18 Jun 2019  •  Blog, NHS  •  12min read

NHS contract reform – what dentists need to know

‘Knowledge is power’ was one of the key messages for NHS dentists at the latest What Next for NHS Dentistry? event.

Panellists, including Eddie Crouch from the BDA, and practice owners involved with the prototype programme, discussed NHS dental contract reform and took questions from the audience.

All agreed that dentists need to act now to get the information that will allow them to understand how their practice specifically will be impacted, any potential negative consequences and any positive opportunities.

There’s a sense that with apparently just months to go before the contract begins being rolled out, this level of detail is missing, possibly due to a lack of action by the Department of Health (DoH) or NHS England.

It’s for this reason that Practice Plan began holding the What Next for NHS Dentistry? events early in 2019. One event was held in Gatwick on 12th June. Alongside Eddie, the panel was made up of two prototype B owners, Len D’Cruz and Nick Barker, and a mixed practice owner, Tina Tanna.  

The reality of running a blend B practice

The reform process has been testing two types of contract:

  • Prototype A – where band one treatments are paid for by capitation and bands two and three are paid for by activity (UDAs)
  • Prototype B – where band one and two are paid for by capitation and band three by activity.

Len and Nick were able to provide some of the nitty-gritty about the practicalities of operating a practice under blend B.

Some of the details they shared included:

  • The band three treatments are accredited with nine UDAs, compared to 12 in the current contract
  • Capitation numbers are based on the number of patients on your list over the past three years prior to converting to a prototype
  • Len’s UDA target dropped from 15,000 to 2,500
  • There is an ‘exchange mechanism’ where, if you go over your capitation target, you are allowed to do less UDAs. For example, Len went over his target by 108% and his UDAs were reduced from 2,500 to 1,600
  • Both Nick and Len saw an increase in their private income of around 10%
  • Waiting times at Len’s practice increased from up to a fortnight to between nine and 12 weeks (due to longer appointment times).

Len and Nick were also in agreement that using more members of the team, such as hygienists, therapists and extended duties nurses (EDNs), was an important part in making the contract work for them.

Len pointed out that therapists not being on the performer list was an aspect to consider when it comes to them being able to start NHS courses of treatment. Nick highlighted that some courses of treatment within the prototypes don’t include an exam and therefore can be carried out by the wider team who can also be involved in any course of treatment where modalities within their scope of practice are included, which is generally the case due to the algorithms in the system.

Nick added, ‘Because more remuneration comes from capitation, you concentrate on access and ensuring that treatment is carried out efficiently by use of the skill mix.

‘To do this effectively, we have set up a small working group within the practice made up of a nurse, receptionist, associate and manager. They get together and work out how to set the appointment book up and zone it for emergencies, new appointments, routine exams and treatments.’

The Oral Health Assessment

The prototype practices have been using a care pathway that includes an Oral Health Assessment (OHA) that gives patients a red, amber or green status across four major dental areas. The panel discussed how this, combined with remuneration being less attached to activity, enabled a greater focus on prevention and more engaged patients.

Len said, ‘The OHA is the most welcome part of the process – the ability to identify patients at risk and manage their risk before doing anything else. And, for patients who didn’t walk away due to the longer waiting times, when they come and experience the OHA and see how different it is to the usual quick check-up, they really value it.

‘It’s almost a private service paid for by the NHS, and it’s a luxury that normally we couldn’t afford. So while it is time-dependent, it does have its rewards.

‘However, it requires huge confidence and belief in the system from the practice team and patients, because when you have a waiting list of over nine weeks, it can be quite alarming from a business point of view.’

Eddie added that evaluation reports showed patients leaving practices involved in the prototype programme before the end of their treatment plan.

He said, ‘The analysis shows that about 30% of patients who initially started out as red on the OHA are not coming back to the same practice. Of course, at the moment, they have the opportunity to go up the road to another practice and get an appointment much sooner. But once the system is more widespread that may not be an option for them.

