Delivering dental access more effectively a pct resource pack for working with providers July 2010 For further information and resources



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Delivering dental access

more effectively
A PCT resource pack for working with providers


July 2010

For further information and resources:

www.pcc.nhs.uk/dentalaccess

Foreword

Good oral health is important to most people throughout their lives.

To support this, people expect to be able to access good quality NHS dental services at a reasonable cost.

Many PCTs and dentists are already working together effectively, and NHS access is increasing. However, in some areas, there is a shortfall which needs addressing.

This resource pack is designed to help PCTs further engage with providers and dentists on delivering dental access more effectively within the current NHS context.

Increasing access to good quality NHS dental services remains a key priority for patients and the Government, and the work is aligned with the wider focus on productivity, efficiencies, accountability and better outcomes for patients.

In particular its focus is:



  • Increasing access to good quality NHS dental services for patients – and improving oral health outcomes



  • Ensuring maximum productivity through effective contract management, implementing the NICE guidelines, developing a local performance policy and using data effectively



  • Promoting active engagement with providers during this period of increased pressures so that good relationships are maintained and promoted



  • Ensuring clarity and fairness by sharing information and putting processes in place to make sure there is a ‘level playing field’ for all locally.

We hope you find the pack useful.



NHS Primary Care Commissioning

July 2010

Please note: Additional flow charts that focus on actions a PCT can take in more exceptional circumstances, including guidelines on use of the Counter Fraud Service, will be produced later in the year. Existing flow charts can be found within the Contract Management Handbook www.pcc.nhs.uk/dap-contract-management-handbook.






1. Introduction

This practical resource pack has been developed in response to requests from PCTs and providers for further support.

The aim is to use the Contract Management Handbook www.pcc.nhs.uk/dap-contract-management-handbook and this pack to improve productivity and quality within the current dental contracting process, while working closely with providers to ensure that good relationships are fostered. A key focus is implementing the NICE guidelines on patient recall intervals.
About the pack
The pack contains four specific additional resources:

An SHA document to discuss with dentists that sets out the commissioner’s understanding of the dental Regulations and expectations relating to the delivery of key clinical services to patients.



A broader framework setting out how the commissioner expects to work with providers across all areas – to be agreed through PCT boards and LDCs.



An outline of the key information that PCTs may share with providers and how to use it effectively within the contract management process.


Examples of contract variations that some PCTs are starting to use to reward and incentivise providers in order to maximise access.


Appendices (Pages 54-72)
The appendices provide additional useful resources:
Appendix A Template letter to LDCs/dentists to invite them to engage in the work
Appendix B NICE guidelines on recall – patient leaflet and poster
Appendix C Template letter to LDCs/dentists to introduce the local performance policy work
Appendix D A ‘Quality Dashboard’ example
Appendix E Guide to developing a compact
Appendix F NHS West Essex case study - developing a local performance policy
Appendix G Step by step guide to running a multiple FP17 report


Five top tips:


  • Use this pack alongside the Contract Management Handbook www.pcc.nhs.uk/dap-contract-management-handbook and use the

whole pack or use specific sections as freestanding resources.


  • Consider sharing the pack with LDCs, providers and dentists and working openly with them so good local relationships are promoted and maintained – see Appendix A for a template letter from PCTs to LDCs and dentists.




  • Try to involve all members of the PCT dental team: dental commissioners, dental practice advisors and consultants in dental public health.




  • Encourage engagement with a mix of clinicians – LDC representatives, associates, vocational trainees, contract holders and local clinical champions.




  • To promote available access to patients, use the low-cost resources in the Communications Toolkit www.pcc.nhs.uk/dap-communicating-with-the-public.


2. Advice to dentists and providers

How to use this section:


  • This briefing note has been designed for PCTs and practices to use to help them clarify a range of issues where PCTs regularly receive enquiries from dental practitioners.




  • The document is designed to be shared with LDCs, providers and dentists, for example, at regular meetings or at a workshop, to gain their thoughts, clarify interpretations and offer support.




  • Please add the SHA or PCT logo before sharing the document.




  • Consider issuing this document with the NICE guidance on recall - the patient leaflet and poster can be found in Appendix B.


Placeholder for SHA NHS Logo




This advice has been agreed by the SHAs in England.


Introduction
Commissioners and providers/dentists have requested further guidance on key dental Regulations relating to the delivery of clinical services to patients.
It is recognised that there are areas of ambiguity within the Regulations, and the aim is to clarify issues and ensure a consistent approach.
The briefing sets out the advice for each issue and gives details of the relevant regulations and guidance in the notes at the end.
It is recognised that there will be exceptions still and, in these cases, further discussions may need to take place between commissioners and providers.
It is also recognised that dentists need to exercise clinical judgement when delivering services to patients, and that clinical policy may change as new evidence emerges.
Further information
Strategic health authorities will aim to expand this guidance to cover other areas in due course.
For further information and resources, please go to www.pcc.nhs.uk/dentalaccess

July 2010



Under the GDS and PDS Regulations, dentists are expected to deliver care to patients in accordance with guidance that is issued by NICE.


For adult patients, NICE recommends that patients should be recalled between three months and two years dependent on their clinical needs. The recommended interval for children is between three and 12 months. The actual interval should be assessed by the dentist based on the patient’s needs.
Dentists should discuss the recommended recall interval with the patient and record this interval, and the patient’s agreement/ disagreement with it, in the clinical record. The recommended interval should also be recorded on the FP17 form.


We want to work with local dental contractors to promote the application of current NICE guidance on dental recall intervals.


The Primary Care Trust (PCT) will review the data supplied by NHS Dental Services (NHS DS) at monthly/quarterly intervals and will discuss with contract holders where there appears to be a high number of patients being recalled after short intervals.

See note 1 below
Please note that NICE has also published a leaflet and poster for patients about recall - this is available at:

http://guidance.nice.org.uk/CG19






Multiple courses of treatment undertaken within a few weeks or months should normally be a relatively rare occurrence. In line with the Regulations, there is an expectation that all necessary treatment will be identified and provided within one course of treatment.


