work on quality indicators, and in particular outcome indicators, is relatively
new in the NHS and even more so in dentistry. The DQOF will therefore
continue to be developed over the coming years. The framework will be
underpinned by the development of a comprehensive set of accredited
clinical pathways.
The Development of DQOF
The DQOF working group followed the process outlined below working back from first principles to
define indicators that support the consensus within dentistry that good oral health is the ideal clinical
outcome:
Principles
For a patient to be in good oral
health, we mean;
They are free from pain
They have good functionality
and aesthetic form to their teeth
– They can “eat, speak and
socialise”*
They have clinically assessed
good oral health now and we are
confident that this will continue
into the future
*(World Health Organisation 1982)
Outcomes (patient view)
The patient’s view of being free
from pain and good functionality
should be covered by patient
experience and PROMS domain
rather than clinical effectiveness
Measures
Clinical components of the OHA:
Improvement Maintenance
Outcomes (clinical view)
The clinical view is covered in this
domain
and focuses on:
Improvement in oral health
Maintenance of good oral health
Caries
Perio
Elements of PDCPA for DQOF
Patient
Assessment
Utility of PDCPA for
DQOF measure
Clinical
Domains

x
C
-
Caries
P
Perio
-

C
P
x
C
x
P
x
C
x
P
x
-
Soft tissue
-
TSL
Key
C
= Clinical Factors
P
= Patient Factors
Measured at Review
Maintenance/improvement
3 categories
Maintenance/improvement
2 categories
Clinical Effectiveness Outcome Indicators for payment (60%)
The following outcome indicators are derived from the clinical elements of the assessment based on
the standardised NHS primary dental care patient assessment (PDCPA) and the associated risk
screening process. The indicator information will be captured at review and achievement of the
indicator is described as either maintaining or improving a patient’s condition.
Measure
Active decayed teeth (dt) aged 5 years old and under, reduction in number of carious
teeth/child
Points –
MAX:600
150
50% Under 5s active decay (dt) improved or maintained
Active Decayed Teeth (DT) aged 6 years old and over, reduction in number of carious
teeth/child
150
75% over 6’s improved or maintained
Active Decayed Teeth (DT) reduction in number of carious teeth/dentate adult
150
75% improved or maintained
75% patients with BPE improved or maintained at oral health review
75
50% patients with BPE 2 or more with sextant bleeding sites improved at oral health
review
75
Patient Experience Indicators for payment (30%)
Measure
Are you able to speak and eat comfortably?
% of patients reporting that they are able to speak & eat comfortably
How satisfied were you with the cleanliness of the practice?
% of patients satisfied with the cleanliness of the dental practice
How helpful were the staff at the practice?
% of patients satisfied with the helpfulness of practice staff
Did you feel sufficiently involved in decisions about your care?
% of patients reporting that they felt sufficiently involved in decisions about their care
Would you recommend this practice to a friend?
% of patients who would recommend the dental practice to a friend
How satisfied are you with the NHS dentistry received?
% of patients reporting satisfaction with NHS dentistry received
How do you feel about the length of time taken to get appointment?
% of patients satisfied with the time to get an appointment
Points - Max:300
MAX: 30
Level 1 45%-54% =15
Level 2 55%-100% =30
MAX: 30
Level 1 80%-89% = 15
Level 2 90%-100% = 30
MAX: 30
Level 1 80%-89%= 15
Level 2 90%-100% = 30
MAX: 50
Level 1 70%-84% = 25
Level 2 85%-100% = 50
MAX: 100
Level 1 70%-79% = 50
Level 2 80%-89%= 75
Level 3 90%-100%=100
MAX: 50
Level 1 80%-84% = 20
Level 2 85%-89% = 40
Level 3 90%-100% =50
MAX: 10
Level 1 70%- 84% = 5
Level 2 85%-100% =10
Safety Indicators for payment (10%)
Safety quality measures will fall under the remit of CQC and work with
professional bodies such as the GDC. The dental profession and
commissioners are committed to ensuring that clinical practice remains
safe and that safety is a fundamental part of the service that is delivered.
Consequently, patient safety overall is not something that should be
rewarded through a quality payment as all dentists should adhere to safe
practices. However clinical aspects of patient safety can be monitored
and rewarded through payment and payment will be made on the
following indicator:
Measure
90% of patients for whom an up-to-date medical
history is recorded at each oral health review
Points – MAX:100
MAX: 100
Indicators for monitoring overall quality (no
payment)
It is proposed that the following quality indicators are monitored
throughout the pilots to understand the impact of the change of
system on clinical behaviour and patient perception.
Measure
Domain
% of children aged 11 who have had an assessment of unerupted canines
Clinical effectiveness
% of children aged 18 and under who have had fluoride varnish in the last
year.
Clinical effectiveness
Was the cost of treatment explained to you before your treatment started?
Patient Experience
Do you understand what you personally need to do to maintain and improve
your oral health?
Patient Experience
Do you understand how healthy your teeth and gums are?
Patient Experience
Advanced care pathways
 Indirect restorations
 Metal based partial dentures
 Endodontic treatment
 Advanced periodontal care
Now starting work on minor oral surgery and intend
then to look at paedodontics
Decision making cascade
Are the general principles for
indirect restorations satisfied
? yes
Are the general patient
factors supportive ?
yes
Are the relevant oral health
risks controlled
yes
Is the proposed restoration
clinically feasible and
beneficial
yes
Offer indirect
restoration
Indirect Restorations (Veneers, Inlays, Crowns & Bridges)

