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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
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 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.
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
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
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?
content
Content
  • Policy Background
  • Funding
  • Current Position
  • Regulation
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
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

slide64
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
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

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