Definitions and interpretation



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PART 91

ADDITIONAL SERVICES
Advanced mandatory services2
101. The Contractor may only provide advanced mandatory services under the Agreement as a referral service.
102. When the Contractor provides advanced mandatory services, the activity undertaken will count towards the number of units of dental activity specified in clause [77] [78]1 in accordance with the provisions of clauses 79 to 82.
103. The Contractor shall provide advanced mandatory services [at the following times/during the following periods]: [to be completed as appropriate by the parties].2
Sedation services3
104. [The Contractor shall provide [ ] courses of treatment that involve the provision of sedation services during each financial year.]4.
105. [The Contractor shall provide [ ] courses of treatment that involve the provision of sedation services during [insert relevant period] and [ ] courses of treatment that involve the provision of sedation services in each financial year thereafter.]5.
106. The Contractor shall provide sedation services [at the following times/during the following periods]: [to be completed as appropriate by the parties].6.
107. The Contractor shall only provide sedation services under this Agreement—
107.1. to a person to whom it is providing an entire course of treatment, during that course of treatment; or
107.2. as a referral service,
and in this clause, “entire course of treatment” means a course of treatment provided by only the Contractor.
108. The Contractor shall only provide sedation services to a patient in accordance with the recommendations contained in the report of the Standing Dental Advisory Committee entitled “Conscious Sedation in the Provision of Dental Care”, insofar as those recommendations and guidelines are relevant to—
108.1. the type of sedation being administered; and
108.2. the patient to whom the sedation is being administered.
109. A copy of the Report referred to in clause 108 can be obtained at http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4069257.
Domiciliary services
110. [The Contractor shall provide [ ] courses of treatment that involve the provision of domiciliary services during each financial year.]1
111. [The Contractor shall provide [ ] courses of treatment that involve the provision of domiciliary services during [insert relevant period] and [ ] courses of treatment that involve the provision of domiciliary services in each financial year thereafter.]2.
112. The Contractor shall provide domiciliary services [at the following times/during the following periods]: [to be completed as appropriate by the parties].3.
113. The Contractor shall only provide domiciliary services under this Agreement—
113.1. to a person to whom it is providing an entire course of treatment, during that course of treatment; or
113.2. as a referral service,
and in this clause, “entire course of treatment” means a course of treatment provided by only the Contractor.
Dental Public Health Services
114. [The parties will need to specify the details of the arrangement where the Board and Contractor have agreed that the Contractor will provide Dental Public Health Services. Details of payments to be made in respect of such services will also need to be included in Schedule 4 to the Agreement]
115. The Contractor shall provide dental public health services [at the following times/during the following periods]: [to be completed as appropriate by the parties].1
Orthodontic services
Units of orthodontic activity to be provided
116. [The Contractor shall provide [ ] units of orthodontic activity during each financial year.]2
117. [The Contractor shall provide [ ] units of orthodontic activity during [insert relevant period] and [ ] units of orthodontic activity in each financial year thereafter.]3
118. The Contractor shall provide orthodontic services [at the following times/during the following periods]: [to be completed as appropriate by the parties].4
Calculation of the number of units of orthodontic activity provided
119. Where the Contractor provides an orthodontic course of treatment to a patient that solely consists of a case assessment, the Contractor provides 1.0 units of orthodontic activity.
120. Where the Contractor provides an orthodontic course of treatment to a patient who is aged under 10 years that consists of—
120.1. a case assessment; and
