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Tackling Inequalities,Meeting Real Needs
Sue Gregory OBE
Deputy Chief Dental Officer (England)
Oral Care Conference: 23rd September 2011
The Node Conference Centre
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 with Obvious Decay Experience by Socio-Ecomonic Status of
Household in the UK, 2003
0
0.5
1
1.5
2
2.5
3
8 year olds 12 year olds 15 year olds
Me
an
Nu
mb
er
of
Te
eth
Managerial andProfessional
Intermediate
Routine and Manual
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 PaperPublication 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 experienceAvailable from April 2011, implementation April 2012
Separate public health outcomes frameworkincluding:
“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 CommissioningCurrently 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.
COMMISSIONING DEVELOPMENT PROGRAMME
Health and well being boards Consortia
Strategy, policy, contract, procedure and assurance of achievement of outcomes
Implementation and development plans to reflect local circumstances
Local intelligence, clinical expertise, innovation and development of integrated care pathways
Peer support, peer review and benchmarking
Maximising performance
NHSCB
national
NHS CB
field force
Localprofessional
networks
Informing needs, demand, supply in primary, community and secondary care
Aggregation of need and assurance of performance
Provider skills networks
Emerging proposals: Dental, Pharms, Optoms
COMMISSIONING DEVELOPMENT PROGRAMME
central
outsourced
centralcentral
outsourced/central
field
place
Clinical advice
Clinical advice
Clinical input to risk
stratification
Clinical input to risk
stratification
Clinical management – sharing good practice, managing
poor performance and assurance of quality
Clinical management – sharing good practice, managing
poor performance and assurance of quality
Clinical practitioners supporting theimplementation of strategy and engaging in
peer review and benchmarking
Clinical practitioners supporting theimplementation of strategy and engaging in
peer review and benchmarking
Clinicians in the proposed model
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.
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
Steele Review- NHS Dental Services in England
A sandal wearing prevention agent of a nanny state?
What does a public health approach in practice mean to you?
• • • •
NEED
Unmet Need Met Need
Appropriate Use
Avoidable Use
DEMANDNeed to achieve met need & Appropriate use of services
Dental Contract Reform
Help!
Help!
Oh my tooth!.
I can’t sleep!
Adapted from Mc Kinley (1979) by Makiko Nishi
Manufacturers of
poor oral healthSugar, smoking, lack of Fluoride, poor plaque
control ……
ILLNESS FACTORIES
Tobacco Sweets Beer
HUR BY HUR CARE F a Chronic Condition
F THE 8760 HURS IN NE YEAR …
Care pathways are usually monitored by looking at process and outcome indicators.
• 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.
Re-orientating dental services towards prevention using evidence-based guidelines 1257
C. Bridgeman, R. Singh, S. Saleem, S. Taylor, R. Harris
• ‘Care 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.
• 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.
•IEF 7cm pI 3-10
•SDS 12%
•Silver stain
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.
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.
Introduction
Conclusions
Results
School of Dental Sciences
Aim
NHS Manchester, NHS Salford, NHS Oldham
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.’
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
Numbers of procedures
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.
Types of procedures
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).
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.
E mail: [email protected]
Care pathways are usually monitored by looking at process and outcome indicators.
• 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.
Re-orientating dental services towards prevention using evidence-based guidelines 1257
C. Bridgeman, R. Singh, S. Saleem, S. Taylor, R. Harris
• ‘Care 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.
• 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.
•IEF 7cm pI 3-10
•SDS 12%
•Silver stain
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.
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.
Introduction
Conclusions
Results
School of Dental Sciences
Aim
NHS Manchester, NHS Salford, NHS Oldham
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.’
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
Numbers of procedures
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.
Types of procedures
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).
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.
E mail: [email protected]
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
Type 3Weighted capitation &
quality model, with separate budget for higher cost
treatments
Pilot Contract TypesType 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.
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
Age
Gender
Oral health status
Deprivation
New or existing patient
Adjusted £ / head
Capitation £
£ / head
Age
Gender
Oral health status
Deprivation
New or existing patient
Adjusted £ / head
Capitation £
New patient visits dentist
Routine care
Assessment oforal health
Disease preventionand management
Continuity of care androutine management
Advanced care
Recommend assessmentof oral health
Definitive care relief
Urgent care
Accept
Decline
Proposed patient Pathway (Steele)
Clinical pathways in primary dental care
Patient Assessment
Risk Screening
Care Pathways
Recall intervals
Patient self-care plan
Patient Assessment
Patient self-care plan
Entry criteria Complexity Assessments
Quality Indicators
Overview of risk screening processRisk
screening
-
-
-
-
-
-
-
-
Domains Risk Category
Prevention
Patient actions……………
Dentist actions……………
T1
Self care plan, preventive and treatment plans
Caries
Perio
Soft tissue
TSL
P
C
C
P
= Clinical Factors
= Patient Factors
KEY
= Time intervalT
P
C
P
C
P
C
Patient Assessment
-
-
-
-
-
-
-
-
Recall
T2T3
Patient actions……………
Dentist actions……………
T1T2
T3
Patient actions……………
Dentist actions……………
T1T2
T3
Patient actions……………
Dentist actions……………
T1T2
T3
Determining the clinical and patient factors for CARIES
Domain
Risk
Teeth with carious lesions
Caries
Sibling experience
Diet
Excess sugar
Frequent sugar
Poor plaque controlNo teeth with
carious lesions
Patient factors
+ =
Actions
(pathways)
Professional Patient
Patient Communication
Age
Clinical factors
Symptoms
Red risk status
Amber risk status
Green risk status
Assigning riskThe patient’s risk status for each domain is determined as follows:
Allocated if there is a red clinical factor, this cannot be modified by patient factors.
