GeneralPracticeManagement

Tajinder Sihra

Len DCruz

NHS Pilots in Primary Care An

Insight into the Future?
Abstract: This article looks at the background to the current changes in primary care dentistry being piloted in England. It looks at the
structure of the different elements being piloted, such as the oral health assessment, interim care appointments and care pathways. It also
examines advanced care pathways and how complex care will be provided when clinically feasible and beneficial to the patient.

The authors have worked in a Type 1 pilot practice since September 2010.
Clinical Relevance: The NHS contract currently being piloted in England delivers care through care pathways and clinical risk
assessments with prevention as an important building block for the delivery of services. There are new measures planned for measuring
quality outcomes in primary care. This has implications for how services are delivered, who delivers them and how dentists will be
remunerated in the future.
Dent Update 2014; 41: 718

Why is change needed?

The NHS was created in 1948
to provide a health service available to all
and financed entirely through taxation.
When first established, the oral health
needs of the population were very
different from today with high decay
rates, routine multiple extractions and
denture placement.1 Over the last 60
years, extensive research has helped to
determine the aetiology of many dental
diseases,2 allowing a large proportion of
dental disease to be preventable now. The
use of fluoride, coupled with this increased
knowledge, has changed the dental needs
of todays population decreasing levels of
dental disease have been reported by the
Adult Dental Health Survey (2009)3 and the
Child Dental Health Survey (2003).4 We now
need to move away from simply addressing

Tajinder Sihra, BDS, Dental Foundation

Dentist, London and Len DCruz, BDS,
LDS RCS, MFGDP, LLM, Dip FOd, Dentist,
Woodford Green, Essex.
January/February 2014

the problems present, to preventing their

occurrence and finding an NHS system
which rewards a preventive focus from
dental teams rather than one based on
activity (ie treatment).1

NHS reforms 2006

The old fee per item NHS system
was appropriate when the NHS was first
introduced but is no longer suited to todays
needs. From 1948 to the new reforms in 2006,
any dentist who wanted an NHS contract
could get one and set up an NHS practice
wherever he/she wanted to, subject only
to being eligible to be on a dental list. The
location of dental practices was market driven
rather than based on where services were
needed most in terms of oral health needs.
In 2006, the NHS reforms were introduced.5
Primary Care Trusts (PCTs) were given power
to commission dental services (previously by
the NHS), patient registration was removed
and the patient charging system was
simplified (Table 1) with the introduction
of Units of Dental Activity (UDAs). With this
system, dentists were paid per course of
treatment. The payment system was such

that, whether a patient had one or multiple

fillings, crowns or extractions, they would pay
the same amount the value for that band
of treatment. This was all with the aim of
improving access and quality and increasing
the focus on prevention.
The Health Select Committee
Report6 found the new system generally
failing to improve access, with many dentists
moving away from NHS dentistry, and the
number of Courses of Treatment (COTs)
decreased. The new simplified patient charges
created concerns of overcharging if a patient
had only one filling, and undercharging
for patients who saved up all their dental
problems for one course of treatment. The
system encouraged Performers to game
the contract to maximize the UDAs per
course of treatment by splitting courses of
treatment artificially rather than providing
the entire planned treatment as one course,
eg providing RCT in one course of treatment
(COT) and claiming 3 UDAs and then 3
months later submitting another COT and
claiming 12 UDAs for a crown on that same
tooth. The number of root canal treatments
(RCTs) decreased by 45% and the number of
extractions increased creating a growing
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Band

Treatment

Patient charge

Units of dental activity (UDAs)

Examination, Radiographs,
Scale & Polish, Oral hygiene
instructions, Diet advice,
Fluoride advice, Fissure sealants

18

2
Fillings, RCT, Extraction

49 (whether one or more of the 3

named provided in same course
of treatment)

3
Crowns, Bridges, Inlays, Onlays,

Dentures

214 (whether one or more of

the named provided in same
course of treatment)

12

Table 1. NHS bands and patient charges (as of April 2013).

concern that patients were not receiving

the quality of care that they needed. It is
important to note that there was no pilot
system to test out the 2006 NHS reforms.
Improvements suggested included:
Reinstating patient registration;
Increasing the number of UDA bands; and
Ensuring the new system was piloted.
There was also the realization of
a need to reward dentists with incentives to
provide preventive care.

