NHS Contract Exceptions Report

NHS practices receive a quarterly report from their PCT, outlining how they did for the previous 5 quarters against 22 Key Performance Indicators.

Because they are judged on these KPIs and their performance influences whether they can get additional UDA contracts or payment for their existing contracts, NHS practices need a way to see how they are tracking against the KPIs ahead of time so that they can correct if necessary.

The report does the following:

Produces the same historical data (or very close) as the official report for the statistics that it offers.
Runs for the current period, so that a site can course correct if necessary.
Runs per provider, so the site can zoom in on problems.
Is able to run for the current quarter as well as the previous 5 quarters. The quarter boundaries are:
- 1st January - 31st March
- 1st April - 30th June
- 1st July - 30th September
- 1st October - 31st December
Runs for the current quarter even if it is not complete. It does not run for future quarters.
It can be scheduled and exported.
EXACT stores the default threshold values as settings, so that they can be updated by the user as required if they change.
Values that exceed the threshold are marked with the Warning "Over".
Values within 10% of meeting the threshold are marked with the Warning "Near".

NHS Contract Exceptions Report explanation

Exception Indicators of Fragmentation (Splitting) of courses of treatment:

Exception Indicator:	FP17s within 3 months of a previous course of treatment

Exception Indicator:	FP17s within 3 months of a previous course of treatment
Rationale	Relatively high rates of forms per patient within a quarter could be caused by high levels of continuations of treatment or free repairs and replacement. High rates of these may be a reflection of failure in the quality of treatments being provided. A common cause is the separate submission of assessment and treatment claims – which is not generally allowed under national regulations. Very high frequency recalling of patients would also have an upward pressure on this rate as would high levels of unplanned treatments, such as urgent or trauma treatments.
Numerator	The number of FP17s (adult, child, total) scheduled during the quarter where there was a previously recorded course of treatment ending less than three months previously. Where there is no recorded end date (incomplete treatments), the date of acceptance is used.
Denominator	The number of FP17s (adult, child, total) scheduled during the quarter.
Threshold	The outlier threshold for this indicator is based on the distribution of rates across contracts for the whole of England and Wales and is calculated as one and a half times the inter-quartile range above the upper quartile.
Warning	Values that exceed the configured threshold are marked with the Warning Over. Values within 10% of meeting the configured threshold are marked with the Warning Near. Thresholds can be customised by the Support Desk personnel on request.
Cross references	Indicators such as Free Repair and Replacement; Continuations; Late Reporting; Band 2 and 3 starting and ending on the same day; FP17s within 12 months; FP17s within 3 to 9 months; as well as other investigations will help to understand the underlying causes.
Exception Indicator:	Band 2 or 3 starts and ends on the same day
Rationale	Where a provider appears to have a high proportion of treatments within 12 months of a previous treatment it is possible that there is a failure to provide adequate preventative advice or treatment during the earlier course of treatment. Alternatively it is possible that intended dental courses of treatment are being split across two claims, rather than being provided in a single course. Measuring Band 2 or 3 rates within 12 months of a previous band 2 or 3, in adults will give a slightly more subtle measure of splitting issues than shorter period recalls. For example dentists splitting treatments over 4 months or recalling for the next phase of treatment, will have higher rates here.
Numerator	Adult band 2 or 3 treatments (FP17s) in the last 12 months.
Denominator	Adult band 2 or 3 treatments (FP17s) in total.