There may be occasions where patients return after short intervals when there is a problem with a tooth, or teeth, that could not have been foreseen during the previous course of treatment, eg damage to a filling, or an unrelated episode of trauma. However, this will be relatively infrequent and high levels of single item courses of treatment (CoTs) in short time intervals would not normally be expected.

In cases where high percentages of patients with the same ID are receiving further treatment after relatively short time intervals, the PCT will need to understand the reasons for this and may put in place support as appropriate.


A higher than average rate of these may indicate that there is an issue with diagnosis and treatment planning so that all the treatment needed is not being identified and carried out within one CoT. Clinical support will be offered where appropriate.
See note 2 below



The purpose of urgent treatments is to enable patients to receive a limited range of treatments for the relief of pain or to prevent deterioration of the oral condition.


Where an urgent CoT is considered appropriate then treatment should be provided to the extent necessary to prevent significant deterioration in oral health or to address severe pain. An urgent CoT may take place over more than one visit.
If a patient is already under treatment, then the dentist should provide any urgent treatment within the banded course of treatment. The normal charge for that band applies.
The Patient Charge Regulations list specific clinical treatments that comprise urgent CoTs and it is expected that dentists will apply their clinical

judgement as to whether an urgent CoT is appropriate.


Some patients who initially attend for an urgent CoT may return for a further Band 1, 2 or 3 CoT. Therefore, the PCT should expect to see some urgent CoTs in contracts and will consider the particular circumstances of the contract and the population it serves. However, large numbers of patients undergoing an urgent CoT before progressing to a full banded CoT would not normally be expected.
Where the contract data shows high levels of urgent CoTs (and there is no specific agreement in place for urgent access sessions), whether in isolation, or closely followed by a Band 1, 2 or 3 CoT, the PCT will discuss this with the contractor.
See note 3 below






Where new, full upper and lower dentures are required, these should normally be provided together as a single CoT.


The provision of a full upper or lower denture as a Band 3 CoT followed by a further Band 3 CoT a few months later to provide the opposing denture would not normally be considered appropriate as there are few clinical indications to support this as a suitable treatment.
Where the data shows the provision of upper and lower dentures as separate CoTs as a pattern of activity across a contract, the PCT will discuss this with the contractor.

Where dentures require adjustment (denture eases) this should be done as part of the same CoT if it is required after the dentures have been fitted. The regulations do not specify a time limit for these adjustments.


Immediate dentures are normally replaced within six to 12 months and would normally be regarded as a separate CoT.

See note 4 below




If an NHS patient clinically requires a scale and polish, then the dentist must offer that treatment under the patient’s NHS treatment plan, eg if a patient is undergoing a Band 1 CoT it would normally be included as part of that CoT.


The Department of Health’s Guide to NHS Dental Services in England highlights this point (Page 13):
You should not be asked to pay privately for any treatment which is clinically necessary. For example, if the dentist says that you need a scale and polish, this should be provided as part of your NHS course of treatment and you should not be asked to pay for it privately, or as a separate course of NHS treatment.’


Scaling and polishing can be carried out privately on an NHS patient if, in the judgement of the dentist, it is not clinically necessary but the patient chooses to have it done. In all instances, the treatment proposed and any options, NHS or private, should be discussed with the patient and clearly documented in the patient’s records. For all NHS patients receiving private treatment options, form FP17DC must be completed and signed by the patient.


Where the contract data shows higher than expected levels of scaling and polishing, especially within short time intervals for the same patient ID, the PCT will discuss this with the contractor.
See note 5 below



Under the Regulations, dentists are expected to submit fully completed FP17 forms within two months of the end of the completed CoT.


Rapid submission of FP17 forms - for example, daily via electronic submission - benefits both contractors and the PCT:

  • It enables both provider and commissioner to have an accurate picture of the services that are being delivered.

  • It makes it easier for providers to reconcile statements from NHS DS and may assist with discussion with the PCT on performance, eg at mid-year review. It may also facilitate cash flow at year end.

Where there are significant numbers of late submissions or incomplete forms, the PCT and contractor will need to understand the reasons for this.


Ultimately, if there is no improvement, the PCT may use its discretion to disallow the activity to be accrued against the annual contract requirement and/or pursue a breach of contract.
NHS DS will, however, still process all forms for patient charge purposes.
See note 6 below

NOTES: The relevant Regulations


Notes

What the Regulations say

References and Guidance


1. Compliance with NICE guidance on treatment intervals


National Institute for Clinical Excellence guidance

    14. The contractor shall provide services under the contract in accordance with any relevant guidance that is issued by the National Institute for Clinical Excellence, in particular the guidance entitled “Dental recall - Recall interval between routine dental examinations”.


The National Health Service (General Dental Services Contracts) Regulations 2005, Regulation 24, Schedule 3, part 2 para 14



www.opsi.gov.uk/si/si2005/20053361.htm
The National Health Service (Personal Dental Services Agreements) Regulations 2005, Regulation 20, Schedule 3, part 2 para 15 www.opsi.gov.uk/si/si2005/20053373.htm
NICE CG19, Dental recall – recall interval between routine dental examinations,

NICE http://guidance.nice.org.uk/CG19





2. Repeated banded courses of treatment after short time intervals


Course of treatment

(a) a course of treatment, means that:

(i) where no treatment plan has to be provided in respect of a course of treatment pursuant to paragraph 7(5) of Schedule 3 (treatment plans), all the treatment recommended to, and agreed with, the patient by the contractor at the initial examination and assessment of that patient has been provided to the patient; or

(ii) where a treatment plan has to be provided to the patient pursuant to paragraph 7 of Schedule 3, all the treatment specified on that plan by the contractor (or that plan as revised in accordance with paragraph 7(3) of that Schedule) has been provided to the patient;


