‘Salaried Dental Services’ BDA 21st May 2012 Colette M Bridgman Consultant In Dental Public Health NHS Manchester / GM Cluster On secondment to NHS CB Authority

During this presentation I will: Give a bit of context to current reforms in NHS Link these changes with how I see the opportunities and challenges unfolding for SDS teams Explore how to define the needs of vulnerable groups, describe the rationale for services and how to monitor outcomes rather than processes Need to respond to the direction towards Consultant / Specialist led care? Finally NHS CB approach – where might that lead us in development of salaried dental services in England.

Advanced Care Pathway Work - Alignment

Current reforms and what it means for dentistry and SDS Liberating the NHS – Government’s vision for health July 2010 Most relevance for dentistry? NHS Commissioning Board / Public Health England / LPN This new architecture will take on many of the roles and responsibilities currently discharged by the Department of Health, Strategic Health Authorities and Primary Care Trusts The NHS Commissioning Board will be responsible for commissioning all NHS dental services

Responsibilities for Dentistry Primary Dental Care NHS Commissioning Board Commissioning Responsibilities for Dentistry Eric Rooney Slides Secondary Dental Care DPH schemes Public Health Local Authority So first translating the national picture into GM. All Primary, Community and Hospital Dental services will be commissioned by the NHS Commissioning Board. DPH schemes by the Local Authority Dir Public Health Public Health England Medical Education England Workforce development

Dir Public Health England Public Health National Local Democratic SoS Public Health England NHS Commissioning Board National Public Health England NHS Commissioning Board Local Democratic Accountability LOCAL NHS CB Sub national Public Health England NHS Commissioning Board Dir Public Health Clinical Commissioning Groups Health and Wellbeing Board Dental Professional Network Clinical Commissioning Groups Clinical Commissioning Groups JSNA Upper Tier Local Authority level Commissioning priorities Cluster level Local Dental Committee LOCALTEAM District level Local Authority Preventive Network Restore Network Oral Surgery Network Ortho Network Special Care Network

Understanding Need and Use of Services at the heart Unmet Need Met Need Appropriate Use Avoidable Use   NEED Need to achieve met need & Appropriate use of services DEMAND

Need Purpose and function: then form…… Need Purpose and function: then form……. ‘Specialist Advanced Treatment in Primary Care’ First can we agree the need, rationale and future development of salaried dental services – can I be controversial on title SDS? Define vulnerable groups by ‘locality’, describe the need consistently plus take account of future demographics and trends Direction? Consultant/specialist led services for vulnerable groups Should be thinking in terms of Complexity/Need and then Competence and Quality – team and environment Consistency of delivery outcomes regardless of Setting

Paediatric - Children first Issues – Safeguarding and GA Referrals +++ Demand led GA list in acute centre Analysis of what is happening and why and pathway designed to improve care Involved all sectors Specialist led triage Child friendly GDS good environment and skills in practice i.e. therapist/IHS CDS responded rapid access Impact - Care pathway agreed Exposed some primary care referral decisions and care below expected standards Reduced reliance on GA and numbers by almost 70% Most received care with LA Followed up and offered continuing care ……… BUT

Can scheme be replicated? Needs to ... Have Consultant/Specialist input and leadership Be needs led and commissioners involved Expose GDPs if isolated – need formal link to specialist/SDS/Secondary Care Deliver evidence informed practice and reflective learning Have end to end care pathway redesign – single operating model and collaboration across sectors like we have never had in dentistry – how do we go from where we are now? Current reforms offer opportunities?

The Service Model – NHS CB Advanced / Specialist Care Coherent inter service relationships with integrated dental pathways the point of all connections has to focus on the needs of users Currently there is a degree of co-operation but little transparency or sense of coherence to meet needs of patients between settings A co-ordinated, patient-centred network of dental services in different settings, embodying alignment of policy making, service commissioning, needs assessment, performance management, funding and consistent delivery of outcome measured quality clinical practice.

End to end redesign integrated pathway to co-ordinate care pathway regardless of setting Underpinning Principles All Primary Care contracts performance managed – frequent referring performers identified / provider informed – training Consistent data capture (central capture and referral management in place – one way) of all referrals to all specialties Aligned need/diagnostic coding and tariff/cost Consistency of Specification: quality standards, equipment environment and qualifications/competence Altered job plans for specialists So referral management ………. Monitoring and evaluation built within a effective single service model with consistent need and outcome measurement

GDPs Collect referrals DRMC Consistent Data Referral management – all referrals are centrally captured for all specialties.

Referrers can easily check the progress of their referral To date over 1500 referrals processed Steady increase in quality and content of referrals Rejections reduced from 18% to less than 5% Diversion from secondary to primary care achieving 30% rate

In doing so by specialty there is a need to have in place: NHS CB. Design a commissioning system for secondary care dental specialties and salaried dental services capable of excellence In doing so by specialty there is a need to have in place: Ability to describe & meet need Have consistent delivery and reporting of evidence based services, diagnosis and outcomes (coding and tariff aligned) Have a clinical consensus on case complexity that can be adopted within agreed care pathways – same quality and reporting regardless of setting A managed clinical network/shared service and single operating model Clinicians leading and influencing change ……. Excellence & investment/shift to in primary care

Outcomes that will assist: Clinical consensus on consistent approach to data collection Robust information on need /procedure assists understanding trends Use evidence base on effectiveness of procedures & outcomes Produce a consensus on exactly what is defined as minor, intermediate or major – competence, qualifications, environment Need to map current service provision and links, WF and costs Space - to think through how it could be – incentives and barriers Describe any innovation in system and validate Same standards and tariffs in secondary and primary care setting?

