Dental Paper                                                Prepared by NHS PCC___________________________________________...
World class commissioningThe aim of world class commissioning, and therefore the ultimate test of its success,will be an i...
Figure 1  Figure 1           Commissioning Health for Best Outcomes                   Population                          ...
 Appropriately resourced – refocus on core budgets and services.This is        where resources are and change here will h...
Delivering Better Oral Health was sent to all dentists and primary care trusts,however we cannot assume that all dental te...
for example children’s centres as sites to deliver a fluoride varnish           programme, or dental practice teams delive...
 If your practices do not employ skill mix is it possible to implement Delivering         Better Oral Health within your ...
The table below from the NHSPCC Oral Health Needs Assessment Toolkit – couldhelp priority setting processPriority Framewor...
Figure 2                                        THE COMMISSIONING QUADRANTS    Quadrant 4                                 ...
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078742Choosing Better Oral...
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  1. 1. Dental Paper Prepared by NHS PCC______________________________________________________________Commissioning to improve oral healthPrimary care trusts have the responsibility to understand the needs of theirpopulation in order to commission effective evidence-informed programmes andservices to reasonably meet those needs. Implementing Delivering Better OralHealth should be integral to that process. There are a number of wider policyinitiatives that PCTs also need to take into account when developing theircommissioning intentions for dentistry.12 January 2009 www.pcc.nhs.uk 1
  2. 2. World class commissioningThe aim of world class commissioning, and therefore the ultimate test of its success,will be an improvement in health outcomes and a reduction in health inequalities.  World class commissioning will deliver better health and well-being  People will live healthier and longer lives (and keep their teeth longer)  Health inequalities will be dramatically reducedWhat does this mean for PCTs?WCC is a shared vision, which has been developed jointly by DH and the widerhealth and care community. It will be delivered by the NHS at a local level and PCTsdevelopment to world class aspiration will be assessed against 11 competencies,outcomes and governance.Robust commissioning processes are based on  Needs assessment and service review  Service and market redesign  Contracting and procurement  Quality assurance and performance reviewThese will be key to success for PCTs. Figure 1 illustrates a commissioning cyclethat PCTs could adopt in commissioning to improve oral health.What does this mean for primary dental care teams?  The days of negotiating, cajoling and modernising to improve outcomes have come to an end?  Specifications and agreed systematic pathways will drive outcomes  Systemising care processes, moving away from variation  Practices will need to ensure they are capable of meeting the needs of patients and requirements of commissioners12 January 2009 www.pcc.nhs.uk 2
  3. 3. Figure 1 Figure 1 Commissioning Health for Best Outcomes Population Challenge to Providers Focus Optimal Population 10. Engaging the 5.Supported self- Outcome public management 4. Responsive 13.Networks,leadership 9. Accessibility Services and coordination 2. Expressed Demand 7. Local Service Effectiveness 1.Known 6.Known Population 12. Balanced Service Portfolio Intervention Health Needs Efficacy 3. Equitable 8.Cost Resourcing 11.Adequate Service Volumes EffectivenessApplying the lessons from the National Support Team on inequalities in oralhealthThe National Support Team helps PCTs make most efficient use of resources toaddress inequalities in health and improve quality of primary care.The team shares lessons learnt and the programme characteristics will include being:  Evidence based – concentrate on interventions where research findings and professional consensus are strongest. Delivering Better Oral Health summarises this for oral health  Outcomes orientated - with locally relevant and owned measurements, eg well understood epidemiological trends, agreed clinical outcome indicators  Systematically applied - don’t depend on exceptional circumstances and champions. All contractors and commissioners should be challenged to deliver what we know works  Scaled-up – industrial scale processes require PCTs to think differently not just to rely on small bench experiments with one or two successful pilots12 January 2009 www.pcc.nhs.uk 3
  4. 4.  Appropriately resourced – refocus on core budgets and services.This is where resources are and change here will have more impact than small project funding  Persistent – continue for the long haul, capitalise on policy priorities, increasing access to NHS dentistry while ensuring that patients receive effective evidence-informed advice and careUse a population approach to commissioning to achieve a change inpopulation health – exploit specialist dental public health adviceLessons learned with primary medical care suggest PCTs need to raise the bar andcommunicate higher expectations for all practices as part of an integratedgovernance approach. As part of that work some practices will require high challengeand high level of support. PCTs will also need to identify and manage incompetentpractice.Strategic planning for preventionPCTs will need to undertake strategic planning steps to stimulate preventiveapproaches in practice and ensure effective interventions are being delivered incontracts to improve oral health. Practices and Local Dental Committees need to beengaged with PCTs to assist in the following steps:Step 1 Set direction – clarify mission  Communicate clear sense of direction – use evidence informed interventions such as those outlined in Delivering Better Oral Health - guidance  Refer back to Options for Change intentions and Choosing Better Oral Health plan for England  Discuss with all stakeholders including patient groupsAll the relevant stakeholders, both internally and externally should know about thedirection.12 January 2009 www.pcc.nhs.uk 4