Mandatory services

NHS (GDS contracts) Regulations 2005 require a contractor to provide mandatory services to a patient by providing to that patient a course of treatment. This is defined in regulations as meaning:

(a) an examination of a patient, an assessment of his oral health, and the planning of any treatment to be provided to that patient as a result of that examination and assessment; and

(b) the provision of any planned treatment (including any treatment planned at a time

other than the initial examination) to that patient, provided by, except where expressly provided otherwise, one or more providers of primary dental services, but it does not include the provision of any orthodontic services or dental public health services

The National Health Service (General Dental Services Contracts) Regulations 2005 , Part 1, Regulation 2



www.opsi.gov.uk/si/si2005/20053361.htm
The National Health Service (Personal Dental Services Agreements) Regulations 2005, Part 1, para 2

www.opsi.gov.uk/si/si2005/20053373.htm

The National Health Service (General Dental Services Contracts) Regulations 2005 , Regulation 14, Part 5


The National Health Service (Personal Dental Services Agreements) Regulations 2005, part 1, Regulation 2 (refers to GDS Regulation 14)




3. Urgent Course of Treatment


A Band 1 NHS Charge is payable pursuant to the NHS Charges Regulations, or would be payable if the patient was not an exempt person;

“Urgent treatment” means a course of treatment that consists of one or more of the treatments listed in Schedule 4 to the NHS Charges Regulations (urgent treatment under Band 1 charge) that are provided to a person in circumstances where—



      1. a prompt course of treatment is provided because, in the opinion of the contractor, that person’s oral health is likely to deteriorate significantly, or the person is in severe pain by reason of his oral condition; and

      2. treatment is provided only to the extent that is necessary to prevent that significant deterioration or address that severe pain; and

“working day” means any day apart from Saturday, Sunday, Christmas Day, Good Friday or a bank holiday.

An urgent CoT attracts 1.2 UDAs



The National Health Service (General Dental Services Contracts) Regulations 2005, Part 1, Regulation 2



www.opsi.gov.uk/si/si2005/20053361.htm
The National Health Service (Personal Dental Services Agreements) Regulations 2005, Part 1, Regulation 2

www.opsi.gov.uk/si/si2005/20053373.htm
NHS (Dental Charges) Regulations 2005 www.opsi.gov.uk/si/si2005/20053477.htm

NHS (Dental Charges) Amendment Regulations 2006 www.opsi.gov.uk/si/si2006/20061837.htm


Department of Health Factsheet 7B (Gateway reference 6990)


4. Provision of dentures



Course of treatment

(a) a course of treatment, means that:

(i) where no treatment plan has to be provided in respect of a course of treatment pursuant to paragraph 7(5) of Schedule 3 (treatment plans), all the treatment recommended to, and agreed with, the patient by the contractor at the initial examination and assessment of that patient has been provided to the patient; or

(ii) where a treatment plan has to be provided to the patient pursuant to paragraph 7 of Schedule 3, all the treatment specified on that plan by the contractor (or that plan as revised in accordance with paragraph 7(3) of that Schedule) has been provided to the patient;


Mandatory services

NHS (GDS contracts) Regulations 2005 require a contractor to provide mandatory services to a patient by providing to that patient a course of treatment. This is defined in regulations as meaning:

(a) an examination of a patient, an assessment of his oral health, and the planning of any treatment to be provided to that patient as a result of that examination and assessment; and

(b) the provision of any planned treatment (including any treatment planned at a time

other than the initial examination) to that patient, provided by, except where expressly provided otherwise, one or more providers of primary dental services, but it does not include the provision of any orthodontic services or dental public health services

The National Health Service (General Dental Services Contracts) Regulations 2005 , Part 1, para 2



www.opsi.gov.uk/si/si2005/20053361.htm
The National Health Service (Personal Dental Services Agreements) Regulations 2005, , Part 1, para 2

www.opsi.gov.uk/si/si2005/20053373.htm

The National Health Service (General Dental Services Contracts) Regulations 2005 , Regulation 14, Part 5


The National Health Service (Personal Dental Services Agreements) Regulations 2005, part 1, Regulation 2 (refers to GDS Regulation 14)




5. Scale and Polishing


10. Mixing of services provided under the contract with private services

(3) A contractor shall not, with a view to obtaining the agreement of a patient to undergo services privately –

a) advise a patient that the services which are necessary in his case are not available from the contractor under the contract; or

b) seek to mislead the patient about the quality of the services available under the contract.
Conditions 58 to 60 of the GDS contract also refer to private services

The National Health Service (General Dental Services Contracts) Regulations 2005, Regulation 24, Schedule 3, Part 2, Para 10,


Guide to NHS dental services in England, Department of Health, 2 April 2009

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_097431



6. Completion of FP17s



Regulations:

Notification of a course of treatment, orthodontic course of treatment etc.



    38.  The contractor shall, within two months of the date upon which—

      1. it completes a course of treatment in respect of mandatory or additional services;

      2. it completes a case assessment in respect of an orthodontic course of treatment that does not lead to a course of treatment;

      3. it provides an orthodontic appliance following a case assessment in respect of orthodontic treatment;

      4. it completes a course of treatment in respect of orthodontic treatment;

      5. a course of treatment in respect of mandatory services or additional services or orthodontic course of treatment is terminated; or

      6. in respect of courses not falling within sub-paragraph (d) or (e), no more services can be provided by virtue of paragraph 5(4)(b) of Schedule 1 (orthodontic course of treatment) or paragraph 6(4)(b) of this Schedule,

send to the Primary Care Trust, on a form supplied by that Trust, the information specified in sub-paragraph (2).

    1. The information referred to in sub-paragraph (1) comprise of—

      1. details of the patient to whom it provides services;

      2. details of the services provided (including any appliances provided) to that patient;

      3. details of any NHS Charge payable (and paid) by that patient; and

      4. in the case of a patient exempt from NHS Charges and where such information is not submitted electronically, the written declaration form and note of evidence in support of that declaration.