NHS pilots
The NHS pilots have been running
since September 2010.7 Their aim is to improve
access, quality and oral health. The system
and remuneration in these pilots are based on
registration, capitation and quality, moving
away from the current contracts based on Units
of Dental Activity (UDA). There are three types.
Type 1 pilots

These practices have been given

the same contract value as the previous year,
provided they deliver the same level of NHS
commitment as they did the year prior to the
start of the pilots. NHS commitment in this
context means providing the same number of
NHS hours on the same number of patients as
had been provided in the previous year. The
purpose of the Type 1 pilot is to explore how
patients can be cared for when adhering to
the new pathway when financial incentives
relating to activity levels or numbers of patients
seen are removed, and how practices organize
themselves as a team to deliver this.

8 DentalUpdate

Type 2 pilots

These practices receive their

NHS payments based on a model of
weighted capitation payments. The practice
remuneration is adjusted depending on the
pilots capitation payments, with capitation
payments for individual patients varying
depending on their age, gender and the
deprivation status of their home postcode.
The capitation payment in Type 2 pilots
relates to all care preventive, routine
and complex treatment. The purpose of
the Type 2 pilot is to explore a payment
system based on weighted capitation
where remuneration is adjusted based on
the patients demographic details (with
payments intended to compensate for the
average cost of care for an individual in
that patient cohort). Therefore, a practices
contract value is effectively dependent on
the number of patients for whom care is
provided.
Weighted capitation

This is the amount of money

contracted to a practice per patient per
year and will vary in amount based on the
patients demographic profile, ie age, sex
and deprivation score of their residential
address.
Type 3 pilots

These practices are also paid

based on a model of weighted capitation
payments. Remuneration levels are adjusted
depending on the pilots capitation
payments, with capitation payment for

individual patients varying depending on

their age, gender and the deprivation status
of their home postcode. With Type 3 pilots,
capitation payment is related to preventive
and routine treatment only. The element
of a Type 3 pilots contract value associated
with complex care (generally Band 3
treatments requiring laboratory work) is
fixed and guaranteed and not subject to
any adjustment associated with capitation.
The purpose of the Type 3 pilots, like Type 2
pilots, is to explore the impact of applying
a remuneration model based on weighted
capitation. The aim of the Type 3 pilots is
also to explore the impact of separating out
the remuneration for complex care.
What is common to all the pilots
is the care pathway which commences with
a detailed oral health assessment.

Oral health assessment (OHA)

The oral health assessment is
the building block of the care pathway and
the outcome of the process is to produce
an individual risk assessment based on
specific patient questions and a clinical
examination.
Figure 1 shows the format for
software of excellence this varies slightly
from system to system in appearance. The
oral health assessment follows a standard
examination familiar to all clinicians, but
additionally software algorithms have
been developed to allow a risk status to
be assigned to this patient (Red Amber
Green, RAG). Based on this information,
recommended evidence-based preventive
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GeneralPracticeManagement

treatment and interventions can be

provided. The clinician must still use his/her
own judgement to decide what treatment,
if any, is necessary.
The OHA starts with a variety
of questions designed to determine the
patients oral health (Figure 2). The key
areas which are mandatory are the medical
history, clinical history (eg sugar intake, fizzy
drink intake, smoking status and alcohol
intake), a Basic Periodontal Examination
(BPE) and the clinical examination. Based on
the responses provided by the patient and
the clinical examination results, the patient
is then assigned to one of three oral disease
risk level groups: Red (high risk), Amber
(moderate risk) and Green (low risk) in each
of the following four fields (Figure 3):
Caries;
Periodontal;
Soft tissues;
Tooth surface loss.
Once assigned to a risk level, a
care pathway with a preventive treatment
plan is formulated by the computer
software, governed by the age-specific
guidelines set in Delivering Better Oral
Health.
Practitioners have reported
good feedback on the OHA, with the
majority agreeing that it encourages selfcare, supports communication with patients
and enables evidence-based care tailormade to each individual.9
Early feedback on the pilots
has shown an increase in waiting time
for examination appointments since the
start of the pilots (Figure 4). This could
possibly be explained by the examination
appointments now routinely taking
longer at 2030 minutes, reflecting the
thoroughness of the assessments and
provision of evidence-based advice and
instructions.

