General dental practice committee report – January 2016
At the beginning of the meeting the Chairman and both vice-chairs were re-elected. Henrick Overgaard-Nielson, Dave Cottam and Richard Emms stood unopposed.
Chief Dental Officer (Sara Hurley) presentation
Sara came to mainly take questions from the floor but she gave a presentation very similar to the one that she gave at the official’s day in December 2015 but updated with her progress. She was a pains to let us know that she has an advisory role and can only give opinion for the changing of policy or commissioning. However she appears to be fighting and getting her name known as a well-informed, researched and presented official who has no interests in just bending when pressure is brought to bear (This brings concerns that she may not be in post for as long a period as expected).
She now has a dental officer team and two vice CDOs. The role over the coming months is to visit all the local NHS England regions (including South (South coast)) and advise on their role to become commissioning support managers rather than commissioners. Her thoughts are that commissioning must happen centrally and developed/supported locally via MCNs and LPNs.
Questions from the floor were varied and she robustly answered them, often giving harsh reality responses. For example a member requested that Sara pushes for the department of health (DoH) to produce a definitive list of what NHS dentistry can offer such as to remove any grey areas and allow private dentistry to fill the areas not on this list. She responded by saying that DoH will never produce such a list and she doesn’t like the idea of one anyway. She would expect the best interests of the patient and the most suitable material/style/technique to be employed for each circumstance. If that was an occlusal composite on an upper molar because that was the most suitable for the patient in that circumstance then that is what she would expect a dentist to undertake on the NHS for that patient.
She confirmed that the maximum that NHS dentistry will receive from the total NHS budget is 3% but she will continue to fight for the return of clawback and unallocated UDAs into the dental budget and not lost. This would include the outcome from such initiatives as the 28 day reattendance program that the Business Services Authority (BSA) at the later part of last year. This money taken from the providers for mis-claiming to be funnelled back into dental budget and not into DoH.
Changes to standing orders
Members of GDPC who are unable to attend multiple meetings due to personal reasons (eg parental leave or maternity) can inform the executive and they will allow extended absence on a case by case basis.
DDRB and contract uplift
GDPC have decided to go with the DDRB system for 2016/17 and the BDA have submitted their evidence for dental practice expenses and the request for dentist 1% uplift. There is a general concern that due to the government’s attitude to use CPI rather than RPI, the possibility of a 0% uplift could occur. However there was general disappointment to news that corporates and large numbers of providers had not passed on any pay rise from the April 2015 uplift onto the performers. Providers in the room gave reasons that the practices are running at 30% reduction in profit from 5 years ago and the only area for efficiency saving is an the associate pay level.
Robert Kinlock, the chairman of the Scottish dental practice committee will give a presentation at the next GDPC main meeting on their “Plan B” which is their response to the NHS decline of funding over the years by encouraging their practitioners into private dentistry to subsidise the NHS income.
DEVOMANC
This is going live on 1st April 2016
As a reminder of what devomanc is and what it could mean for more areas who are watching how this goes. This is specifically for the population of greater Manchester;The deal
Commenting on the historic signing of a memorandum of understanding between the GMCA, the government, NHS England and 12 CCGs (alongside letters of support from NHS providers) in February 2015, NHS England Chief Executive Simon Stevens said the agreement ‘charts a path to the greatest integration and devolution of care funding since the creation of the NHS in 1948’ (NHS England 2015b). With this came the announcement that £6.2 billion of health and social care budgets would be brought together. The vision is: ‘to ensure the greatest and fastest possible improvement to the health and wellbeing of the people of Greater Manchester’.
A second memorandum of understanding was signed in July by Greater Manchester’s public health leads, Public Health England, NHS England, CCGs, NHS providers and ‘blue light’ services (Greater Manchester police, ambulance, fire and rescue services), to create a ‘framework by which partners will create a single unified public health leadership system’. A Director of Population Health Transformation has been appointed to lead on the role that public health plays.
In the intervening months, Manchester has submitted proposals as part of the Spending Review process, requesting additional investment to help achieve sustainability and fund a number of transformation initiatives.