The Seven Pillars of Commissioning The Seven Pillars of GP Commissioning Professional Standards Partnership Working Clinical Engagement Leadership Accountability Governance Public Participation

From the old world to the new From compliance States a minimum performance standard that everyone must achieve Uses hierarchy, systems and standard procedures for co-ordination and control Threats of penalties/sanctions/shame creates momentum for delivery Based on organisational accountability To commitment States a collaborative goal that everyone can commit to Based on shared goals, values and sense of purpose for co-ordination and control Commitment to common purpose and creative energy for delivery Based on relational commitment Source: Helen Bevan 2011

Our priority programmes are .... Quality care, clinically led - Our plan on a page About us.... Our group 41 member GP practices £265m budget -211,000 population and growing -a young population; 56% under 30 -Over 30% from BME groups -High levels of deprivation -High prevalence of long term conditions Our plan is to.... ...deliver a better balanced system for Central Manchester shifting from:- - Hospital care to services delivered in the community - Clinical care to patient self care - Measuring quantity to measurement of quality - What the NHS spends to what it can afford Success will be:- Improved life expectancy Improved quality of life for people with long term conditions Effective recovery from ill health & injury Excellent patient experience Safe and effective services; no avoidable harm Hitting our targets A balanced budget bridging our 2% financial gap Our priority programmes are .... Public health, prevention and patient partnerships Empowering patients Promoting healthy lifestyles Supporting self care Preventing ill health Identifying disease early and reducing its progression Supported by.... Patient and public involvement at every level of our organisation Our 41 member practices within four localities Clinical and managerial leadership - CCG Board Health and Wellbeing Board Clinical Integrated Care Board Quality of care Quality improvement Primary care Education and learning Medicines optimisation Quality assurance Driving quality and safety in the services we commission Our Mission ‘Informed by the views of local people and working closely with other health and social care professionals; Central Manchester Clinical Commissioning Group will design and develop health services which are high quality, safe and affordable and which will support communities to be the healthiest they can be.‘ Commissioning colleagues Partner CCGs Manchester City Council NHS Greater Manchester Commissioning support services Our provider partners - CMFT - MMHSCT - NWAS Adult social care Children’s services Primary Care Voluntary sector Service reform and integrated care Long term conditions management Integrated care pathways for planned and urgent care Mental health services Services for children We will be:- -Fair in the way we make decisions -Honest about the decisions we make and why we make them -Open in our approach to decision making, encouraging involvement in our processes and structures -Intolerant of poor quality services and health inequalities -Robust in our support for the NHS and local health services This is our existing ‘Plan on a Page’. It has proved useful in concisely describing who we are and what we do However, it could be improved to clearer state our vision and describe how we will measure how we are doing A culture of continuous improvement Making it happen Leading the health system Measuring quality & outcomes Shifting resources to community settings Incentivising for quality Contracting and performance Development of an excellent commissioning organisation Strong leadership A great team Good systems and processes April 2012 – March 2015

Public health, prevention and patient partnerships People die too young in Central Manchester. We also know that people die younger, and are more ill, in some parts of our locality than others. Central CCG will work with Manchester City Council to deliver targeted programmes addressing these health inequalities; preventing people becoming ill (or more ill), identifying illness early and supporting our communities to manage their own health and use the right services when they need them. Healthy Lifestyles Improve access to following services for those in most need: Health Trainers Stop Smoking Service Oral health improvement Weight management programmes Sexual Health services Alcohol awareness Mental Health promotion Supporting self care Establish locality based delivery of long term condition self management programmes Deliver enhanced Choose Well campaign Improved patient information on treatment of minor ailments in children Telehealth for patients where appropriate Preventing ill health Establish brief intervention programmes for smoking, alcohol and weight Increase immunisation and vaccination rates Identify disease Increase delivery, and uptake, of health check programmes Cancer awareness and early detection campaigns Improve screening rates – adult, pregnancy, neo-natal Promote HIV testing Improving services Redesign Sexual health services (young people’s services and general outpatient services- developing GM specifications) Drugs Service re-design and re-tender Review of alcohol care pathway Reform of School Nursing service Our most important role is to help people live longer and healthier lives in Central Manchester. This programme includes a number of projects to improve access to health promotion and prevention services and to enable patients to look after themselves better Specific outcome measures will be developed for this and the other programmes over the next 2 months. These will then help us meet the high level outcomes meausres on the Plan on a page Outcomes TBC TBC TBC TBC TBC

Local Professional Network – to have those conversations and influence Steering Group Narrative and Vision Establishment?? Don’t miss the opportunity for Dentistry!