‘Access is a big issue – practices that have come into the programme later in the process and have the benefits of seeing what has happened to others, have been able to take on more patients to try to offset this. But until that issue has been solved, our confidence in the department rolling out something where access could drop significantly is something of a concern. Indeed, unless access is more secure, the likelihood of rollout is very much in doubt.’

The rollout of reform

When it comes to the actual way contract reform will be rolled out, Tina, who has a large NHS contract alongside a private list, spoke about the confusion and lack of information available. She said, ‘It is difficult to know what to do, the jury is still out and a lot of people are just worried that the grass won’t actually be greener.

‘For example, if you meet your capitation targets, what happens then – do you just stop seeing new patients, and how does the NHS and private mix in? A bit like Brexit, I think we’re all just fed up of ‘the reformed contract’ and when it is happening…the other big thing is no information has been given out officially about the financial element of it, so none of us can go home and work out whether it’s viable or not.’

Eddie said, ‘At the moment we are hearing that people won’t be given the flexibility of choosing whether you can go into A or B. That will be pre-determined by the commissioners which I think is wrong because you need to work out what will work for you before you move into it.

‘You will have the opportunity to stay in the UDA contract but that is failing dramatically. Clawback is rising exponentially, people are being quizzed about their prescribing and the BSA are constantly doing record audits – all of which puts pressure on the UDA target. I don’t think the rollout will hit the April 2020 target.’

Nick said that the rollout was likely to be gradual rather than a big bang, and added, ‘The design of the contract is still not set. We don’t know yet whether it’s the choice of getting blend A or B, or even X or Y, because there may be other areas that the DoH is going to look at and they’re still considering what exactly is going to happen.

‘As a profession, as far as the BDA or Local Dental Committees (LDCs) are concerned, we want to keep it as a capitation-centred system so you’re paid for the patients you see, not for what you do to them.’

Increasing reliance on private income

Eddie discussed the increasing financial pressures on NHS practices such as below-inflation pay rises and increasing CQC fees. In these circumstances, he said that it was difficult to see how someone without a large private income would struggle to manage such things as replacing a piece of equipment.

Len added, ‘Viability of the NHS is all about having a plan B – a private option. We’ve just invested £300,000 into our practice building. That money has not come from NHS dentistry, it’s come from private patients. We could not have survived on a purely NHS practice, and neither can you.’

Talking about the viability of the NHS led Tina to comment on the recruitment and retention issues she has seen within her practice. She said, ‘NHS dentistry is becoming very hard, we’re working around the clock and there is that treadmill.

‘Two or three of our young dentists have left recently to go into private practice because they can’t see a future in the NHS. I was talking to one of them after they left and he was telling me that he sees five patients a day – who wouldn’t want to do that?

‘I don’t think NHS dentistry in its current format will survive long-term, like Len my practice would not have survived without private income.’

Get the information you need now

The panel were unanimous that dentists considering their options should already be seeking as much information as possible about reform and how it will affect them, and that they need to do that now.

They suggested using the BDA, LDCs and Local Dental Networks (LDN) and attending events as the best approach.

Eddie said, ‘Get out there and go to events like this, get yourself properly educated now, before you have to make a decision that will affect the long-term future of your practice.’

Len added, ‘Make a positive choice – don’t just let it run over you and think that it is going to happen anyway. It could be a potential opportunity for you.

‘It’s transformed the way we practise, our staff would never go back to UDAs again. For us, it was a great opportunity – don’t miss out, take the chance to look at it.

‘We hear time and again how emotionally draining it is to work for the NHS. It is stressful to hit targets, but there are routes out of it, private dentistry is one of them, as is a capitation-focused system that allows you to access private dentistry when you want. Get properly educated and ask for help if you need it.’

Another What Next for NHS Dentistry? event will be held on Wednesday 19th June in Manchester and places are free to book. More events in different locations will be taking place across the country throughout the year, find out more here.

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