NHS England (West Midlands) Community Dental Services Review
Presentation to joint meeting of Birmingham and Solihull HOSC. 29 November 2018 NHS England (West Midlands)
NHS England in the West Midlands covers:
• Birmingham and Solihull • Coventry and Warwickshire • Herefordshire and Worcestershire • The Black Country
What are Community Dental Services (CDS)?
• All Community Dental Services offer elements of Children’s Dentistry and Special Care Dentistry. • Across the West Midlands a varied set of other services are provided, often for local historic reasons including: – More complex treatments not available locally in High St (Restorative in Birmingham); – domiciliary care (both Solihull and Birmingham); – sedation services (both, but differences in eligibility); – general anaesthetics for children and/or adults - may be offered for extractions only or for comprehensive care; (provided for children at the Birmingham Dental Hospital under the secondary care contract for both areas); – dental Public Health services for Local Authorities (Epidemiology (both) and Oral Health Improvement (both)).
The CDS in Birmingham
• Provided by Birmingham Community Healthcare Foundation Trust; • Services are provided from the following Health Centres - Aston, Farm Road, Northfield, Soho, Sparkhill, Stockland Green, Richmond Primary Care and Attwood Green; • Child General Anaesthetic cases are referred into the Birmingham Dental Hospital; Adult Special Care provided at other hospital venues • Mobile services are available, mainly for children; • Across the four local authority areas BCHC currently deal with approximately 30,000 appointments per annum for children and 23,000 for special care patients; • By comparison, there were 744,429 courses of treatment delivered as a whole by primary care dentists in Birmingham (source: NHS Dental Statistics for England 2016/17).
The CDS in Solihull
• Provided by Heart of England Foundation Trust; • Services are provided at Grove Road, Hurst Lane, Land Lane and Shirley; • GA for adults previously offered from Spire Parkway. GA for children is by referral to the Birmingham Dental Hospital; • Mobile services are provided to children in targeted/special schools; • Service provides more than 3,000 attended appointments for children and more than 4,000 for special care dentistry patients; • By comparison, there were 136,726 courses of treatment delivered as a whole by primary care dentists in Solihull in 2016/17 (ibid).
Aims of the Review of the CDS
• To review current CDS service provision in order to – fully understand the nature of each service in light of the relevant Guides for Dental Commissioning; – identify, assess and consult upon options for change in order to improve equity of access to CDS services across the West Midlands Local Office.
Indicative timetable
• Phase 1 – fact-finding (establishing details of current services): September 2016 to June 2017; • Phase 2 – Public and Patient Engagement: July 2017 to March 2018; • Phase 3 – Identifying options for change, engagement and consultation: March 2018 to March 2019; • Phase 4 – Implementation (dependent on outcome of consultation – to be confirmed). Engagement (to date and in future)
• Two stakeholder engagement events were held in March 2018 to discuss findings of Phase 1 (fact- finding); • A Patient and Public Engagement Study was completed; • Further events were held in April 2018 to discuss findings of Phase 2 (patient & public engagement) and options for change; • Approval to publish a consultation document is to be sought from the relevant NHSE Board early in December.
Key elements of Stakeholder Engagement (and Consultation) • How many Community Dental Services should there be in the West Midlands? • What should be the ‘core offer’ of the Community Dental Services? • How should the services most appropriately be paid for? • How should the services most appropriately be staffed, led and managed?
How many Community Dental Services should there be in the West Midlands? (1) Why this is important? • Economies of scale; • Equitable access for patients; • Quality of service (including common policies and standards); • Making best use of staff with scarce skills and experience; • Fit with overall direction of travel (e.g. STPs). How many Community Dental Services should there be in the West Midlands? (2) Participants at the event commented on four models: • Option 1: One service for each Local Authority (LA) area (current provision); • Option 2: One service for whole Local Office (i.e. covering 10 LA areas); • Option 3: One service for each STP (or ICS) area; • Option 4: Another configuration (more than one, less than ten). NB – participants were also invited to identify any other models that they felt were preferable. None identified.
