NHS dental contract reform in England remains on the horizon, although there is a feeling it is not as close as it once was. April 2020 had been put forward as the date that reform would begin being rolled out. However, that has almost certainly been shelved as the regulations that enable prototyping of the contract to happen have been extended for another two years.
This means that if you are a dentist struggling with delivering NHS services and hoping that reform could offer salvation in the coming months, this is unlikely to happen. It also means that the uncertainty and confusion that surrounds the details of reform and how/when it will be rolled out remains.
To address that feeling of confusion and bring about some clarity, Practice Plan has held a series of events throughout 2019 where dentists can listen to and directly question key figures from dentistry and those who have been involved in reform in some way.
At the latest of these ‘What Next for NHS Dentistry?’ events held in Nottingham, Eddie Crouch, Vice-Chair of the BDA’s Principal Executive Committee; Ian Redfearn, owner of a Prototype A practice; and Joe Hendron, owner of a former Prototype A practice, formed a panel to discuss reform and take questions from delegates.
Is it harder or easier to manage a reformed contract?
One question that was asked from the audience early on was a simple but pertinent one: ‘is it harder or easier to manage under the reformed contract compared to the existing one?’
Ian was unequivocal in his answer: “It’s definitely harder to manage.”
He explained that running a prototype contract has meant juggling more balls to hit multiple targets rather than just the one aim of achieving 98% of UDAs by 31st March.
Ian added, “You constantly have to monitor your capitation as well as your activity level, and in order to maintain your capitation you take on more patients who all need some treatment, and that then has an impact on activity.
“We found that we were running out of activity by the end of the year and that continues to be a challenge that I’m not comfortable with. And there’s no doubt that our waiting times for an appointment under the reformed contract are longer than they were previously, and I’m not comfortable with that either.
“We’ve not yet had to take on any additional clinical time in order to address that, so we haven’t had any extra costs to manage that appropriately. If or when we have to do that, our views on the prototypes may well change.
“There has been a number of prototype practices who were forced to take on additional dental/therapist hours for no extra money, which inevitably affects the bottom line. At the moment we’re maintaining a zero stay with that, I’m not sure how long that will be sustainable.”
An empowering and motivating care pathway
However, there were also some positive points when it comes to delivering the reformed contract.
For example, the care pathway involves Oral Health Assessments (OHAs), which include around 80 questions based on social history and clinical examination, that give patients a Red, Amber or Green (RAG) score for their dental health. This has been very effective in improving communication with patients as well as having a positive impact on their motivation to look after their teeth.
Ian also described it as ‘empowering’ for the dentist, as it enables them to put the responsibility for their dental health in the hands of the patient. And it provides evidence that a patient may not be looking after their teeth appropriately, which the dentist can use to explain why they may not be willing to carry out more advanced treatments.
Joe explained that in the pilot programme they had seen improvements in areas such as smoking cessation, however such things were not being measured. Patients responded positively to the RAG scoring system and they felt they had more time to spend with patients, but in doing so their activity level was deemed to have dropped.
“They reintroduced UDAs when we moved from pilot to prototype and we had the two targets to get, trying to maintain access and activity, as well as squeeze in prevention. And this is when we started struggling,” said Joe.
“It just didn’t work, and this is why we had to say ‘we’re under so much stress, the books are crammed full and we’re expected to see more patients because we’re below a target arbitrarily set by those in charge of contract reform, we just can’t do this anymore.’
“Before any dentists walked out on us, we decided enough is enough and left the prototype programme in 2018. We made our targets and hit 100% but I lost a practice manager who had been working for us for 28 years on the back of it, which is a sad indictment.”
Positive patient surveys
Eddie said that patient surveys carried out in the early days of the reform programme had been positive, however none have been carried out since fees for interim care were introduced.
He said, “The patient surveys that were done right at the beginning of the piloting show that patients really quite liked the new way of delivering the service; it’s certainly the way we were all taught in dental school to deliver dentistry.
“Strangely enough, they haven’t done many surveys since they started introducing a fee for interim care, which they weren’t doing at the start. In the beginning you could do a course of treatment over several months and the patient would only pay a band one fee, and patients quite liked that.
“Patients will obviously really benefit from the quality of care but it does worry me that you’re being incentivised to speed up because you’re juggling the target of number of patients and the target of UDAs.”
The different blends of reformed contracts
There was discussion around how reform will happen. While there have been no definite specific details given, it is believed that it will not be a big-bang approach and that dentists will be given a choice of whether to stay in the UDA contract or move to a reformed one.
However, it is not thought that dentists will be given a choice of which reformed contract they move into – prototype A or B. The difference being a different blend of capitation and activity.
In the A contract, band one treatments are paid for by capitation, which accounts for around 60% of remuneration, and bands two and three are paid for by activity.
In the B contract, bands one and two are paid for by capitation, which accounts for around 85% of remuneration, and band three is paid for by activity.
Eddie said that the BDA prefers the Blend B contract due to the lesser reliance on activity. Although Ian’s experience was that increasing your patient numbers naturally led to a rise in activity levels.
Ian added, “We know that some dentists on GDS contracts are really struggling to hit targets this year and no doubt that is because a band three treatment is very expensive for patients.
“I am noticing that patients are taking the option, where possible, to avoid a band three treatment. If that continues and you’re in a Blend B contract where all your activity comes from band three, that could present some challenges.”
Joe advised that anyone thinking of taking a reformed contract should make sure they have a stable patient base as capitation levels are set by looking at numbers over the past three years.
He added, “Your activity element should be achievable for the first few years. However, if you keep the same number of patients and you’ve done all the work you need to do, you’re going to run out of UDAs. And then you’ll have to find new patients and then you may have to start putting people onto longer recalls to squeeze in new patients, and is that the right thing to do for them?”
Capitation and activity levels
One of the most recent updates to the reform programme is that they are looking into introducing weighted capitation based on patients’ age, sex and postcode, and that non-capitated activity will be a universal fee irrespective of your geographical location.
Eddie said, “That may in some cases mean that the number of patients you need to see will reduce, for example if you’re working in a high-needs area – if they get those calculations right.
“The figures I’ve seen do cause me some concern because they’re basing it on activity done in a certain period of time and quite a lot of red or high-risk patients don’t finish a course of treatment, even in a UDA contract.
“If they calculate the capitation value based on that then they will be flawed as well, so you can’t guarantee that the calculations they are making will be accurate.”
The discussion was wide-ranging and delegates fielded lots of questions to the panel, highlighting the sense that many are hungry for more information about the details of reform and how they may be able to prepare.
Much of the advice was to find as much information as you can, as early on as possible. For example, from events like the ‘What Next for NHS Dentistry?’ series, the BDA’s regularly updated FAQ on contract reform or by speaking to your local LDC, LDN or BDA branch.
Knowledge is power and, while reform remains on the horizon, it could be the best way to stay in control of your future.