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Presentation to Northern LDC. Donncha O’Carolan Chief Dental Officer 5 April 2012. Overview of Presentation. GDS Budget & Pressures New GDS Contract Local Decontamination Guidance. DHSSPS Structure. GDS Budget. GDS Budget – Structure . GDS Budget – Structure . GDS Budget – Structure .

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Presentation to northern ldc

Presentation to Northern LDC

Donncha O’Carolan

Chief Dental Officer

5 April 2012


Overview of presentation

Overview of Presentation

  • GDS Budget & Pressures

  • New GDS Contract

  • Local Decontamination Guidance


Dhssps structure

DHSSPS Structure


Gds budget

GDS Budget


Gds budget structure

GDS Budget – Structure


Gds budget structure1

GDS Budget – Structure


Gds budget structure2

GDS Budget – Structure


Gds budget structure3

GDS Budget – Structure

 Net

 Patient

 Pressure


Gds budget investments

GDS Budget – Investments

  • £4 million (recurrent) into practice allowance

  • £3 million (non-recurrent) into QIS

  • £500k (recurrent) into VT grants

  • >£500k (recurrent) into extending registration period

  • £400k (recurrent) salaried dental services

  • £5.7 million Improve access via dental tender

  • £1.1 (recurrent) into commitment payments


Gds budget other investments

GDS Budget: other investments

  • £120k CPD for DCPs

  • £300k for 5 additional dental students

  • £3 million re-equip school of dentistry

  • £100k additional registrar posts

  • Occupational health services for the whole dental team


Gds budget proportion of earnings

GDS Budget: Proportion of Earnings


Gds budget overall earnings expenses

GDS budget – Overall Earnings & Expenses


Gds budget increased provision

GDS Budget – increased provision


Gds budget1

GDS Budget


Gds budget market changes

GDS Budget: Market Changes


Gds budget market changes1

GDS Budget: Market Changes


Gds budget proposals for savings principles

GDS Budget: Proposals for Savings- Principles

  • Must have potential to realise savings for GDS budget

  • Can be implemented within existing GDS contract or with minor regulatory change

  • Can be implemented within coming financial year

  • Must be consistent with direction of new GDS contract

  • Comply with equality legislation & other regulatory requirements.


Gds budget proposals for savings

GDS Budget – Proposals for Savings

  • QIS- £1.16m transfer to GDS budget

  • Core service

    • Molar endo – prior approval

    • Co/Cr – prior approval

    • Bridgework – posterior/large; prior approval

    • Veneers -all prior approval

  • Alter time bar on S&P


Gds budget proposals for savings1

GDS Budget – Proposals for Savings

  • Orthodontic treatment – IOTN 3.6, all other ortho prior approval

  • Practice allowance –new criteria

    • Average of 750 patients/DS, with average 200 fee paying

  • Removal of commitment payments


Gds budget potential savings

GDS Budget: Potential Savings

  • QIS funding transfer to the GDS budget - £1.161m

  • Move to a core service under the SDR: ~ £2m;

  • Altering claims conditions on S&P: ~ £1m

  • Changes to the practice allowance: ~£344k

  • Ceasing commitment payment: ~ £3m

  • Restricting orthodontic treatment to IOTN 3.6: ~£1.5m (full year effect realised over a 24 month period)


Process timeline

Process & timeline

  • Restrict orthodontic treatment

    • This will require amendments to the GDS Regulations and the SDR

    • Consultation with BDA/PCC/ wider dental profession and public

    • Subject to the consultation/approval of the Assembly, could be implemented from summer 2012.

  • QIS funding to transfer to GDS budget

    • No changes to regulations or the SDR are necessary

    • The HSCB could action this with effect from 1 April 2012.


Process timeline1

Process & timeline

  • Move to a core service under the SDR

    • This will require amendments to the SDR

    • consultation with BDA/PCC/ wider dental profession and public

    • Subject to the consultation this could be implemented from summer 2012.