120.2. the provision of orthodontic treatment to the patient following the case assessment,
the Contractor provides 4.0 units of orthodontic activity.
121. Where the Contractor provides an orthodontic course of treatment to a patient aged between 10 and 17 years that consists of—
121.1. a case assessment; and
121.2. the provision of orthodontic treatment to the patient,
the Contractor provides 21.0 units of orthodontic activity.
122. Where the Contractor provides an orthodontic course of treatment to a patient who is aged 18 years or over that consists of―
122.1. a case assessment; and
122.2. the provision of orthodontic treatment following the case assessment,
the Contractor provides 23.0 units of orthodontic activity.
123. Where the Contractor—
123.1. provides a repair to an orthodontic appliance of a patient; and
123.2. the orthodontic course of treatment in which that orthodontic appliance was provided is being provided by another contractor, hospital or relevant service provider under Part 5 of the 2006 Act,
the Contractor provides 0.8 units of orthodontic activity.
Under provision of units of orthodontic activity
124. The Board shall not pursuant to Part 22 of this Agreement be entitled to take any action for breach of clause [116][117]1 (including termination of the Agreement) where clause 125 applies.
125. This clause applies where the Contractor has failed to provide the number of units of orthodontic activity it is contracted to provide pursuant to clause [116][117]2 where—
125.1. that failure amounts to 4 per cent or less of the total number of units of orthodontic activity that ought to have been provided during a financial year, and
125.2. the Contractor agrees to provide the units it has failed to provide within such time period as the Board specifies in writing, such period to consist of not less than 60 days.
126. [ ]3
127. Clauses 124 and 125 shall not prevent the Board from taking action under Part 22 of this Agreement for breach of the Agreement (including terminating the Agreement) on other grounds.
Mid-year review
128. Clauses 129 to 140 (except clause 136) only apply where services are to be provided under the Agreement from 1st April in the relevant financial year.
129. In clauses 130 to 141, “required to provide” or “required to be provided” in relation to units of orthodontic activity means required to be provided in accordance with clause [116] [117]1.
130. The Board shall, by 31st October in each financial year, determine the number of units of orthodontic activity that the Contractor has provided between 1st April and 30th September of that financial year based on the data provided to it by virtue of clauses 221 and 222.
131. Where the Board determines under clause 130 that the Contractor has, between 1st April and 30th September, provided less than 30 per cent of the total number of units of orthodontic activity that it is required to provide in that financial year, clause 132 shall apply.
132. Where this clause applies, the Board may—
132.1 notify the Contractor that it is concerned about the level of activity provided under the Agreement in the first half of the financial year, setting out—
132.1.1. the number of units of orthodontic activity that it has determined that the Contractor has provided;
132.1.2. the percentage of the total number of units of orthodontic activity required to be provided during the financial year that the number in clause 132.1.1 represents; and
132.2. require in that notification that the Contractor participate in a mid-year review of its performance in relation to the Agreement with the Board.
133. Where a mid-year review is required by the Board pursuant to clause 132.2, the Board and the Contractor shall discuss at that review—
133.1. any written evidence the Contractor puts forward to demonstrate that it has performed a greater number of units of orthodontic activity during the first half of the financial year than those notified to it pursuant to clause 132.1.1; and
133.2. any reasons that the Contractor puts forward for the level of activity in the first half of the financial year.
134. The Board shall prepare a draft record of the mid-year review for comment by the Contractor and, having regard to such comments, shall produce a final written record of the review.
135. A copy of the final record of the mid-year review shall be sent to the Contractor.
136. [Where an Agreement does not commence on 1st April, clauses 128 to 135 and 137 to 140 are varied to the extent that―