Interim Care appointments (ICs)

The computer software will
also formulate one or more Interim Care
appointments (ICs). IC appointments
may involve preventive treatment and/or
advice, instead of (or as well as) treatment
to address dental decay (eg fluoride
application, prescription of higher strength
fluoride). Each patient is provided with a
printed self-care plan showing all these
details. A clinical care pathway is formulated

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GeneralPracticeManagement

Figure 1. Screen shots of (a) clinical history, (b) social history, (c) extra-oral examination recording, as
shown on exact software of excellence and (d) soft tissue.

practitioner survey showed the majority

agree that the pilot approach has the
potential to improve the oral health of
their patients and the new way of working
provides better care for their patients.
However, problems were reported with the
software causing disruption to clinics in the
early stages,9 such as getting used to the
new software and information which must
be completed before oral health assessment
can be completed.
The ICs and longer OHAs place a
large strain on the appointment books. The
majority of dentists and practice staff agree
that, if the current pilot is implemented,
there will be a shift in skill mix in practice.
Nurses are currently being trained to carry
out extended duties, such as fluoride
application and oral hygiene education,
and the use of dental therapists to carry out
non-complex care for children and adults
will increase. This may result in an increase
in demand for dental therapists and a
decrease in demand for dentists owing to
differential labour costs.

Care pathways

Figure 2. Format of oral health assessment.8 Key: SCP Self Care Plan; RAG Red/Amber/Green;
ICM Interim Care Management.

Figure 3. Self Care Plan showing RAG score.

at the OHA and a new pathway will start

again at the Oral Health Review (OHR) at the
determined recall interval.
January/February 2014

The response to ICs documented

in the Dental Contract Reform Pilots
Evaluation (Figure 5) shows patients
and practitioners agree that it is helpful
in continuing to motivate patients to
improve their oral health; however, uptake
varies among those who do not value the
preventive ethos or have not understood
the value of it in their individual cases.
Early feedback from NHS
Dental Pilots has, overall, shown a positive
response to the new system. The majority of
patients report that they now understand
more about their oral health and generally
find the new RAG system (Figure 6) and selfcare plans (SCPs) helpful in understanding
the health of their teeth and gums. The

Care pathways have been

defined as the methodology for the mutual
decision-making and organization of care
for a well-defined group of patients during
a well-defined period.10 The development
of clinical guidelines was recommended to
minimize variation in the quality of care. It
also allows for determination of thresholds
for treatment. In the NHS Pilots, Delivering
Better Oral Health (DBOH)11 has been used
as the evidence-based toolkit to formulate
the care protocol an action plan based on
national clinical guidelines. The aim of the
care pathway is to:
Enhance the quality of care by improving
patient outcomes;
Promote oral health;
Increase patient satisfaction; and
Optimize resources (utilizing the whole
dental team).

Care pathways have been used
as a tool to achieve continuity of care and
provide a consistent pathway for given
clinical conditions.
Figure 7 illustrates the flow of
a patient through the care pathway. Those
patients attending for urgent care are
provided with pain relief or stabilization
and then offered an oral health assessment.
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GeneralPracticeManagement

Figure 4. Average waiting time for existing patients.8

Patients entering the care pathway via the

oral health assessment are given an RAG
status (as explained earlier). Care protocols
are part of the self-care plan. The care
protocol for each diagnostic group defines
the number and type of each preventive
intervention (as recommended by DBOH)
and also the recall period (recommended by
NICE guidelines).12 These can be over-ridden
based on the clinicians judgement. The care
protocol also specifies that, for patients in
the Red category, no complex treatment
(including root canal treatments, crowns,
bridges, cobalt-chromium dentures) can
be provided, only stabilization of the active
disease. Conversely, any patients in the
Green category would be entitled to any
treatment deemed necessary on the NHS.
Those patients who fall into
the Red high risk category would be
re-assessed at their next recall appointment.
If their RAG status improved, they may then
be entitled to complex care. In the case of a
Red patient requiring root canal treatment,
who is re-assessed and found not to have
improved in RAG status, there are two
options, either leave the tooth as it is or
extract it.13