Arrangements in Greater Manchester will continue to be part of the national NHS and social care system, but there will be a shift in focus towards people and place rather than individual organisations, and integration will seek to go beyond just health and social care to include other services.
What’s ‘in’?
The whole system: acute (including specialised services) and primary care (including GP contracts), community and mental health services, social care, public health, and (subject to further discussions) health education and research and development.
Components of the Greater Manchester health and social care model include moving to a single estates function, single workforce transformation plan, single information governance and data sharing agreement, new hospital models, and establishing an academic health science system known as Health Innovation Manchester (HIM).
Including HIM, there are nine early implementation priorities: a public health placebased agreement and programmes; seven-day access to primary care; a dementia pilot in Salford; reaching a final decision about which hospitals will work together as single services, as set out in the Healthier Together programme; a programme to transform children and young people’s mental health services; establishing workforce policy alignment; a three-year strategy to improve independence for people with learning disabilities and/or autism; and a pilot supporting people with mental health-related barriers into work.
The desired outcomes
A strategic sustainability plan (see below) was agreed as one of the deliverables in the memorandum of understanding, which will set out the expected outcomes for the Greater Manchester deal. The figure below shows some of the early outcomes agreed.
Governance arrangements
Now operating in shadow form, the Greater Manchester Health and Social Care Partnership Board will be responsible for the financial and clinical sustainability of health and social care through delivery of the strategic plan, describing how a sustainable health and social care landscape can be achieved over the next five years. Membership includes the GMCA; 10 local authorities; 12 CCGs; 15 NHS providers; NHS England; representation from primary care, patients and the third sector, the fire and rescue service, and police and crime commissioner’s office. Underpinning the strategic plan will be 10 five-year locality plans, developed with each of the local health and wellbeing boards. This board is underpinned by an overarching provider forum and joint commissioning board. Pooling of local authority and health resources will take place at locality level, with £2.7 billion already agreed across the 10 boroughs.
Next steps
Full devolution and final governance arrangements in place from April 2016.
From a GDPC/BDA level there is a substantial fear that dentistry will become swallowed up in this process and effectively commissioned as an extension of CCGs services. From 1st April 2016 and for the meantime dentistry will continue to be commissioned from NHS England for greater Manchester.
Contract Reform
29 practices have signed up to the prototypes on top of the pilot practices that are going forward, which is giving a total of 80 practices. Which is someway short of the 100 promised for the program. All practices now know whether they are blend A or B and most are going live now or in coming weeks.
There is a general concern over the number of practices who have walked away from the prototype contract and the lack of enthusiasm for new practices to take up the offer of a blend to try.
The BDA will form a shadow evaluation group to consider the evidence from the process as soon as data starts coming back from the practices. BDA have also completed an associate contract which can be used for any prototype practice.
Commissioning guides
The implementation of the NHS specialty commissioning guides continues. NHS England has convened implementation groups covering: Managed Clinical Networks, communication, regulation, data and training. The BDA is not represented on any of the implementation groups, clinical dental input seems to be being obtained from LDN Chairs and Consultants in Dental Public Health. The other members of the groups are dental commissioners, NHS England central personnel and primary care commissioning.
There is not of any outputs from the groups to date, however it is expect that they are working on strengthening of Managed Clinical Networks with a standard national policy to cover their key functions and deliverables, improvement and standardisation of secondary care dental coding, improvement in dental specialty data, some amendment to the dental regulations and standard PDS agreement, particularly in the area of orthodontics and an accreditation process for level 2 care.
In November, NHS England convened a meeting of commissioners, dental public health staff, a few LDC representatives and LDN Chairs. The stated purpose of the meeting was a training day to consider implementation of the commissioning guides. The CDO and the new deputy CDOs were present. The main messages from the day (presentations and group work) are:
- The Guides are an important component of NHS Dentistry’s response to The five-year forward view. They are a first step in an evolving process.
- Patients are at the centre of the service and specialist care must be delivered closer to home with reduced waiting times and higher quality. Patient involvement and patient feedback is very important.
