Dental Contract Reform: Prototypes Prototype expression of interest form: non-pilot NHS dental contracts Completion notes

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Paulina Alaina Gibbs
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1 Dental Contract Reform: Prototypes Prototype expression of interest form: non-pilot NHS dental contracts Completion notes This document sets out the completion notes for non-pilot NHS dental contracts completing the online expression of interest form to take part in the prototyping stage of the dental contract reform programme. This document should be read in conjunction with the online expression of interest form. To apply to become a prototype, existing NHS dental contract holders must complete an online expression of interest form. Please note that the expression of interest form must be fully completed in order for it to be considered. There is no save and continue function; therefore the expression of interest form must be completed in one sitting. To support applicants a downloadable PDF version will be available to enable applicants to review the questions before completing the form. In order to avoid technical issues while completing the online form, applicants should ensure that they temporarily allow pop-ups in their internet browser if prompted to do so. Please note that applicants should complete one expression of interest form for each contract they are applying for. Question Guidance notes Mandatory field SECTION A: Prototype principles and requirements 1. Is the person completing this form the contract holder or an authorised representative of a partnership/body corporate? 2. Does the applicant accept that the programme will determine the prototype remuneration blend for practices which are selected? 3. The DH and its agents will require access to practice data, including data from NHS BSA DS, both during the selection process and for the duration of prototyping. Please confirm that the contract holder consents to practice data being accessed. 1

2 SECTION B: Eligibility criteria Please see the document Supporting information for dental prototypes for further details of prototype eligibility criteria. All applicants must complete all questions in the eligibility criteria section to confirm that they are eligible to become a dental prototype. Applications failing to meet the eligibility criteria will not be considered for prototyping. SECTION C: IT and software 15. What software system is currently used by the practice? 16. Does the contract holder currently use an IT system at the practice (all locations), which is capable of full clinical charting and recording of clinical data? 17. Does the contract holder currently use an IT system at the practice (all locations) for the transmission of data to NHS BSA DS? 18. Does the contract holder currently use an IT system at the practice (all locations), which is capable of electronic appointment booking? Please select your software supplier from the list provided. Please do not contact your software supplier at this stage. If your software supplier is not currently involved with the contract reform programme, they will be contacted by a representative of the programme. 2

3 SECTION D: Contact details applicant s lead contact person 19. Applicant s nominated lead contact person Title Full name (first name and surname) Role (eg principal, manager) address Telephone number 20. Second contact (optional) Name address Telephone number Please give details of the applicant s nominated lead contact person. This person should be an individual nominated for all communication between the programme and applicant. Please indicate the name, telephone number and address of the lead contact at the practice. Please ensure that the address provided is correct, as this will be used to notify you of the outcome of your application. Details of a second contact can also be provided though this is not mandatory. SECTION E: Contract and practice information 21. Practice name Please provide the name of the practice. 22. Practice address Please provide the address of the practice for which you are completing the expression of interest and should be the registered contract address as specified in your NHS contract: Please separate lines of the address with a comma (, ). 23. Practice postcode Please provide the postcode of the practice address as specified in your contract. 24. Name of owner of the practice Please provide the name of the practice owner 3

4 25. Address where the contract is held (if different from the practice address) 26. Contract holder s name (if different from the name of the owner) Please provide the address of the practice owner. Please separate lines of the address with a comma (, ). Please provide the name of the contract holder as it appears on your NHS contract. SECTION E: Contract and practice information continued 27. Please state the start date for the contract that this expression of interest relates to? This is the date your NHS contract started. This should be in the format: DD/MM/YYYY If your contract began prior to 1 April 2006, please enter 01/04/ What type of provider are you? Please select the appropriate response from the list: 29. How many sites does your contract cover? sole provider partnership dental body corporate limited liability partnership Please enter a numerical field for this response. If the contract you are completing the expression of interest for is situated in just one site, please enter 1. If, however, your contract is provided over multiple sites, please indicate this by entering the relevant number in this field. 4

5 30. Contract number Please provide the contract number of the contract for which you are completing the application form. 31. Are any other NHS dental contracts provided at this location? 32. How many foundation trainees do you have at the practice? 33. How many dental chairs are there in the practice(s)? This is the contract number as it appears on the first page (top right hand corner) of your monthly schedules provided by NHS BSA DS. Please ignore the first 3 characters (eg Qxx), as these are not required for your expression of interest. Your contract number must be entered in the format: /0001 All contracts delivering NHS dental care in the practice to which this application relates must be included in the prototype. to indicate whether there is more than one contract at the address. If you answer yes you will be asked to provide the contract numbers of the additional contracts provided from the location. This should be in the same format as above. Please separate each contract number with a comma (eg /0001, /0002). Please indicate how many foundation trainees you have the practice. If you do not have a foundation trainee, please select 0 from the drop down list. Please give number of dental chairs there are at the practice for which you are completing the expression of interest. 5

6 34. Are there any active referrals or investigations into the practice, contract holder, or individual performer by any relevant regulatory body (eg GDC, CQC, NHS England), or any investigations resulting in action in the previous three years? Please indicate yes or no. If you select yes, please use the space below to provide brief details (max. 50 characters, eg Active GDC investigation ). Please note that a positive response will not result in automatic exclusion from selection. SECTION F: Additional information 35. Additional information You may use this section to provide any additional information that you think may be relevant to your application (max. 500 characters). If you are unable to complete the application form after consulting these completion notes, please contact the dental contract reform helpdesk, via: To submit a query please select dental contract reform from the list, then complete the form and submit. Please note you do not need to register on the webpage to submit your query. This document was produced by the dental contract reform programme Department of Health Legislation and Policy Unit Dental and Eyecare Services Room 201, Richmond House PrototypeApplications@pcc.nhs.uk 15 January

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