Flexible Commissioning - a new approach

Dental contract reform has been on-going for over a decade. Recently Flexible Commissioning (FC) has been implemented by some areas to meet oral health needs and commissioning challenges. This approach uses the existing contractual framework, substituting a percentage of a practice's contract value to deliver additional services instead of units of dental activity (UDAs)¹ or alternatively funding programmes with additional financial resource.

This has always been possible within the existing NHS General Dental Services (GDS) and Personal Dental Services (PDS) contracts via the two main components: mandatory services (UDAs) and additional services (which may include dental public health, orthodontic, sedation or other services).^2,3 An interesting outcome of the substitution method of flexible commissioning is that where UDA values are lower the UDA target reduction is greater. This has the effect of reducing UDA value inequality. The March 2021 dental contract reform and arrangements letter (NHS England) describes a flexible commissioning toolkit that is intended to make it easier to target local oral health priorities, using the flexibility that exists in the current contractual arrangements.⁴

The NHS England Yorkshire and the Humber Dental Commissioning Team are at the forefront in developing and implementing flexible commissioning. The Yorkshire and Humber Flexible Commissioning programme has been supported by the Local Dental Networks, dental public health colleagues, Health Education England (HEE), Local Dental Committees, NHS Business Service Authority (NHS BSA) and by local authorities in the region. This paper is a continuation of the article published in 2020.¹

© pbombaert/Getty Images Plus

Programme model

The key elements of the Yorkshire and the Humber Flexible Commissioning Programme are set out in Figure 1.

Figure 1.

Elements of the Flexible Commissioning Programme

The programme was co-produced with a range of stakeholders as described in a previous paper.1

The objectives of the programme were to

• Improve access to dental care

• Develop skill mix care delivery

• Improve evidence-based prevention and

• Facilitate Making Every Contact Count (MECC) delivery.⁵

The programme framework incentivised the delivery of a number of programme access and prevention components as shown in Table 1.

Table 1.

Components of the Flexible Commissioning Programme

Prevention	Evidence informed pathways based on Delivering Better Oral Health (DBOH)6 and informed by learning from In Practice Prevention (Y&H) and Starting Well (Hull & Wakefield)
	Whole population	All children - DBOH recommended prevention All adults - DBOH lifestyle advice and signposting to local Health & Wellbeing Services
		Making Every Contact Count (MECC)
	Target groups	Children 0-18 Caries Referred for extractions under general anesthetic Older Adults Dementia Dry Mouth Osteonecrosis of the Jaw Risk Diabetes High needs / Phased treatment approach
Access	Open to new patients (all ages) on NHS webpages (formerly NHS Choices) Acceptance of referrals from CDS and 0-19 workforce Was Not Brought Policies / Safeguarding Implementation of Dental Check by One (DCby1)
Skill mix	Appointment of a practice Oral Health Champion Training for DCPs & whole dental team in association with HEE Y&H DCP led pathways - skill mix
Audit and evaluation	Completion of NHS BSA bespoke audit and reporting tool (Snap Tool)

Dental nurses were trained by HEE to deliver targeted one-to-one prevention sessions for children and adults with disease or disease risk embedding skill mix within dental teams. To date HEE have trained over 170 dental nurses through the delivery of a bespoke course including dental health education, fluoride varnish application and implementation of MECC.⁵

Practices who joined the programme were asked to be open for new patients through their NHS webpages and to work with health visitor and social care teams to facilitate access for vulnerable children and adults. Practices within the programme were also asked to work with local community dental services to accept the safe discharge of healthy level 1 patients and to engage in MECC delivery contributing to local health improvement and health inequality strategies.

' The NHS England Yorkshire and the Humber Dental Commissioning Team are at the forefront in developing and implementing flexible commissioning.'

All practices were required to appoint and train an Oral Health Champion (usually an enhanced trained dental nurse) to lead the programme internally. The Champions were given the opportunity to join a region-wide Champion peer review group on a virtual platform to provide support for implementation. Currently the membership of this informal peer review and support group is 109. An initial training event was held to provide information to the 147 practices involved in the programme.

