1 1 IMPROVING DENTAL CARE AND ORAL HEALTH A CALL TO ACTION February 2014 Gateway reference: 01173
2 2 Background NHS dental services are provided in primary care and community settings, and in hospitals for more specialised care. NHS England directly commissions all dental services for the NHS. There are over a million patient contacts with NHS dental services each week Dentists working in general dental practices are not NHS employees. They are independent providers from whom the NHS commissions services. They are responsible for whom they employ within their own dental teams and for the management of their practices. It is common for dental practices to offer both NHS-funded and private services. The NHS in England spends around 3.4bn per year on dental services; the value of the private market is estimated at 2.3bn per year.
3 3 Background (2) 21 Dental Local Professional Networks have recently been established across England to promote a strategic, clinically informed approach to the planning and delivery of dental services that reflects the needs of local populations. The primary care dental team is diverse, comprising: dentists; dental therapists; dental hygienists; dental technicians; clinical dental technicians; and dental nurses. Adult patients make a financial contribution for receiving dental care from the NHS unless they meet certain exemptions. There is a 3-band fixed charge for primary care treatment depending on the care provided by the dental practice. The dental charges system contributed 653m to the NHS budget last year.
4 4 Call to action objectives Last summer NHS England published The NHS belongs to the people a call to action which set out the challenges that this country faces in continuing to secure and improve high quality services in the face of demographic pressures and rising public expectations, against a backdrop of financial constraint. The subsequent calls to action for general practice (August 2013) and community pharmacy (December 2013) have set out to stimulate debate in local communities amongst everyone who works in health and social care or who uses the NHS. We asked how we, as a commissioning body, could best facilitate and support transformational change to the NHS that is nationally enabled but locally delivered. We now want to stimulate the debate around NHS dental services. As the single commissioner of all dental services in the NHS we can achieve national strategic planning and consistency in approach and direction.
5 Call to action objectives (2) These slides set out the case for change to the way that dental services in primary care are commissioned and delivered. We describe the many strengths in the current system that we want to maintain and build upon. But we also describe the challenges that we need to address in the interests of sustainability, efficiency and improved quality, and in meeting our goals of improving oral health and continuing to improve access to NHS dental services. In primary care improvements will come against a backdrop of contractual reform. The current contract between NHS England and dental providers is based almost purely on activity. Work has been underway for the last few years to design a contractual system that better aligns financial incentives with the desired outcomes of increased access and improved oral health. We will work closely with a range of national partners across health and social care, including patient groups, the British Dental Association and other professional organisations, Health Education England, Public Health England and Dental Local Professional Networks to develop our strategic approach to the commissioning of dental services. 5
6 6 Financial Challenge Primary care services, like other parts of the NHS, face a challenge to close the projected 2021/22 funding gap of 30 billion. At the same time primary care must provide more personalised, accessible community-based services for patients, particularly for older people and those with multiple long term conditions. The NHS in England spends 3.4 billion per year on primary and secondary care dental services, with over 1 million patient contacts with NHS dental services in England each week. Financial inefficiencies could be reduced, and better value for money secured.
7 7 National and local discussions We will host national and local discussions over the next three months (February to May 2014). A national stakeholder event will be held in London on 7 April Who can get involved? Patients, patient groups, voluntary and community sector groups Everyone who works in health and social care Dental Local Professional Networks Healthwatch organisations Local authorities Other providers of healthcare services Professional organisations Local education and training boards and academic health science networks
8 8 Process We are publishing Improving Dental Care and Oral Health A Call to Action alongside a data pack with key facts and figures about dental services in England At the end of this slide pack we ask a number of questions. You can respond to our online questionnaire, you can comments, or you could write to us at by 16 May Contact details are provided at the end of this pack. You may only be interested in responding to some of the questions. It is fine to leave some questions blank if you wish. We do not want to limit the discussion, so you should feel free to tell us anything else that you think would be helpful in developing the strategic framework for the commissioning of NHS dental services (the online questionnaire enables you to do this). The questions are designed to stimulate debate. If you are responding on behalf of an organisation you may wish to first canvass the views of your own colleagues, members or stakeholders to inform your response to us. We would be particularly interested to learn of any workshops, meetings or polling that you have held in response to the call to action.