SFE

3.9 It is the contractor who collects the NHS charges from those patients. Furthermore, in accordance with its contract condition set by virtue of paragraph 38 of Schedule 3 to the GDS Contracts Regulations, the contractor is required to make returns of information to the PCT within specified time periods about the courses of NHS treatment it provides, and in those returns it has to provide information about whether an NHS charge was payable in respect of that treatment.



The National Health Service (General Dental Services Contracts) Regulations 2005, Regulation 24, Schedule 3, part 5 Para 38



www.opsi.gov.uk/si/si2005/20053361.htm
The National Health Service (Personal Dental Services Agreements) Regulations 2005, Regulation 20, Schedule 3, part 2 para 38
Statements of Financial Entitlements para 3.9 (GDS and PDS):

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_097377

PCR regulations: http://www.opsi.gov.uk/si/si2006/20061837.htm










3. Guide to developing a local performance policy


How to use this section:


  • This guide is organised under a set of key topics, each of which might form a section of the performance policy document.




  • For each topic, there is an introductory narrative and, where appropriate, suggested template text which can be adapted for local use. Useful references (e.g. relevant regulations, advice and guidance documents) are signposted.




  • It is suggested that PCTs work with the LDC and local providers and dentists to develop the performance policy.




  • The pack contains a template letter to introduce the process to LDCs and dentists and invite them to attend an introductory workshop – see Appendix C.




  • There is a helpful case study at Appendix F about the development of a local performance policy at NHS West Essex.




  • There is also a Word template performance policy, based on the guide, and which can be adapted by PCTs, on the PCC website www.pcc.nhs.uk/dap-delivering-dental-access-more-effectively.




Introduction
1. This guide has been developed to assist PCTs in engaging with providers and dentists to develop a local performance policy for primary care dentistry.
2. Successful engagement will need input from all members of the PCT dental team – dental commissioners, dental practice advisors and consultants in dental public health – and it is desirable to engage a mix of clinicians, including LDC representatives, associates, vocational trainees, contract holders, local clinical champions and, where appropriate, deanery representatives.
3. The GDS and PDS dental regulations require dental contractors to comply with all relevant legislation and “have regard to all relevant guidance issued by the PCT, the relevant strategic health authority and the Secretary of State”. Therefore, the document must be signed off by the PCT’s PEC or Board so that its formal status as a PCT policy is clear.
Benefits
4. Having a published performance policy benefits both provider, commissioner and the public: it enables local contractors to be clear about what the PCT expects of them and to prepare accordingly, it enables the PCT to demonstrate a transparent and equitable approach to managing performance, and it enables the public to feel confident they are getting value for money from public services.
5. Having a performance policy will help a PCT to:


  • support the QIPP agenda

  • formalise contract performance management activity across all dental contracts

  • implement the NICE guidelines on patient recall

  • ensure a consistent, transparent and equitable approach

  • provide assurance to the PCT Board and the public that contractual requirements are being met.

6. Having a performance policy will help dentists and their teams to:




  • influence and contribute to the local priorities for NHS dentistry

  • understand the PCT’s performance expectations, both clinically and for contract delivery

  • discuss their performance on a regular basis

  • implement the NICE guidelines on patient recall

  • understand what metrics will be used to measure their performance

  • understand what support is available from the PCT

  • be clear how any contract disputes will be handled.



Additional resources
7. A number of additional documents, which are complementary to this section, can be found in the appendices. These include:


  • Appendix C: A template covering letter for PCTs to introduce the performance policy work to the LDC and local clinicians

  • Appendix D: Screenshots from the Quality Dashboard available on E-reporting. Further information on how to use this is contained in Section 5 of the guide to developing a local performance policy.

  • Appendix E: Guide to developing a compact with local stakeholders.

8. There is also a Word template performance policy, based on the guide, and to be adapted by PCTs, on the PCC website www.pcc.nhs.uk/dap-delivering-dental-access-more-effectively.




Case studies and examples
A case study looking at how NHS West Essex developed its performance policy is given in Appendix F.
Two examples of PCT performance policies – from NHS South West Essex and NHS West Essex – are available on the PCC website www.pcc.nhs.uk/dap-delivering-dental-access-more-effectively. NHS PCC acknowledges the invaluable assistance of these PCTs in producing this guide.



1. Policy Context and Purpose of Document
This section should set the policy context and should mention key national policies (see below) and any relevant local policies. It should also set out the purpose and scope of the document.




Suggested text


  • XXX PCT is responsible for ensuring that high quality NHS dental services are available to anyone in the PCT’s area who wishes to use them. These NHS dental services should represent value for money for patients and taxpayers.

  • Our aim is to encourage, recognise and reward high performing dental practices, identify and support providers who do not currently meet performance standards and, ultimately, take action (where performance does not improve) when providers are unable to deliver against contractual performance standards.

  • This document sets out how the PCT will carry out these responsibilities through the management of its NHS dental contracts. Specifically, this document:




    • Sets out the clinical and non-clinical performance standards

    • Makes clear how XXX PCT will manage performance

    • Sets out a transparent, consistent, and equitable approach

    • Provides assurance to PCT Board that contractual issues are being properly managed

    • Formalises performance management activity across all dental contracts

    • Demonstrates how XXX PCT will meet the QIPP agenda.






Processes
Stakeholders with an interest in the development of this document might include:

  • Local clinical champions

  • LDC

  • Health Overview & Scrutiny Committee (who may be particularly interested in access and in meeting need)

  • PCT dental commissioning group (or equivalent)

It may also be useful to share this work with other neighbouring PCTs



References, Regulations & Resources


  • Our vision for primary & community care

  • Developing the NHS Performance Regime, Department of Health, June 2008, Gateway 10029

  • NHS Operating Framework

  • Local Oral Health Needs Assessment

  • Any relevant local primary care policies, e.g. clinical governance policy

  • Dental Access Plan

  • CQC standards.

