23 Sep 2020  •  Blog, Covid-19  •  11min read By  • Nigel Jones

Will COVID-19 break the contract reform logjam?

Martin Woodrow, Chief Executive of the BDA, talks to Nigel Jones, Sales and Marketing Director at Practice Plan, about how COVID-19 may impact the timescale and nature of contract reform, the new contractual arrangements from NHS England during the pandemic and the results of a report into the resilience of mixed and private practices…

Nigel: Most people have found it challenging to stay up to date with the moving goalposts and the fact that we have different approaches in different parts of the UK. How did you find managing through that situation?

Martin: It has been a four-nation issue. We’ve got devolved offices in the four countries in the UK and there’s been a huge amount of pressure on those offices and the representatives in those nations. They’ve all had to do the same process of saying, ‘Right. What have we got here that’s fit for purpose?’

And whilst there’s been some consistency, you’ll know that while there are similarities between the contractual frameworks of England and Wales and perhaps similarities between Scotland and Northern Ireland, essentially, they’re very different frameworks moving at very different paces in terms of their approach to the pandemic.

The four countries, therefore, need to respond differently, so we’ve had to maintain updates from all four of those nations and get involved in those discussions and ongoing negotiations across the four countries.

Nigel: One of the things that must count as a real success has been the way that NHS England has responded to your approaches in terms of how to structure contractual payments, both retrospectively and right now. Because that seems to have been a pretty good deal…

Martin: I think it’s a fair place that we’ve got to at the moment and I think most practitioners recognise it as such. It’s been a struggle but also a productive working relationship; between ourselves and our colleagues in NHS England and other bodies have probably done the work of years in the space of weeks and months.

We’ve felt frustrated, similar to the view expressed by Nishma Sharma from the OCDO when you recently spoke to her, around the pace of things coming out of NHS England at times. It’s not necessarily the people who are dealing with it either in the office of the CDO or within NHS England, but the machinery of government just takes a lot of time to churn through. And it’s not dentistry specifically, it’s for all of the professions.

Nevertheless, we’ve been able to work effectively with NHS England, to point out the challenges and restrictions facing practices, and we also have to be realistic in terms of what we can expect them to do from a contractual point of view. And they’ve taken that on board.

The framework we’ve got at the moment is fair in recognising the limitations that are on activities going backwards to the period before 8th June, where practices began providing care again. Then there was a long discussion about the abatement, so the reduction in their contract value to reflect the expenses that weren’t being occurred around things like lab bills at that time and materials. That was a really long, painful process to get that particular piece of work over the line.

At the end of May, just before we did come back to a routine face-to-face care, there’d been a piece of advice, a prompt to prepare as the CDO called it, that had been sitting around for eight or nine days that they tried to get out prior to that and hadn’t been able to. That was hugely frustrating.

And quite rightly, the profession gets upset in a period of time where they’re already under stress and strain. It’s one of the learning lessons for this. The machinations of government just move too slowly at times.

Nigel: Do you feel that the current arrangements that have been put in place are a demonstration of trust in the profession by NHS England?

Martin: We find ourselves in a fair situation where there is a threshold of activity that practices are meant to deliver. And it is a trusting relationship where they are being asked to do that and it’s not a case of just once you’ve reached your 20% of activity, you can put your feet up and do something else or treat private patients. But you should be doing the same amount of work that you’ve done for the NHS that you did previously.

There is a trust element that is hugely important for the profession. For years and years, we’ve been asking for a contractual framework that isn’t so interventionist and so difficult to adhere to with a UDA system that is widely discredited. The profession say they don’t want to chase activity like that and this is the opportunity to demonstrate, albeit in a short period of time, that there is an alternative way.

What we do now and how the profession reacts at the moment really does frame what comes next for the rest of this financial year and beyond, because we’ve been asking for reforms of contract since 2006. This could be the kind of paradigm shift that we wanted to make that break. From a really unpleasant situation, we could get something good for NHS contracts, but it does rely on the profession, on dentists to deliver at the moment.

Nigel: I think that idea of the pandemic, horrific as it’s been, also acting as a catalyst for change is a really important thing not to lose sight of. I know that Jason Wong’s been leading a working party that published a report on resilience in practices. How did that process go and what were the main conclusions and recommendations?

Martin: While we feel we’ve been able to achieve a fair deal for NHS practises, it has been frustrating that practices that rely on private income have been left very vulnerable. There’s a real disparity.

