FOR APPROVAL SMT/
PRIMARY DENTAL CARE ORAL SURGERY PILOT MODEL
BACKGROUND
Trust Oral Surgery (OS) waiting lists have grown significantly over the last 3 years. One potential solution is to utilise increased provision by High Street Oral Surgeons who, background research suggests, would be able to see approximately 75% of patients referred to Trust OS services.
CONTEXT
Minister McGimpsey directed the Service to pilot three new dental contracts, oral surgery, General Dental Services and orthodontics. A new OS primary care contract is needed to secure sufficient OS capacity from High Street Specialists. As OS is, in contractual terms, less complex and diffuse than general dentistry, a pilot OS contract could lead to resolution of the OS waiting list problems and also act as a pathfinder project for the wider new GDS contract.
SUMMARY
A pilot model is proposed that at its heart has a Referral Management Centre (RMC). All referrals from Southern Area practitioners will come through the RMC which, in turn, will determine if the patient is best seen in primary or secondary care. The pilot will run for 6 months before being evaluated. If successful, the model could be rolled out across Northern Ireland. However, a new approach such as this is only feasible in the long term if a proportion of funding currently used for secondary care OS services is redeployed to follow the movement of patients. This proposal will only proceed on the basis that it meets value for money criteria.
EQUALITY AND HUMAN RIGHTS
Screening has excluded equality and human rights issues.
RECOMMENDATION
SMT is asked to approve the proposed pilot model and project support requirements. In particular, SMT support is sought for the use of a RMC which will, almost certainly, result in a greater proportion of OS patients being seen in primary care.
Dr S Harper
Director of Integrated Care
PRIMARY DENTAL CARE ORAL SURGERY PILOT MODEL
EXECUTIVE SUMMARY
Northern Ireland has a small but potentially productive group of High Street Oral Surgery practices. Research shows that many of the patients currently seen by hospital-based Oral Surgeons could appropriately be treated in primary care. The main barrier to moving oral surgery patients from secondary to primary care is the current level of remuneration payable to High Street specialists under the GDS contract. An OS pilot is proposed with (yet to be agreed) more attractive levels of remuneration that will fully engage primary care specialists. This will reduce secondary costs but increase primary care costs. If the pilot proves successful a mechanism needs to be developed to allow some of the current baseline secondary care OS funding to be moved to primary care.
1.0 BACKGROUND – ORAL SURGERY SERVICES
1.1 The General Dental Council defines the specialty of Oral Surgery as, “the treatment and ongoing management of irregularities and pathology of the jaw and mouth that require surgical intervention.” Oral Surgery services in Northern Ireland are currently provided in primary and secondary care settings.
1.2 Specialist Oral Surgery Services are provided in four main ways:
1) Hub and spoke Hospital Dental Services (HDS) – In Local Hospitals delivered by teams that have evolved to be Consultant-led, but by the medical specialty of Oral and Maxillofacial Surgery (OMFS). The service hubs are based at Altnagelvin Hospital and the Ulster Hospital with spokes for outreach services both within and outwith these Trust areas.
2) BHSCT HDS - In the Dental Hospital by a small team led by an Academic Consultant in Oral Surgery who is in a joint appointment post between QUB and BHSCT.
3) Primary care-based specialists - In High Street Oral Surgery practices led by Specialist Oral Surgeons who have completed a training programme in Hospital units and are on the GDC specialist list. There are six practices (Ballymena, Ballymoney, Belfast x 2, L’derry and Newry) with a workforce of approximately nine WTE dentists in total. Most of the dentists are Specialist Oral Surgeons but some are not. They all work under the same GDS contract and remuneration model as General Dental Practitioners (GDPs).
4) NHSCT Community Dental Service (CDS) - There is also a very small Community Dental Service Oral Surgery Service which is essentially for internal referrals in NHSCT and is led by one part-time Oral Surgery Specialist who previously owned a High Street Oral Surgery practice.
