Meeting 14th November 2018

LOCATION

THE HUNTINGDON MARRIOTT HOTEL

CHURCHILL ROOM

WEDNESDAY 14^th November 2018

7pm Arrival for 7-30pm Start

MINUTES

1. Attendees:

Jaco Craig - LDC Chairman

Bharpur Sanghera - LDC Secretary

Patrik Zachrisson - LDC Treasurer

Mariana De Villiers - LDC Administrator

Marlise De Vos

Julia Hallam-Seagrave

Amiras Chokshi

Peter Mullins

Claire Jackman

2. Apologies:

Maria Ross-Russell

3. Guests:

Tom Norfolk - LPN Chairman

Francis Scriven - Anglia Orthodontics

Jaco Craig welcomed Orthodontist Francis Scriven to the LDC Meeting.  Francis was nominated as a co-opted member by Jaco Craig and seconded by Gawain King.  He accepted the nomination and provided a brief update on Orthodontic Procurement following a recent Orthodontic Market Engagement event:

Across NHS England many orthodontic Personal Dental Service (PDS) Agreements are due to expire on 31 March 2019. There is a legal requirement set out in the 2015 European Procurement Directives which requires NHS England to carry out a competitive tender process. NHS England is keen to adopt consistent principles to re- procuring services.

In 2008/9 a national epidemiological oral health survey of 12 year old children was undertaken across England. As well as surveying oral health, Orthodontic need was also assessed, Survey evidence suggests that 33% of 12 year olds would need orthodontic intervention. It is a pragmatic figure which is widely accepted. Not all children with ‘need’ will want orthodontic treatment. Some children with ‘need’ will want private orthodontic treatment. Not all children with ‘need’ will maintain oral health suitable for orthodontic treatment

Orthodontic Planning Areas (OAP) have been identified and are based on Local Authority area but have been modified where a Local Authority is small or large. A Lot is the potential contract size and geographic area. When calculating lots, current patient flows and hospital treatment provision were taken into account. The lots will be commissioned within OPAs. The OPAs are mainly based on Local Authority areas except where the Local Authorities cover a large or small geographical area or there are access issues that need to be taken into account. The identified need within each OPA is based on the projected number of 12 year olds resident in the OPA in 2018. There has been a dramatic increase in population and housing in this area.

The lot size must be at least 1,050 UOAs per annum i.e. 50 cases as a minimum. The aim is to commission lots based on a minimum size of 6,500 UOAs which equates to about 250 to 350 starts. Currently, there are 45 PDS Orthodontic contracts commissioned and the aim is to reduce these to 37 going forward, geographically placed in order for a patient not to travel more than 30 minutes to a practice.

The aspiration is to commission orthodontic contracts for 7 years in the first instance with the option available to both parties to extend for up to a further 3 years by mutual agreement. This model would provide long term planning an activity as well as stability within practices.

Current providers of Orthodontics might be asked to roll out contracts for a few months in the transition period. All providers need to re-apply for contracts. Applications is via the portal and involve a number of stages: Registration, ITT Stages and Invitation to tender. Bidding for contracts is via the dynamic purchasing system where a number of questions will need to be answered. In order to submit tenders for contracts commencing in April 2019 accreditation for this need to be gained before the invitation to tender is published.

Stage 1- Request to Participate: Assessment of an eligibility questionnaire to assess an organisations core competency. The purpose of the questionnaire is to receive proposals in a consistent format to allow the Commissioner to measure which provider is best suited to deliver services in any particular location. Each question will have a weighting (%), the weighting will represent the importance of the question to the Commissioner. Supporting documents / attachments may be requested

 Stage 2 – Tender Process: To receive proposals to deliver specific lots and will test in more detail an organisation’s ability to meet the Commissioners requirements. Tenders cannot be re-submitted.

Stage 3 - Moderation of individually scored proposals to form a consensus

Stage 4 - Final adjudication

 A decision panel will assess the tenders and would consist of clinicians, procurement experts, commissioning experts and representatives from Local Dental Committees (LDCs).

Quality would be assessed on numerous questions in order to understand times, accessibility, etc.  The procurement needs to be forward looking and bidders need to also articulate services that is going to be offered with the contract. Contracts would only be awarded to Specialist Orthodontists. The aspiration is to assess 80% on quality and 20 % on financial outcome.