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 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 FrameworkQuality 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 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:
The Development of DQOF
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
Principles
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
Outcomes (patient view)
The clinical view is covered in this domainand focuses on:Improvement in oral healthMaintenance of good oral health
Outcomes (clinical view)
*(World Health Organisation 1982)
MeasuresClinical components of the OHA:
Improvement Maintenance
Caries
Perio
Elements of PDCPA for DQOFClinical
Domains
Measured at Review
Caries
Perio
Soft tissue
TSL
P
C
C P= Clinical Factors = Patient Factors
Key
P
C
P
C
P
C
Patient Assessment
-
-
-
-
-
-
-
Utility of PDCPA for DQOF measure
x
x
x
x
x
x
Maintenance/improvement3 categories
Maintenance/improvement2 categories
Clinical Effectiveness Outcome Indicators for payment (60%)
MeasurePoints –
MAX:600 Active decayed teeth (dt) aged 5 years old and under, reduction in number of carious teeth/child
50% Under 5s active decay (dt) improved or maintained
150
Active Decayed Teeth (DT) aged 6 years old and over, reduction in number of carious teeth/child
75% over 6’s improved or maintained
150
Active Decayed Teeth (DT) reduction in number of carious teeth/dentate adult
75% improved or maintained150
75% patients with BPE improved or maintained at oral health review 7550% patients with BPE 2 or more with sextant bleeding sites improved at oral health review
75
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.
Patient Experience Indicators for payment (30%)Measure Points - Max:300
Are you able to speak and eat comfortably?
% of patients reporting that they are able to speak & eat comfortably
MAX: 30 Level 1 45%-54% =15Level 2 55%-100% =30
How satisfied were you with the cleanliness of the practice?
% of patients satisfied with the cleanliness of the dental practice
MAX: 30 Level 1 80%-89% = 15Level 2 90%-100% = 30
How helpful were the staff at the practice?
% of patients satisfied with the helpfulness of practice staff
MAX: 30 Level 1 80%-89%= 15Level 2 90%-100% = 30
Did you feel sufficiently involved in decisions about your care?
% of patients reporting that they felt sufficiently involved in decisions about their care
MAX: 50 Level 1 70%-84% = 25Level 2 85%-100% = 50
Would you recommend this practice to a friend?
% of patients who would recommend the dental practice to a friend
MAX: 100Level 1 70%-79% = 50Level 2 80%-89%= 75Level 3 90%-100%=100
How satisfied are you with the NHS dentistry received?
% of patients reporting satisfaction with NHS dentistry received
MAX: 50Level 1 80%-84% = 20Level 2 85%-89% = 40Level 3 90%-100% =50
How do you feel about the length of time taken to get appointment?
% of patients satisfied with the time to get an appointment
MAX: 10Level 1 70%- 84% = 5Level 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 Points – MAX:100
90% of patients for whom an up-to-date medical history is recorded at each oral health review
MAX: 100
Indicators for monitoring overall quality (no payment)
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
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.
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
Are the general patient factors supportive ?
Are the relevant oral health risks controlled
Is the proposed restoration clinically feasible and
beneficial
yes
Are the general principles for indirect restorations
satisfied ?
yes
yes
yes Offer indirect restoration
Decision making cascade
Page 5
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
i
Level 1
Restorations not involved in anteriorGuidance, where there are adequateSound or restored teeth to predictablyMaintain the existing occlusion(conformative approach)
No more than 3 units of crown or bridge work
Level 2
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
Level 3Extra 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 carried out by GDPWork to be carried out by a GDP who
has additional competencies Work to be referred to Specialist Services
Risk Screening and entry
criteria to be determined
(* - crowns which are produced in a lab)
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
Hygienist
Smoking cessation adviser
Extended duties dental nurse
Therapists
“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”
Smile4Life Award Scheme
and enables Early Years Foundation Stage settings to demonstrate and be recognised for their oral health improvement activity through the
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 andincreased access
• 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
Implementation of Smile4Life Programme
What’s in it for you?
Primary/Secondary care interfaceClinical leadershipNetworksTraining and developmentQIPP