9 9 Process (2) The responses will be independently analysed and reported. We will consider the responses to help us develop a strategic framework for commissioning NHS dental services, which we aim to publish later in 2014 ensuring that it is aligned with NHS England s eventual wider strategic framework for commissioning primary care. Our area teams will use the national framework, working with local communities, to implement strategies to meet local circumstances and priorities. This will require concerted cross-sector working by partners, both nationally and in local communities. NHS England cannot achieve the necessary change alone. We will be guided by the five domains of the NHS Outcomes Framework, which exists to act as a catalyst for driving up quality throughout the NHS by encouraging a change in culture and behaviour: - preventing people from dying prematurely - enhancing quality of life for people with long term conditions - helping people to recover from episodes of ill health or following injury - ensuring that people have a positive experience of care - treating and caring for people in a safe environment and protecting them from avoidable harm
10 10 We have made good progress in recent years The oral health of the population has been steadily improving over the past 40 years There has been an increasing focus on prevention, including the establishment of dental public health programmes Access to NHS dental services has improved considerably, with 1.4m more people having seen an NHS dentist in a 24 month period since 2010 There is good patient satisfaction with NHS dental services; the most recent GP Survey reported that 83% of patients had a positive experience in accessing NHS dental services We hold excellent data on disease prevalence and clinical activity 21 Dental Local Professional Networks have already been established across England since 2012 Dental professionals are generally supportive of the direction of travel that has been set out in previous reports - the Steele Report (2009) and Securing Excellence in Commissioning NHS Dental Services (2013) - and of the on-going contract reform process
11 But there are challenges for the future NHS England wants to develop a strategic framework that: Improves oral health and leads to better clinical outcomes Delivers excellent patient experience Encourages a preventative approach to good oral health, including the promotion of self care by patients and a better appreciation of good oral health generally Increases access to dental services, including the extension of patient choice Develops a pathway approach to commissioning and delivering dental services, within an integrated primary care model that ensures that patients are seen and treated according to clinical need in the most appropriate location Reduces health inequalities Promotes greater patient and public involvement in the planning and commissioning of dental services Develops a workforce that is appropriate for the future 11 Ensures that resources are used appropriately and effectively, ensuring best use of tax payers money
12 12 The case for change Oral health should be for life. The two common dental disease dental decay and gum disease are chronic and the damage they cause is cumulative and costly. The NHS is still dealing with, and paying for, the consequences of disease that developed more than 50 years ago. The trends in disease prevalence and the way it has been managed are visible in the oral health of different generations. We still need to deal with this burden of the past and manage the demands of the present, but keep a very clear focus on the future so that we can minimise the risk, discomfort and costs for future generations Professor J Steele, An Independent Review of NHS Dental Services in England, 2009
13 Meeting our objectives In Securing Excellence in Commissioning NHS Dental Services (2013) we proposed that to be an exemplar commissioner our strategic framework for commissioning dental services will require: Consistent care pathways across England that ensure that all patients receive a consistent approach to assessment and treatment, according to clinical need and complexity A national package of tools to enable a consistent care pathway approach to commissioning by area teams Consistent standards, and consistent outcomes for monitoring safety and quality Comparable costs and coding Consistent information, and commissioning intelligence for service planning, performance management and financial control Sharing of meaningful information about patient outcomes and commissioned services with the public to allow patients to make informed choices National consensus on these elements, for local translation into implementation 13
14 Key Challenges The next few slides provide more information on key challenges that we face around: Improving oral health: quality and prevention 2. Improving oral health: reducing health inequalities 3. Access 4. Information for patients 5. The pathway approach and integrated care 6. Patient and public engagement 7. Workforce