Advanced care pathways

Figure 5. Staff views on whether the OHA enables better care to be provided to patients.13

Figure 6. Helpfulness of Red/Amber/Green rating (Patients).8

12 DentalUpdate

Advanced care services are

resource intensive treatments, which
include indirect restorations, metal-based
partial dentures and advanced endodontic
and periodontal treatments. It is good
clinical practice only to provide these
treatments when the maximum benefit in
terms of outcome can be achieved for the
patient. Evidence suggests that, if they are
provided in the presence of active disease,
ie periodontal disease and/or dental caries,
the outcome is much reduced.14
These pathways were originally
devised by clinicians and representatives of
the British Society of Restorative Dentistry
and the British Society of Periodontology.
The pilots are exploring ways of managing
the gateway to advanced care by ensuring
that the treatment provided fulfils two
essential criteria:
The treatment is clinically feasible;
The treatment is beneficial to the patient.
The exercise of clinical
judgement is required to decide on how
beneficial and feasible the advanced care
treatment will be and, whilst no objective
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GeneralPracticeManagement

Skill level 3: Work to be referred to

specialist services.
There are significant longterm infrastructure implications of these
proposals, including the commissioning of
sufficient Level 3 services, education and
training programmes for Level 2 dentists
and remuneration models commensurate
with the skill level.

Skill mix

Figure 7. Diagrammatic representation of a care pathway.13

More specific care pathways

are now being developed, for example, for
red caries children (children at high risk
of developing caries) or red periodontal
disease adults (adults at high risk of
periodontal disease), and as the evidence
base in these areas improves the pathway
will be modified. Figure 8 shows how the
new model may change and favour a
greater skill mix in the dental practice.15
With the focus moving to
prevention, more members of the dental
team can become part of the care pathway.
As shown in Figure 9, a patient with a
carious lesion would be diagnosed by the
dentist, prescribed high fluoride toothpaste
and fluoride mouthwash for prevention,
provided with a restoration by the hygiene
therapist and more prevention advice and
topical fluoride application by an extended
duties nurse.
Figure 10 shows how some
practices within the pilots have changed
their skill mix to meet demands of the new
system.8

Quality

Figure 8. Adult amber caries patient.15

criteria or descriptors have been developed

so far, this will no doubt be the subject of
some debate.
The pilots are also testing how
the skill level of the practitioner can be used
to ensure the best possible outcome for the
patient.
January/February 2014

The descriptors of the skill levels

are as follows:
Skill level 1: work to be carried out by
GDP and set at the equivalent of the Dental
Foundation year;
Skill level 2: work to be carried out by
GDP who has additional competencies;

The Department of Health is

piloting a method of measuring the quality
of the work provided by dentists and
the clinical outcomes they achieve. This
is thought to be a better way of holding
dentists to account rather than simply
measuring activity.
The Dental Quality and Outcome
Framework (DQOF) equates to 10% of the
practices contract value and is weighted as
follows:
60% Clinical effectiveness;
30% Patients experience;
10% Safety.
With clinical effectiveness, the
focus is on ensuring that preventive advice
that is given is acted upon and results in
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GeneralPracticeManagement

Figure 9. Practice owner views on whether and how to consider changing his/her practice skill mix
in future.8

advanced care for high risk patients, as

these patients will not be entitled to
complex care unless their oral health
improves. This may mean dentists are
carrying out advanced care less frequently.
Less clinical judgement the preventive
clinical care pathway may become quite
prescriptive and, whilst there is an option
always to override these, this may trigger
exception reports if this is done too often
by the dentist.
The new NHS contract will be
based on a care pathway principle and the
remuneration for practices will be based on
a capitation model. Advanced care will be
available for patients for whom it is clinically
feasible and beneficial and the dental team
will become increasingly involved in the
delivery of a preventive care pathway. For
some this contract will be an opportunity
and a chance to develop themselves and
their practices, whilst for others it might
appear as a worrying challenge. Many
details are yet to be finalized, along with
statutory regulations, but the direction of
travel is now well established.