1.3 Those who are allowed to carry out oral surgery procedures are:
· General Dental Practitioners (GDPs), if the procedure is within their competence (GDC expected competencies include relatively simple procedures such as removal of roots, biopsies and dentoalveolar trauma).
· Specialist Oral Surgeons in ‘High Street’ practices – (wisdom teeth and exposure of canines for orthodontic treatment).
· Specialist Oral Surgeons working in Hospitals – (cysts of the jaw and medically compromised patients).
· OMFS Consultants – (cleft lip and palate, road traffic accidents).
1.4 There is therefore a hierarchy of increasing specialisation with the most difficult cases being seen by the OMFS Consultants. This system operates efficiently when case complexity is matched to level of specialisation. However, at the moment it appears that many cases that could be seen by High Street Oral Surgeons are making their way to the HDS. This is the key issue that the proposed Oral Surgery Pilot seeks to address and is discussed in more detail below.
1.5 The OMFS service model is somewhat complicated by the fact that Specialist Oral Surgeons work under the supervision of OMFS Consultants but their activity is credited to the OMFS Consultant.
1.6 It should be noted the provision of Oral Surgery services in Hospital-based secondary care forms part of the wider Review of Consultant-led Hospital Dental Services currently underway at DHSSPSNI. This pilot will help inform that review.
2.0 BACKGROUND – CURRENT WAITING LISTS FOR HOSPITAL-BASED ORAL SURGERY SERVICES
2.1 There is a rising number of Oral Surgery referrals and there are believed to be several reasons for this:
(1). Younger dentists have received less practical oral surgery experience during training.
(2). Oral Surgery can be somewhat traumatic and complications can occur so it is not viewed as a ‘Practice Builder’ and is often referred out.
(3). Patients may seek free treatment in secondary care rather than paying for it in primary care under the GDS scale of patient charges.
(4). Demographic changes – Northern Ireland’s population has a growing proportion of older people and elders have more complex medical and dental needs.
2.2 There are significant numbers of patients waiting (circa 1000) and waiting times (approximately 1 year) in all Trusts (see Appendix 1) except WHSCT and consideration is currently being given for a regional tender approach to the Independent Sector to clear the current backlog.
2.3 The situation in SHSCT appears to be particularly challenging and seems to be associated with difficulties with the contracting and cost of the provision of Oral Surgery (OS) services, as delivered through the OMFS team by SEHSCT. Services are provided at Craigavon Area Hospital and Daisy Hill Hospital. Recent data shows that approximately 2400 OS cases are referred to the HDS each year from GDPs in the Southern Area and there are approximately 1000 cases on waiting lists (2:1, Craigavon:Daisy Hill). SHSCT has expressed interest in a longer term solution for their service needs, but is likely to use an Independent Sector tender to clear the current backlog which will not form part of the pilot).
3.0 BACKGROUND-remuneration of Oral Surgeons
3.1 High Street Oral Surgeons feel that they are not well remunerated under the GDS system. They complain that the Item of Service fees do not recognise that they are specialists and that they receive the same fees per procedure as GDPs. It could be argued, however, that as specialists they are highly skilled and can carry out such treatments at a faster pace than GDPs and are remunerated appropriately. They are also able to carry out private treatment (subject to market demand) for higher levels of remuneration. The practices have varying levels of GDS commitment with more health service provision tending to come from associates. One practice owner has very publicly withdrawn from the GDS on two occasions but has ultimately returned.
4.0 BACKGROUND – new primary care dental contracts
4.1 Negotiations have been ongoing between the DHSSPSNI and the Northern Ireland Branch of the BDA since 2006 and latterly the HSCB have been involved in the process. The basic model of the general contract has been developed but the key issues of fees and remuneration system have not been addressed. Separate contracts have been proposed for specialist Orthodontics and Oral Surgery services provided in primary care.