[ ]1


[ ]

[ ]
Action the Board can take following a mid-year review


137. Where, following the mid-year review and the provision of the final record of that review to the Contractor, the Board, having taken account of any evidence or reasons put forward by the Contractor at that review, nevertheless has serious concerns that the Contractor is unlikely to provide the number of units of orthodontic activity that it is required to provide by the end of the financial year, the Board shall be entitled to take either or both of the steps specified in clause 138.
138. The Board may―
138.1. require the Contractor to comply with a written plan drawn up by the Board to ensure that the level of activity during the remainder of the financial year is such that the Contractor will provide the number of units of orthodontic activity it is required to provide; or
138.2. withhold monies payable under the Agreement.
139. The maximum amount that may be withheld pursuant to clause 138.2 is—
139.1. the amount that is payable under the Agreement in respect of the number of units of orthodontic activity required to be provided in a financial year, less
139.2. the amount that would be payable under the Agreement as a relevant proportion of that amount if the Contractor provided in the whole of the financial year only twice the number of units of orthodontic activity that he provided between 1st April and 30th September.
140. Nothing in clauses 137 to 139 shall prevent the Board and the Contractor agreeing to vary the Agreement in accordance with clause 288 to adjust—
140.1. the level of activity to be provided under the Agreement; or
140.2. the monies to be paid by the Board to the Contractor under the Agreement.
141. Where the Board withholds monies pursuant to clause 138.2, it shall ensure that it pays the withheld monies to the Contractor as soon as possible following the end of the financial year where the Contractor has—
141.1. provided the number of units of orthodontic activity required to be provided; or
141.2. failed to provide that number of units of orthodontic activity, but that failure amounts to 4 per cent or less of the total number of units of orthodontic activity that ought to have been provided during that financial year (and therefore clauses 124 to 126 to apply).
Patients to whom orthodontic services may be provided
142. The Contractor may provide orthodontic services to—
142.1. [only] persons who are under the age of 18 years at the time of the case assessment; [and]
142.2. [only] persons who have attained or are over the age of 18 years at the time of the case assessment.1
143. The Contractor may only provide orthodontic services to a person aged 18 or over at the time of the case assessment if [the Agreement has to specify the circumstances in which or criteria that need to be satisfied before orthodontic services are provided to a person who is over the age of 18 years at the time of the case assessment].2
144. The Contractor shall only provide orthodontic treatment to a person who is assessed by the Contractor following a case assessment as having a treatment need in—
144.1. grade 4 or 5 of the Dental Health Component of the Index of Orthodontic Treatment Need (see The Development of an Index for Orthodontic Treatment Priority: European Journal of Orthodontics 11, p309-332, 1989 Brooke, PH and Shaw WC - the article is also available at www.dh.gov.uk) or
144.2. grade 3 of the Dental Health Component of that Index with an Aesthetic Component of 6 or above,
unless the Contractor is of the opinion, and has reasonable grounds for its opinion, that orthodontic treatment should be provided to a person who does not have such a treatment need by virtue of the exceptional circumstances of the dental and oral condition of the person concerned.
Orthodontic course of treatment
145. Subject to clause 146, the Contractor shall provide orthodontic services to a patient by providing to that patient an orthodontic course of treatment.
146. The Contractor may provide orthodontic services that are not provided by virtue of an orthodontic course of treatment where—
146.1. it provides a repair to an orthodontic appliance of a person; and
146.2. the orthodontic course of treatment in which that orthodontic appliance was provided is being provided by another contractor, hospital or relevant service provider under Part 5 of the 2006 Act.
147. The Contractor shall use his best endeavours to ensure that an orthodontic course of treatment is completed, and that it is so completed within a reasonable time from the date on which the orthodontic treatment plan was written in accordance with clause 151.
148. If an orthodontic course of treatment is—
148.1. terminated before it has been completed; or
148.2. otherwise not completed within a reasonable time.
149. An orthodontic course of treatment may only be terminated by—
149.1. the Contractor by virtue of—
149.1.1. a notice under clause 33;
149.1.2. clause 38;
149.1.3. clause 39;
149.2. the patient; or
149.3. a person specified in clause 27 acting on the patient’s behalf.
150. If the Contractor is unable to complete the course of treatment which has been commenced for reasons beyond his control, he shall give notice to the Board of the extent of the treatment so provided and the reason for his inability to complete the remainder.
Orthodontic treatment plans
151. Where the Contractor has, following a case assessment, determined that orthodontic treatment should be provided to a patient, it shall, at the time of that case assessment, ensure that the patient is provided with an orthodontic treatment plan on a form supplied for that purpose by the Board which shall specify—
151.1. the name of the patient;
151.2. the name of the Contractor;
151.3. particulars of the places where the patient will receive orthodontic treatment;
151.4. the telephone number at which the Contractor may be contacted during normal surgery hours;
151.5. details of the orthodontic treatment which is, at the date of the examination, considered necessary to secure the oral health of the patient;
151.6. the NHS charge, if any, in respect of those services if provided pursuant to the Agreement; and
151.7. subject to clause 60.1, any proposals the Contractor may have for private services as an alternative to the services proposed under the Agreement, including particulars of the cost to the patient if he were to accept the provision of private services.
152. If the patient, having considered the treatment plan provided pursuant to clause 151, decides to accept the provision of private services in place of orthodontic services under the Agreement, the Contractor shall ensure that the patient signs the treatment plan in the appropriate place to indicate that he has understood the nature of private services to be provided, and his acceptance of those private services.
153. Where, for clinical reasons, the services included in the orthodontic treatment plan under clause 151 need to be varied, the Contractor shall provide the patient with a revised orthodontic treatment plan in accordance with that clause.
154. Subject to clauses 147 and 149, the Contractor shall provide the orthodontic services which are detailed in the orthodontic treatment plan provided pursuant to clause 151 or, where the orthodontic treatment plan is revised, pursuant to the revised orthodontic treatment plan.
Monitoring outcomes
155. The Contractor shall monitor, in accordance with clauses 156 to 160, the outcome of the orthodontic treatment it provides.
156. The Contractor shall, in respect of orthodontic courses of treatment it provides in which orthodontic treatment is provided following the case assessment, monitor the outcome of that orthodontic treatment in accordance with clause 157.
157. The Contractor shall, in respect of—
157.1. where the total number of orthodontic courses of treatment provided is 20 or fewer, all the cases of orthodontic courses of treatment it provides; or
157.2. where the total number of orthodontic courses of treatment provided is greater than 20―
(i) 20 of the cases; and

