Purpose of paper

Following the presentation on Dental Contract Reform to the Health Social Care Committee [the Committee] members on 27 September, Abertawe Bro Morgannwg University Health Board [ABMU] was asked to provide a briefing on the Prototype practices.  The two Prototype practices in ABMU preceded the roll out of the current contract reform programme that was introduced from September 2017 and remain in place.  This paper sets out the background to the Prototype approach and its current status within the dental contract reform programme.  Attached, for ease of reference, is the section on Dental Contract Reform extracted from ABMU’s submission to the Committee for its review.

Background- Welsh Dental Pilots Programme

In November 2007 the Minister for Health and Social Services requested that a Task and Finish Group be convened to review the dental contract that had been introduced the previous year and look at a range of issues to improve the way in which the contract worked, several problems having already been identified.  For example, it had already been highlighted that the contract, being based on dentists’ delivery of a set number of Units of Dental Activity [UDAs] was not incentivising the provision of oral health advice.  It was tending to drive increased intervention but also made it challenging for dentists to treat patients with high need as they received the same payment for a patient whose course of treatment might take six sessions as for one who could be treated in one visit.  

The group’s report to the Minister highlighted many of the complexities in NHS dentistry and, particularly given the recent experience with the new contract, recommended that any proposed changes to the dental contract be pilotted thoroughly, carefully evaluating any changes to the patient pathway.

Introduction of Pilot programmes, April 2011

The Pilot Programme sought to move away from the existing system of payment for dentists through Units of Dental Activity and quantified service delivery, and towards a system that focussed on care tailored to the individual patient, based upon risk assessment.   Two different pilots were developed and 8 practices across Wales were selected to adopt them.

The Quality and Outcome Pilot was designed to test a new way of working addressing issues of access, quality and prevention by removing the UDA target from the whole of a practice’s contract and instead based payment on a Capitation and Quality Payment that focussed on patient numbers and promoting prevention.  Through the removal of UDAs it was hoped to give clinicians more freedom to make their own decisions, using their own clinical judgement about what was in the best interests of their patients.   Under this pilot model practices received the same contract sum as they had previously.

The Children and Young Peoples Pilot for 0-17 year olds aimed to incentivise  prevention in the care of 0-17 year olds, complementing the Designed to Smile programme and test the introduction of Quality and Access indicators.  All children in the pilot practices were taken out of the UDA-based system, with payment to dental providers based on a formula linked to a deprivation based capitation plus access, quality assurance, Designed to Smile and prevention. Practices were also allocated additional monies to increase access.

Between 2013 and 2015 the number of Pilot sites was reduced and a core group selected to continue the Quality outcome pilot only as the learning from the Children’s Pilot was complete.   Within ABMU, Belgrave Dental Centre had been testing the Children’s Pilot; Eastside Dental had tested the Quality and Outcome model. 

PROTOTYPE CONTRACTS 2016

By 2016 ABMU was the only Health board in Wales that wished to continue to support its two Pilot sites, namely Eastside Dental and Belgrave Dental Centre to pursue a new model which built upon the learning from their pilot experience.

ABMU was confident it could do so based on the effective communication it had established with the two Practices from 2011 and the learning gained.  The positive experience and maintenance of activity and access within the pilots was also complemented by continuation of the less positive experience of the 2006 (Wales) Dental Contracts.  These continued to fail to demonstrate effective outcomes, and an increasing number of performers and providers were being performance managed.  By 2014 over thirty dentists within ABMU were under professional scrutiny, including Reference Panels, usually as a consequence of having misinterpreted the contract regulations sometimes resulting in inappropriate claims for treatment. 

The Prototypes continued to run the pilot systems of a Dental Care Assessment, Increased prevention focus, patient recall intervals based on NICE guidance, providing more access to new patients in a prudent healthcare environment, where a Red/Amber/Green scoring gave clear indicators to the patients’ journey. The Prototype practices trailed a new ‘Banding’ arrangement, where five Stages were trialled as opposed to the 3 bands applicable under the UDA contract.

The introduction of five Stages of treatment following assessment and planning comprised Urgent care, Risk Reduction, Stabilisation, Restoration of Function, and Advanced Care. This supported the Dental care Assessment and patient’s journey along Prudent Healthcare principles, allowing the Practice teams to review the patient’s progress before committing to Advanced care. It also tested a more equitable system for patient charge revenue.