How many Community Dental Services should there be in the West Midlands? (3)
10 services 1 service STPs Other
Commonality of approach Skills mix Consistency in record keeping Equity of resources and services Interaction with STP/ICS Impact of service failure Disruption to services Achieving economies of scale Local Knowledge What does this mean for Birmingham and Solihull? If ten services: Status quo remains – with its existing advantages and disadvantages. Little disruption to services but misses the opportunity to address existing issues re inequity of provision etc.;
If one service: Current services in Birmingham and Solihull would instead be delivered by a single provider responsible for a much wider area. Significant disruption to services but opportunity to achieve greater efficiency and greater consistency of provision;
If aligned to STPs: Services would be delivered on the Birmingham and Solihull STP footprint; a single service covering both local authority areas working to common policies and standards;
If another option: It may be possible to achieve many of the advantages of an STP-aligned model but (clearly) there would potentially be a disconnect with the relevant STP. What should be the core offer of the Community Dental Service? (1) Why is this important? • Addresses current significant variance of offer to patients across the West Midlands; • Ensures greater equity of access to services for patients; • Helps ensure that scarce skills and experience are used where they are most needed. What should be the core offer of the Community Dental Service? (2)
Birmingham Solihull Adults: Level 2 Special Care Dentistry (SCD) Yes Yes Level 3 SCD Yes Yes Urgent Care & Domiciliary for Level 2 & 3 SCD Yes Yes- OOH separate patients contract. Children: Medically compromised children (Level 3) Yes Yes Anxious children needing IS, IV or GA including Yes (GA under Yes (GA under acute high caries child (Levels 2 and 3) secondary care secondary care contract) contract) Level 2: Hard tissue defects, medical co-morbidity, In some cases. In some cases. dental-alveolar trauma, complexities affecting developing dentition or dental hard tissues Mobile service for special schools Yes (some) Yes (some) What does this mean for Birmingham and Solihull? • Non-core elements (for example out of hours services, sedation services for anxious adults) may be commissioned separately; • Existing CDS providers will be able to bid to deliver these services (as will High St dentists); • Greater equity of core services across the two areas.
How should the services most appropriately be paid for? (1) Why this is important? • Provides an appropriate level of financial stability to services; • Promotes responsiveness to patient needs; • Enables providers flexibility in how they use their resources; • Balances risk between Commissioners and Providers; • Provides appropriate incentives (for example to address delivery issues); • Does not inadvertently encourage restriction of access. How should the services most appropriately be paid for? (2)
Block Activity Capitation Mixed Model Flexibility - patient need Flexibility - resource allocation Underperformance - recovery of cost Perverse incentives to restrict access Incentivises service improvement Flexibility - range of services/patients Incentive to address delivery issues What does this mean for Birmingham and Solihull? • Contract for Birmingham based on a mixed model (activity – UDAs, contacts – and block); • Contract for Solihull is a Block contract; • Agreeing a Local Office-wide basis of payment would lead to greater fairness for Trusts and encourage greater equity of access for patients. How should the services be staffed, managed and led? (1) Why is it important? • Ensuring robust governance arrangements; • Making best use of scarce skills (clinical, leadership etc.); • Ensuring safety while achieving value for money; • Empowering staff to challenge (appropriately).
How should the services be staffed, managed and led? (2) • Participants at the Engagement Events gave their views regarding: – The preferred model of clinical leadership/service management; – Which staff should most appropriately carry out specified tasks within the CDS. • There was little consensus between participants; • However, views expressed have been used in assessing options for the future CDS (e.g. in respect of the number of services); • We do not feel that it is appropriate for us to be prescriptive in this regard and so will not be consulting on these points. General Anaesthetic provision
• There are a number of problems currently with existing arrangements for Treatment under General Anaesthetic for both children and Special Care adults; • The CDS review gives an opportunity to reconsider the way in which services are delivered to address these issues.
Current Issues
• Theatre access is at acute hospitals who provide anaesthetic and theatre support – a number of trusts have reduced or withdrawn sessions over recent years; • The staff who provide dental treatment are employed within the community dental services rather than the acute hospital trusts; • There are governance issues around the oversight of services delivered under these complex arrangements; • There are currently long waiting times in many areas across the West Midlands for both adult special care and children due to lack of theatre availability.
Proposed Way Forward
• Consolidating services to ensure these are robust and facilitate reduction in waiting times; • Increasing capacity and improving facilities through commissioning additional dedicated theatre space; • Contracting directly with Hospitals to address governance issues.
Next steps: CDS Consultation
• Document for approval by internal NHSE Forum on 5 December; • Publication (if approved), shortly thereafter; • 12 week consultation regarding – The number of Community Dental Services within the West Midlands Local Office; – The nature of the core services to be provided by the CDS; – A recommendation as to payment model.
Questions and comments.