As the discussion and speculation about the roll-out of NHS dental contract reform has rumbled on, there has been more and more talk about flexible commissioning. But while those who are familiar with the initiative and have been involved with it so far may understand what it means and the potential it has for the future delivery of NHS services, there are many who are unclear about the finer details.
To find out more about what flexible commissioning is, how it has been implemented so far and how it may be used in the future, I asked Chris Groombridge, who has been involved with its inception: What potential does flexible commissioning hold for contract reform?
Chris: ‘Flexible Commissioning (FC) started as a way to facilitate the delivery of certain key services that the 2006 dental contract does not largely cover.
FC has two elements. One is about using the current existing contract value of a practice in a different way, e.g. to facilitate the redirection of resources and funding for the delivery of prevention in practice – we all know that the current dental contract does not actually pay for prevention.
The second element is also about using the Financial Statutory Instrument (FSI) of 4% to give practices new funding to deliver outreach, e.g. supervised tooth-brushing programmes and prevention and care in residential and care homes and to the vulnerable.
It began as a concept in February 2014 when members of the Local Dental Committees (LDCs) for Hull & East Yorkshire, North Yorkshire and South Humber came together with Simon Hearnshaw, the Chair of the Local Dental Network (LDN) for North Yorkshire and Humber, to attempt to find an interim solution to the failed current dental contract.
The current dental contract does not deliver for patients (dentists are paid to deliver widgets called Units of Dental Activity – UDAs – not patient care); for dentists (who have to deliver targets which are not necessarily linked to patient care); or for NHSE commissioners (who have little room for manoeuvre in relation to the actual contract and each year witness clawback going up and up – in 2018/19 clawback nationally was £138.4 million. It is projected to be in excess of £200 million in 2019/20 and approximately 20% of practices nationally are now paying clawback for under-delivery of UDAs, i.e. widgets).
The only winner of the 2006 dental contract, which the House of Commons Health Select Committee in July 2008 declared “unfit for purpose” and which was imposed on the dental profession with six weeks’ notice, is HM Treasury who do gain budgetary control (not necessarily a bad thing) and widgets to count!
From February 2014, discussions took place in August and September with the former Chief Dental Officer Barry Cockcroft and the Association of Dental Groups (ADG). What the local LDN and local LDCs did not know is that the ADG, independent of the LDCs and LDN had developed their own version of FC. When they were laid beside each other, you could hardly tell the difference.
From this point the LDCs and LDN were fortunate to have NHSE Commissioners in Yorkshire and Humber who were willing to commission an FC programme called In Practice Prevention (IPP). This ran over three years (as well as another element for residential and care homes) in 26 dental practices and was evaluated by Professor Paul Brocklehurst and Fiona Sandom of Bangor University.
After the evaluation, the commissioners had the confidence to contract two phases of FC. Phase one, incorporates IPP and will start in January 2020 and cover 100 practices, although 640 practices are eligible to participate.
The eligibility criteria is that a practice has to deliver 96% of their current dental contract and be open on NHS Choices (I know some reading this last point will worry, do not, you use managed waiting lists to address this specific point).
Phase one uses the current existing contract value – of up to 10%, in different ways to deliver prevention within a practice, using the whole dental team and skill mix.
Over three years Care Clinical Pathway templates have been designed and tested. One of the practices which has participated from the beginning is 543 Dental Centre where, with Software of Excellence (SOE), templates for FC have been built with a reporting capability.
543 Dental Care and SOE have agreed to share the templates and reporting capability with every practice participating in phase one of FC via NHSE Yorkshire and Humber. All dental software providers are going to be given a copy of the templates and reporting capability so they can support practices with FC.
For phase one, the reporting consists of 14/15 yes or no questions, 14/15 number questions. The reporting will be carried out on a quarterly basis and will be monitored by the Business Service Authority (BSA).
Phase two is outreach, e.g. supervised tooth-brushing programmes for children aged two to five, prevention and the provision of treatment to residential and care homes. The eligibility criteria is the same as phase one.
Phase two is new money, i.e. up to 4% of funding via the FSI. This is to begin around April 2020.
When FC was started, it was never seen as a replacement to Dental Contract Reform (DCR) and it still isn’t. It was about addressing the shortcomings of the 2006 dental contract while we wait for DCR and to also buy further time for DCR.
In addition to what is happening regionally in Yorkshire and Humber, national templates/service specifications are being designed by NHSE, DoH, BDA, ADG, BSA and LDNs covering prevention, i.e. tooth brushing in settings (ages two to five), older people and care homes, Primary Care Networks (PCN), Performers List Validation by Experience (PLVE) support, and research and development.
To paraphrase, Eric Rooney, the Deputy Chief Dental Officer, on Friday 8th November at the National Dental Advisors Conference (NADA) in Leeds – it is about reforming dental contracts. FC is a model of contract variation which sits alongside DCR and PCNs.’
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My thanks to Chris for explaining the genesis of flexible commissioning and the plans for its future development.
The recent extension of the prototype regulations feels like an indication that those in power are still not ready to roll-out a reformed dental contract. However, while the profession may be willing to accept such a delay in order to ensure that the contract that is eventually arrived at is one that works for dentists and patients, many may not be willing to simply continue as they are.
Some have suggested the need for an interim measure while refinements are made to make sure that the reformed contract is right. Perhaps the rising profile of flexible commissioning means it could be just what is needed to help NHS practices struggling under the current contract.