Processes
Stakeholders with an interest in the development of this document might include:


  • Dentists and their teams

  • Local clinical champions

  • Local Dental Committees

  • Health Overview and Scrutiny Committee (who may be particularly interested in access and in meeting need)

  • PCT dental commissioning group (or equivalent).

It may also be useful to share this work with other neighbouring PCTs, or across the SHA.







2. PCT Expectations
This section should set out the PCT’s expectations across the full range of performance, including clinical and non-clinical aspects. Depending on local history, there may be issues relating to harmonisation (e.g. where a PCT has inherited a legacy of different policies from predecessor organisations) that need to be handled on a fair and consistent basis.





Suggested text
A key aim of this document is to make explicit the standards – both clinical and non-clinical – that the PCT expects of its primary care dental providers. The dental regulations require contractors to comply with all relevant legislation and “have regard to all relevant guidance issued by the PCT, the relevant strategic health authority and the Secretary of State”. This means that contractors should take account of this document and, in particular, the performance expectations set out below.
It is important to note that performance will not be measured simply in terms of units of dental activity (UDAs) - access, quality and patient experience are all important.
The PCT’s expectations are summarised below, together with the relevant reference to the Regulations (where appropriate):
Access

  • XXX PCT is responsible for ensuring access to NHS dentistry for anyone who seeks it within the PCT’s area.


Patient Experience and Choice

  • To be completed according to PCT’s practice/policies


Activity

  • all contractors to deliver 100% of their contracted activity each year

  • even delivery of activity throughout the year (contractors receive equal monthly instalments of their annual contract value based on the expectation that the agreed contract activity will be provided reasonably evenly over 12 months of the year - or the contract period if the contract is part-year - thus ensuring continuity of patient care and access to services). XXX PCT will also take account of any special circumstances that might have occurred during the year.


Quality and Governance

  • delivery of high quality clinical services within current clinical guidelines (e.g. NICE) and within the PCT’s clinical governance standards and policies (e.g. decontamination)

  • keeping of good clinical records

  • completion of treatment plans in line with the Regulations

  • each practice to have appropriate arrangements for infection control and decontamination.




References, Regulations & Resources


  • Compliance with relevant legislation & guidance issued by PCT, SHA or Secretary of State – GDS Regulation 24, Schedule 3, Part 10; PDS Regulation 20, Schedule 3, Part 10

  • Compliance with NICE guidance GDS Regulation 24, Schedule 3, Part 2; PDS Regulation 20, Schedule 3, Part 2

  • Infection Control– GDS Regulation 24, Schedule 3, Part 2; PDS Regulation 20, Schedule 3, Part 2

  • Submission & completion of FP17s - GDS Regulation 24, Schedule 3, Part 5, para 38; PDs Regulation 20, Schedule 3, Part 5, para 39Compliance with PCT clinical governance arrangements - Regulation 24, Schedule 3, Part 10

  • Practice quality assurance system - GDS Regulation 24, Schedule 3, Part 10; PDS Regulation 20, Schedule 3, Part 10

  • Premises, facilities & equipment - GDS Regulation 24, Schedule 3, Part 2, para 12; PDS Regulation 20, Schedule 3, Part 2, para 13

  • Treatment Plans - GDS Regulation 24, Schedule 3, Part 2; PDS Regulation 20, Schedule 3, Part 2

  • Patient Records - GDS Regulation 24, Schedule 3, Part 5; PDS Regulation 20, Schedule 3, Part 5

  • Activity - type and level of activity to be delivered must be specified in the contract/ agreement (GDS & PDS Regulations Part 5)

  • Even delivery throughout the year - Revised guidance: primary care dental contracts - Advice on managing end of year issues Department of Health April 2008, Gateway 9787.




Suggested text – continued…
Submission of FP17s

  • FP17 forms should be fully completed and submitted to NHS Dental Services (DS) within two months of completion of the course of treatment

  • although NHSDS will process all forms received, the PCT has discretion to discount any activity relating to forms which are submitted late

  • XXX PCT will discuss with the contractor the reasons for late submission of any claims before taking any action. Prior warning will also be given to the contractor of any historic patterns of late submission and the PCT’s intention to disregard any future late claims.


Infrastructure

  • premises and equipment: adequate and sufficient premises, facilities and equipment standards met

  • staff training and development: staff receive regular update training

  • adequate policies and procedures are in place: e.g. equal opportunities, handling serious untoward incidents.



Processes
It may be useful to discuss this section initially with the PCT PEC or Commissioning Forum.
Discuss also with local dentists, local clinical champions and the LDC.




3. Key Principles
This section should set out the key principles on which the document is based, and should dovetail with Section 1.



Suggested text
This document is based on the following key principles, which reflect the national policy context outlined in Section 1:


  • Collaborative - the development and implementation of this document will be based on a two-way dialogue with contractors

  • Transparent – there will be clear and predetermined performance measures and interventions

  • Consistent – there will be a broadly uniform approach across the PCT

  • Celebrating success – identifying and rewarding high performance, sharing good practice

  • Proactive – XXX PCT will aim to identify any underperformance at an early stage so that it can be addressed, especially where there is a risk to patient safety

  • Proportionate – XXX PCT will aim to ensure that any actions taken are proportionate to the risk involved

  • Supportive – initial interventions will seek to offer support and focus on recovery while ensuring the root causes of a problem are addressed.




Processes


Discuss with local dentists and clinical champions and the LDC.

References, Regulations & Resources


  • Developing the NHS Performance Regime, Department of Health, June 2008, Gateway 10029, Department of Health, June 2008, Gateway 10029.



4. Supporting Contractors
This section should describe the PCT’s role in helping and supporting its contractors. It may be helpful to think in terms of developing a reciprocal approach or ‘compact’ setting out the respective expectations and responsibilities of the PCT on the one hand and its contractors on the other. See Appendix E for more details on how to develop a compact.
The performance spectrum diagram in “Developing the NHS Performance Regime” may also be useful. The PCT will need to work through the performance spectrum from one end to the other and consider what support it might offer and the actions it will take in a given set of circumstances, for example:


  • Approach to risk sharing

  • Specialist support from PCT staff, e.g. finance, public health

  • Circumstances that are likely to lead to decommissioning a practice

  • Interventions and support that PCT might undertake to improve performance

  • Rewards for, and recognition of, good practice (see 4.1 below).