Decision panel to make recommendation, recommendation will be formally approved by NHS England. Bidder(s) will receive notification of the decision which will include details of their scoring and the relative merits of their bid and if unsuccessful the winning bidders score and merits. A 10 Day standstill period will follow. Formal announcement will be made following the successful completion of the standstill period. Unsuccessful bidders will be notified with feedback. A mobilisation period of 3 – 6 months will be allowed whereupon treatment will start.

Some issues have been identified within the procurement process;

• Minimal engagement with the Managed Orthodontic Clinical Network (MCN)
• Positioning and size of Orthodontic contracts
• Existing providers not being offered a contract
• Some orthodontic contacts are quite small.
• Most orthodontic contracts are multi-skilled – it seems that corporate practices are being favoured

It must be noted that once the tender process has started, the Area Team is legalistically not allowed to discuss any aspect.

A national methodology has been used to establish a viable UOA price for a “stable” practice that has a cohort of patients already in treatment, in retention as well as taking on new patients.  This will be a benchmark price of £56.89 with the bidder considering local market factors such as contract size and location when submitting their contract price.  The benchmark price is at 2017/18 rates and will attract Doctors and Dentists Remuneration Body (DDRB) uplifts each year thereafter.

Where a contractor chooses not to continue or is not awarded a contract and agrees to complete active courses of treatment or supervised retention, the contractor will receive a one off close down payment of £662 per patient or £25 for patients under retention. Some contracts have already changed hands. The outgoing practitioner is encouraged to complete treatment.  The LDC also supports this. It is worth mentioning that the incoming practitioner needs to stipulate in the bidding process that he/she is willing to take over from outgoing practitioner. He/She is not forced to take over all patients.

Currently contracts have been awarded to the lowest bidder.

Tom Norfolk – LDN Chairman

Tom is involved in a Dental Strategy Core Group looking at Issues relating to Access for Dental patients in pain, especially within Peterborough which may be rolled out elsewhere. Out of Hours and Emergency Access remains a serios problem in the Peterborough area.  Countywide within Cambridgeshire and Peterborough, 1000-1500 patients per month are turned away, with 400-600 patients per month at the Peterborough DAC.

The Dental Strategy Core Group is a small working group which will consider issues and try to present solutions to NHSE with the aim of improving patient care.

A shortage of performers within the area remains a concern. Various factors contribute to this shortage, such as newly qualified dentist would rather seek employment within the bigger cities, UDA Values are not attractive, the uncertainty of Brexit, etc.

With regards to Dental Practice Advisers, the Medical Directorate at NHSE has seen an increase in their workload. The number of complaints and whistleblowing issues reported to NHSE and to the General Dental Council has increased quite substantially and the PAG and PLDP’s are rather busy. Dentists are encouraged to self-reflect and to make changes to improve their patient care.

LDCs are welcome within the LDNs. Individual dentists and LDCs can feed information and concerns into the LDN which may be considered at the Dental Strategy Core Group. Tom expects to have a plan to present to dentists in Peterborough very shortly.

NHS England is responsible for commissioning primary and secondary care dental services in the East of England and this includes community dental services. Re-procurement of special care dentistry and prison services are in the early stages.

Special Care Dentistry:

NHS England Midlands and East (East) is currently reviewing existing community dental services and it has been identified that there are likely to be variations in the way services have been commissioned and delivered.

Community dental services are intended to treat patients of any age whose care cannot be met by other local general dental practitioners due to their special needs; whether that is medical, physical or behavioural. Some community dental services also provide primary dental care services to vulnerable people of all ages to ensure that there is access for all patients.

There are four providers of community dental services across the East of England covering Suffolk, Cambridgeshire and Peterborough, Great Yarmouth and Waveney, and Norfolk. The current services are delivered from a number of clinics in each of these areas.

Current position

As all of the current contracts come to an end in March 2019, NHS England is re-procuring these services in line with the NHS England guidance for commissioning dental specialties (Special Care Dentistry), which supports general dental services for vulnerable adults and children, and also supports hard to reach groups to ensure 2 that patients have access to general dental services.

It is intended that services will continue to be provided from various locations in the East of England, however it is inevitable as a result of the re-procurement that there may be some changes to the current locations for the delivery of services.

NHS England is currently undertaking a programme of engagement including collating the views of existing patients and holding local engagement forums. In addition, NHS England is in communication with local authorities regarding the responsibility for epidemiology, dental public health and health promotion services which will be considered as part of the new service. These views will inform future service delivery and simplify the referral process.

The benefits of this change are:

 There will be a consistent service provision across the East of England;

 Providing appropriate and patient led services in the right place; and

 More cost effective use of NHS resources.

