‘Salaried Dental Services’BDA 21st May 2012

Colette M Bridgman

Consultant In Dental Public Health

NHS Manchester / GM Cluster

On secondment to NHS CB Authority

During this presentation I will:• Give a bit of context to current reforms in NHS • Link these changes with how I see the opportunities and

challenges unfolding for SDS teams• Explore how to define the needs of vulnerable groups,

describe the rationale for services and how to monitor outcomes rather than processes

• Need to respond to the direction towards Consultant / Specialist led care?

• Finally NHS CB approach – where might that lead us in development of salaried dental services in England.

Advanced Care Pathway Work - Alignment

Current reforms and what it means for dentistry and SDS

Liberating the NHS – Government’s vision for health July 2010

• Most relevance for dentistry? NHS Commissioning Board / Public Health England / LPN

• This new architecture will take on many of the roles and responsibilities currently discharged by the Department of Health, Strategic Health Authorities and Primary Care Trusts

• The NHS Commissioning Board will be responsible for commissioning all NHS dental services

Public Health England

NHS Commissioning

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Public Health

Primary Dental Care

Secondary Dental Care

DPH schemes

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EducationEngland

Workforce development

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Commissioning Responsibilities

for Dentistry

Eric Rooney Slides

Public Health England

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Health and Wellbeing Board

Understanding Need and Use of Services at the heart

    NE

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Unmet Need Met Need

Appropriate Use Avoidable Use

DEMANDNeed to achieve met need & Appropriate use of services

Need Purpose and function: then form…….‘Specialist Advanced Treatment in Primary Care’

First can we agree the need, rationale and future development of salaried dental services – can I be controversial on title SDS?

• Define vulnerable groups by ‘locality’, describe the need consistently plus

take account of future demographics and trends• Direction? Consultant/specialist led services for vulnerable groups• Should be thinking in terms of Complexity/Need and then Competence and

Quality – team and environment • Consistency of delivery outcomes regardless of Setting

Paediatric - Children firstIssues – Safeguarding andGA Referrals +++ Demand led

GA list in acute centreAnalysis of what is happening and

why and pathway designed to improve care

Involved all sectors Specialist led triageChild friendly GDS good

environment and skills in practice i.e. therapist/IHS

CDS responded rapid access

Impact - Care pathway agreedExposed some primary care

referral decisions and care below expected standards

Reduced reliance on GA and numbers by almost 70%

Most received care with LAFollowed up and offered

continuing care ……… BUT

Can scheme be replicated? Needs to ...

Have Consultant/Specialist input and leadership

Be needs led and commissioners involved

Expose GDPs if isolated – need formal link to specialist/SDS/Secondary Care

Deliver evidence informed practice and reflective learning

Have end to end care pathway redesign – single operating model and collaboration across sectors like we have never had in dentistry – how do we go from where we are now? Current reforms offer opportunities?

The Service Model – NHS CBAdvanced / Specialist Care

• Coherent inter service relationships with integrated dental pathways the point of all connections has to focus on the needs of users

• Currently there is a degree of co-operation but little transparency or sense of coherence to meet needs of patients between settings

• A co-ordinated, patient-centred network of dental services in different settings, embodying alignment of policy making, service commissioning, needs assessment, performance management, funding and consistent delivery of outcome measured quality clinical practice.

End to end redesign integrated pathway to co-ordinate care pathway regardless of setting

Monitoring and evaluation built within a effective single service model with consistent need and outcome measurement

Underpinning PrinciplesAll Primary Care contracts performance

managed – frequent referring performers identified / provider informed – training

Consistent data capture (central capture and referral management in place – one way)

of all referrals to all specialtiesAligned need/diagnostic coding and tariff/costConsistency of Specification: quality standards, equipment environment and qualifications/competenceAltered job plans for specialists

So referral management ……….

Referral management – all referrals are centrally captured for all specialties.

To date over 1500 referrals processedSteady increase in quality and content of referrals

Rejections reduced from 18% to less than 5%Diversion from secondary to primary care achieving 30% rate

Referrers can easily check the progress of their referral

NHS CB. Design a commissioning system for secondary care dental specialties and salaried dental services capable of excellence

In doing so by specialty there is a need to have in place:

• Ability to describe & meet need• Have consistent delivery and reporting of evidence based services,

diagnosis and outcomes (coding and tariff aligned)• Have a clinical consensus on case complexity that can be adopted within

agreed care pathways – same quality and reporting regardless of setting• A managed clinical network/shared service and single operating model• Clinicians leading and influencing change …….• Excellence & investment/shift to in primary care

Outcomes that will assist:

• Clinical consensus on consistent approach to data collection • Robust information on need /procedure assists understanding

trends• Use evidence base on effectiveness of procedures & outcomes • Produce a consensus on exactly what is defined as minor,

intermediate or major – competence, qualifications, environment • Need to map current service provision and links, WF and costs• Space - to think through how it could be – incentives and barriers• Describe any innovation in system and validate• Same standards and tariffs in secondary and primary care setting?