  • Alter S&P time-bar

    • Will require amendments to the SDR

    • Consultation with BDA/PCC/ wider dental profession and public

    • Subject to the consultation, could be implemented from summer 2012


Process timeline2

Process & timeline

  • Removal Commitment payment

    • will require amendment to both the GDS regs and SDR

  • Practice Allowance amendments to criteria

    • will require amendment of the SDR

  • Consultation with BDA/PCC/ wider dental profession and public

  • Subject to the consultation/ approval of the Assembly, could be implemented from summer 2012.


New dental contract

New Dental Contract


Primary dental care strategy 2006

Primary Dental CareStrategy 2006

  • Local commissioning of services;

    • Access to appropriate dental care for everyone who needs it;

    • A clear definition of treatments available under the health service;

    • A greater emphasis on disease prevention;

    • Guaranteed out-of-hours services;

    • A revised remuneration system, which rewards dentists fairly for operating the new arrangements.


Problems with existing system

Problems with existing system

  • Quantity not quality is rewarded;

  • Treatment rather than prevention is rewarded;

  • Demand led rather than needs led;

  • SDR > 400 items is administratively complex;

  • Patient charges are difficult for the public to understand


Problems with existing system1

Problems with existing system

  • Dentists incomes directly related to the volume of treatment provided causes remuneration treadmill;

  • HSCB lacks control over targeting services at areas and patients with greatest need.

  • 50 year old system no longer meets the needs of patients, oral health care professionals or society at large.


Options for new system

Options for New System

  • Prof Ciaran O’Neill looked at range of remuneration systems

    • Retrospective Fee for Service (Item of service);

    • Prospective Payment System (Full capitation);

    • Salaried/Sessional system

  • Advised blended service


Essential services

Essential Services

  • Periodontal treatment

  • Restorations

  • Endodontics (except molars)

  • Crown work

  • Extractions & surgical

  • Dentures –acrylic

  • Children’s treatment

  • Miscellaneous items


Exceptional treatments

Exceptional Treatments

  • Molar endodontics

  • Co/Cr dentures

  • Bridgework

  • Veneers


Care payments

Care Payments

Quality care payments (QCPs)

  • Practice environment indicators

    • Practice inspection

    • Recognised charter-mark

  • Practitioner indicators

    • Peer review / clinical audit

    • Higher qualification


Patient care payment

Patient Care Payment

  • Weighted Capitation formula

  • Adjusted for Age

  • Adjusted gender

  • Adjusted for additional needs

  • Adjusted for ‘new patients’

  • Adjusted for list turnover


Orthodontics

Orthodontics


Oral surgery

Oral Surgery


Pilots

Pilots

  • Use Pilot PDS

  • Consultation October 2010 – March 2011

    • Responses very supportive

  • Oral Surgery pilot well advanced

  • Orthodontic contract will be phased in

  • GDS will follow oral surgery


Progress on new contract

Progress on New Contract


Why has it taken so long

Why has it taken so long?

  • Resources

  • Addressing access issue

  • IT system at BSO

  • GDS budget – controlling pressures

  • Legislative problems – e.g. pensions, performers lists

  • Proposals from BDA?


How will new contract impact on profession

How will new contract impact on profession?

  • Local commissioning – HSCB will target resource at need.

  • Control of entry –performers lists

  • Fixed GDS budget and global sum formula

  • Focus on prevention

  • Out of hours responsibility of HSCB


What s in for profession

What’s in for Profession?

  • Limits number of dental practices

    • Increase value of practices?

  • Can opt out of Out of Hours

    • Work-life balance?

  • Performer/provider contracts

    • Career structure?

  • Capitation payments

  • Improved cash flow

  • Global sum

    • More stable budgetary position?