4.2 A considerable amount of work was undertaken in 09/10 to develop an Oral Surgery contract model. OS was seen as a manageable way to begin piloting the new contractual arrangements (the aging BSO dental payment system makes piloting of the general contract difficult). A simplified, banded model was developed and it was hoped to pilot this across all OS sites. However, progress stalled when the BDA sought a fee increase of 100% on the extant SDR.
4.3 A new pilot model has been in development since April this year when we essentially started over again. A key challenge has been to reconcile a demand-led service model with a capped budget. Added value services and an interface with the CDS were explored before it became apparent that some local service difficulties in the SHSCT may present an opportunity for a discrete pilot model to be tried. The model that has now been proposed is outlined in section 5.
4.4 A formal consultation process has been carried out on the use of Personal Dental Services (PDS) legislation for the pilots for the new contracts. This consultation ended on 31/1/11 and a summary paper was presented at the HSCB public Board meeting of 31/3/11. As the consultation had a positive outcome pilot models can now be run under the PDS legislation.
4.5 The next formal procedural steps required to establish a PDS pilot are:
1. HSCB to seek Expressions of Interest.
2. Replies will inform an HSCB Proposals paper on the pilot for submission to DHSSPS.
3. DHSSPS will then issue Implementation Directions to the HSCB to commence the pilot.
4. HSCB draws up Agreement(s) i.e. legal contract(s) with pilot participant(s) in line with Directions.
5. HSCB to publish details of pilot scheme.
5.0 THE PROPOSED OS PILOT MODEL
5.1 The model can be briefly outlined as follows:
· Remuneration System – A banded model where cases are classified into four groups based on treatment complexity is proposed. The fees practitioners will receive for each band is still to be negotiated. Further negotiation is also required to determine whether the pilot contract will be with practitioners or practices. There are advantages and disadvantages of each:
o Practitioner based contracts. This has been the preferred model from the beginning of negotiations. Each practitioner in the contracted practice would be paid as per the agreed bands. Consideration may need to be given to different levels of payment for specialists and non specialists working in OS practices if this model is used. The levels could reflect years of experience and degree of competence of the practitioners which may in turn reflect the types of treatment that they are able to successfully undertake.
o Practice based contracts. To date this system has not been discussed with the BDA / Practitioners. Under this system the practice owner enters into a contract with HSCB to provide OS services for the duration of the pilot. The Board may want to stipulate the criteria that must be met by each performer within the pilot practices (e.g. must have worked in a specialist practice for x of the last y years, be on the GDC specialist list or have carried out xxx types of procedures in the bandings). The payments to each practitioner would then be the internal business of the practice. This would be easier for the Board to administer although there may be regulatory issues to deal with as those with associate status effectively become employees of the practice. Issues such as superannuation also become problematic.
· Claiming options - The practitioners claim fees for work done as per the bands described above. This could be carried out in a number of ways:
o Claims could be transmitted electronically to the BSO with the relevant patient details. Patients seen in the pilot must pay the same fee as those who receive the same treatment under the standard GDS contract so within practices patient contributions need to be calculated under the old system. When the claim is submitted to BSO it can also be under the old codes and then converted to the relevant band at the BSO for payment. Alternatively the practice can convert to appropriate band and submit the claim for payment to the BSO. Either way there will need to be discussions with the BSO on the processes to be used to ensure maximum governance and minimum risk. There may also need to be an offline system developed at the BSO to cope with this pilot as the current dental payment system is over 20 years old and rather inflexible.
o The claims could also be processed by integrated care business support staff at the local offices of the LCG where the practice is based. There is currently a model to pay practitioners who make claims for the NIC-PIP trial activity and this could be used as the basis for an OS pilot claims system. If this is the preferred approach for the pilot, discussions with the local office staff will need to commence as soon as possible. There will also need to be communications with the BSO as consideration need to be given to other payments that are related to the payment of treatments such as maternity leave, superannuation, practice allowance etc. With either process new forms need to be designed and a database/spreadsheet developed to collect the information for payment and evaluation.