Threshold	he outlier threshold for this indicator is based on the distribution of rates across contracts for the whole of England and Wales in 2010
Warning	Values that exceed the configured threshold are marked with the Warning Over. Values within 10% of meeting the configured threshold are marked with the Warning Near. Thresholds can be customised by the Support Desk personnel on request.
Cross references	FP17s within 12 months of a previous (below) includes checkups as well – and will detect splitting of checkups from treatments. This indicator can be used in conjunction with FP17s within 3 months of a previous and FP17s within 3 to 9 months of a previous FP17.
Exception Indicator:	FP17s within 12 months of previous
Rationale	This indicator could result from a practice policy to maximise UDA within the contract. Exceptionally high rates are likely to be associated with practices with a recall policy not in line with NICE guidelines, for example a default maximum recall period of 12 months for adults.
Numerator	Number of FP17s scheduled during the quarter where there is a matching previous FP17 where the completion date on the earlier FP17 is within 12 months of the acceptance date of the later one.
Denominator	Number of FP17s scheduled during the quarter.
Threshold	The outlier threshold for this indicator is based on the distribution of rates across contracts for the whole of England and Wales in 2010
Warning	Values that exceed the configured threshold are marked with the Warning Over. Values within 10% of meeting the configured threshold are marked with the Warning Near. Thresholds can be customised by the Support Desk personnel on request.
Cross references	This indicator may be associated with Free Repairs and Replacements Continuations; Forms per patient etc
Exception Indicator:	Free repair and replacement rates
Rationale	Where there are high numbers of free repairs and replacements this will compromise the levels of access in the practice. In addition it could be an indicator of a failure to provide an adequate level of quality in treatments, and an unnecessary diversion of resources.
Numerator	Number of FP17s scheduled during the quarter where there is a free repair or replacement indicated.
Denominator	Number of Band 2 or 3 FP17s scheduled during the quarter.
Threshold	The outlier threshold for this indicator is based on the distribution of rates across contracts for the whole of England and Wales and is calculated as one and a half times the inter-quartile range above the upper quartile.
Warning	Values that exceed the configured threshold are marked with the Warning Over. Values within 10% of meeting the configured threshold are marked with the Warning Near. Thresholds can be customised by the Support Desk personnel on request.
Cross references	Free repairs and replacements could be an underlying cause for exceptions in other indicators including UDA per patient and Forms per patient.
Exception Indicator:	Continuations of treatment
Rationale	There is a much higher than expected number of claims for continuation of treatment, in many cases for patients whose initial course of treatment was only Band 1 (i.e. examination, scale and polish etc). This could indicate a misunderstanding by the provider, of the requirement to identify all the required treatment at the outset and to submit a single claim for all necessary interventions.
Numerator	Number of Band 2 or 3 FP17s scheduled during the quarter where there is a continuation of treatment indicated.
Denominator	Number of Band 2 or 3 FP17s scheduled during the quarter.
Threshold	The outlier threshold for this indicator is recalculated each quarter and is based on the distribution of rates across contracts for the whole of England and Wales. It is calculated as one and a half times the inter-quartile range above the upper quartile.
Warning	Values that exceed the configured threshold are marked with the Warning Over. Values within 10% of meeting the configured threshold are marked with the Warning Near. Thresholds can be customised by the Support Desk personnel on request.
Cross references	High Continuations rates may explain other indicators such as Forms per Patient and UDA per Patient.