Local decontamination guidance

Local Decontamination Guidance


Content

Content

  • Policy Background

  • Funding

  • Current Position

  • Regulation


Policy background

Policy Background


A protocol for the local decontamination of surgical instruments

A Protocol for the Local Decontamination of Surgical Instruments

  • Issued July 2001,

  • Health Estates DHSSPS

  • Key areas

    • All local decontamination outside of clinical setting where possible

    • Recommends automated washing

    • Downward displacement autoclaves- not suitable for processing wrapped instruments or hollow instruments

    • Do not re-use single use instruments

  • Described as short term strategy


Bda a12

BDA A12

  • Issued February 2003

  • Key points

    • Where possible instruments to be decontaminated in a separate room

    • Recommends washer disinfector over manual cleaning

    • Wrapped instruments must be sterilised in a vacuum autoclave

    • Single use instruments used wherever possible & discarded after use


Hine review of decontamination of endoscopes

Hine Review of Decontamination of Endoscopes

  • May 2004 problem identified with decontamination of endoscopes/ risk of cross infection with blood bore viruses

  • Review of effectiveness of arrangements for decontamination of endoscopes & lessons learnt

  • Service wide review of decontamination of all re-usable medical devices


Audit of dental practices

Audit of Dental Practices

  • Letter issued to GDPs August 2004 re quality assurance of decontamination processes

  • Protocol for the local decontamination of Surgical Instruments (July 2001) reissued & dentists asked to comply

  • Letter from CDO issued all GDPs December 2004

    • Review current policies & procedures

    • Complete audit

    • Conform with recommendations in A12


Audit of dental practices outcomes

Audit of Dental Practices- Outcomes

  • Overall compliance good (53% amber, 47% green)

  • Priority areas

    • Amalgam separators

    • Chart recorders for autoclaves

    • Independent water bottles

    • Dedicated rooms for decontamination

    • Washer disinfectors

    • Disposable instruments


Audit of dental practices follow up 2005 06

Audit of Dental Practices – follow up 2005/06

  • Series of training workshops across NI(Dr Wil Coulter & Dr Caroline Pankhurst)

  • Cross Infection Control Manual

  • Cross Infection Control CD-ROM

    • Launched 2 May 2006


Development of action plan

Development of Action Plan

  • October 2006; DHSSPS, Health Estates, Dental Directors, Dr Wil Coulter

  • Looked at priority areas from audit

  • Amalgam separators, chart recorders autoclaves & independent water bottles largely achieved & funding provided through QIS 2005 & 2006

  • Separate decontamination room, washer disinfectors & disposables logistically & financially more difficult to achieve

  • Needed to develop an action plan listing priorities


Workshop february 2007 publication of action plan

Workshop February 2007 & Publication of Action Plan

  • CDO, Dental Directors, Dental Practice Advisers, Infection Control nurses, LDCs, representatives RoI

  • Action plan agreed, developed & published (annual report 2007/08)

    • Washer disinfectors

    • Quality of water supply

    • Improved surgery layouts

    • Use vacuum autoclaves

    • Appropriate testing equipment

    • Procurement of equipment


Other policy influences

Other Policy Influences

  • DH England working on HTM 01-05

    • Health Estates had observer status

  • BDA developing new A12

    • Working drafts shared with DH, subsequently withdrawn

  • Scotland

    • Glennie Group

    • Top ten tips

  • Ensured DHSSPS action plan consistent with working drafts HTM 01-05 & Scotland

  • Nov 2007 QIS letter; Policy position; funding for priority areas; Advice & support; 3-5 year lead in time.


Evidence base

Evidence Base

  • Advisors HTM01-05; BDA, MHRA, HPA, Infection Protection Society, Healthcare Commission, Decontamination experts, GDPs, microbiologists, engineers

  • Evidence base published: Acts & Regulations; Codes of Practice; British, European & International Stds, research papers, Official Publications


Further support

Further Support

  • Supported Labour Government, Coalition Government, Minister DHSSPS.