15 15 1. Quality, outcomes and prevention We want our approach to commissioning to be on improving oral health and good clinical outcomes, rather than simply activity; we are continuing to design potential new contractual arrangements for NHS dentistry based on quality and outcomes and which support a focus on preventative care and continuing care rather than purely activity We want to support innovation and excellence in all aspects of how patients experience NHS dental services but we need to know how to measure excellence Quality has to be well defined at all stages of the pathway and measurable if we are to achieve consistently good services across the country We cannot currently benchmark our performance against international comparisons for example reducing the incidence of premature failure of treatment and minimising disease progression - and we lack data to benchmark performance nationally There is a wide variation on levels of oral disease across the country, and we need to understand the reasons for current variation in outcomes where they exist
16 16 1. Quality, outcomes and prevention (2) Dental professionals want to encourage self care by patients and carers, and to promote a preventative approach to good oral health prevention of dental disease that can otherwise have a lifelong impact is good for the patient and is a better use of valuable NHS resources We want to understand the extent to which dental professionals can help with the wider public health agenda around prevention and improved lifestyle One aspect of a quality service is how well information flows through the health system for the benefit of patient care (between primary care dentistry and other health professionals; between primary care dentistry and hospital services; and between the NHS and social care services); currently, information could flow better We are working to develop new models of patient registration; our aim is to ensure that a new system of registration creates clear expectations of a practice s responsibilities towards a registered patient in terms of the care they can expect and the oral health outcomes that the practice is helping them achieve We need a commissioning framework that puts safety and quality at the heart of patient care, and that complements and supports the roles of the Care Quality Commission and General Dental Council
17 17 2. Reducing health inequalities There is a wide variation in levels of dental disease across England. Levels of oral disease are highest in the most deprived areas. Concerns about NHS dental charges can be a very real barrier for those on low incomes. We need to ensure that it is better known that NHS dental care, as well as being free to all children, is also free or partially free to adults on qualifying benefits or low incomes. Clear information to patients that explains the dental charges system and what help with charges is available - is important to ensure patients are not discouraged from seeking the dental care they need. Although some ethnic groups are known to have a higher prevalence of certain oral diseases they are less likely to access NHS dental services ( Oral Health and Access to Dental Services for People from Black and Minority Ethnic Groups, Race Equality Foundation, 2013)
18 18 2. Reducing health inequalities (2) For some patients, the problem is not lack of available NHS dental services but a reluctance or inability to take up services that are available locally. Some patients may not physically be able to reach a high street dental practice or community dental service. We need to ensure that where patients are housebound or living in care domiciliary services (where the dentist goes to the patient s home) are available. We know that currently this is too patchy. There are also patients who for cultural or other reasons may not see regular dental care as a priority. Others may be aware they should go but are afraid to access care those with dental phobia for example. Collectively patients who face these kind of barriers to accessing dental services can be described as seldom heard. On a day to day basis they are invisible to the NHS - only finally accessing care when their symptoms (and usually pain) have become so acute that they or their carers are driven to seek help. Overcoming the barriers that this seldom heard group face in accessing care needs to be a key part of our approach to commissioning future dental services if we want to improve access and outcomes for all.
19 19 3. Access 1.4 million more people now see an NHS dentist within a 24 hour period since 2010 but there is further to go to ensure that in all localities those who want to are able to find an NHS dentist. Many people want to attend the dentist regularly at the intervals their dentist recommends based on their oral health. Others choose to only attend irregularly or when in pain. Access can be improved to both routine care and urgent care particularly out of hours and for those without a regular NHS dentist. While regular attendance by a patient is widely regarded as positive continuing care from a familiar practice over time has benefits for a patient s oral health - services need to be designed in a way that also enables care to be easily given to irregular attenders.