Teeth that can be restored and made functional
Teeth with good prognosis

Patients co operation does not preclude indirect restorations

The patients Medical History does not preclude crown and/or bridge work
Risk Screening
and entry
criteria to be
determined

i
Level 1


Level 2
Restorations not involved in anterior
Guidance, where there are adequate
Sound or restored teeth to predictably
Maintain the existing occlusion
(conformative approach)
No more than 3 units of crown or bridge
work
Work to be carried out by GDP

Restorations that contribute to anterior
guidance where there are sufficient sound or
restored teeth to predictably maintain the
existing occlusion (conformative approach)
Extra coronal restoration of any one posterior
 sextant (all teeth), not involved in anterior
guidance where a terminal unit is involved
 More than 3 units of crown or bridge work
 Slight limitation of mouth opening
Work to be carried out by a GDP who
has additional competencies
Page 5
(* - crowns which are produced
in a lab)
Level 3
 Extra coronal restoration of the complete anterior
guidance including pontic units
 Extra coronal restoration of opposing sextants
(all teeth)
Restoration that are supported by

osseointegrated implants
 Significant re- organisation of occlusion
 Evidence of significant parafunction
 Significant/severe limitation of mouth opening
Work to be referred to Specialist Services
Learning from the Pilots

Qualitative
the experiences and impact on
– Dentists
– PCTs
– Patients

Quantitative
Clinical data set from Oral Health Assessment
PCR ??
Next steps

Develop proposals for the new contract, and
for reforms to the patient charging system to
fit in with the new contract.

The changes will require legislation, which
will be introduced to Parliament in a Bill –
timing to be confirmed.

Public consultation on the changes……
Leading to……Legislation to introduce new
contract
Windsor Dental Practice, Salford
Extended
duties
dental nurse
Hygienist
Therapists
Smoking cessation adviser
“Specialisation” and the Workforce

Need to look at those areas of care outside of
mandatory services, including:- orthodontics
- domiciliary
- sedation

Piloting within salaried services

Impact of skill-mix
Background
• Local Area Agreement (LAA) identified
children’s oral health as a local priority
• Lancashire County Council funded a LAA Oral Health
Lead to work with NHS colleagues
• Children and Young People’s Oral Health Strategy
developed and approved by the LA/NHS partnership
“Be Healthy Theme Group”
and enables Early Years Foundation Stage
settings to demonstrate and be recognised
for their oral health improvement activity
through the
Smile4Life
Award Scheme
Politics of the Smile4Life
Programme
• Is consistent with the Coalition direction of travel
– Focus on public health and prevention
– Focus on encouraging healthy behaviours
– Focus on collaboration with local authorities
responsibility for outcomes
– Focus on oral health
of school children and
increased access
Implementation of Smile4Life
Programme
• Salaried Service OHI team to act as experts and
advisors
• Local Children’s Centres to identify Oral Health
Champion
• Dental practice staff to link with local settings
What’s in it for you?
Primary/Secondary care interface
Clinical leadership
Networks
Training and development
QIPP