Almost 100 dental professionals gathered to hear a panel of experts discuss the potential impact of contract reform at the recent What Next for NHS Dentistry? event held in Durham.
Such a gathering suggests a deep feeling of wanting more answers and understanding about what the profession will face from April 2020. Beyond this, there was also a sense of catharsis as those attending shared their experiences of working in the NHS and their thoughts – and fears – about what may lie ahead.
Attendees at the event were able to probe a panel for both their first-hand insight of being involved in the reform process, and their expert opinions. The panel included principal dentist Onkar Dhanoya, who is also Chair of North Tyne Local Dental Committee, President of the BDA’s Northern Counties branch and Senior Vice-Dean of the FGDP(UK), and Shiv Pabary MBE, a member of the GDPC Executive, Education Associate for the GDC and Local Dental Adviser to NHS England.
They were joined by Louise Hunter, principal dentist and owner of a mixed practice, and Joe Hendron, 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.
The prototype experience – losing patients and profits
Joe revealed it was the ‘constant churn’ of trying to get new patients into a busy appointment book, in order to meet the targets, that was one of the main reasons he left. “The stresses that was putting 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’.”
Fellow panellist Shiv was part of the pilot process. He said: “We really embraced the change and we were actually over-delivering before we became a pilot. Within three years we lost 38% of our patients, people were waiting a long time for appointments and it was obvious that if we carried on into the prototypes that we would face clawback, so we left. The sad thing is that the Department of Health (DoH) just dropped us and we then had to try and build the practice back up.”
A dentist in the audience who had been a prototype B practice, but was due to leave the programme in a matter of days, said he was doing so with a ‘heavy heart’ but that profits had been ‘reducing significantly’. In the first year of being a prototype the practice lost £25,000 and in subsequent years their waiting times went up and they faced clawback of £70,000.
There was general concern among panellists and delegates that many of those who have chosen to enter the prototype programme, and are therefore potentially more motivated to make it work, are failing. Onkar highlighted the fact that those in the third wave, who have all the knowledge and learnings from the previous two waves, have also had ‘a huge drop in patient numbers even though they were prepared’.
‘Prevention is just a strapline’
The prototype blend B has been acknowledged as the preferred option of the BDA. And during the event Joe shared statistics from the latest evaluation that show 21% of blend B practices aren’t meeting their targets, compared to 32% of blend A and 38% of UDA practices. The evaluation also showed that both A and B practices required additional surgery time and more recruitment, without any additional funding, to deliver the targets.
Chris Groombridge from the Association of Dental Groups (ADG) was a member of the audience and confirmed that, as a group they support the dental contract reform process and they also support blend B. He said: “We believe that the access targets are too high, that the business sustainability model needs addressing – as stated in the evaluation reports from May 2018, we have real concerns about the 24-25% clawback in the prototypes and prevention, frankly, is just a strapline. The four concerns that the ADG have are the same that the BDA has.”
Sustainability of the models tested through the prototypes and due to be rolled out from April 2020 was also a big discussion point. There was a unanimous feeling that it simply isn’t viable, and that the basic fact of prevention taking time to carry out was still being missed by the DoH and NHS England.
One audience member, Ian Gordon, said: “Having worked out how much you would get for a patient for full capitation care, it comes to £6 a month. So, it’s not the UDAs that are the problem, it’s not the access targets that are the problem, it’s the financial envelope of how much we’re being paid for the number of patients we’re expected to see. I don’t think that’s a very sustainable business model.”
From the panel Shiv also urged people to take a wide view of the business when it came to judging sustainability: “You can’t just look at your set of accounts and say ‘this has/hasn’t worked for us’ because the comments from the evaluation reports show that there has been a lot of investment by most of the practices in terms of skill mix, recruiting more therapists or hygienists etc, and the extra hours needed. So, it’s not what you earn or what you make as a practice, it’s the time you’re spending to keep the numbers up – and there’s a cost to that.”
Defend yourselves from a ‘malignant NHS’
Onkar described his feelings about what reform could mean: “Clinically, the care pathways are very good. But from a managerial point of view it feels like we’re replacing one treadmill with two. You’re counting patient numbers and you’re counting UDAs.”
A former BDA Chair, John Renshaw, was among the audience and said that from his involvement with contract reform since 1985 ‘there’s never been anything that has ever made it better, it’s only ever made it worse in the long run’. He also urged dentists not to solely rely on NHS income. John said: “The Government doesn’t want, in any way, shape or form, to pay for NHS dentistry. You only have to look at the rise in patient charges to see where they really feel the benefit comes from and it’s not from dentistry…It’s possible for almost everybody to be able to move at least partially into the private sector and the thing that the private sector gives you is some defence against the malignancy of the NHS – and I use that word advisably.” His words were greeted with a round of applause.
Chris also received a round of applause when he exhorted the profession to take control of their own destiny: “Maybe it’s about time that as a profession you got control of your own future and set your own destiny instead of having your destiny permanently set for you…if the direction of travel is going towards mixing and, eventually, maintenance schemes, wouldn’t it be better for the profession to be realistic and instead of reacting, get ahead of the game and start planning their own future.”
Chris then said: “NHS dentistry has provided great care to patients for many years and hopefully will continue to do so but practices need to be realistic and in the current climate should develop other sources of income.”
A flexible future?
When it came to discussing the long-term viability of NHS dentistry Chris raised the point of a closing gap between the cost of NHS and private treatment. He said that by 2022 private and NHS exams only will be on a parity and by 2029 NHS and private dentistry as a whole will be on parity.
Shiv also discussed the possibility of a core contract, and the need for honesty with the population around that, but also that this was unlikely to receive government support. He said: “If we told the DoH that within the budget that we have we could sort out pain, anterior aesthetics and function and the rest of treatment would need to fall under private care, they would not go anywhere near that. They say that we need to do anything that is clinically necessary but within the same financial envelope.”
One glimmer of hope that was discussed was the experimentation with what is known as flexible commissioning. Chris revealed details of how a programme called In Practice Prevention (IPP) has been implemented in 26 practices in North Yorkshire and Humber. Flexible commissioning has also been successfully implemented by the NHSE regional dental commissioners to provide additional sedation and ensuring domiciliary care in 103 care homes in North Yorkshire and Humber. He added: “We’ve done it and we’ve proved it can work, the question now is whether we can get it rolled out further across the region, and the idea is that if the model works there, it could be rolled out nationally.”
Whether flexible commissioning could be a positive feasible route forward remains – like so many aspects of the future of NHS dentistry – unknown.
There will be more ‘What Next for NHS Dentistry?’ events held around the country. For more information contact firstname.lastname@example.org ,call 01691 684163 or visit: www.whatnext-nhsdentistry.co.uk