The Seven Pillars of GP Commissioning

The Seven Pillars of Commissioning

From the old world to the new

From compliance

States a minimum performance standard that everyone must achieve

Uses hierarchy, systems and standard procedures for co-ordination and control

Threats of penalties/sanctions/shame creates momentum for delivery

Based on organisational accountability

To commitment

States a collaborative goal that everyone can commit to

Based on shared goals, values and sense of purpose for co-ordination and control

Commitment to common purpose and creative energy for delivery

Based on relational commitment

Source: Helen Bevan 2011

...deliver a better balanced system for Central Manchester shifting from:-

- Hospital care to services delivered in the community

- Clinical care to patient self care

- Measuring quantity to measurement of quality

- What the NHS spends to what it can afford

Success will be:--Improved life expectancy

-Improved quality of life for people with long term conditions

-Effective recovery from ill health & injury

-Excellent patient experience

-Safe and effective services; no avoidable harm

-Hitting our targets

-A balanced budget bridging our 2% financial gap

Public health, prevention and patient partnerships - Empowering patients- Promoting healthy lifestyles - Supporting self care- Preventing ill health- Identifying disease early and reducing its progression

Quality of care- Quality improvement

-Primary care-Education and learning-Medicines optimisation

- Quality assurance-Driving quality and safety in the services we commission

Service reform and integrated care-Long term conditions management-Integrated care pathways for planned and urgent care-Mental health services-Services for children

Making it happen- Leading the health system- Measuring quality & outcomes- Shifting resources to community settings- Incentivising for quality- Contracting and performance

Our 41 member practices within four localities

Our provider partners- CMFT- MMHSCT- NWAS- Adult social care- Children’s services- Primary Care- Voluntary sector

Clinical and managerial leadership- CCG Board-Health and Wellbeing Board-Clinical Integrated Care Board

April 2012 – March 2015

Our group

-41 member GP practices-£265m budget-211,000 population and growing-a young population; 56% under 30-Over 30% from BME groups-High levels of deprivation-High prevalence of long term conditions

Our Mission‘Informed by the views of local people and working closely with other health and social care professionals; Central Manchester Clinical Commissioning Group will design and develop health services which are high quality, safe and affordable and which will support communities to be the healthiest they can be.‘

We will be:--Fair in the way we make decisions-Honest about the decisions we make and why we make them-Open in our approach to decision making, encouraging involvement in our processes and structures-Intolerant of poor quality services and health inequalities-Robust in our support for the NHS and local health services

Patient and public involvement at every level of our organisation

Commissioning colleagues- Partner CCGs- Manchester City Council- NHS Greater Manchester- Commissioning support services

A culture of continuous improvement

Development of an excellent commissioning organisation-Strong leadership-A great team-Good systems and processes

People die too young in Central Manchester. We also know that people die younger, and are more ill, in some parts of our locality than others. Central CCG will work with Manchester City Council to deliver targeted programmes addressing these health inequalities; preventing people becoming ill (or more ill), identifying illness early and supporting our communities to manage their own health and use the right services when they need them.

Supporting self care

Establish locality based delivery of long term condition self management programmes

Deliver enhanced Choose Well campaign

Improved patient information on treatment of minor ailments in children

Telehealth for patients where appropriate

Preventing ill health

Establish brief intervention programmes for smoking, alcohol and weight

Increase immunisation and vaccination rates

Identify disease

Increase delivery, and uptake, of health check programmes

Cancer awareness and early detection campaigns

Improve screening rates – adult, pregnancy, neo-natal

Promote HIV testing

Improving services

Redesign Sexual health services (young people’s services and general outpatient services- developing GM specifications)

Drugs Service re-design and re-tender

Review of alcohol care pathway

Reform of School Nursing service

Public health, prevention and patient partnerships

Outcomes

TBC TBC TBC TBC TBC

Local Professional Network – to have those conversations and influence

• Steering Group• Narrative and Vision• Establishment??• Don’t miss the opportunity for Dentistry!