Other issues to consider include:




  • Developing clinical leadership and clinical engagement – whether/how the PCT will support training for local clinical leaders

  • Links with local deanery

  • Supporting and developing training practices.

It is important that local dentists have ownership of this part of the policy. It is recommended, therefore, that PCTs develop this section in collaboration with them and other key local stakeholders such as the LDC. The generic material included below may be helpful for this.






Suggested text
The PCT’s aim is to support contractors in delivering high quality NHS dental care that represents value for money to both patients and taxpayers. The diagram below is taken from the Department of Health document “Developing the NHS Performance Regime”, and illustrates the spectrum of performance.

.




Processes
Discuss with local dentists and clinical champions, PCT commissioning forum (or equivalent), LDC, Deanery.

References, Regulations & Resources


  • Developing the NHS Performance Regime, Department of Health, June 2008, Gateway 10029, Department of Health, June 2008, Gateway 10029

  • Relevant PCT policies eg clinical governance

  • Back on track - Restoring doctors and dentists to safe professional practice (NCAS framework document http://www.ncas.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=9418)

  • Courses for GDPs eg part time course offered Autumn 2010 by UCL Eastman Dental Institute covering:

  • Clinical leadership and service delivery

  • Clinical excellence

  • Improving oral health.

Contact tel: 020 7905 1234/1261

E-mail: m.kelly@eastman.ucl.ac.uk




Suggested text (continued)
XXX PCT will use metrics and other information sources to identify where practices lie on this spectrum, with the aim of helping them move towards excellent performance. These metrics are explained fully in section 5.
At the ’failing’ end of the performance spectrum, there will be actions and interventions the PCT will take to support practices where contact performance has been consistently poor, and where recovery is either impossible or likely to require significant external support. At the excellent end of the performance spectrum, of the PCT will continue to provide some practical help, such as seasonal reminders regarding end of year submissions, as well as celebrating success and sharing good practice.
Regular monitoring will enable the PCT and practices to spot trends and identify issues which need to be discussed at an early stage. This can help prevent an issue developing into a major problem by the year end, when it may be more difficult for remedial action to be taken.
The PCT will seek to create an environment where contractors feel able to identify concerns and seek PCT support.
The PCT will establish several communication mechanisms to support and assist practices, including:


  • Sharing best practice (both from within PCT area and externally)

  • Setting up/supporting local learning networks for dentists (including both contract holders and associates)

  • Alert letters to all contractors at risk of under-delivery in January each year

  • Regular practice newsletter.






4.1 Identifying and Celebrating Success
In this section, the PCT should set out the mechanisms and/or incentives that it will use to reward excellent performance. These might include:


  • Article about practice in regular PCT newsletter

  • Sharing particular aspects of good practice

  • Recognition system based on principle of earned autonomy, e.g. practices subject to a lighter performance monitoring regime

  • Support for high performing practices to become accredited training practices

  • High performing practices eligible for accreditation to provide an increased range of specialist dental services commissioned through an AWPP (any willing PCT accredited provider) process.



Suggested text
XXX PCT wishes to recognise and publicise excellence. In this context ‘excellence’ may mean either

high performing and innovative contractors who consistently meet the challenges arising

from national and local priorities, or those who are able to demonstrate above average achievement across the balanced scorecard service performance domains.
XXX PCT also recognises that high performing providers are valuable role models which can

provide peer support to their local dental colleagues.


Insert explanation of: PCT mentoring scheme, recognition scheme etc as appropriate.





Processes
Discuss with local dentists, clinical champions and Local Dental Committee. It may also be useful to involve local patient representatives and/or Health Overview and Scrutiny Committees.





5. Measuring Practice Performance
This section should set out how the PCT proposes to monitor and measure contract performance, both clinical and non-clinical, and might include:


  • Explanation of the PCT’s process for performance managing contracts. This might include an annual timetable, PCT’s practice visit programme etc

  • Explanatory list of key metrics that PCT will use to measure practice performance, e.g. number of UDAs/UOAs delivered, balanced scorecard, recall intervals, exception reports etc

  • How clinical performance will be managed, including the role of the Dental Practice Adviser, NHS DS Clinical Policy Adviser and the link to the PCT’s clinical governance framework

  • Frequency that the PCT will carry out the various monitoring activities

  • Thresholds for intervention/investigation (for example, under-delivery of more than 4% in two successive years; more than X% of Band 1 - Band 1 treatment for the same patient within six months; more than 10% of Band 3 - Band 3 treatments for the same patient within two months)

  • What information the PCT will be sharing with practices routinely

  • How the practice can best prepare for good performance

  • How patients will be involved in this process.

A quick and easy approach which might be adopted – perhaps pending the development of a comprehensive balanced scorecard - might be to use the new quality dashboard on E-reporting (see Appendix D).This includes information on the percentage of FP17s for the same patient within specified recall intervals, by contract and a trend analysis over time. Together with information on a clinical indicator (e.g. percentage of patients with more than one Band 3 in a given period, single inlays or single tooth dentures (as these should be exceptional)), this simple analysis can be used as the basis for discussion with clinicians.





Suggested text
XXX PCT will monitor performance under its contracts with dental providers in order to help ensure service standards remain consistently high.
Occasionally, the PCT may need to intervene to address underperformance. Interventions will be proportionate to risk and will initially be aimed at supporting recovery. XX PCT will always aim to identify underperformance at an early stage so that it can be addressed before it becomes a serious problem.
Where a provider underperforms seriously or persistently, then the PCT’s intervention may be aimed at safeguarding patient safety or public money and/or initiating action to procure services from elsewhere.
It is not possible to provide template text for the remainder of this section, as each PCT will need to agree and define the metrics it will use to monitor its dental contracts.



