The government has been trialling pilot programmes across England to improve healthcare for GDPs and GPs since September 2011. The programme began with seventy dental practices across England commencing pilots between July and September 2011, with new practices, as well as some community centres, joining them later on.
The purpose of this initiative is to test a new prevention-based clinical pathway. So far there are three types of dental pilots running, and the Department of Health is learning and making changes to these as they progress.
The main aim of the scheme is to promote and encourage healthy oral environments. This will be achieved chiefly through preventative care, and practices will also be supported through the exploration of new remuneration models. Practices are financially compensated based on the quality of care they provide and how many patients they see, rather than by the number of different types of treatment they provide.
As mentioned above, all three pilots are testing a new prevention-based pathway. This includes an oral health assessment, which involves a Basic Periodontal Examination (BPE) and an assessment of the patients’ current general health and lifestyle factors that may increase the risk of disease in the future.
When given their oral health assessment, each patient is given a status: red, orange or green. Red indicates that the patient is of high clinical need; amber indicates that the patient shows symptoms that could possibly increase the risk of dental disease (such as no caries but poor plaque control); and green denotes no clinical need. Clinical factors that could lead to a red or amber listing include visible damage, i.e. carious lesions. Relevant patient factors include age, symptoms, use of fluoride toothpaste and diet. Patients are told their status and given advice on what they can do to improve it or prevent disease. Patients are also given a plan to follow at home on how to maintain or improve their oral health. An oral health review appointment follows any necessary treatments.
The differences between the three types of pilots are as follows:
Type 1
The purpose of Type 1 pilots is to explore how many patients can be cared for when following the new pathway, specifically when any financial incentives relating to activity levels or patient numbers are removed. Type 1 pilots are expected to deliver the same service and have the same NHS commitment as they had prior to the pilot commencing. They are expected to provide care for a pre-determined number of people, and practices involved in these should be free to provide clinical care as they judge appropriate.
Type 2
Type 2 pilots are a weighted capitation and quality model. These pilots test dentists’ responses to the system as well as the implications of applying a national weighted capitation model, where capitation payments vary depending on the age, gender and index of deprivation of the patient. This pilot will help to assess whether the factors used to weight capitation are effective in meeting need.
Type 3
Type 3 pilots are similar to Type 2 in that they are also remunerated based on their number of weighted capitated patients. However, for Type 3 pilots the capitation payment is only related to preventative care and routine treatment. Any complex care treatment - generally treatments that fall under B and 3 and require laboratory work - will have a fixed value and will not be subject to any adjustment associated with capitation, unlike Type 2.
The programmes were updated in April 2013, and patients who were unwilling or unable to commit to continuing preventative care, or who were solely seeking resolution of symptoms, would still be provided for. However, treatment would obviously be limited to what the patient was willing to adhere to. GDPs would provide fillings and extractions but may not offer treatment such as crowns if the patient was not willing or found it difficult to improve their oral health.
Since the pilots have been running, the main problem dentists have experienced has been the cultural change that a preventative approach requires. Changing diets and oral health habits can be daunting and hard to maintain. Parents can find it particularly difficult to change children’s diets and habits and often give in and revert back. Managing patient flow has also proved difficult for practices; patients coming on and off practice lists have made it difficult to organise appointment books. There has also been a fall in treatment volumes; this was expected to some degree, although the fall has been greater than expected. Treatment volumes may have fallen due to the fact that appointments are taking much longer because they involve much more in-depth oral health examinations. This also affects waiting lists.
Although I do not work in any practice that is currently involved in any pilot schemes, the information and current statistics I have read suggest they would benefit patients much more than the current Units of Dental Activity (UDA) system, which can prove challenging for some practices. The pilots seem to be much more patient-focused, and place a massive emphasis on improving patients’ oral health in the long-term, rather than just on providing routine care. As we know, if patients are knowledgeable about diet and good oral health, it can benefit them greatly by cutting down the need for treatment and reducing the risk of future health problems, while saving the NHS money in the process. Routine treatment only solves their current problems, whereas sound advice and long-term maintenance can prevent the need for avoidable future treatment.
It is still too early to say whether the pilot schemes will work well in this country. A dental team can only help the patient by providing routine care and advice on how to maintain a healthy mouth – it is each patient’s willingness to listen, learn and improve that will make the real difference to their oral health. I do believe it is time for England to make a change, and although it may be a long process, the pilot schemes seem to be heading in the right direction.
More information on the pilot schemes and the latest report from Department of Health detailing their findings after the first two years can be found at www.gov.uk.
Beth Powe, RDN