World class dental commissioning

Success is measured and rewarded on evidence based preventive care and improved oral health, and is being delivered through three new model dental practices. 

The procurement process started with information sessions for bidders to understand the ethos of the new approach. At the time nearly all procurements had Units of Dental Activity (UDAs) as the only contract currency.

Clinical engagement consulting was carried out to agree what should be included in the new contracts and training sessions for local dentists were provided. The proactive involvement of the local profession and the support of the Local Dental Committee (LDC) have been key points in the success of this initiative.

Changing a contract from a UDA focus to improved health outcomes requires a new way of thinking and operating. Successful bidders included the whole range of implications in their tenders.

Alan McGlaughlin, principal dentist at Dentistry@BD4 comments: “Before, dentists were reluctant to pass a patient on to a hygienist because that simple decision was tied in with payment systems. Now nurses and hygienists can do a lot more without everyone worrying about who gets the money out of it.”

Patients attending the new dental practices reflect the profiles of age, gender, ethnicity and deprivation to those of the local community and are risk assessed into oral health pathways, using questionnaire, interviews and a clinical examination.

Three practices are now up and running and all are showing considerable signs of success – from practices, dentists, patients and improvements in health. There are also a number of learning points to take from the process.

The biggest challenges were around the skill mix and the need for a whole team approach.  With the new model, everyone including receptionists, nurses, hygienists and therapists have a role to play in patient health as well as the dentist.

Induction and training involves the whole team so a strategy to help smokers can involve prompts from the receptionist towards information leaflets, followed up with co-ordinated questions and guidance from the dentist, therapist, hygienist and nurse.

Victoria Bell, dentist at Dentistry@BD4 sums up the view that has been heard from all the dentists. 

She says: “I qualified two years ago and have had several jobs so far.  It can be difficult to find somewhere that allows you to work as you wish. 

“Now if someone has poor dentition we can discuss the treatment plan together. We will carry out the treatment needed provided the patient makes an effort to look after their teeth.  We can give them oral health care instructions, smoking cessation advice, alcohol advice if needed and book them in with our hygienist before bringing them back for treatment-providing they improve. This gives them an incentive to change their habits.

“I always wanted to put patients first and care for them, not changing treatment plans because of how I will be rewarded.  In previous jobs I have found this challenging and there has been less job satisfaction. Everyone here has the same ethos.”

For a PCT to make this process work it needs initial commitment and accountability at the top. In the case of Bradford and Airedale a director of primary care championed the cause at board level.

NHSBA acknowledges the key role of IT support for new models and has a positive working relationship with involved dental software suppliers.

For any PCT looking to make a significant change to health improvement in their area, a world class commissioning approach to dentistry is not only feasible but looks as if it will bring significant health improvements.

Alan McGlaughlin sums this up:  “Poor oral health is down to much more than just teeth – diet, smoking, alcohol and substance abuse, education.  If you can give someone a healthy mouth then they are a much happier person.  That’s good for everyone and satisfying for dentists.”

Bradford and Airedale’s tips for PCT managers

Allow time for:

The procurement process and to introduce operational processes

Performance review process to allow development of quality and health improvement frameworks

Procure and recruit the vision

Select providers with a vision of health outcome

Recruit staff who want to work this way

Wide implications of focus on health outcome vs activity requiring huge changes in mindset and vision but also:

Operational planning

Skill mix model – including hygienists, therapists, additional skills dental nurses; training; redefining roles

Induction – include oral health assessments, DBOH, team approach to prevention eg smoking

Changing payment systems; payment to reflect team approach including financial incentives via provider contracts and payment mechanisms within the practice for performers

Ensure outward links

Practices need to be outward looking

Know their local partners for oral health improvement and develop referral mechanisms

Accept uncertainty

Both parties must be comfortable with a degree of unpredictability/uncertainty

Grown up relationships with trust and a degree of challenge on both sides