Exception Indicators of Patient Case-Mix:

Exception Indicator:	UDA per Form

Exception Indicator:	UDA per Form
Rationale	A high UDA rate per form is a fundamental indicator of the profile of bands of treatment at the provider. Exceptional rates need to be investigated to ensure that the range of treatments being provided covers the full range of services expected of NHS contracts, and is not intended to maximise the UDA rate. For example, the proportion of inlays among tooth restorations can have a dramatic effect on the UDA rate per form in some contracts
Numerator	UDA scheduled during quarter
Denominator	FP17s scheduled during quarter
Threshold	The outlier threshold for this indicator is recalculated each quarter and is based on the distribution of rates across contracts for the whole of England and Wales. It is calculated as one and a half times the inter-quartile range above the upper quartile
Warning	Values that exceed the configured threshold are marked with the Warning Over. Values within 10% of meeting the configured threshold are marked with the Warning Near. Thresholds can be customised by the Support Desk personnel on request.
Cross references	High levels of Band 3 to Band 2 treatments might influence this indicator, more specific indicators such as high inlay rates compared with fillings will be of interest to commissioners.
Exception Indicator:	No clinical data
Rationale	All treatment FP17s would be expected to provide information about the treatment in the form of clinical data. The treatments are chosen from about 20 categories which includes an option for ‘other treatment’. Band 2 and 3 FP17s should not be submitted without any clinical data.
Numerator	Number of FP17s with no clinical data set.
Denominator	Total FP17s scheduled during the quarter.
Threshold	The outlier threshold for this indicator is recalculated each quarter and is based on the distribution of rates across contracts for the whole of England and Wales. It is calculated as one and a half times the inter-quartile range above the upper quartile.
Warning	Values that exceed the configured threshold are marked with the Warning Over. Values within 10% of meeting the configured threshold are marked with the Warning Near. Thresholds can be customised by the Support Desk personnel on request.
Cross references	N/A
Exception Indicator:	Band 3 to 2 rate
Rationale	Attention tends to focus on fragmentation of treatments as a cause of excess UDA per patient. A completely different reason for high UDA rates is the mix of band 3 to band 2 treatments. Band 3 treatments carry four times the UDA of a band 2. Commissioners will want to understand the justification for exceptionally high ratios of band 3 to band 2 treatments. An example which has been found to be a significant factor in some contracts is high rates of inlays compared with fillings
Numerator	Band 3 adult FP17s scheduled in the quarter.
Denominator	Band 2 adult FP17s scheduled in the quarter.
Threshold	The outlier threshold for this indicator is recalculated each quarter and is based on the distribution of rates across contracts for the whole of England and Wales. It is calculated as one and a half times the inter-quartile range above the upper quartile.
Warning	Values that exceed the configured threshold are marked with the Warning Over. Values within 10% of meeting the configured threshold are marked with the Warning Near. Thresholds can be customised by the Support Desk personnel on request.
Cross references	A high band 3 to band 2 ratios may be associated with high rates of UDA per patient. This would suggest that case-mix is part of the explanation, at least. A recent study found high inlay rates to be an important cause in some contracts
Exception Indicator:	Band 1 urgent treatments
Rationale	Unusually high rates of urgent treatments would not be expected, except where the contract was for an emergency dental service. Commissioners will want to understand why a contract had an exceptionally high rate of urgent treatments. Urgent treatments might also be an indicator of failed treatments or a lack of preventative treatment.
Numerator	Band 1 urgent UDA
Denominator	Total UDA
Threshold	The outlier threshold for this indicator is recalculated each quarter and is based on the distribution of rates across contracts for the whole of England and Wales. It is calculated as one and a half times the inter-quartile range above the upper quartile.
Warning	Values that exceed the configured threshold are marked with the Warning Over. Values within 10% of meeting the configured threshold are marked with the Warning Near. Thresholds can be customised by the Support Desk personnel on request.
Cross references	Other indicators of failure such as free repair and replacement and continuations might be of interest here. High rates of urgent band 1 treatments might be associated with high number of Forms per Patient.
Exception Indicator:	Inlay Rates
Rationale	Inlays are a form of indirect restoration of tooth loss, ranging from a small cavity to partial tooth loss. A clinical judgement is required to determine the appropriate restoration for each situation – but there is some evidence that inlays are being used for inappropriately small cavities where a direct restoration would be more appropriate. There is also evidence that the appropriate materials are not always used, sacrificing the permanence of the restoration, for cost. Inlays attract a Band 3 reimbursement, compared with band 2 for fillings. Where low cost materials are used inlays are the cheapest band 3 intervention available, which could present perverse incentives to dentists keen to maximise their UDA. It is also known that exempt adults are significantly more likely to be given inlays, than charge payers. Charge payers may be discouraged by the higher patient charge for band 3 treatments, opting for direct fillings instead. Where the inlay rates are exceptionally high, commissioners will want to understand the clinical justification from the dentist and also whether patients are being asked to choose between different restorations on cost grounds
Numerator	Adult FP17s – number of teeth with inlays on claim.
Denominator	Adult FP17s – number of teeth with inlays or fillings on claim.
Threshold	The outlier threshold for this indicator is based on the results of an analysis and investigation in 2010. The outlier threshold is set at 0.20 and the amber threshold at 0.10.
Warning	Values that exceed the configured threshold are marked with the Warning Over. Values within 10% of meeting the configured threshold are marked with the Warning Near. Thresholds can be customised by the Support Desk personnel on request.
Cross references	Exceptional inlay rates may be one of the explanations for high UDA per form, and thus high UDA per patient