  5. 5. Delivering Better Oral Health was sent to all dentists and primary care trusts,however we cannot assume that all dental teams know what is required or that PCTs,particularly those without a consultant in dental public health understand it.Both primary care dental teams and the PCT have responsibilities to ensure thatpatients are empowered to know and understand self-care messages and what toexpect from their dentist, eg all children should receive fluoride varnish applicationtwice a year and those giving concern should receive fluoride varnish three to fourtimes yearly, young adults with active caries should be prescribed high strengthfluoride toothpaste.Action - reassess direction for your PCT/practice Reassess the direction – what has and has not been happening? Has there been a local launch of Delivering Better Oral Health? What engagement has taken place between the profession, the PCT and the local population?Step 2 Environmental analysis  The policies Choosing Better Oral Health & Delivering Better Oral Health - how well are they known and understood among members of your team?  Flexibility in the new contract, - how is this being exploited, eg the dental public health component? Are any practices locally delivering any aspects? The benefits of for example fluoride varnish application have been known for some time – are practices delivering this effective preventive intervention in appropriate treatment plans?  Patients and their needs – is there an oral health needs assessment and supporting strategic plan, which has been shared with all practices and is it understood?  What self care messages are readily available? Have these been developed jointly. Do dentists understand the impact they could have highlighting common risk messages, for example, promoting breast feeding to expectant mothers, by exploiting opportunities to offer brief interventions on smoking cessation and signposting patients who want to quit?  Those who don’t attend services and their needs. How do we understand those needs and reach them appropriately? For example, what are the opportunities for you to deliver care using a more innovative approach, using12 January 2009 www.pcc.nhs.uk 5
  6. 6. for example children’s centres as sites to deliver a fluoride varnish programme, or dental practice teams delivering evidence informed dental public health programmes  Primary dental care teams – what prevention are teams delivering at present and how well does that match Delivering Better Oral Health evidence?Step 3 Consider options and choicesPriority  The patient and residents needs and how best the PCT can serve them must always remain at the heart of the planning process. How can primary care dental teams work with the PCT to deliver these aims?Feasibility  Once priorities are established, what are the options available to implement and what are the practicalities in doing so?  How will existing providers react – request more funds for doing what they should have been doing? Some practices may already be implementing but is the PCT aware of it?Contractual issues  Does the PCT need to improve the content and key performance indicators in specifications for new providers? What levers are there for existing contracts?  Opportunity to build Delivering Better Oral Health into service specifications. Primary care trusts may need to offer support and training to implement locally and to assist primary dental care teams employ and understand flexibility of new contract to work more preventively. What support could your PCT offer locally to make implementation a reality?  Consider opportunities to encourage primary dental care teams to undertake dental public health componentsRisk assessment  Whatever choices are made, a risk assessment must be undertaken to ensure that the PCT or practices are not exposed to adverse financial or delivery impact12 January 2009 www.pcc.nhs.uk 6
  7. 7.  If your practices do not employ skill mix is it possible to implement Delivering Better Oral Health within your existing contracts? What are the barriers or opportunities?  Will those who are at least risk get more preventative treatment than they need if NICE recall guidance is not adhered to? No change to population oral health  Could implementation of Delivering Better Oral Health slow progress on opening access?  Possible increase in health inequality gapQuestion - what are the risks locally? Without employing skill mix, will dentist capacity used to implement Delivering Better Oral Health requirements impact on the challenges of meeting vital signs requirements? Is the PCT recognising practices that have embraced evidence informed preventive approaches to care and developed their teams? Has the PCT created opportunities to develop practice staff and encourage skill-mix opportunities?Step 4Planning – write your plans and share  Take stock, use vital signs data, Oral Health Needs Assessment and review all the information from above to develop local practice or PCT goals and targets.  Capture your plan for implementing Delivering Better Oral Health guidance in some kind of written document and think about the resources required to ensure delivery, i.e. purchase of Fluoride Varnish, Training for practice dental nurses etc.  Keep your plans simple, easy to read and understand.Step 5Implementation of Delivering Better Oral Health guidance – be persistentPurpose of this paper is to shape implementation plans and support priority setting12 January 2009 www.pcc.nhs.uk 7
  8. 8. The table below from the NHSPCC Oral Health Needs Assessment Toolkit – couldhelp priority setting processPriority FrameworkIncidence / prevalence How common is the problem/need?Capacity to benefit Will the proposed service benefit few or many patients?Inequalities How does the proposed service address health inequalities?NHS priorities Which NHS priorities does the service address, and how?Time to benefit Will the proposed service provide a quick win or is there an associated lag time?Fit with wider PCT work programme How does the proposed service fit with overall priorities within the PCT?Effectiveness, cost-effectiveness, What is the evidence to support servicevalue for money provision by different providers?Risk assessment What is the risk to the PCT associated with not proceeding with the service?Step 6Evaluation  Agree key performance indicators and use the emerging clinical data set  Ensure NHS epidemiological surveys are commissioned  Use findings from the national adult dental health surveys at a local level (synthetic analysis) and expand local intelligence by linking oral health questions to lifestyle surveys  Use information sources and resources available at public health observatories linked to the dental observatory12 January 2009 www.pcc.nhs.uk 8
  9. 9. Figure 2 THE COMMISSIONING QUADRANTS Quadrant 4 Quadrant 1Quality assurance and Remedial Agree process with Needs assessment andperformance review action partners service review Evaluate impact on oral health OHNA linked to Joint improvement strategic needs assessment Joint provision review and Assess qualitative and equity audit and clinical outcomes development of Oral Health Strategy Manage performance of the contract Agree priorities and investment in strategic plans Public and patient Implement contract involvement Design and agree Negotiate and agree person centred models contracts of delivery based on oral health need Link improvement in Oral Health Define expected outcomes in all services whether of specification including GDS/PCDS/Secondary Care clinical indictors Open up to market/support existing practices to Assess adopt new ways of proposals working to embrace against DBOH requirements specification Contracting and Market services procurement and redesign Quadrant 3 Quadrant 2 References and acknowledgements Delivering Better Oral Health 12 January 2009 www.pcc.nhs.uk 9
  10. 10. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078742Choosing Better Oral Healthhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4123251North West Dental Observatoryhttp://www.dental-observatory.nhs.ukFigure 1 reproduced from diagram produced by Professor Chris Bentley –National Support Team – Health InequalitiesFigure 2 adapted from Oldham PCT WCC document (unpublished)12 January 2009 www.pcc.nhs.uk 10

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