The future for the whole profession of dentists working under the reformed contract within the NHS is unclear, but here we look specifically at how associates could be impacted by the changes. Len D’Cruz, whose practice has been involved with the pilots and prototypes, gives his thoughts on this question…
‘Whilst there is still some significant resistance to UDAs as a metric of activity, it is likely to still be used in the reformed contract in England and Wales when it ‘potentially’ rolls out from 2018. This means associates may still need to do activity, but they will need to be more than just UDA machines.
The prototypes are testing a number of key components of a future system including the care pathway, a set of clinical measures and a remuneration system designed to provide access using a capitation and activity measure to deliver this political imperative. Along the way, they road-tested proxy measures for quality (dental quality outcome framework) allied to contractual payments, but the success of this has been limited, resulting in the probable abandonment of it in a substantive contract.
That leaves two activity measures; capitation – basically maintaining an agreed list of patients on your books who remain on your list for three years, unless they go elsewhere – and activity – the current unit being the UDA. Recognising that delivering the care pathway requires more time, the Department of Health has reduced the number of UDAs a prototype practice is required to achieve to earn the same contract value. For Band 3 that is 30% less than what the practice was doing before they went into the pilots/prototypes and 20% for Band 2 treatments.
This creates some issues for practice owners in the mechanism needed to pay their associates. Logically, a practice should pay its dentists in the same way they get paid themselves. In other words, an associate should be allocated a list of patients for whom they provide NHS dental care and they have an allocation of UDAs to facilitate that treatment. They get paid per patient on their list and for the UDAs they do on them.
That is the simplest way to pay associates, but this only works in smaller practices and where the associates have built up a list of their own. It is not so effective with a larger practice that has part-time associates, or for new dentists who join the practice who will not have a list. It also creates an internal market as dentists compete for patients.
Other methods include sessional payments or hourly rates, but here the risk of being considered a “worker” or an employee become more significant, which has tax implications for both parties and creates rights and obligations that currently do not exist in the usual self-employed associate model.
There has been some exploration of skill levels and the notion that patients would not be entitled to advanced care unless the patient oral environment is suitable and the treatment is clinically feasible and beneficial. This puts the onus on the patient, with the support of the dental team to take responsibility for protecting and maintaining their own oral health. It also implies that there would be three levels of complexity delivered by dentists with different skills. Level one was a GDP – the treatment they would be expected to carry out would be that of a one-year qualified dentist (i.e. at the end of foundation training). Level two would be work carried out by a GDP who has additional competencies – essentially a dentist with a special interest, and Level 3 was a registered specialist.
This was very much the direction of travel at the start of the piloting process, but the Department of Health and the commissioners have gone distinctly lukewarm about the idea, since it would have a significant impact on the way dental care is delivered in the high street, with less work being done by a GDP and more by Level 2 and Level 3 dentists and others including DCPs such as therapist, hygienists and extended duty dental nurses.
Prevention is a key part of the system and if a sustainable contract is going to be designed for the next few generations to come, it will have to incentivise prevention, reflect the declining disease levels in younger groups, but recognise the increasingly complex needs for older patients and have a fair system for patients to make a contribution through patient charges. It should also ensure dentists do not deskill.
The associate of the future will need to embrace the minimal intervention dentistry agenda, be preventively focussed and be able to lead a team of multi-disciplinary professionals. They will also need to learn how to offer private treatment ethically and deliver it confidently and successfully. There is no more new money in NHS dentistry and the future success of an associate depends on their ability to work as part of a team offering high quality care for ever more discerning and demanding patients.
The only other jigsaw piece missing is the one marked Brexit. A potential outcome could be the requirement of EU dentists to sit the ORE exam currently needed by dentists from outside the EU. If this results in limiting the number of dentists joining the NHS performers list, it means overnight, the value of a UK dental degree and experience of working in the NHS has just attracted a huge premium. Happy days for associates at last.’