- Centralised Referral Management Services are important because they provide the data necessary for commissioning. Although GDPs will no longer be able to refer directly to a specialist, they should be able to give a preference and the patient should have a choice of provider. There should be some guidance from MCNs on when and how to refer.
- LDNs and MCNs are key to successful implementation but both need proper resourcing.
- Levying of patient charges and inclusion in the dental performers list for hospital dentists were being looked at by NHS England.
- Primary and secondary care should not be paid different amounts for the same treatments done on the same types of patients.
- Local Dental Networks are very important in being a bridge between commissioners and the profession. LDNs have a clear mandate to deliver the commissioning guides and should be the strategic heart of commissioning dental services. LDNs need to be able to communicate easily with an NHS England hosted website with a secure area where LDNs can communicate and share good practice, successes and failures. LDNs needed recognition and support at Director level within regional teams and this needed to come from NHS England centrally.
- Work is going on in the Regulatory Implementation Working Group to make changes to regulations to enable the implementation of some parts of the guides.
- Hospital coding for dentistry is a real issue. There is working group looking at this.
- LDNs need to build relationships with HEE, Healthwatch, CCGs, LDCs.
Henrik Overgaard-Nielsen set out the BDA’s views on the guides in general. The pace of development of the guides seemed to have sped up considerably but the infrastructure/resources needed to implement them properly was lacking.
NHS England responded that reforming dental specialist care was a hugely complex area and this work provided an opportunity to describe what the speciality is. NHS England needed to make the best use of available resources with clinicians leading the way. MCNs would be developed to put appropriate local structures in place and there were some great examples of innovative work across the LDNs.
The BDA said that implementation was too rushed and it was admitted that some LDNs were trying to be too innovative. Implementation groups had been formed to cover some areas including regulation and MCNs. It was hoped that there would be some money for leadership training and development perhaps joint training of dental leads and LDN representatives. Overall the NHS was required to make cost efficiencies which will involve greater use of the BSA in contract management, there wasn’t enough dentistry commissioning capacity.
The BDA was concerned about the use of Referral Management Centres which seemed to be recommended as the norm within the guides. NHS England’s response was that they should be labelled, Referral Management Systems. The RMS should identify whether the referral has been made correctly, that is whether the case is Level 2 or level 3. Capacity was needed to assess the Level correctly and workforce planning was needed. Local practitioners can sometimes require support to provide Level 1 restorative care.
Training and accreditation for Level 2 remained an issue for the BDA. The HEE needed to get involved and engage with the process, the new COPDEND. The new Chair of COPDEND, Nicholas Taylor, would have to take the lead. More than training courses, were needed but some form of peer review. It shouldn’t be forgotten that re-validation will be on the agenda soon.
In response to the BDA’s comment on the medico-legal risks to unaccredited GDPs providing Level 2 care, NHS England agreed to include a line about these issues. The BDA was concerned that once implemented, the effect of the guides would be to encourage Level 2 referrals because GDPs would feel they were not being remunerated properly for this treatment if they provided it under their GDS contract/PDS agreement.
There was concern about the shortage of consultants in some specialties in some areas. Work at Level 3 would be done by non-consultants and it was felt that more reference should be made to consultant-led teams. Regarding treatment under GA, the Paediatric Guide made reference to children having treatment under GA should have treatment planned by a Specialist in Paediatric Dentistry. There was not enough specialists to achieve this so the guide should refer to a Specialist in Paediatric Dentistry or a dentist who is a member of a team led by a Specialist in Paediatric Dentistry. The effectiveness of MCNs was also variable. Time to devote to MCNs needed to be built into consultants’ job plans to ensure they were able to participate fully.
The absence of good clinical coding and outcome data was also a major issue for NHS England. Coding was being worked on. Eventually there would be PROMs and PREMs in place.
The clinical confidence of FDs was discussed and it was recognised that this was a role for HEE to provide training opportunities and support for dentists lacking confidence in an aspect of level one care.
Collection of DMF data via FP17s
The new clinical information
From 1st April 2016, NHS England have said that certain changes are being made to the FP17 form including the addition of three new clinical items:
- the number of teeth which are decayed
- the number of teeth which are missing, and
- the number of teeth that are filled.