Summary

By supporting the Prototypes and, previously, the pilots, ABMU benefitted and demonstrated:

· Enhanced methodology and implementation of Co-production in Dental Practice

· Increased use of Skill mix allowed advancement in Prudent Healthcare Principles by engaging the Patients at the onset of their Journey in Prevention Based Care.

· That  Dental Care Plans and Toolkits can evidence patients health improvement

· Increased Prevention

· Increased recall intervals

· Reduced courses of treatment, with a reduction in repeated courses within one year

· Increased access for patients

· Courses of treatment tailored to the Patients needs and wishes.

· Reduced pressure on the Dental workforce to hit UDA targets and practice within their competencies.

· Increased team motivation where Dental Care professionals can work to the upper limit of their competencies.

CURRENT STATUS

As is implied by their name, in 2016 it was thought that the Prototypes would provide the model for dental contracts for the future.  However, as conveyed to the Health Social Care and Sports Committee, not all Health Boards had had the same positive experience of the pilots and in some areas there had been a significant loss of patient income which had not offset expenditure on dental services to the level required.  In ABMU, although there had initially been problems in one practice, once the new approach had been established and both practices were in a position to attract more new patients, patient income rose to its former levels.  

In the intervening period, the new Chief Dental Officer, who had overseen the test of several ‘compromise’ or ‘blended’ contracts in England, shared her view that greater progress could be made at less risk to both practices and Health Boards if UDA targets were merely reduced rather than eliminated.  This would release practice time to complete a new, comprehensive Assessment of Clinical Oral Risk and Need [ACORN] .  The ACORN data has, to date, provided a robust source of information for practices and Health Boards on whether the practices are responding appropriately to different categories of patients, eg to reduce or extend recall intervals, introduce more or less dental clinical professionals and create more capacity. The Prototype practices have participated in this exercise and noted where they too can make greater progress in  these areas.

Although some disappointment may have been expressed initially that the prototype approach was not being adopted adopted at scale, the current Welsh Government approach is supported.  The Contract reform programme is developing a new primary dental care framework that uses Prototype learning but not the historical Terms of Reference, and the timescale of its roll out is determined by the learning being gleaned Wales wide as well as local circumstances. It is providing a much bigger, Wales wide, test than the Pilots/Prototypes ultimately could and the prospect of a ‘zero’ UDA contract such as the Prototypes work to has not been excluded from consideration.  

For example, Cardiff and the Vale and ABMU Health Boards are currently in discussion with the Public Health Wales project leads with a view to introducing the Prototype approach in two brand new practices which are opening in their respective Health Boards.  It is considered that, in what comprises a ‘green field’ site, this would appear to offer a more appropriate basis on which to start a new contract than set a UDA contract then gradually reduce it.  It is still anticipated that, ultimately, UDAs will be phased out of primary care dental practice, but in a phased, managed basis with the support of the ACORN data and pump-priming being made available through the WG Innovation Fund (announced September) to broaden practice teams.

Lindsay Davies, Head of Primary Care

HEALTH SOCIAL CARE AND SPORTS COMMITTEEINQUIRY INTO DENTISTRY IN WALES – EXTRACT FROM ABMU’S SUBMISSION

1. Welsh Government’s Dental Contract Reform

1.1In 2017 four of 95 general dental contractors in the Abertawe Bro Morgannwg University Health Board [ABMU] area volunteered and met the locally developed criteria to test out a Wales-revised version of the 2005 General Dental contract which aims to reduce the disincentives to providing holistic, preventive care that are inherent in the original.  The problems associated with the 2005 contract are described in other Health Board submissions and were so significant that three alternative models were being piloted across Wales within three years of its inception.  By 2011 only ABMU was content to pursue a more effective alternative and continued to support two practices operating without an ‘activity’ target with very positive results in terms of treatment and access.  These two ‘Prototype’ practices are now providing a helpful foundation and in-built control test for the dental contract reform programme introduced from September 2017.  The six practices (four Contract Reform and the two Prototypes) have, for the past year, formed a ABMU Contract Reform group, supported by the Health Board, Public Health Wales and the Chief Dental Officer  to share learning, and views on the proposed programme, its benefits, potential pitfalls and how it can be taken forward.  ABMU is also represented on the Chief Dental Officer’s [CDO’s] national contract reform group through the Dental Director and Primary Care Manager who has driven and supported much of this work locally.