20 20 3. Access (2) Ease of access can be improved for example by introducing, where appropriate, extended hours that allow patients to attend appointments after work or at weekends. Local provision needs to ensure there is care available tailored to those with special needs. This is often provided through community dental services but high street practices have potential to see a wider a range of patients. While there is urgent care provision in every locality we know that routes into urgent care are too variable and often obscure to patients. Access to urgent care should be clearly and accessibly signposted. We also need to understand how our eventual strategic framework for commissioning dental services can contribute to NHS England s review of Urgent and Emergency Care Services. Some A&E Departments continue to have to deal with patients who would be more appropriately treated by urgent dental care services.
21 21 4. Information for patients In 2012 the Office of Fair Trading reported that dental patients often do not benefit from timely, clear and accurate information to make informed decisions regarding their choice of dentist or dental treatment. In particular: 39 per cent of NHS dental patients who had visited the dentist in the past two years reported that there were no leaflets or posters in the practice that provided information on NHS charges 56 per cent of dental practices do not display private fee information at the practice reception 82 per cent of dental patients who recently received a course of dental treatment that incurred a charge did not receive a written treatment plan 20 per cent of dental patients who joined a private dental payment plan stated that they felt that they were put under pressure by their dentist to sign up to the plan Around 500,000 patients each year may be provided with inaccurate information by their dentist regarding their entitlement to receive particular dental treatments on the NHS and as a result are required to pay for private dental treatment unnecessarily
22 22 4. Information for patients (2) The Office of Fair Trading concluded that effective, sufficient enforcement action against dentists and dental practices is not being prioritised and pursued by NHS commissioners, Care Quality Commission and General Dental Council where dentists and dental practices have breached relevant regulations or standards.
23 23 5. The pathway approach, and integrated care The process for the reform of contracting arrangements between NHS England and dental providers in primary care is focused on achieving a patient-centred pathway approach to delivering dental services - the pathway should start with prevention and then develop so that patients are seen in an appropriate setting by an appropriate dental professional at the appropriate time Services should be patient-centred at all stages of the pathway Our aim is increased integration of care across primary, community and hospital settings, and the re-location of activity from hospitals to community settings where this will improve quality or access, or allows equivalent levels of quality and outcomes at lower cost We want to understand the scope for extending the NHS Healthcheck model to dental settings, to explore whether we can increase the number of patients who are identified of being at risk of other diseases and conditions (such as diabetes and hypertension); we are aware of some pilot initiatives in this regard and wish to promote excellence
24 24 5. The pathway approach and integrated care 2 There are no established pathways of care for dental services, which means that we are not reaping the benefits of this approach for dental patients as we have successfully done for other clinical specialties Patients with long term conditions should expect that dental professionals are able to play an appropriate role in the long term management of their oral health and we want to explore how this can best be achieved, learning also from our engagement with stakeholders on the calls to action for general practice and community pharmacy One of the challenges for the NHS and local authorities is to develop shared care arrangements so that local dental teams can routinely develop care packages for complex cases jointly with hospitals and social care services The flow of patient information between professionals could be improved We want to consider the role of other professionals in promoting good oral health; for example the role of Community Pharmacists in promoting good oral health
25 25 6. Patient and public engagement Patient, carer and public insight should be at the heart of how we plan and deliver dental services in the NHS Patients should be more involved in the management of their own oral health care The role of patient forums can be strengthened in regard to dentistry We are exploring how patient insight can be an integral part of quality; we plan to implement the Friends and Family Test for NHS dental services by end March 2015, and we want to consider how this might be combined with an enhanced patient survey and reporting system
