PROPOSAL FOR PILOTING A NEW GENERAL DENTAL SERVICES (GDS) CONTRACT

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1 FOR APPROVAL PROPOSAL FOR PILOTING A NEW GENERAL DENTAL SERVICES (GDS) CONTRACT EXECUTIVE SUMMARY The GDS budget transferred to HSCB in July 2010 and was overspent in that financial year by 2.5 million. In the following year (2011/2012) there was an overspend of 6.5 million. Current projections from HSCB Finance Directorate for 2012/2013 are that the overspend will be approximately 11million. However, it should be noted that HSCB has allocated an additional 9million to the GDS budget in , reducing the projected overspend to approximately 2million. A new GDS contract is necessary to remove the demand led, item-ofservice nature of the current contract and so make the spend more predictable and controllable, whilst maintaining quality and access. DHSSPS has progressed the new GDS contract process by issuing the BDA with a contract framework on 6 th December A response has not yet been received. The Board s principle role in the process of introducing a new contract is to take the contract framework and use it to give substance and detail to the piloting arrangements. This means working with dentists representatives (preferably the BDA) to identify the operational scenarios that any new working arrangements will be required to address, and drawing up solutions within the pilot contract. The pilot should operate for one year before being evaluated. The Department s provisional start date for a new GDS contract is April INTRODUCTION There are currently 1074 General Dental Practitioners (GDPs) working in 390 practices in Northern Ireland. The standard business model has the principal dentist owning/leasing the premises and equipment, paying for support staff materials and all other running costs of the practice. There is normally a contract in place between the principal dentist and the associate dentists. A common arrangement is for the associate to pay the principal 55% of their gross income to cover practice running costs. 1

2 Fees for NHS dental care paid to dentists include an earnings element and an expenses element. The NHS fees come from a combination of patient charges and the General Dental Services (GDS) budget. Patient contributions are currently set at a rate of 80% of the gross fee. The gross fees for each of the 400 plus treatments available under GDS are set annually by DHSSPS and can be found in the Statement of Dental Remuneration (SDR). A significant number of patients receive free treatment and in these cases the GDS budget covers 100% of the gross fees to the dentist. While the fee-for-service element accounts for the majority of GDS funding received by practitioners (60%), there are two other remuneration streams through which dentists are paid under the Health Service. These are block payments, which make up 17% of dentists Health Service earnings, and capitation payments which make up 23% of dentists Health Service earnings. BACKGROUND The GDS budget transferred to the Board in July Around this time there was a change in some of the factors affecting the number of registered patients and the number of GDS dentists. The result was a significant increase in the GDS spend. Table1. GDS allocation and spend Financial Year GDS Allocation Actual Spend Over Spend million 90.5 million 2.5 million million 96.0 million 6.5 million million* 100.0million* 2.0million* *Projected It should be noted that 9million of HSCB funding has been added to GDS in ; leaving approximately 2m of a projected overspend. The current GDS contract is demand-led and the overspend on the GDS budget will persist under the current contract unless measures can be introduced to reduce block grants and/or capitation payments or rationalise the volume of Health Service treatment carried out by GDPs. Any controls must comply with legislation and be sympathetic to patient health needs (as opposed to demands). 2

3 Recent Developments The changes agreed by HSCB and DHSSPS to the current SDR were initially projected to save 6 million if introduced in April However, implementation has been delayed because: A Judicial Review into the proposed new pharmacy contract found that the DHSSPS should have undertaken a Regulatory Impact Assessment (RIA). As a precaution DHSSPS has carried out a partial RIA on the proposed SDR changes DHSSPS concluded that a twelve-week consultation was required for changes to GDS Regulations and this is currently underway ending on 3 rd April The changes will be introduced later in 2013 Latest financial projections Initially, the 2012/2013 overspend in the GDS budget was projected to be 6million (assuming the agreed changes to the SDR were introduced in April 2012). When it became clear that the SDR changes required public consultation and that there may only be a half-year effect, the overspend was revised to 9 million. The latest projection is that, as a result of a further delay with the consultation exercise, there will be no savings in the GDS budget and the projected overspend in GDS will be approximately 11million for The changes to the SDR will provide a short-term solution to the shortfall in the GDS budget. There may need to be additional changes to the SDR for to achieve financial balance in that year. 3

