Nigel Jones explores the stress of facing clawback and the implications that contract reform may have…
The run-up to April can be particularly stressful for NHS dentists as the pressure to achieve targets and avoid clawback becomes even greater.
It has been said that the predicted total of clawback for the year will be more than £200 million, which is up from £138.4 million in 2018/19 and £88.7 million in the previous year.
No doubt many dentists will once again be lamenting that much of that money will be distributed elsewhere in the NHS than dentistry.
Perhaps, with the end of March deadline for UDAs to be achieved still looming large in the mind, some may be thinking about what they could do to avoid this kind of stress in the future.
A reasonable question to ask would be whether or not contract reform offers any hope of solution to this?
UDAs in contract reform
During the pilot testing phase of contract reform, there was no involvement of the UDA. However, when they progressed to prototyping the contracts in practices, it was brought back in, which means that in the current reformed contracts being tested in prototype practices the UDA is still used as the measure of activity.
For those in prototype A practices, activity accounts for approximately 40% of remuneration and in prototype B practices, it accounts for approximately 15%. The rest of remuneration comes from capitation.
When it comes to the setting of UDA and capitation values under reform, Eddie Crouch, vice-chair of the BDA’s Principal Executive Committee, said, ‘They’re working on the stats at the moment and doing calculations on things like the deprivation score for where the patient lives, the age and sex of the patient.
‘We don’t have the exact figures yet but there has been an indication of between £35 and £55 for a capitation fee.
‘The inequality of the UDA that has been around since 2005 will be eliminated in reform. That’s because they are going to give the same value to the non-capitated activity, which is what they’re calling the UDA in the reformed contract, for every patient across the country.’
Clawback in the prototypes
When it comes to comparing clawback between the two prototypes and those working under a general dental services (GDS) contract, it seems that while there is improvement it may not be to the degree some are hoping for.
Forty per cent of practices under the current GDS contract face clawback compared to 33% of prototype A practices and 25% of prototype B practices.
Eddie said, ‘Clearly, from a monetary point of view, having a higher capitation level works better. But let’s not forget that prevention is an activity, it just isn’t measured as such by the UDA.
‘The higher the capitation level, the greater clinical freedom you have to deliver staged care. In principle this is a good thing, however, when there have been contracts of this nature in the past, there has been an element of under-treatment and supervised neglect.
‘And we need to be confident that capitation levels are calculated correctly. We suspect under the prototyping that list size of patients may have been over estimated or some suspect deliberately inflated. Meaning practices had to seek new patients from the word go.’
There are positive elements to the reformed contract, notably the care pathway which has been acknowledged as helping patients to take responsibility for their teeth and become more motivated to improve their oral health.
Measures taken to avoid clawback
But, the pressure of meeting UDA targets and the potential of facing clawback does still remain to a certain extent.
In order to meet those targets and reduce the risk of clawback, many dentists from within the prototype programme have spoken of the need to work longer hours and take on additional staff, without receiving any extra funding.
Joe Hendron, who was the 2018 LDC Conference Chairman and a practice owner who withdrew his practice from the prototype programme in an open letter to the then Health Secretary Jeremy Hunt, described the emotional and financial pressure he felt under.
He said the ‘constant churn’ of trying to get new patients into a busy appointment book, in order to meet the targets, was one of the main reasons he left.
Joe added, “The stresses that were being put on my staff led to my practice manager of 28 years leaving the business. We sat down together and calculated the number of new patients and UDAs we would need in order to reach the target, and she simply said, ‘I’ve had enough’.
“One of the initial aims of Prof Jimmy Steele’s reforms was to find an alternative to the UDA. This is why they did not have them in the pilot phase. The contract reform team panicked when there was a reduction in activity in the initial stages and reintroduced the UDA in the prototype phase. Had they let things run a little longer, I feel that activity would have recovered, once all of the patients had been through the Oral Health Assessment which is recognised as taking longer than the standard examination.”
The need to have a team that includes a wide mix of skills and roles has also been widely spoken about.
Preparing for change
It seems that while reform, when it eventually happens, may bring about some changes – some of which, like the care pathway, are probably more welcome than others – when it comes to clawback, the analysis shows that it is still very much part of an NHS dentist’s working life.
The figures mentioned earlier in this article reflect the difference you can expect in terms of the possibility of clawback. Compared to the current situation for practices under the current contract, 7% fewer practices working under the prototype A contract and 15% fewer practices working under the prototype B contract faced clawback.
While these statistics show an improvement, some will still be questioning whether it is enough of one. If you are looking to reform as a path away from clawback, it might be worth exploring some level of independence from the NHS.
Many of those involved in prototype practices have said that they found that, in order to be sustainable, they needed to spread their sources of income and that their private work increased.
Reform will undoubtedly bring about changes. Exactly what those are and how they could positively or negatively affect not just your practice’s risk of clawback, but other aspects of managing the business, are things that are worth giving some thought to now, so you can be as prepared as possible when rollout happens.