Processes
PCTs may find it helpful to consider, in the context of their local governance system/SFIs, what constitutes “material financial risk” as this is not defined in the dental Regulations.
PCTs may also wish to discuss and explain the use of metrics with practices and the LDC.

References, Regulations & Resources


  • PCT clinical governance framework

  • Dental Contract Management Handbook – Appendix A & B

  • Quality Dashboard on E-reporting.





5. 1 Mid-Year Reviews
The GDS and PDS Regulations are quite specific regarding mid-year reviews, and PCTs may wish to consider reproducing the exact wording from the Regulations in this section of the document.
This section should also explain:

  • What form the mid-year review will take (where one is undertaken)

  • Circumstances in which the PCT will withhold payments

  • Any additional activities the PCT wishes to combine with the mid-year review process/meeting.



Suggested text
The GDS and PDS Regulations require the PCT to determine, by 31 October each financial year, the level of activity that the contractor has provided between 1 April and 30 September that year.
Where the contractor has provided less than 30% of the contracted activity, the PCT will notify the contractor that it is concerned about the level of activity delivered in the first half of the year, and require him/her to participate in a mid-year review meeting. This meeting will held at the PCT’s premises. [Insert any further details about the format of the mid year review meeting.] Following this, the PCT will produce a draft report of the meeting which it will send to the contractor for comment. A final record of the meeting will then be produced, having regard to any comments made, and a copy sent to the contractor.
Where, following the discussion at the mid-year review meeting, and subsequent sending of the final report to the contractor, the PCT remains concerned about the ability of the contractor to provide the contracted level of activity by the end of the financial year, the PCT may do either or both of the following:


  • require the contractor to comply with a written action plan designed to ensure delivery of the required activity by the year end

  • withhold monies payable under the contract.

The Regulations stipulate that the maximum withholding is the total contract value less twice the value of the activity provided between 1 April and 30 September. Any monies withheld will be paid to the contractor as soon as possible after the end of the financial year if the contractor delivers 100% of contracted level of activity. In the event of under-delivery amounting to 4% or less, the PCT will pay the withheld money, but Regulation 19 (Regulation 15 in PDS Regulations) will apply (see section 5.3 below).


The level of activity or the contract value may be adjusted by mutual agreement in accordance with the Regulations (Schedule 3, Part 8, Para 59 (4) and Part 9 Para 61).



Processes


Discuss with local dentists and Local Dental Committee.


References, Regulations & Resources


  • NHS (GDS Contracts) Regulations Schedule 3 Part 8 para 59(4);also Part 9 para 61

  • NHS (PDS Agreements) Regulations Schedule 3 Part 8 para 59 (4); also Part 9 para 61.



5. 2 End-of-Year Reviews
This section will explain how the PCT will manage end-of-year reviews, including the process that the PCT will follow in particular circumstances – for example, which practices will have face-to-face meetings followed by a letter confirming action agreed? In what circumstances will end year reviews be handled solely by letters?
Other issues which may need to be considered will depend on local circumstances and may include:


  • Mixed contracts - will the PCT allow ‘netting off’ of underperformance on, say, UDAs against over performance on UOAs?

  • Transfer of activity between branch surgeries – will this be allowed and, if so, with what provisos?






Suggested text
The NHS Dental Regulations require that PCTs provide all contract holders with an annual report on performance and to undertake an annual end-of-year review.
Once the annual report has been prepared, the PCT will contact each contract holder regarding their annual review. This may involve a face-to-face meeting.
Contract holders that achieve 96%-100% of their contracted activity will not be required to attend a meeting as part of the end-of-year process (unless the contract holder specifically requests a meeting or there are other performance issues that have arisen).
Contract holders that deliver less than 96% of their contracted activity will be required to attend an end-of-year review meeting. See also Section 5.4 below.




Processes
Discuss with local dentists and Local Dental Committee.


References, Regulations & Resources


  • NHS (GDS Contracts) Regulations Schedule 3 Part 5, para 39

  • NHS (PDS Agreements) Regulations Schedule 3 Part 5, para 40

  • NHS Dentistry Revised guidance: primary care dental contracts Advice on managing end of year issues (Department of Health, April 2008, Gateway 9787).




5. 3 Managing Under-delivery – Over 96% but Less Than 100%
This section should set out how the PCT will manage one-off instances of under-delivery, when it is less than100%, but is over 96%, in the context of other aspects of the contractor’s performance being satisfactory.




Suggested text
The GDS Regulations (Reg 19) and PDS Regulations (Reg 15) say that a PCT is not entitled to take action for a breach of contract in relation to under provision of UDAs or UOAs, providing that failure amounts to 4% or less during a financial year, and the contractor agrees to provide, and does provide, the units it has not provided within such period of not less than 60 days that the PCT specifies in writing.
This is designed to enable dentists to benefit from the security of monthly contract payments, but without having to manage workload precisely to the year-end.
Any contracts which deliver 96% or more (but less than 100%) of their agreed contracted activity will be required to make good the shortfall in activity in the following financial year, within a specified time period agreed with the practice (which will be at least 60 days).
The under-delivered UDAs or UOAs will be recorded on the NHS Dental Services Payments-on-Line system, and contract holders will be required to deliver this activity in addition to their contracted activity for that year.



Processes
Discuss with local dentists and Local Dental Committee


References, Regulations & Resources


  • NHS (GDS Contracts) Regulations, Regulation 19

  • NHS (PDS Agreements), Regulation 15.




5. 4 Managing Under-delivery of Under 96%
This section will explain the PCT’s approach to managing serious instances of under-delivery (e.g. where there is a breach of contract). Points to consider include:


  • Will the PCT issue remedial breach notices automatically in all cases? Or only following discussion to ascertain whether there is any reasonable cause for the breach?

  • Explanation of remedial breach process, including what may happen if the breach is repeated

  • The PCT’s expectation that the contractor will make good 100% of the shortfall, on the basis of a reasonable repayment plan agreed with the contract holder. See also Section 7.

