1. The role of PCTs in commissioning dental
The experience of Lincolnshire PCT,
as a commissioner of dental services, has been a positive one
in that the PCT has seized the opportunity to undertake procurement
as a vehicle for addressing the challenge of access in the county.
A procurement exercise in 2006-07
resulted in the award of ten new contracts across the county in
areas of highest unmet need.
The reforms allowed the PCT to decide
on the type of service and the location of that service, the new
arrangements allowed the PCT to focus on the more challenged localities,
in terms of access to mandatory dental services, within the county.
Recently there has been the opportunity
to align localities were there has been significant demand to
those of highest oral health need. Lincolnshire PCT has developed
an Oral Health Strategy and an associated draft action plan. The
PCT has identified access and health inequalities as two major
target areas to address within the strategy. There are areas of
significant deprivation within the PCT and while access is improving,
the PCT recognises that more work needs to be done in these areas.
The commissioning process is now
needs based and the PCT has learned a great deal through each
procurement exercise in terms of quality, value for money, and
the move towards an outcome based commissioning approach. A second
review of access was undertaken in early 2007 and it was agreed
to commission an expansion of mandatory services through current
providers and secure additional capacity through a further procurement
tender exercise. This has been actioned through 2007-08 along
side rapid reprovision where an existing provider has decided
to leave the NHS.
The new reforms have allowed the
PCT to drive these changes forward to address access and health
inequalities within the county. Local councillors have been involved
in the review and consultation process and acknowledge that the
reforms have brought about improvements in the commissioning of
NHS dental services.
Orthodontics and minor oral surgery
are an access challenge for the PCT. The PCT is commissioning
services to address this: expressions of interest have been requested
for additional orthodontic capacity and a scoping exercise is
underway for minor oral surgery services. Again, the reforms have
allowed the PCT to determine where this additional capacity should
be located rather than provider.
2. Numbers of NHS dentists and the number
of patients registered with them &
5. Patients' access to NHS dental carean
There are 85 NHS dental providers
in the county and due to the action outlined above this has increased
the numbers of dental performers since April 2006. The number
of patients registered with an NHS dentist is no longer held by
the PCT but the majority of dental practices retain a practice
list in order to manage their contracted activity through the
provision of courses of treatment.
The PCT established a dental contact
list in Autumn 2005 in readiness for the new capacity planned
to be in place from April 2006. The PCT, through contract negotiations
leading up to April 2006, offered existing providers the opportunity
to increase their contracted activity and see new patients (for
example, where a practice wished to retain a VT as a 1st year
However, since the implementation
of the new contract, approximately 55,000 patients have been offered
a place with an NHS practice. The majority of these have been
placed with a new provider but some existing providers have also
offered NHS places. The PCT has used the contact list to populate
the new dental practices as they came on line and this was strictly
managed to ensure fairness and equity of provision. The contact
is still used, particularly for areas where new capacity has been
secured for areas of unmet need. In areas where there is a choice
of NHS dental provider, patients now have direct access to these
practices via practice contact details.
This year there has been positive
feedback from the Lincolnshire Health Scrutiny Committee on the
progress made by the PCT in addressing access to NHS dentistry
since April 2006.
8. The quality of care provided to patientsunder
The PCT has experienced an increase
in referrals to specialist and secondary care. This in part will
be due to the improvement in access to mandatory services and
new patients can be seen and their needs assessed. However, the
Lincolnshire LDC has asked the PCT to investigate whether this
increase could be due the clinical practice of overseas dentists
with little experience of the NHS. In addition, secondary clinicians
have asked the PCT to investigate whether clinical practice has
changed due to the implementation of the new contractual arrangements.
This debate often focuses on the more complex treatments in Band
One particular area is oral surgery
and the PCT is undertaking a process mapping exercise in January
2008 as well as looking at the inappropriate referrals received
by secondary care.
The PCT has developed a service specification
to try and incorporate quality elements into the new services
commissioned, rather than solely activity and price based, and
this is reviewed after each procurement exercise. The PCT is also
developing KPIs and a balanced scorecard for NHS dental service
providers. The PCT has faced a challenge with information available
from the DPD and FP17s to effectively monitor prescribing profiles,
value for money and quality standards.
Many local practitioners still believe
the new contract to be activity driven, hence we are working with
the LDC to develop KPIs and a balanced scorecard (such a system
has been developed for primary medical service providers).
PALs and the PCT complaints department
receive a number of complaints about the treatment charges, which
are followed up with the dental practice. Patients like the simplicity
of the new charge bands but are still confused about what is available
on the NHS.
However, patients are reluctant to
complain or pursue complaints because they are concerned that
their practitioner will not continue to see them. Patient perception
still exists that it is difficult to access an NHS dentist.
9. Dentists' workload and incomes
10. The retention and recruitment of NHS dental
Some local dentists have decided
to leave the NHS since April 2006 and the reason given is the
workload associated with the new contract (ie the UDA rate in
Lincolnshire is low when compared to other PCTs in the SHA area).
Their view is that their clinical behaviour has not changed since
the implementation of the new contract and they continue to undertake
complex treatments under Band 2 rather than focus purely on UDAs.
Their view is that the contract is activity driven and just a
different treadmill. Such a case was reported in the local press
The PCT has been able to re-provide
this activity. However, we wish to develop an approach which balances
workload with the quality agenda as we move towards 2009.
The PCT is working with the Post
Graduate Deanery to extend the current network of training practices.
There is a possibility of three new applicants this year, two
of which are from new practices to the county.
In addition, some of the existing
VT training practices have raised an issue about retaining their
VT as a 1st year associate. The PCT has taken the approach not
to commit growth in a locality where there is not an unmet need;
hence VT training practices in these localities will not be able
to retain their own VT. Local training practices affected by this
approach, believe that this is a negative factor arising from
the new commissioning arrangements.
However, the PCT is working with
the deanery to look at the role of an enhanced training practice
and how the PCT may wish to remunerate such practices.
Some practices have advised the PCT
that retention of dentists is more difficult because of the low
UDA rate. One practice has undertaken a recruitment drive for
overseas dentists and has experienced significant turnover: they
believe that the dentist gains experience of the NHS with their
practice and then looks for another practice with a higher UDA
rate to which to relocate.