4 NEW CONTRACT DEVELOPMENT Methodology The key stages in the development of a new GDS contract are: 1. The Department, working in collaboration with HSCB, negotiate a contract framework with the BDA. An agreed contract framework document is produced. 2. Working within the boundaries of the contract framework, the Board and the BDA (or other dental representatives) agree the detail of the pilot contract. 3. Piloting begins with a representative group of practices. The scope of the contract framework may allow some variation between pilot practices in the detail of the contract arrangements. 4. The pilots are thoroughly evaluated and the optimum contract option is identified. 5. Further discussions take place between DHSSPS, HSCB and the BDA before the substantive new contract is rolled out. DHSSPS has developed a contract framework with payments to practitioners based on a capitation formula and the attainment of specified practice quality standards. The capitation payments are weighted according to: Historic patient list size and trends Disease risk and prevalence in the practice population The range of care to be provided Anticipated arrival /departure of dentists/hygienists/other staff at the practice level (including trainee dentists/staff) This formula takes into account a number of demographic factors including the deprivation profile and age profile of patients registered with the practice and is similar to that used in GP services. It fits well with TYC and the QICR programme where health and social care services aim to simultaneously improve quality and efficiency. 4

5 Advantages Can be tested using existing Primary Dental Services (PDS) pilot legislation Spend is predictable Encourages preventative activity Reduces unnecessary treatment Removes treadmill effect for General Dental Practitioners (GDPs) Opt-in nature of pilot PDS means that GDPs have an option to remain within existing GDS arrangements Disadvantages Requires a significant amount of work to develop a pilot contract and further work before agreement can be reached with each participating practice Different payment and monitoring arrangements would be required within BSO/HSCB (see below) Resource intensive for pilot monitoring and evaluation. Dentists may not provide necessary treatment leading to supervised neglect or increased referrals While the contract is at the framework stage it is not possible to provide detailed information on how the pilots will operate that is the function of pilot development group composed of representatives from HSCB and the dental profession. However, a list of potential questions and answers on the pilot has been developed (Appendix 1). The exact nature of the definitive contract depends on the outcome of the pilot. Supporting Evidence A similar contract with the Oasis Group is in its third year and monitoring data from Oasis practices and their patients is encouraging to date. It shows: High patient satisfaction Good quality care Low levels of untreated need Removal of treadmill effect for dentists Similar trends are emerging from analysis of three other salaried practices which have been in existence within the GDS for up to five years in the Northern LCG area. Monitoring As well as ensuring that the current quality of care is maintained at a high level, it will be important to monitor two other possible areas of concern: Under treatment where there is unmet patient need 5

6 Timing Increased referrals into secondary care of treatments that had previously been possible in GDS practice (increasing the length of waiting lists and the cost of carrying out treatment) Ideally, BDA will agree in principle to the new GDS contract framework proposed by DHSSPS to allow HSCB to begin to develop piloting arrangements with representatives of the profession. However, in the event that BDA do not accept the contract framework, HSCB may continue to develop the piloting arrangements with other representatives of the profession. The pilot scheme would involve a small number of interested and representative practices and last for one year followed by a short evaluation period. A pilot also offers an opportunity to modernise and integrate fully the IT capabilities within GDS dentistry to focus on a more streamlined approach to returning data to BSO, communicating with practices and referring patients for specialist care. RECOMMENDATION HSC Board is asked to note the current estimate for GDS overspend in , the upward trend of the overspend and to approve HSCB meeting with the BDA (or other representative dental groups) to develop a piloting arrangement for a new GDS contract. Dr Sloan Harper Director of Integrated Care 6