We have tried in so many different ways to seek support for private dentistry across the pandemic period and we just could not achieve what we would want to do for private dentistry. And that’s a real shame.

Private dentistry’s been left in the same place as lots of other businesses, and in some senses, dentistry has been in a worst position given that associates relying on private income, if they earned more than £50,000, were struggling to get even self-employed support. It’s a real problem. We’ve made the case time and time again to the Chancellor that there needs to be more support.

Jason Wong, newly appointed Deputy Chief Dental Officer, brought stakeholders together to say what is the issue with mixed practices in particular? Is there a vulnerability here in the system? I was a member of that working group, and the BDA provided some background research – we asked practices (and had around 3,000 respond) what their sentiment was like in dentistry at the moment, whether they felt vulnerable, how long they felt they could last.

A report was published which makes a number of recommendations to support dentistry, particularly private or mixed practices. For example, it says there should be an extension of the original job retention scheme for the sector. It makes recommendations about repayment terms for the business interruption scheme and business rate relief for dental practices, which is one of the real bugbears that we’ve had during the pandemic.

It also focuses particularly on the dental laboratories sector, because that is a sector that really has struggled during the pandemic period with the reduction, inevitably, of the amount of lab work that’s been undertaken and will take some time to recover.

We’ve already written again to the Chancellor about the report and the need for action, and it’s also gone to Jo Churchill, Parliamentary Under Secretary of State at the Department of Health and Social Care, who will hopefully make some representations as well on behalf of the sector.

Nigel: It seems like it would be in the interest of the Chancellor and the Treasury to follow the recommendations. But what’s your sense of optimism with this?

Martin: I think you’re absolutely right. We’ve long articulated the argument that NHS dentistry provision relies on the private sector. More than 50% of the money spent on dentistry is spent on private care. And there is a huge interrelationship between the two parts of the dental sector that cannot be unentwined easily.

The issue is that, important as we think it is to the health of the nation, we are one small business sector, and it is difficult to get our voice heard. What is easier for us in the sector is to influence the people that we are used to influencing, and have a relationship with, such as NHS England and the Department of Health.

We’re in a different environment now. The Treasury has had intense lobbying over the last few months from groups of MPs raising the issue of the status of private dentistry and very unusually, even when a group of 20 plus MPs wrote to the Chancellor, they didn’t get a reply to that letter. And that’s hugely unusual.

I think it just demonstrates the amount of pressure that the Treasury has been under, as we all have been. But that is a concern. We won’t let up on it, we’ll continue to persist and badger them on it. I’m an optimist. I’m not saying that we’re going to get something out of it, but we will make every effort that we can to do that.

Nigel: When it comes to the NHS reformed contract, what are your thoughts about how you try to shape that contract in the post-COVID world and the timescales for seeing what that would look like?

Martin: It feels as if since 2011, there’s been a very conservative approach to contract reform, a real reluctance to take a leap of faith and move ahead. There’s been constant reinvention of the process of prototypes and, before that, pilots.

Could this be the thing that breaks the logjam? Necessity is the mother of invention and at the moment we’ve had to design a contractual framework at very short notice.

The second half of the financial year is a month away. While what we’ve got as a current temporary arrangement can persist, we’re involved in discussions with NHS England about changing that. I think that there will be a gradual change across the second half of this year.

Necessity means that from April 2021, we will actually need a new contractual framework because in the current environment, the UDA, apart from being deeply unpopular and really not fit the purpose, and a contract based on chasing activity simply doesn’t work. So, we have to do something different.

Across the backend of this year, I think we’ll see a fairly simplistic framework, a bit of change there. That will give us a bit of room to have something from April next year. Now, normally you’d say that’s just not going to happen in six months’ time, but given the circumstances, it actually is more likely than it was previously.

It may be something that needs developing and needs to be iterative. But my hunch is that we’ll probably see things develop that way and that we may well, by necessity, need to move relatively quickly.

Nigel: Martin, thank you so much for speaking to me, it has been a fascinating discussion into what is happening within the profession during these strange times.

Watch the full interview, which took place on 3rd September.

Nigel was speaking to Martin as part of our ‘Inside Out: NHS Dentistry Discussed’ series. The next free webinar in this series will take place on Wednesday 30th September with John Renshaw, a long-standing major player in dental politics and former Chairman of the BDA.



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