(ii) in addition, 10 per cent of the number of cases over 20,


monitor the outcome of that orthodontic treatment in accordance with “Methods to determine outcome of orthodontic treatment in terms of improvement and standards” (see the European Journal of Orthodontics 14, p125-139, 1992 Richmond S., Shaw W.C., Anderson M. and Roberts C.T. - the article is also available at www.dh.gov.uk).
158. The following time period is specified as the relevant time period for calculating the number of orthodontic courses of treatment that need to be monitored in accordance with clause 157: [the parties need to specify here the time period during which the outcomes need to be monitored which may, if the parties so agree, link to the financial year to match the time period during which the obligation to provide units of orthodontic activity relates].
159. As part of its monitoring of the outcome of orthodontic treatment, the Contractor shall, in respect of the patients whose courses of treatment are monitored for the purposes of clause 158, calculate a Peer Assessment Rating of the patient’s study casts—
159.1. taken at or after the case assessment but prior to the commencement of orthodontic treatment; and
159.2. taken at the completion of the orthodontic course of treatment,
using either the Clinical Outcome Monitoring Program software (See Clinical Outcome Monitoring Program – Version 3.1 for Windows 98, XP and 2000. See also Weerakone S and Dhopatkar “A: Clinical Outcome Monitoring Program (COMP): a new application for use in orthodontic audits and research”, American Journal of Orthodontics and Dentofacial Orthopaedics 2003;123:503-511) or by applying the methodology set out in “An introduction to Occlusal Indices” (see Richmond, O’Brien, Buchanan and Burden, 1992, Victoria, University of Manchester, ISBN 1-898922-00-4).
160. In clause 159, “Peer Assessment Rating” means an index of treatment standards in which individual scores for the components of alignment and occlusion are summed to calculate an overall score comparing pre and post treatment. A description of this methodology can be found in the European Journal or Orthodontics 14, p180-187, 1992, Richmond S, Shaw WC, Roberts CT and Andrews M: “Methods to determine the outcome of orthodontic treatment in terms of improvement and standards”.
Completion of orthodontic courses of treatment
161. The Contractor shall indicate on the form supplied to the Board pursuant to clause 221 and clause 222 whether or not the orthodontic course of treatment was completed.
162. If the Board requests in writing that the Contractor provides reasons for the failure to complete one or more orthodontic courses of treatment, the Contractor shall, within such time period as the Board may specify, provide the reason or reasons for the failure to complete that course of treatment or those courses of treatment.
163. If the Board—
163.1. determines that the number of orthodontic courses of treatment provided by the Contractor which have not been completed is excessive; and
163.2. does not consider that the reasons given by the Contractor for the failure to complete the orthodontic courses of treatment are satisfactory,
it shall be entitled to exercise its powers under clauses 308 to 315 on the grounds that the Contractor is not, pursuant to clause 147, using its best endeavours to ensure orthodontic courses of treatment are completed.
Referral services1
164. If the Contractor provides advanced mandatory services, domiciliary services or sedation services as a referral service, it shall, at the time of the first examination of the patient, ensure that the patient is provided with a referral treatment plan on a form supplied for that purpose by the Board which shall specify—
164.1. the name of the patient;
164.2. the name of the Contractor;
164.3. the particulars of the places where the patient will receive the referral service to be provided to him by the Contractor;
164.4. the telephone number at which the Contractor may be contacted during its normal surgery hours;
164.5. details of the services which are at the date of that examination considered to be necessary for the Contractor to provide having regard to the reason for the referral; and
164.6. any proposals the Contractor may have for private services as an alternative to the services proposed under the Agreement, including particulars of the cost to the patient if he were to accept the provision of private services.
165. Where the services included in the referral treatment plan need to be varied for clinical reasons, the Contractor shall provide the patient with a revised referral treatment plan in accordance with clause 164.
166. The Contractor shall, subject to the termination of a course of treatment in accordance with clause 45, provide the services which are detailed in the referral treatment plan, or where a revised treatment plan is provided pursuant to clause 165, pursuant to that revised treatment plan.
167. Clauses 164 to 166 shall not apply where a patient has been referred to the Contractor for advanced mandatory services limited only to examination and advice, and the Contractor only provides examination and advice in respect of that patient.
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