In the most recent update to the contract reform process, there have been proposals to extend the regulations that allow prototyping to continue for another two years.
The regulations had been due to run out in March 2020, but with news of an extension it indicates that the reformed dental contract will not happen in April as had been originally suggested.
There has also recently been suggestions that a new model of weighted capitation is being looked at, which could also need testing.
To discuss these issues and try to shed light on what is happening, we gathered a panel of dentists involved in the reform process and invited NHS dentists to attend our What Next for NHS Dentistry? event in Chelmsford.
The panel included Eddie Crouch, Vice-Chair of the BDA’s Principal Executive Committee, Bhavin Patel, an associate in a prototype B practice, and Nick Barker, owner of a prototype B practice and Chair of the Essex Local Dental Network.
Delegates at the event were able to question the panel directly to help gain more understanding of the finer details and how they could be impacted in the future.
Calculating capitation values
One such question was, given the current variations in UDA values across the country, what would be the most ideal way for capitation values to be assessed.
Eddie responded, “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.”
Advice on maintaining your contract value
Another audience member asked what contract values would be based on and what they could be doing now to ensure their current value stays the same under reform.
Nick said, “It’s the same contract, it’s just reformed. Which is why your practice’s contract value won’t change and could only change with agreement between both parties.
“Don’t change the demographic of your patients or necessarily the way you’re working prior to moving over to contract reform, or think that you can set yourself up in a better position for joining contract reform other than to ensure you are maintaining capitated numbers. There is a look back over three years to calculate the figure and the local area teams are asked to see how you’re performing, and I’m not sure anything you did now would necessarily change that.”
Both Nick and Eddie cautioned against anyone having their contract values rebased without good reason.
Eddie added, “Try and make sure you hit the target that you’ve got because they’re saying that initially only people who are within five per cent either way of what they perceive you should be delivering in the contract, will be allowed to enter into a reformed contract.
“If you’re outside of that they’re not going to let you go in at the outset because it will be too disruptive for you and it might be disruptive for access across the system.
“But they are saying, and this is the worry, that if you were prepared to rebase and then get inside that five per cent, they might allow you to get involved in the contract reform process. But that might be an easy and irreversible way of losing value on your contract.
“So I would definitely encourage you to try and keep your contract value and roll-out at the time that’s pertinent to you.
“We’re hoping that NHS England and Department of Health will actually give practices the figures of what they’re expecting you to deliver, i.e. how many patients you have to see and what activity you have to do if you went into a prototype A or prototype B contract. And then we’d like them to give you a choice of either going into A or B.
“That’s what we’re asking for but I don’t think we’re going to get it however it will not stop BDA pushing for this.”
Delivering care in a reformed contract
When it comes to knowing which prototype contract might work best for your practice, there was discussion around the ways both are remunerated:
- 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.
Both types of contract have the same care pathway that has been almost universally praised as being a way of re-educating, motivating and improving patients’ dental health.
Patients are given an Oral Health Assessment (OHA) which generates a Red, Amber or Green (RAG status) that then determines the intervals at which they are seen. Although, the panel were keen to point out that the software can be over-ridden by the dentist if needed.
Bhavin, who has been involved with the pilot and prototyping of the reformed contract for eight years, spoke about his experience delivering treatment in this way.
He said, “It allows me to spend more time with my patients. I spend 30 minutes doing an OHA for new patients, after which they get a RAG score for the four main clinical domains and from there we can create a tailored treatment plan. And patients really understand the traffic light system.
“Having more time allows me to go through more options, to gain better consent and increase rapport, and the patient feels they’ve had a more thorough examination.”
Nick added, “The care pathway was designed by dentists, for dentists so it doesn’t use an activity model. At the end of the OHA they receive a printed self-care plan, which is what it’s entitled, and you can give it to the patients and say, ‘this is what you need to do to achieve good oral health, which will then help us to help you maintain that position. Without doing so, as dentists, we are very limited in what we can achieve’.
“The self-care plan is centred in prevention, so we’re trying to prevent disease rather than using activity levels and being paid for treating disease rather than stopping it altogether.
“And it is helping to drive behaviour change in patients. They’re given the information about what they need to do and why, and we are seeing improvements.”
Skill mixing and appointment zoning
Both Nick and Bhavin also talked about embracing new ways of working and a new mindset, not just for the dentists but for all members of the team.
Under a reformed contract there is more scope to utilise Dental Care Professionals (DCPs) as once the dentist has opened a course of treatment there is, for many patients, a further stage, called an Interim Care Management appointment, which can be solely delivered by a DCP.
And Bhavin said they had implemented a fairly rigid appointment zoning system to help them adapt to delivering the new contract.
He said, “If someone wants to book at a certain time for a certain type of appointment they may not be able to. We have slots for emergency care, private treatment, check-ups, etc, and it ensures that every day you can hit your target and fulfil your contract over the year.
“It requires a lot of discipline and it can be quite unnerving at first, especially for the front desk team to say to a patient ‘you can’t be seen here at that time’. But now it’s second nature and I could not go back to working from a chaotic book where one minute I’m doing check-ups and the next I’m doing treatment and the next I’m doing pain, it just wouldn’t work.”
There was discussion around how easily skill mixing could be implemented in a smaller practice.
For example, Bhavin works in a seven-surgery practice using hygienists, dental nurses and oral health educators. Whereas Eddie said that it could be difficult for single-handed practitioners with smaller premises and teams.
Eddie also said that suggestions had been made about pooling resources, but questioned whether smaller practices would be inclined, or be able, to share their DCPs and how practical this would be in rural areas.
He added, “Realistically, the demise of the single-handed or two-surgery practice is on the horizon.”
Preparing for the future
When it comes to the future of working in an NHS practice, there is no start date for reform to begin being rolled out and the belief is that it wouldn’t be a big bang approach, but rather ‘ink spotting’, i.e. rolling it out in spots across the country that gradually expand.
The exact way that reform will happen is another uncertainty. As Eddie said earlier, the feeling is that practices won’t be given a choice between contract A or B (or another blend that doesn’t yet exist), but they may well be given a choice between staying in the current UDA contract or moving to a reformed contract.
When it comes to knowing what the best choice is for you, and how to plan ahead, the advice was to start finding out the information you need now so that you can understand how reform will affect your individual practice through active networking in local and national bodies. Being well-informed is the first step to help you know what options you have and which the right one for you is.