It is intended that the new service will start from 1 April 2019. NHS England will update stakeholders throughout the process. Any queries should be directed to Julie Bradshaw, NHS England’s secondary care dental commissioning manager at england.essexatcontract@nhs.net

Indemnity

Over the past few years there has been a significant year-on-year increase in the number of claims, along with a sharp rise in compensation and legal costs. Claims that run into hundreds of thousands are no longer unusual. All these factors have to be reflected in the cost of membership.

Dental professionals must have adequate and appropriate professional indemnity before they can treat patients,

What seemed striking in the most recent changes was that NHS England also introduced and defined a new phrase: ‘appropriate cover’, which relates to clauses about indemnity.

Clause 251 went from: ‘The contractor shall at all times hold adequate insurance against liability arising from negligent performance of clinical services under the contract’, to: ‘The contractor shall at all times have in force in relation to it an indemnity arrangement, which provides appropriate cover.’

‘appropriate cover’ is contractually defined as ‘cover against liabilities that may be incurred by the contractor in the performance of clinical services under the contract, which is appropriate, having regard to the nature and extent of the risks in the performance of such services.’

As well as the three dental defence organisations, there are a number of commercial and specialist insurers in the market that provide indemnity for dental professionals, so there is no shortage of competition.

However, the fact is that most dental professionals belong to a dental defence organisation because they offer more than indemnity for negligence claims. Dental Defence Union (DDU) membership includes access to expert dentolegal advice from dentists; legal support and assistance with performance, disciplinary and hearings relating to your clinical work; help with press enquiries; and online CPD.

There are significant differences between insurance from a commercial provider and the indemnity currently provided by dental defence organisations.

The benefits of DDU membership are provided on an occurrence basis, which means that if an incident occurred while a member is in active membership, they can seek assistance whenever in the future they are notified of a problem. This could be 10 days, 10 months or even 10 years after the incident took place – as long as they were a member of the DDU at the time they saw the patient they will be supported.

By contrast, insurance companies usually offer cover on a ‘claims-made’ basis, which means that a dental professional must have cover in place when they report a claim and when the incident took place, which could be many years earlier. If the dental professional wants to change provider, they may need to buy, at an extra cost, run off cover, which may be required for years. (Run off Cover – relates to the fact that the insurance product may not cover the dentist when the alleged issue is reported.)

While the DDU’s assistance or indemnity is provided at the board of management’s discretion, the board has a legal obligation to act fairly, in the interests of their members and in accordance with their memorandum and articles of association. This document is publicly available on their website, along with member guide, which gives examples of the types of circumstances where the DDU is unlikely to provide support.

At the same time, the discretion to be flexible and responsive to the needs of members and support issues in the interests of the wider membership is retained. Unlike an insurance policy, there is no ‘small print’ buried in a long list of exclusions; no limits on the size of claims that can be indemnify; and no excesses to pay.

4. Patrik Zachrisson – LDC Treasurer – Annual Report

The LDC successfully sponsored Continuous Development (CPD) Event held on 17^th October 2018. The LDC is looking at sponsoring further CPD courses and is in dialogue with Maria Ross-Russel from East of England Deanery.

The Cambridgeshire and Peterborough LDC continues to be in a healthy financial state.  Over the last year the reserves have continued to increase, ensuring financial stability and flexibility for the future.

Cambridgeshire LDC continues to have responsibility for accepting funds from the Area Team on behalf of all LDCs in our area – monthly payments are made to Norfolk and Suffolk LDCs in line with the percentage share values previously agreed.  Cambridgeshire LDC does not make an administrative charge to the other LDCs for this service.

I would like to express my thanks to fellow committee members for their help and support in my role as Treasurer of the Cambridgeshire and Peterborough LDC

Patrik Zachrisson

LDC Treasurer

5. Bharpur Sanghera - LDC Secretary Report 2018

The dental profession has continued to see further change this year, both locally and nationally.

Our LDC has tried to keep pace with this change by engaging regularly with the Local Area Team and East Anglian Dental Network - Core Group.

We have liaised with our fellow LDC’s via the East of England Secretaries Meeting.

We have received regular updates from Nick Stolls on the work of the GDPC and from Tom Norfolk, the Chair of the Local Dental Network in East Anglia.

A number of Managed Clinical Networks have now been formed and are providing advice to the Local Dental Network.

Our colleagues in our region have managed the challenges of recruitment becoming more of an issue in affecting the delivery of contracts, although the LAT have muted a more pragmatic approach to contract management, which is welcomed. Delays caused by Capita are improving and we will continue to monitor this situation into the next year.

