1. Tackling Inequalities, Meeting Real Needs Sue Gregory OBE Deputy Chief Dental Officer (England) Oral Care Conference: 23rd September 2011 The Node Conference Centre

2. 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?

3. Oral Health in 12 year olds

4. 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

5. 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

6. Source: Children’s Dental Health in the United Kingdom – Social factors and oral health in children. Office for National Statistics

8. Adult Oral Health Source: Adult Dental Health Survey 2009- Executive Summary, NHS Information Centre

9. 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

10. Source: NHS Information Centre: Outcome and impact – a report from the Adult Dental Health Survey 2009

11. 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).

12. 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

13. 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

14. 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

15. 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.

16. 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)”

17. 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

18. 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

19. 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

20. 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.

21. 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 Local professional 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

22. COMMISSIONING DEVELOPMENT PROGRAMME central outsourced central outsourced/central field place Clinicians in the proposed model

23. 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?

24. 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?

25. Strength of local professional networks? Local knowledge and expertise, enables:- - meaningful, intelligent interpretation of data - local investigation - local action - local relationships

26. 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.

27. 22 nd 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

29.  A sandal wearing prevention agent of a nanny state? What does a public health approach in practice mean to you?

30. NEED Unmet NeedMet Need Appropriate Use Avoidable Use DEMAND Need to achieve met need & Appropriate use of services Dental Contract Reform

31. Help! Oh my tooth!. I can’t sleep! Adapted from Mc Kinley (1979) by Makiko Nishi Manufacturers of poor oral health Sugar, smoking, lack of Fluoride, poor plaque control …… ILLNESS FACTORIES Tobacco Sweets Beer

32. H  UR BY H  UR CARE  F a Chronic Condition  F THE 8760 H  URS IN  NE YEAR …

35. 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

36. 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

37. Type 3 Weighted capitation & quality model, with separate budget for higher cost treatments 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. 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.

38. Capitation – potential variables

39. New patient visits dentist Routine care Assessment of oral health Disease prevention and management Continuity of care and routine management Advanced care Recommend assessment of oral health Definitive care relief Urgent care Accept Decline Proposed patient Pathway (Steele)

40. 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 criteriaComplexity Assessments Quality Indicators

41. Overview of risk screening process Risk 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 interval T P C P C P C Patient Assessment ---------------- Recall T2 T3 Patient actions…………… Dentist actions…………… T1 T2 T3 Patient actions…………… Dentist actions…………… T1 T2 T3 Patient actions…………… Dentist actions…………… T1 T2 T3

42. Determining the clinical and patient factors for CARIES Domain Risk Teeth with carious lesions Caries Sibling experience Diet Excess sugar Frequent sugar Poor plaque control No teeth with carious lesions Patient factors + = Actions (pathways) Professional Patient Communication Age Clinical factors Symptoms

43. Red risk status Amber risk status Green risk status Assigning risk The 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.

44. 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

45. 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.

46. 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 domain and focuses on:  Improvement in oral health  Maintenance of good oral health Outcomes (clinical view) *(World Health Organisation 1982) Measures Clinical components of the OHA: Improvement Maintenance Caries Perio

47. Elements of PDCPA for DQOF Clinical Domains Measured at Review Caries Perio Soft tissue TSL P C CP = 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/improvement 3 categories Maintenance/improvement 2 categories

48. Clinical Effectiveness Outcome Indicators for payment (60%) Measure Points – 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 maintained 150 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 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.

49. Patient Experience Indicators for payment (30%) MeasurePoints - 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% =15 Level 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% = 15 Level 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%= 15 Level 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% = 25 Level 2 85%-100% = 50 Would you recommend this practice to a friend? % of patients who would recommend the dental practice to a friend MAX: 100 Level 1 70%-79% = 50 Level 2 80%-89%= 75 Level 3 90%-100%=100 How satisfied are you with the NHS dentistry received? % of patients reporting satisfaction with NHS dentistry received MAX: 50 Level 1 80%-84% = 20 Level 2 85%-89% = 40 Level 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: 10 Level 1 70%- 84% = 5 Level 2 85%-100% =10

50. 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: MeasurePoints – MAX:100 90% of patients for whom an up-to-date medical history is recorded at each oral health review MAX: 100

51. Indicators for monitoring overall quality (no payment) MeasureDomain % 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.

52. 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

53. 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 Offer indirect restoration Decision making cascade

54. Page5 Indirect Restorations (Veneers, Inlays, Crowns & Bridges)  Teeth that can be restored and made functional  Teeth with good prognosis  Patients cooperation does not preclude indirect restorations  The patients Medical History does not preclude crown and/or bridge work i Level 1  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 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 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 carried out by GDP Work to be carried out by a GDP who has additional competenciesWork to be referred to Specialist Services Risk Screening and entry criteria to be determined (* - crowns which are produced in a lab)

55. Learning from the Pilots  Qualitative the experiences and impact on – Dentists – PCTs – Patients  Quantitative Clinical data set from Oral Health Assessment PCR ??

56. 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

57. Windsor Dental Practice, Salford Hygienist Smoking cessation adviser Extended duties dental nurse Therapists

58. “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

60. 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”

61. Smile4Life Award Scheme and enables Early Years Foundation Stage settings to demonstrate and be recognised for their oral health improvement activity through the

62. 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

63. 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

64. What’s in it for you?  Primary/Secondary care interface  Clinical leadership  Networks  Training and development  QIPP