22 Oct 2020  •  Blog, Covid-19, Practice Management  •  7min read By  • Nigel Jones

Being an NHS prototype practice during the pandemic…

Before COVID-19, reform of the NHS dental contract was probably one of the most talked about subjects in dentistry. Which perhaps goes to show the magnitude of the impact of the pandemic on the profession, that it managed to eclipse such an otherwise significant subject.

To find out how those involved with the reform process have fared since the pandemic broke out and how it could affect the future of the contract, Nigel Jones spoke to Ian Redfearn, owner of a prototype A practice…

Nigel: How did being a prototype make a difference to what was happening in your practice during lockdown?

Ian: We’re used to working a little bit differently, with a wider team of dental care professionals and a risk assessment at the centre of everything we do.

Our mentality is not, and hasn’t been for a number of years, about delivering a routine system of recalls for everybody. And that has definitely allowed us to be able to think a bit more differently during these times.

There are lots of questions in terms of how our contract is being managed during the pandemic, and with all the issues that the powers that be have been dealing with, we are way down the list. But at the moment we’re being trusted to get on and do the job, and that’s what we’re trying to do.

Nigel: Do the current arrangements for NHS dentists in England – being paid 100% of contract value for the achievement of that threshold of 20% of activity – apply to you as a prototype?

Ian: It’s far from clear, we can only assume so. We are monitoring our courses of treatments in what appears to be the key measure at the moment. And even though we’re still functioning as an urgent dental centre, we’re comfortably above that 20% threshold.

So, it does appear that we are still okay, but I’m not sure how they could have possibly applied that different target to our capitation list as well. I don’t expect it will be measured in the same way in terms of courses of treatment, but I’d expect some sort of measure for activity as best they can.

Nigel: How has your private income been affected?

Ian: It disappeared. We’re probably 90% NHS and 10% private but we’ve had no capacity to take on any new private work. But we have that cushion of 90%, so we will be okay for the foreseeable future. And, obviously, it’s very different for a practice where the mix is more uneven and that’s a horrendous challenge to be facing.

We have a large patient base and limited capacity, compared to pre-COVID-19, to see them. We’re finding that all our time is now taken up with completing treatments, just looking after the normal routine emergencies of people who break a tooth or when someone loses a denture. There’s no capacity to do much else at the moment and that won’t change until the fallow times and guidance change.

Nigel: Are you expecting contractual arrangements to pretty much continue along the same lines as they currently are for the rest of the financial year?

Ian: I think 20/21 will be a completely different year to everything else, but who knows? Looking at what’s happening with the big picture of COVID-19 numbers, the nation isn’t going to be anywhere close to some kind of normality for another six months.

Until we’ve got a vaccine that works and until we’ve got predictable, rapid testing, such as some kind of saliva test that’s sufficiently sensitive, things aren’t going to change.

I fully expect us to be working this way until well into the middle of next year.

I’ve heard some people say COVID-19 is going to change everything and that prototypes and UDAs are out. Any new contract is going to be more preventative measured and allow more innovation in terms of local contracting and other activities, such as dentists working in the community, etc.

It’s not a million miles away from what we’re doing now as a prototype so I’d be surprised if it looked massively different from what we’re doing at the moment.

There will have to be some sort of activity measure in that reformed contract. We’re operating in a very high-trust environment at the moment, and there is no doubt that there are a number of practices who are seeing that 20% threshold as a 20% target.

We’re getting patients through from other practices because they can’t see their own dentist. Some practices are still not open, they’re not doing AGPs, etc, and I do worry that in this high-trust environment we’re not showing ourselves in the best light, and we’ve been here before.

When we had the so-called pilot PDS pre-2006, which is not too dissimilar to what we’re doing now – a scheme where we were paid a fixed contract value and there were no measurements at all. That was a great opportunity, we were able to do all sorts of innovative stuff but, unfortunately, there were a minority of practices, but a sizable minority, who took the opportunity to not do any dentistry.

As a consequence of that, we ended up with the UDA and a contract that had activity at the centre of it because a proportion of the profession demonstrated that they couldn’t be trusted to do anything other than be paid based on activity.

My concern is that we are operating in another high-trust environment now, and we need to be doing the right thing to show that we can be trusted – pay us the money and we’ll look after our patients.

Nigel: You mentioned earlier that being a prototype and working differently with a wider team of DCPs has stood you in good stead for this crisis. How key is having economies of scale and a flexible workforce to making this contract work?       

Ian: There’s no doubt that there’s economies of scale but I’ve always believed that a 50/50 split of clinical work between the dentist and the dental therapist actually works out. If you are in a two-surgery practice, I think one dentist and one therapist is a perfectly viable model going forward.

Over many years, a one-to-one ratio, of dentist to dental care professional, has consistently worked well in our practice and seems to be the right mix to deliver a full range of comprehensive care for all our patients.

It’s purely down to what clinical work can be done; it’s nothing to do with the contract, it’s just what can be done by each individual based on scope of practice.

The old model of the associate working under a practice owner is no longer fit for purpose. There are all sorts of opportunities for a more well-defined career pathway for dentists, as they move into practice. Some may well want to stay in an assistant position, and that is absolutely appropriate for significant numbers.

But for others, there are opportunities for some sort of career development into other positions and specialisms.

You can begin to see these career development positions being offered and I think they make a lot of sense going forward, both professionally and economically.

Nigel: Thank you Ian for sharing your particular insight into the prototype experience during this time and predictions of what might happen moving forwards.  

Watch the full interview, where Nigel and Ian discuss further details about being a prototype practice in general and during a pandemic. The interview took place on 17th September.

Nigel was speaking to Ian as part of our ‘Inside Out: NHS Dentistry Discussed’ series.

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