References

Figure 10. Changes to the skill mix in the practice as a consequence of the care pathway.8

a measurable difference in a patients oral

healthcare. Table 2 illustrates the measures.
It is also interesting to note
that a patients views will be taken into
account and form part of the measure that
ultimately determines a practices income
at the end of the year. Whilst these are
necessarily subjective views, raising quality
with patients in mind is an essential part
of providing a consistently high quality of
care and means that the whole team will be
required to deliver on these outcomes.

Summary
There are some concerns which
have already been highlighted by the pilots:
Waiting times have increased significantly

16 DentalUpdate

owing to longer oral health assessments (30

minutes) and the introduction of ICs;
Patient acceptance of a new system.
Patients under the current system
have become accustomed to receiving
treatment at the same appointment as the
examination, and being entitled to complex
care, even if their oral health is not optimal.
The introduction of NICE recall guidelines
has proved difficult for patients to accept as
they are used to 6-monthly check-ups;
Adapting to new systems for both
dentists and patients. As explained earlier,
getting accustomed to the new computer
software takes some time, as does
explaining the new oral health assessment
procedure to patients;
De-skilling of dentists in providing

1. Department of Health. NHS Dental

Services in England: An Independent
Review by Professor Jimmy Steele.
London: Department of Health, 2009.
2. Larson RH, Rubin M, Zipkin I. Frequency
of eating as a factor in experimental
dental caries. Archiv Oral Biol 1962; 7:
463468.
3. Adult Dental Health Survey 2009.
London: Information Centre for Health
and Social Care, 2011.
4. Child Dental Health Survey 2003.
London: Office of National Statistics.
5. Transforming NHS Dentistry.
Conservative Party Policy, May 2009.
6. House of Commons Health Committee.
Dental Services Fifth Report of Session
200708. London: The Stationery
Office, 2008.
7. NHS Dental Pilots: Proposals for Pilots.
London: Department of Health,
December 2010. Gateway reference
15285.
8. Dental Contract Reform Pilots Evaluation.
London: Department of Health, 2012.
Gateway reference 18199.
9. Dental Contract Pilots Evidence and
Learning Reference Group. NHS Dental
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GeneralPracticeManagement

Clinical Effectiveness Outcome

Indicators (60%) - Measures
Active decayed teeth (dt) ages 5 years old and under, reduction
in number of carious teeth/child

Points MAX: 600

10.

150

50% Under 5s active decay (dt) improved or maintained

Active decayed teeth (dt) ages 6 years old and over, reduction in
number of carious teeth/child

11.
150

75% over 6s improved or maintained

12.

Active decayed teeth (dt) reduction in number of carious teeth/

150
dentate adult

13.

75% improved or maintained

75% patients with BPE improved or maintained at oral health
review

75

50% patients with BPE 2 or more with sextant bleeding sites

improved at oral health review

75

14.

15.

Table
2. Update
Clinical effectiveness
outcome indicator
measures.
Dental
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Contract Pilots Early Findings. London:

Department of Health, October 2012.
Gateway reference 18199.
Harris R, Bridgman C. Introducing care
pathway commissioning to primary
dental care: the concept. Br Dent J
2010; 209: 233239.
Delivering Better Oral Health An
Evidence-based Toolkit for Prevention.
London: Department of Health, 2007.
Gateway Reference: 8504.
Dental Recall Intervals. National
Institute of Clinical Excellence (NICE)
CG19 October 2004.
Dental Contract Reform Programme
Clinical and Software Training. Primary
Care Contracting (PCC) personal
communication.
Dental Contract Reform Programme.
(Notes to support care pathway
approach. Department of Health,
2011)
Brocklehurst P, Tickle M. The policy
context for skill mix in the National
Health Service in the UK. Br Dent J
2011; 211: 265269.

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January/February 2014