The inclusion criterion to join the programme was the delivery of at least 90% of annual contract value.

The programme was supported by work with NHS BSA developing outcomes data collection tools including quarterly data submission surveys and a programme dashboard. A bespoke programme clinical delivery data report was provided by dental insight at the BSA.

Outcomes

The Yorkshire and the Humber Flexible Commissioning Programme started in late 2019. Of the 149 practices who initially joined the programme, 146 have remained enrolled. Although sites were not targeted, 48% of participating practices were located in deprived areas (IMD 1 to 3). Over the first 12 months the programme delivered the following outcomes

Access

The 146 Flexible Commissioning practices in the region have delivered approximately 39,500 new adult patient appointments and 18,500 new child patient appointments. The total number of new adult and child patient appointments seen through the programme represents 24% of the total new appointments in the region.

In terms of Dental Check by One (DCby1) in some localities the flexible commissioning sites delivered 12% more access for children under one year old.

The facilitated access for 3,500 children referred by health visitor and social care teams reflected the development of simple and effective patient pathways for vulnerable children. Of the 1,100 referrals from social care teams a significant proportion were looked after children a group with established health inequality.⁶

At the end of quarter four (Dec 2021) most practices (65%) reporting a waiting time in excess of 26 weeks for a first appointment for a non-urgent new patient via the online reporting tool.

Prevention

Oral Health Champions within each flexible commissioning practice delivered most of the evidence based targeted prevention pathways based on DBOH.⁷ The champion training commissioned by HEE and delivered locally by the Leeds Dental Institute included modules on behaviour change and fluoride varnish application. The prevention pathways were developed with the paediatric and special care dentistry Managed Clinical Networks.

Around 50,000 targeted prevention sessions were provided for children and over 15,000 for adults with disease or disease risk shown in Table 3.

Table 2.

Rates of fluoride varnish for children April - October 2021

	Fluoride Varnish Rate 0-3-year olds (%)	Fluoride Varnish Rate 3-16-year olds (%)
FC practices	27.1	69.8
Non-FC practices	23.2	62.3

Over 5,000 referrals were made by flexible commissioning practices into wider health and wellbeing services, integrating general health improvement into oral health services. 4,000 of these were referrals to smoking cessation services. The small number of weight management interventions reflect the requirement for greater training.⁸

Despite the restrictions imposed on delivery of care by the ongoing pandemic, evidence from FP17 data show that there was an increased rate of application of fluoride varnish by FC practices for children compared to non-FC practices in Table 2.

Table 3.

Programme delivery for 2021/22 - including Q4 2020/21

Delivery outcomes		Numbers delivered
Referrals from wider health and social care services
	Referrals from CDS	919
	Health Visitor Referrals	2,336
	Social Care Referrals	1195
	Total	4450
Referrals into health and wellbeing services
	Smoking cessation	4118
	Alcohol reduction	497
	Weight management	48
	Other	550
	Total	5,213
Targeted prevention sessions for children
	Caries	46,774
	General anaesthesia	3,973
	Total child sessions	50,747
Targeted prevention sessions for adults
	Dry mouth	1,177
	Dementia	441
	Osteonecrosis of the jaw	616
	Diabetes	2,380
	High needs	10,545
	Total adult sessions	15,159

' The 146 Flexible Commissioning practices in the region have delivered approximately 39,500 new adult patient appointments and 18,500 new child patient appointments.'

Impact of COVID-19

The pandemic had a significant impact on the delivery of the programme. The suspension of all routine dental care in England started soon after the third wave of practices enrolled in the programme.

An online survey was conducted with the practices enrolled in Flexible Commissioning to evaluate the impact of the COVID-19 pandemic on the delivery of the programme in late 2021.