  • Making good the shortfall – will the PCT accept activity or cash (or a mix of both)? Over what timescale is repayment to be made? (NB. A PCT would normally expect repayment to be by 31 March of the year in which the end-of-year review takes place).



Suggested text
Under-delivery of more than 4% of the annual contracted level is a breach of contract under the dental Regulations. In such circumstances the PCT will automatically issue a remedial notice.
Where contractors wish to put forward exceptional circumstances as a reason for any under-delivery, these will be reviewed on a case by case basis, taking into account such factors as the contractor’s history of delivery.
The remedial breach process is explained in Section 9. Each case will be examined on an individual basis. The PCT will need to understand what has led to the breach position, and how things can be put right to avoid it happening again.
The expectation is that the contractor will make good 100% of the shortfall, on the basis of a reasonable repayment plan agreed with him/her. Insert explanation of how the PCT will expect the shortfall to be made up and the timescale.


Processes


Obtain input from PCT Finance department

References, Regulations & Resources


  • NHS (GDS Contracts) Regulations Schedule 3 Part 9 para 73

  • NHS (PDS Agreements) Regulations Schedule 3 Part 9 para 71.




5.5 Managing Persistent Under-delivery of More Than 4%
The PCT has a responsibility to patients, the public and other dental contractors to address repeated under-performance which has not been agreed in advance. The PCT is likely to wish to manage ongoing under-delivery in successive years differently from one-off instances.




Suggested text
XXX PCT’s aim is to ensure the provision of high quality dental services that represent value for money for both patients and taxpayers.

Where any contracts underperform by more than 4% in two successive years, the PCT will reassess the position (including considering any mitigating factors such as high clinical needs or decreasing patient numbers) and may seek to renegotiate the contract value on a recurrent basis in order to release money that can be re-invested in dental care elsewhere. This is likely to entail agreeing:


(a) an appropriate new recurrent contract value, and

(b) a one-off reduction in the new contract value to reflect the repayment due from the previous year.


Any adjustments to contract values will be processed through NHS Dental Services to ensure that the provider’s superannuation contributions are amended appropriately to reflect the revised sum.
The PCT may appeal to the NHS Litigation Authority where there is a failure to agree a revised contract in cases of persistent under-delivery.


Processes
Discuss with local clinicians, Local Dental Committee.

References, Regulations & Resources


  • Dental Contract Management Handbook Department of Health, January 2010, Gateway 12589 section 04.05

  • NHS Dentistry Revised guidance: primary care dental contracts Advice on managing end of year issues (Department of Health, April 2008, Gateway 9787).








5. 6 Over-delivery
Any payment for over-delivery is discretionary. This section will explain how the PCT will manage instances of over-delivery, for example:


  • Payment of up to 4% of the contracted UDAs/UOAs, subject to prior agreement from the PCT where the contract is meeting agreed quality standards

  • The PCT may wish to agree to count some over-delivery of UDAs/UOAs completed in the previous financial year against the contractor’s annual requirement for the next year. In this case, all income from patient charges relating to courses of treatment completed in the previous year would still be credited to that year’s accounts and could not be carried forward into the next year’s accounts. Department of Health advice is that “PCTs would need to consider carefully the implications of bringing forward any significant amount of activity from the previous year, in terms of the impact on service levels and patient charge income in the new year. In line with the 4% tolerance for under-delivery, PCTs might wish to limit any flexibility of this kind to 4% of the annual UDA/UOA total. “

  • No carry forward of activity to the following financial year?

  • No payment or carry forward of activity for over performance above a certain level?

  • Over performance by vocational trainees – Any activity over and above 1875 UDAs will not be counted towards the practice’s contracted activity level.






Suggested text
The PCT should set out its policy in respect of over-delivery here, using the checklist above. Consider including:


  • process for prior agreement of any over-delivery

  • timescale, e.g. minimum period before year-end that the PCTs requires to consider any applications from contractors

  • circumstances where the PCT will consider applications, e.g. from specific geographical areas where there is still a demand gap

  • any limits on the number of time a contractor may seek agreement for over-delivery.




References, Regulations & Resources


  • The dental Regulations are silent on the subject of over performance, so any payment for over performance is at the PCT’s discretion.

  • Revised guidance: primary care dental contracts - Advice on managing end of year issues Department of Health April 2008, Gateway 9787.






5.7 Managing Recall Attendances
This section should clarify the PCT’s expectations in this area, specifically:


  • Compliance with current NICE guidelines

  • Appropriate clinical behaviour and treatment planning

  • Repeated Band 2 & Band 3 claims after short intervals for the same patient ID.

It should also describe the PCT’s approach to identifying issues and/or outliers, and how the PCT will manage/mitigate risk of under-delivery for practices which work with the PCT to bring their clinical practice into line with the NICE guidance (see Section 4 on risk sharing).








Suggested text
The PCT expects local contractors to deliver services in accordance with current NICE guidance on dental recall intervals and, therefore, would not normally expect to see large numbers of people being recalled within a few weeks or months.
The PCT will review the data supplied by NHS DS at monthly/quarterly intervals in line with the metrics described in Section 5 above. This will include benchmarking with neighbouring PCTs. Where the data indicates there may be an issue, the PCT will need to discuss this with the relevant contract holders. The PCT will need to understand whether high rates indicate that there is an issue with treatment planning and, if so, if there is a need for clinical support.
The PCT will seek to identify and recognise practices that are working well within NICE guidelines and share good practice locally.
Where a practice works with the PCT to increase compliance with NICE recommendations, and this makes the practice vulnerable to under-delivery of contracted activity, the PCT will consider underwriting this for the current contract year and/or take this into account when reviewing activity for the year.






Processes
Inclusion of the NICE guidelines in the PCT’s clinical governance framework for NHS dentistry.
Consult with the LDC.
Publicise PCT approach to all local dentists.

References, Regulations & Resources

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