Our LDC is working with David Barter, the head of commissioning, to find solutions to the ongoing problem of access of NHS Dental services by patients, particularly in the Peterborough region.

We have worked diligently to support and engage with our colleagues in our joint endeavour to set up a local PASS scheme. This scheme has now been established and provides a valuable local resource for our colleagues, who can self-refer or may be signposted by other organisations if deemed suitable.

We sent a two person delegation to the Annual LDC Conference in Belfast this year, which proved to be highly educational and useful. The conference is available to view online.

The Electronic Referral Management Service is now live in our region and appears to be running more smoothly.

Finally, the LDC will continue to assist our members over the coming year to help manage the challenges that may result, due to the effects of Brexit on the dental profession. We will continue to monitor the contract reform process and endeavour to provide information to our members of any significant developments. 

Bharpur Sanghera

Cambridgeshire and Peterborough LDC Secretary

6. Jaco Craig - Chairman’s LDC report 2018

This has yet again proved a very challenging year for the profession, a trend that is likely to continue for the foreseeable future until more certainty can be gained on the direction of NHS dentistry.

A great emphasis was placed by the Department of Health (DoH) on the prototypes when this was first rolled out and how this final stage in the development of the new dental contract would provide the answers and direction needed. There has, however, been very little positive feedback on this, with the profession aware that the business model being tested by these prototypes is failing to deliver for either the profession in terms of financial security or the DoH in terms of patient charge revenue (PCR).

Significant uncertainty remains on the proposed tiering system that looks bound to be introduced and how this will impact the provision of services in Primary Care Dentistry.

With Orthodontic PDS contracts coming to an end March 2019, East of England Area Team (EEAT) have put these contracts out to tender with the aim of reducing the number of contracts held from 45 to 37, 10 year contracts with a better geographical distribution.

The East of England has seen a record in clawback from under delivered UDA’s in 17/18, with one of the main reasons being the inability to recruit GDP’s to our area. Whilst a recent national problem, predominantly rural areas appear to be far more affected. Where it was possible to recruit new General Dental Practitioners (GDPs), a time consuming, laborious process of inclusion on our performers list coupled with some extraordinary incompetence of the part of Capita, resulted in significant underperformance by practices, some waiting for over  9 months for new associates to be included on the EoE performer’s list. The (late) concessions made by NHSE for practices where inclusion took longer than 4 months provided some relief but fell well short of any real practical benefit as most found it simply impossible to make up the UDA’s lost during this time. Some progress has been made in streamlining the process this year, however, it still appears overly complicated and needlessly time consuming when the profession is struggling to recruit and retain dentists willing to work within NHS dentistry.

Yet again, the nominal uplift in remuneration sanctioned by the DDRB will continue the trend of decreasing taxable incomes for NHS dentists. This continued decline in income is clearly not sustainable, having a profound impact on the ability of practices to recruit and retain dentists in our area, and on morale and motivation within the dental profession as a whole. With the onus on providing an ever increasing quality of care to patients, the pressures faced by those providing mostly NHS dentistry is at an all time high and, not surprisingly, the British Dental Association’s (BDA’s) most recent Dentist Satisfaction survey makes for some troubled reading.

In light of the above, the LDC has continued to engage with the EEAT to campaign for some local flexibility on the issues driven by national guidance.  David Barter, Head of Commissioning EoE, has indicated that they are happy to engage in a constructive and meaningful way with the profession to progress dentistry in our area. A Direct Commissioning Oversight Group (DCOG) has been set-up to consider business plans for recurrent commissioning that could be funded by clawback money.  Access to urgent care remains an issue within our area and on the invitation of David Barter, the LDC will draft a proposal to address the issue in a way that is beneficial to its members and the EEAT.

This year saw the implementation of the PASS scheme set up by Norfolk LDC, supported by LDC’s in EoE which is set up to provide pastoral support to NHS dentists in need.

It is envisioned that the role and function of the Deanery may well change in future and the LDC has continued to explore ways in which we can assist members by providing them with an affordable and convenient means of fulfilling their required CPD hours. Despite some initial setbacks experienced in the practical application of the venture, we are due to have further meetings on this subject early 2019 and will hopefully be in a position to partly fund CPD events within Cambridgeshire by the Autumn of 2019.

Jaco Craig

Chairman, Cambridgeshire and Peterborough LDC

7. Date of next meeting:

Wednesday, 6^th February 2019