  • NI, Scotland, England – all moving to similar standards but on different timetable.

  • ROI; New National stds for Prevention & Control of Health Care Associated Infections


Funding

Funding


Investments into gds

Investments into GDS

  • Practice Allowance: £4million additional (2007)

  • QIS: £3million additional (2007/08)

  • Commitment payments: £1.1million additional (2009)

  • Registration: £500k additional (2009)

  • Vocational training: £500k additional (2007)


Funding1

Funding

  • Profits: 07/08 £121,200: 09/10 £129,900:10/11 £122,900

  • QIS money 2005 - 2010 key priority decontamination (approx £1million recurrent)

  • Addition QIS money 2007/2008 £3 million

  • Practice allowance ↑ from 5% to 11% September 2007

    • ‘increasing practice requirements in relation to the provision of high quality premises, health & safety, staffing support & information collection & provision


The health service 60 years old

The Health Service - 60 Years old

“We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving – it must always appear inadequate.”

Aneurin Bevan - 1948


Current position

Current Position


Presentation to northern ldc

  • Nov 2009 DH publish HTM 01-05 (Hard Copy)

  • 10 Feb 2010 DHSSPS issue NI position, accept HTM01-05 with modifications (PEL(10)04):

    • Washer disinfector – manual cleaning not a validated process

    • Timescale: must have achieved best practice by 2010-12

    • Instruments processed in a type N autoclave cannot be subsequently wrapped & stored – use within working day

    • Exemplar room layout; fig 1 does not apply (no WD)


Minimum standards for dental care and treatment

Minimum Standards for Dental Care and Treatment

  • Primary Care Private & HS

  • RQIA will inspect against

  • HSCB will commission against

  • Std 13:’Prevention & Control of Infection’

    ‘Your dental service meets current best practice on the decontamination of reusable dental & medical instruments’.

  • Issued March 2011


Rqia regulation private dentistry

RQIA -Regulation Private Dentistry

  • Legislation – HPSS (QIR) NI Order 2003

  • Amend Order through regulations to permit regulation of all private dentistry

  • Regulation commenced 1 April 2011

  • RQIA; Register & annual inspection

  • Any dental practice which provides any private dentistry

  • Inspect against dental standards

  • Inspection Reports published on the RQIA web-site


Other guidance since pel 10 04

Other Guidance sincePEL (10) 04

  • Scottish Health Technologies Group Advice Statements

    • Wrapping Dental Instruments

    • Benchtop steam sterilisers

  • Sterilization of Dental Instruments (SDCEP)

  • BDJ: Time-dependent recontamination rates of sterilised instruments

  • IDJ: Three Steps to Decontamination Heaven


Review of pel 10 04

Review of PEL(10) 04

  • DHSSPS reviewed PEL (10) 04 in summer 2011

    • HSCB

    • RQIA

    • NIMDTA

  • Await results of recontamination studies UCL

  • Offered meeting with BDA


Non compliance

Non-compliance


Compliance

Compliance

  • DHSSPS has provided significant funding

  • Minister will be held accountable for delivery

  • Profession will be expected to deliver

  • All 14 Oasis practices are compliant (230 across UK)

    • Do not report significant problems

  • Other NI practices have already complied or are close to compliance

  • DHSSPS, NIMDTA & HSCB considerable resource into training to aid compliance


What s next

What’s next?

  • Direct Access

  • Amalgam


Contacts references

Contacts & References

  • CDO website for Newsletters, annual reports & other publications

    http://www.dhsspsni.gov.uk/pgroups/dental/dental.asp

  • PEL (10) 04 on HE website

    http://www.dhsspsni.gov.uk/index/hea/decontamination-general-dental-practices.htm

  • Dental Standards

    http://www.dhsspsni.gov.uk/index/dental/dental-pubs.htm

  • HE contact number for advice

    028 90 523802


Thank you

Thank You


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