1.2The ABMU pre-2017 legacy is that, from 2011 onwards the two Prototype practices had  their standard Unit of Dental Activity [UDA] target removed from their contract and were instead paid on a Capitation and Quality Payment which focused on patient numbers and promoting prevention.  The UDA activity is still recorded as a background check.  They introduced a new Dental Care Assessment service, increased the focus on prevention, recalled patients based on NICE clinical guidance (rather than fixed 6 month periods) and scored patients’ oral health cards as Red/Amber/Green to give clear indicators of the patients’ journey and facilitate a genuinely co-produced plan.  Following assessment and planning, five stages of treatment were identified: Urgent care, Risk Reduction, Stabilisation, Restoration of Function and Advanced Care. This allowed Practice teams to review the patient’s progress with them before committing to providing advanced care, e.g.crowns, implants. The Prototypes also tested a more equitable system for patient charge revenue and allayed fears associated with that aspect of the pilot. By 2017 it had been demonstrated successfully that removing the UDA as a driver from these practices gave clinicians more freedom to make decisions, using their own clinical judgement about what was in the best interests of their patients.  Once established, it became evident that more individual patients were being seen and the proportion of patients provided with advanced treatment had reduced.

1.3The national dental contract reform programme launched by the Chief Dental Officer in 2017 built upon the Prototypes as well as experience introduced from elsewhere in the UK.  They were joined by four other practices in ABMU (14 across Wales) to test a ‘blended’ contract methodology which comprises a compromise between the GDS contract and the prototype described above.  Phase 1 of the contract reform programme (September 2017 – March 2018) reduced – rather than eliminated - the UDA target by 10%, easing the time/financial pressures on practices to enable them to complete and submit clinical profiles on all patients assessed and treated.  

1.4The six, very different, practices who comprise the Phase 1 Contract Reform group hold a total contract value of approximately £2.2 million to deliver 86,833 UDAs or equivalent.  The UDA rates per practice varied from £23.13 - £38 (average £26) for contracts ranging from 5,800 to 34,500 UDAs.  Between them, they can provide a true test of what can be delivered with contract restrictions lifted to varying degrees.

1.5In June 2018 Public Health Wales colleagues produced and shared the initial draft of the practice-based patient and practice profiles drawn from the data collected by the practices the ‘ACORN’ reports).  Further, more detailed profile information which would support decision making (factoring in practice size, contract value etc.) is awaited from year-end returns.  However that available to date indicates that Health Boards and Practices can be confident in reducing further UDA targets in return for specific quality initiatives to secure greater, more appropriate, patient access to General Dental Services with improved health outcomes.  

1.6The Wales contract reform programme has, as an aim, that 10% of Wales’ practices will be testing the reformed contract by 31 March 2019.  The current thinking within ABMU is that the next phase of the reform project, from October 2018, will seek to reduce the contract targets by 10% in at least two more practices* and drop further the UDA target in the phase 1 practices in return for specific quality initiatives, some of which are already being explored. Some examples discussed within the Primary Care team and/or contract reform group to date include initiatives that could:

· improve practice sustainability and retain Dental Foundation trainees in struggling practices

· improve patient access to general dental services with demonstrable increases in unique patient numbers (in contrast to current high levels of repeat attenders) and/or

· support enhanced skills training of General Dentists to help reduce what are currently secondary care waiting times for treatment which could be delivered out of hospital. 

*NB 10% of contractors in Swansea and Neath Port Talbot = 8.  There are currently no contract reforming practices in Bridgend county.  

1.7ABMU is aware that not all practices are in a position to embrace the multi-disciplinary approach upon which a holistic model of service depends.  This is particularly the case in those who are single-handed and/or operating in small premises that cannot accommodate additional staff, e.g. hygienists, therapists, dental nurses.  As an integral part of its service planning and development in 2018/19 ABMU will undertake a survey, jointly with the Local Dental Committee, of practice staffing and facilities to help gauge the extent to which practices are in a position to remodel the services they provide.

ABMU’s view, based on its experiences to date with the Prototype Practices and the wider contract reform is that the changes have resulted in improved access, especially for the most vulnerable, and care provided driven by the need of the individual rather than a contract target.  However, as the programme is rolled out it is important that it is underpinned by robust governance and that changes for individual practices are based on the needs of the local population and not simply an ‘all-Wales’ framework.  Experience from the Prototype practices should be shared nationally and these practices should continue to drive and test innovation.  Local management teams will need to ensure they have the resources and the capabilities to support the changes and provide reassurance to Health Boards and Welsh Government.