From the online survey to practices:

• 95% of practices thought that delivery of the flexible commissioning programme was affected by COVID-19

• Around two fifths of these practices estimated that under normal circumstances, if not affected by COVID-19, delivery of the flexible commissioning programme could have been improved by between 25% and 50%

• Almost a third felt that this improvement would have been greater than 50%.

Cost effectiveness of the programme

Most practices (93%) opted to take the maximum 10% contract variation, which equates to a potential spend of £7.7million annually, with a range between practices around £250,000 to £10,000. It would be expected that such a range would lead to wide variation in the activity that a practice would have the capacity to deliver, however performance of delivery did not correlate with contract value.

Contract values and programme data have been used to assess value for money and cost-effectiveness. This has permitted modelling of values for the elements of the programme enabling benchmarking of delivery performance and analysis of return on investment. More data are required to inform service design ideally with the programme delivered under 'normal' 100% contract delivery expectations.

This evaluation has however shown that Flexible Commissioning practices fall broadly into three groups:

• Group 1: Engaged with delivering all elements of the programme and some evidence of delivering value for the investment.

• Group 2: Engaged with some but not all elements of the programme.

• Group 3: Poor/no compliance and delivery of the programme. Little or no return on investment.

Group 2 with support (training, targeted peer support etc) could potentially increase their delivery and cost effectiveness.

Summary of findings

The FC programme was launched in early 2020 just before the coronavirus pandemic forced healthcare services to shift their focus to a pandemic response. In many respects the positive engagement across the programme during a very challenging period underlines the commitment of dental teams and stakeholders to embrace the process of incremental reform of the existing dental contract and the fact that we need to capture the 'innovations in health driven by the COVID-19 response'.⁹ Some of the systems connectivity and consequent development of patient pathways for more vulnerable groups have developed at speed because of the general access challenges.¹⁰ The development of safe discharge arrangements between community dental services and flexible commissioning sites has been largely successful in terms of developing closer links and improved communication across care boundaries.

As the contractual requirements and targets return to the pre-pandemic levels, it is critical that programme development and improvement does not lose momentum.

Despite the limitations on delivery of primary dental care services imposed by the pandemic there is evidence that the FC practices are having an impact on delivery of prevention and to a lesser extent access. There is a considerable variation in volume of programme components delivered between practices. Some of this can be explained by size of the practice, but it is probable that practice readiness and understanding of the programme will have had an impact.

The provision of evidence informed pathways, local public health support for the development of referral pathways and the establishment of peer support forums have undoubtedly helped those practices who have engaged with training and support. Expansion of the programme may be supported by the requirement of practices to have a minimum level of staff trained and competent in place before programme commencement. Continued work with HEE to support training and associated workforce development is essential. Development of a dedicated NHS resource hub would also support sharing of best practice.

' Oral Health Champions within each flexible commissioning practice delivered most of the evidence based targeted prevention pathways based on DBOH'

The FC programme has supported the introduction and development of skill mix in practices. To an extent this supports the recent contract changes around skill-mix development announced this year.¹¹ It remains to be seen if dental nurses will be included as members of the wider dental team who will be able to open courses of preventive care.

Overall, the Yorkshire and Humber Flexible Commissioning initiative has demonstrated that it is possible to commission outcomes-based programmes that can impact on the delivery of preventive care, reduction of inequalities, improved access to new patients and contribute to improvement of general health through MECC. Change management required was supported by clear communication with practices, appropriate training, specific data collection, embedding of skill-mix, programme support and critically buy-in from stakeholders.

Acknowledgements

The regional teams of NHS England, Health Education England, Local Dental Networks, Local Dental Committees, local authorities, Community Dental Services and especially the practices delivering the programme and the champions leading it. Partnership work with the NHS Business Service Authority and Health Education England was critical to evidencing and evaluating outcomes and training and developing the workforce. Special thanks to Mr Colin Sullivan, Clinical Photographer, Medical & Dental Illustration Department, Leeds Teaching Hospital Trust for his help designing Fig. 1. ◆