7 Appendix 1 POTENTIAL FAQS FROM STAKEHOLDERS INVOLVED IN PILOTS Patients Will I get the same range of care as I am able to get in the current system? During the pilot, yes and there will be an increased emphasis on prevention of oral disease. However, when the substantive contract is rolled out the range of treatments available may be less than is available under the current system. Will I pay any more for my treatment? No patient charges and exemption categories will be the same during the pilot as they are for those patients seen under the standard (GDS) contract. It is not envisaged that the substantive new contract would have increased patient charges. Can I leave or join a pilot practice? Yes you will be able to move between practices in the same way that you currently can. However, pilot practices may have an upper limit placed on the number of patients they can register and once they reach this point they won t be able to take on new patients. At this stage it is not clear how the substantive contract will deal with an increase in the total number of registered patients (over and above increases in the NI population) but there are a number of options including keeping the global sum fixed and reducing capitation payments, increasing the global sum and keeping the capitation payments fixed and reserving a fraction of the global sum for growth in registrations. HSCB/BSO/PHA Will increased administrative resources be needed to manage pilot contracts? The contract itself should be simpler than the current GDS contract. There will be significantly less prior approval of treatments and the amount of claim information that will be needed by BSO will be considerably less than under the GDS. Data will, however, need to be data collated and analysed for the evaluation and this will require administrative resources. Furthermore, pilot PDS legislation requires very detailed monitoring of the pilot contract (see below). This will be resource intensive for HSCB and BSO. What is involved in the evaluation? As well as gathering data on the dental care provided in practices, the pilot will be evaluated for patient experience, quality of care and value for money. These 7

8 aspects will require data to be collected at baseline and at the end of the pilots, to allow comparisons to be made. Qualitative and quantitative methodologies will be used. The evaluation will require significant administrative resources. How will HSCB/BSO monitoring change for those in the pilot? The emphasis will shift from monitoring over-treatment to detecting under-treatment but this should not place any extra demands on HSCB resources. There would be a dramatic reduction in the need for prior approvals and pre-treatment examinations by dental advisers. However, monitoring of practice referral patterns will need to take place and there are many additional elements of monitoring required by pilot PDS legislation (e.g. confirming the amount of private work carried out by practices, confirming opening hours) What are the public health benefits of a new contract of this type? There will be a strong incentive for practitioners to prevent oral disease and maintain good patient oral health. Additionally, in practices, IT systems can be used to gather population oral health data. This will lessen the reliance on costly and complex epidemiological surveys. Providers Will there be an element of capital allowance for buildings or equipment? No, the current situation where dentists provide suitable premises and equipment will continue. How does a weighted capitation formula work? It uses criteria such as age, gender, socio-economic deprivation and regularity of attendance to classify patients into groups with similar dental needs, risks and attendance records. The capitation payment received for each patient should reflect the relative workload for the dentist. An enhanced fee for those with special needs who meet specified criteria will remain. The system incentivises prevention and the maintenance of good oral health. Can dentists stay in the existing GDS contract? Yes, during the pilot period practices have to apply to join the pilot. If they do not apply they remain on the current contract until the new contract is rolled out in During the pilot period will I be able to replace staff or increase staff numbers? Like for like changes will be permitted but the inclusion criteria for the pilot will include practice stability. Arrangements for unforeseen, staff changes (illness or maternity 8

9 leave) will be discussed and agreed at the pilot development meetings between HSCB and BDA (dental representatives). During the pilot will there still be an obligation to submit item of service payment claims? No, data transmission will only be necessary for registrations, epidemiological data and for monitoring and evaluation. Will be there be increased administration for those practices in the pilot? There will be a need for HSCB to gather data on how the pilot is performing and this will involve additional administration but the payment process will be simpler and there will be much less prior approval. Overall, pilot practices will have to undertake an amount of paperwork comparable to the current system. Will new practices be able to open under the new contract? Not in the way they currently can. Instead primary dental care will be actively commissioned by the HSCB so that practices are only etablished in areas where there is a clearly defined need. 9

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