26 26 7. Workforce The Steele review in 2009 recommended that the NHS should find ways to support dental teams to make best use and most cost-effective use of the available dental workforce, recognising changing disease prevalence, new technologies and patient and commissioner expectations. Whatever changes are made to how dental services are planned and delivered, we need a joined up approach to workforce planning with Health Education England and the professional organisations to reflect changing disease prevalence and changing demographics It is likely that dental providers will need to re-shape the workforce to some extent, so NHS England and Health Education England will want to support the profession in doing this in a way that meets the changing health needs of our population For example, we may need fewer dentists in the future based on current workforce and training numbers and the projected prevalence of oral disease but we will need more dental care professionals (Centre for Workforce Intelligence, A Strategic Review of the Future Dentistry Workforce, December 2013)
27 27 7. Workforce (2) There is a shared challenge amongst NHS England, Health Education England and dental providers to support dental teams in the move away from working in isolation, and to actively support the development of larger teams in the interests of better patient care We want to support the development of managed clinical networks that will provide a range of competencies, skills and services in primary care across the network We want to nurture a professional culture that allows generalist skills to thrive while at the same time recognising and developing special interests so that dental practices in primary care are competent to deal with more complex cases Clinical leadership and management skills could be developed in ways that will benefit local strategic plans for dentistry
28 28 NHS Presentation to [XXXX Company] [Type Date] Questions for discussion
29 29 Our objectives Our Questions 1) Are they the right objectives, and what others to those we have listed are necessary for a modern strategic framework for NHS dental services? 2) What other actions, to those we have listed, will help us achieve our objectives for NHS dentistry? Reducing inequalities 3) What do you consider to be the main health inequalities, and how should the new commissioning framework for dental services aim to reduce them? 4) How can we improve the oral health of people with particular needs (including issues of access and take-up of NHS dental services) such as: frail elderly people; children; mental health users; people from black and minority ethnic groups; seldom heard groups; and people with dental anxiety?
30 30 Access Our Questions 5) How can we further improve ease of access to dental services? 6) How should dental out of hours and urgent care services be organised, and how do we ensure that access to these services is easily signposted for patients? Data and intelligence 7) What data do we need to support commissioners and providers in focusing on improving quality, outcomes and access? Inspection and monitoring 8) How do we best describe the role of NHS England in monitoring safety and quality alongside the role of the Care Quality Commission and the General Dental Council? Innovation 9) How do we support and promote innovation in improving oral health?
31 31 Quality, prevention and integrated services Our Questions 10) How do we best develop consistent standards that can be used to monitor safety and measure quality across all dental services? 11) To what extent can dental services be safely and appropriately moved from hospital to primary care settings while maintaining quality and outcomes, and what are the barriers and enablers to achieving this? 12) How can we support dental services in providing a preventative focused practice? 13) How can we ensure that supporting lifestyle change - so as to improve general and oral health - is an integral part of the work of the dental team? 14) Should we develop more widely the integrated role of dental professionals in the identification and management of chronic or acute disease? 15) What contribution can dental professionals make to addressing a person s wider social care needs?
32 32 Our Questions Workforce 16) What kind of workforce will be needed in the future? 17) How do we support the workforce (current and future) in adapting to future needs? 18) How do we support the move to a more integrated approach to working, within managed clinical networks? Information and communication 19) How can we improve the flow of communication and information sharing between dental services and health professionals, and dental services and patients?
33 33 Our Questions 20) How do we ensure that patients easily understand the NHS dental charges system and exemptions, and are provided with accurate, timely information in this regard by dentists and dental practices? 21) How do we ensure that patients who are considering purchasing private dental payment plans are provided with sufficient and accurate information by dentists and dental practices that enable them to make an informed choice on how they pay for their dental treatment? Other 22) Please tell us anything else you feel is necessary for us to know in meeting our objectives of improving dental care and oral health.
34 34 Contact details Please submit your response by 16 May 2014: Online: Post: Martin Smith, Primary Care Strategies, NHS England, Room 4E56 Quarry House, Leeds, LS2 7UE If you have any questions or comments about this call to action please contact Martin Smith (Senior Programme Manager) at ( )
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