Towards the end of 2018, we were told that NHS England are committed to a phased rollout of the new dental contract from April 2020. This declaration of a date comes after years of testing variations (albeit, some would say these were just mildly tweaked iterations of each other rather than any real differences) of a new contract, which at times felt like it had no real end-date in sight.
Throughout this testing via pilot practices and a prototype programme, while many have been in favour of some aspects – such as the Oral Health Assessment, that many agree is positive – there has also been a lot of commentary from those involved about the target-driven nature of the contract, the cost to practices to achieve these targets and the continued use of UDAs.
Now a date has been set, I asked Joe Hendron, whose practice was a prototype until 2018 when he pulled out, citing his reasons in an open letter to the then-Health Secretary Jeremy Hunt: With the date for contract reform set for April 2020, what can NHS dentists expect after that?
Joe: ‘We have been promised from the beginning that rollout of a reformed dental contract will not be a ‘big bang’ and that providers will have a choice whether to sign up for the new system or remain under 2006 conditions.
“A choice?” you say – yes, but not for too long. There are many fundamental changes required in the new ways of working, the software as well as the monitoring processes and hopefully adequate training for this will be provided by NHS England (NHSE). The software companies, NHSE staff and NHS Business Services Authority will be unable to cope with a wholesale conversion. However, as time goes on, that choice to stay within the 2006 regulations will diminish and ultimately all provision of primary care dentistry will be under what we know as prototype conditions.
We all know of the continually changing shape of NHSE, Area Teams and the cuts in staffing dedicated to dental commissioning. The training available to each of the waves of pilot/prototype practices has reduced with each wave and I am concerned that come rollout, it could be a matter of, “these are the new regulations – get on with it.”
“The training available to each of the waves of pilot/prototype practices has reduced with each wave and I am concerned that come rollout, it could be a matter of, “these are the new regulations – get on with it”
Dental IT companies have received very little funding to develop the new software required and most of the pilot/prototypes have complained from the first wave that there are too many glitches which have not been ironed out. When we joined as a wave-two pilot we were required to invest in new hardware with more powerful PCs and larger monitors to accommodate the Carestream R4 Clinical+ upgrade and the pilot software. Of course, there was no additional funding for this, but we had no choice.
Practices will have TWO targets to achieve – maintaining a level of patient access AND activity measured by the UDA. Despite all the work that has been done since 2010, with promises that we will have a more preventive approach, a better way of working that avoids the ‘treadmill’ and an alternative to the UDA, we have a reformed contract which preserves the UDA! It smacks of that children’s story The Emperor’s New Robes when promises made were, in the end, unfulfilled.
“Despite all the work that has been done since 2010, with promises that we will have a more preventive approach, a better way of working that avoids the ‘treadmill’ and an alternative to the UDA, we have a reformed contract which preserves the UDA!”
An Oral Health Assessment, which is included in the new contract, will highlight care needs and advanced treatment involving crowns, bridges and endodontics will only be provided if certain criteria are met. This has met universal approval but it takes time to do it effectively.
No decision has yet been made about whether blend A or B of the prototype, which differentiates how much care is covered by capitation and how much by UDA activity, will be used. Some commentators favour blend B where the UDA target is much smaller but it requires maintaining a certain amount of band three treatments. Others favour blend A as there are more UDAs to count and associates can be paid more easily. But, ultimately, it’s still the UDA.
Activity is based on historic values and the targets in each blend are reduced, supposedly to give more time for prevention. But prevention is not measured per se, so will it be provided by those who are driven by targets alone? Our experience during the pilots was that much more preventive treatment and advice was given when there were no activity targets.
Access targets are based on historic values and it is not clear whether capitation will maintain patients over a three or a five-year period. Practices which have a stable patient base will do better than those which have a high turnover of patients. My experience in two years of the prototype is that it is very, very difficult to maintain the access numbers. As patients who have little or no demand for treatment drop off the list they are replaced by patients who often have considerable treatment needs. The number of patients under active treatment rises and one is trying to squeeze patients into an ever-increasingly dense appointment book, which lengthens waiting times. It is my opinion that this will be worse with a five-year registration.
“My experience in two years of the prototype is that it is very, very difficult to maintain the access numbers. As patients who have little or no demand for treatment drop off the list they are replaced by patients who often have considerable treatment needs.”
Should an associate leave, fall ill or take maternity leave – even if a suitable replacement is in place – access levels will fall for a period, and this can be very difficult to make up.
Practices will have to consider skill mix and the role of nurses with skills in oral health ducation and the additional use of hygienists and therapists will help to provide a more preventive team approach. This will often require additional surgery time and doubtless an increase in expenditure. It is recognised by Professor Eric Rooney, Deputy Chief Dental Officer, that the business model requires a lot more work.
We have only had evaluation of the prototype system for the first year and I am looking forward to the evaluation for the second year. The Department of Health and Social Care and the contract reform team have cherry-picked their preferred headlines from the evaluation data but there were more questions than answers, and yet they are still proceeding with the rollout. The pilot/prototype practices volunteered to enter the scheme and the report shows not all were as happy as Prof Rooney made them out to be.
Read the evaluation reports as they become available and choose your next steps very carefully.’
Thanks to Joe for sharing his thoughts on what NHS dentists can expect from April 2020 onwards based on his experience. While none of us has a crystal ball to foresee the future of dentistry, there is a sense from those who have been through the prototypes that there are still unresolved issues with the proposed contract, such as the use of the UDA, the cost – in time and money – to the practice to achieve activity targets, and the inclusion of access targets.
Bearing in mind that we are now less than 18 months away from April 2020, this is a lot for NHS dentists to consider when it comes to choosing carefully, as Joe cautions, what future they want. To make the right choice it is perhaps wise to begin those considerations sooner rather than later.