For around a year most of us involved in dentistry have been working towards contract reform being rolled out in April 2020.
However, as that date draws ever closer and there is no sign of any imminent change or decisive action, the rumblings and speculation that this isn’t going to happen are growing.
When and how contract reform will be rolled out was one of the big topics of debate at the What Next for NHS Dentistry? event held by Practice Plan on 16th October in Leeds.
Dentists were invited to come and hear from and ask questions of a panel of experts from within dentistry including Eddie Crouch, vice-chair of the BDA’s Principal Executive Committee; Joe Hendron, owner of a former prototype practice; Chris Groombridge, director of the Association of Dental Groups; and John Renshaw, former chair of the BDA.
The rollout of reform
Eddie suggested that political uncertainty would make any rollout difficult and that the prototype programme, which is currently in the fourth wave of practices taking part, could run for another one or two waves.
He said, “We have to build into all of this the political uncertainty there is at the moment. We’re on our fourth minister for dentistry in two years, we have Local Area Teams (LATs) and civil servants having to reapply for their own positions. So, there is no continuity to drive it forward.
“We have all this uncertainty and you’re expected to roll out a reformed contract which may involve new legislation or regulations and you’ve got everyone concentrating on how to get out of the EU.
“I think they will take in more practices to the reform programme and we will get more waves of prototypes while they get their ducks in a row and we hopefully get some political stability.”
Chris, “We may be wrong, but our latest information is that they don’t have confidence that it will be as early as 2021. The view of the LAT in this area is that you will be waiting a long time yet for contract reform.”
Dentists caught in the crossfire
When it came to how reform may happen, it was suggested that those practices with the best chance of success will be among the first involved in the rollout.
Eddie added, “We’re hearing now that if it’s going to be rolled out, they’re going to analyse the data they have about practices and offer the reformed contracts to people who fit in with this analysis.
“So, it won’t be rolled out en masse. It will be rolled out to practices that have a fighting chance of making it work. And if they gain momentum, the other practices get lost in the periphery and eventually everyone is drawn into it.”
John said, “The NHS has been trying, and failing, to cut costs since around 1980. It’s not a new drive aimed at dentists – it has been happening across dentistry but also optics and pharmacy.
“I don’t say that’s the wrong thing for a government department to do because that’s what they have to do. They can’t just go throwing money out of the windows and hoping for the best.
“The problem is that the people caught in the crossfire between the Government and patients is the dentists. We’re the ones taking the shells.
“Patients do like this deal, because it’s better for them – no argument. But who’s paying for it, it’s not the Government, it’s the dentists. That was never meant to be part of the deal and I would never have signed up to a deal like that.”
A positive patient experience
The panel agreed that when it came to patients ‘liking this deal’ it’s because the care pathway under the reformed contract is a good clinical service. Patients receive an Oral Health Assessment and a Red, Amber or Green status (RAG) which has proven to be effective in helping them to take control of their dental health and improve it.
Joe gave examples from his time as a prototype practice in which they had success, particularly when it came to aspects of care such as smoking cessation. However, he added, “Unfortunately that wasn’t measured by the contract reform programme, they were counting fillings and extractions, etc, that we weren’t necessarily doing.
“The RAG score is a good approach and provided that you have the time to do it, you can make a difference.”
The problem is that the time is not always available. As a pilot practice, which didn’t have UDA targets, Joe and his team were able to spend up to 30 minutes conducting Oral Health Assessments and Risk Assessments. However, as a prototype practice working under UDAs it became increasingly hard to find this time as well as meet access targets.
A negative experience for dentists?
John described the predicament of the reformed contract as the ‘unsquarable circle’ – something that is trying to work for the patients, the dentists and the Government.
He said, “The contract has three elements – the patients, the dentists and money. Those are the three central pillars of any contract.
“What we’ve got, and have had since 1948, is a government that wants more output – more patients seen – for less money. Unfortunately as dentists, what we want is less patients, an ability to do better quality work, to get paid well for it, and have a life.
“Those two are so far apart, you could be arguing about the contract for the next 1,000 years.”
How can I prepare for a 2021 rollout?
When asked by an audience member for guidance on how practice owners could best prepare for a reformed contract being rolled out in 2021/22, Joe advised spreading your sources of income.
He also said that it would be wise to begin building up patient numbers before your contract starts.
He said, “To have a future in NHS dentistry, you need to have a wide number of sources of income in order to try and survive. Whether that’s orthodontics, implants or the private side of dentistry. To rely on a one or two per cent fee increase in an NHS contract for the next 10 or 15 years isn’t necessarily the best approach.
“Practices in wave three of the prototypes increased their access before they started to 103/105%. That dropped off over time but only to around 98% in the first year, whereas wave one and two practices dropped by 30 to 40%.
“So, line extra patients up if you can. Try and make sure your patient base is stable because every patient that you don’t see over three years drops off that list.
“Having them on a six-month recall is also advantageous. We suffered because most of ours were on a 12-month recall, but if you have them on a six month recall you have scope to increase your access and increase the number of patients you can see.
“If you have an extra surgery or room you can turn into somewhere for a therapist or EDN, that would also be wise.”
Eddie sounded a note of caution about building up a patient list too soon though.
He said, “We have no idea when they will do the calculations for capitation targets, so if you are seeing lots of new patients they may expect you to deliver that going forward, so it can actually be a disadvantage.”
Joe agreed, that it would be sensible to start this kind of action three to four months before the start of your contract date.
The potential of flexible commissioning
Flexible commissioning, which in phase one involves delivering up to 10% of your contract flexibly, is being rolled out in Yorkshire and Humber. Phase one is a universal prevention programme. In April 2020 there will be a second phase aimed at delivering prevention to areas of social deprivation and linking to primary schools, nurseries and care homes.
The criteria in phase one to be involved is that you are hitting 90% of your UDA target and that you are on the NHS Choices list.
Eddie confirmed that within days there was going to be a meeting between the BDA, NHSE and BSA about developing a model of flexible commissioning that could be ‘rolled out across other areas to help struggling NHS practices on the brink of collapsing to stop having massive clawback’.
Chris, who has been involved since the inception of flexible commissioning, confirmed that clawback was an issue with rates of 44% in North Yorkshire and Humber, compared to over 20% nationally so ‘something had to be done’. He also said that the projection for clawback nationally was in excess of £200 million for the next contract year, up from £138.4 million in 2018/19 and £88.7 million in the previous year.
He added, “Flexible commissioning is about buying time and plugging the gap, it was never envisaged when we started the process in 2014 as a substitute for contract reform. It’s about making practices more financially viable and about getting prevention delivered, which the current contract doesn’t pay for.
“It’s about ensuring in phase one and two that prevention is delivered to specific groups, children and the elderly.”
Joe compared flexible commissioning to a sticking plaster that was a good idea for the next two to three years but added, “If everyone signs up to this, very soon the clawback will reduce to zero and then will we be seeing enough patients after that? Will NHS England think further than that?
“But from a short-term point of view I think it could be good if you’re not able to make your targets and you have the staff who can do other work beyond fillings and extractions, etc.”
Thinking about the next five years
When it came to thinking about the longer-term view, the panellists were asked for their one line of advice.
Universally, it was advised to spread the sources of income, with Chris saying practices should aim to be 30% private and John saying ‘salvation is not going to come from the NHS.’
So, when it comes to planning a sustainable future, much like in clinical dentistry, it seems that managing risk will play a big part.
Practice Plan is holding two more What Next for NHS Dentistry? events in November. You can book your free places by clicking the links below: