24 Jun 2019  •  Events, NHS Dental Landscape  •  12min read

Weighing up the pros and cons of dental contract reform

When NHS dental contract reform begins being rolled out, practices may well find themselves working under new targets and a new way of being paid.

This might sound a little vague and that’s because it is. There is still much that is unknown about the specifics of what will actually happen when the new contract begins being rolled out. The powers that be are saying this will be from April 2020, although some have questioned whether this is truly feasible.

At the moment, it appears that once reform starts, practices will be given the choice of whether they want to stay in their current UDA contract or take one of the reformed contracts on offer.

However, it’s not yet clear whether, should they choose the latter, they will be given a choice of whether they go into a ‘blend A’ or a ‘blend B’ contract, or whether one will be assigned to them.

The blend A and blend B contracts have been trialled by prototype practices for several years. The key difference between the two is how dentists are remunerated, with those in blend B more heavily weighted towards capitation rather than activity.

Eddie Crouch, Vice-Chair of the BDA’s Principal Executive Committee, has said that practices may not be given a choice between A and B, but that this might be decided at local area team level. He also said that the Department of Health have said they don’t want ‘flip flopping’, i.e. practices going into one blend of contract and then, if it isn’t working for them, being able to move into the other blend.

Eddie was speaking as part of a panel of dentists at a What Next for NHS Dentistry? event held in Worsley. Other members of the panel included Ben Atkins, former owner of a prototype B practice; Ian Redfearn, owner of a prototype A practice; and Daniel Jenkinson, owner of a mixed practice.

Our experience under blend A and blend B

As dentists who have been involved in operating under the different blends of contract, Ben and Ian said that they felt, remuneration aside, there was little difference when it came to running the practice.

Ian commented, ‘Under blend A we’re seeing new patients and inevitably, they need treatment. So, the activity is happening anyway.

‘Our experience has been that under the prototypes there’s a few more plates to spin.  You’re watching capitation levels, activity levels and other things as well – the whole contract is more complicated.

‘The tendency for us is to over-deliver on activity because we are taking on new patients.’

Ben added, ‘For my associates, the biggest challenge was understanding that if we take on more patients then the UDA number reduced. The smaller the number of UDAs we need to deliver, the more prevention-focused we can be, so there was a big incentive to grow the patient list.

For me, the big issue is not which contract but the idea of launching two more contracts because the commissioners struggle to run just one.

‘For me, the big issue is not which contract but the idea of launching two more contracts because the commissioners struggle to run just one.’

Different levels of clawback

However, Eddie disagreed that there wasn’t a difference between the two and pointed to the statistics around clawback for the different contracts:

  • 40% of practices under the current GDS contract face clawback
  • 33% of prototype A practices face clawback
  • 25% of prototype B practices face clawback.

Eddie said, ‘Clearly, from a monetary point of view, having a higher capitation level works better. But let’s not forget that prevention is an activity, it just isn’t measured as such by the UDA.

‘The higher the capitation level, the greater clinical freedom you have to deliver staged care. In principle this is a good thing, however, when there have been contracts of this nature in the past, there has been an element of under-treatment and supervised neglect.

‘And we need to be confident that capitation levels are calculated correctly – and we know that under the prototypes they seem to have been deliberately inflated so that those entering had to catch up from the word go – and that they are risk-assessed to the number of patients you’re taking on.’

A positive clinical pathway

One thing all three agreed on, was that the care pathway is a positive element of the reformed contract. Under the pathway, patients are given an Oral Health Assessment (OHA) and then receive a Red, Amber or Green (RAG) status.

Although Eddie highlighted that analysis from the prototypes shows that 30% of patients who are given red status often don’t return to the same practice to complete treatment or be reviewed along the care pathway. Whilst there are practices locally outside the prototypes, many may choose to go to another nearby practice, although with recent news of more NHS practice closures he also pointed out that this may not be an option in the longer-term.

Ben said, ‘The clinical pathway is brilliant. It actually makes a difference. Patients are taking responsibility for their teeth. The RAG status provides evidence of how well the patient is looking after their teeth, which can be really motivating for them to improve.

The clinical pathway is brilliant. It actually makes a difference. Patients are taking responsibility for their teeth

‘However, it also means that you can say that you’re not going to deliver a particular course of treatment because you can see from the RAG report that they haven’t been looking after their teeth.

‘Practices who don’t buy into that approach have a 12-month waiting list. We embraced it and have a two-week waiting list which means we created more time to do private work, which then went up by 30%.

‘I think it’s imperative that practices don’t have all their eggs in one basket in case you don’t have the level of flexibility within your team to deliver treatment in this way.’

Ian agreed and added, ‘If a patient is red, they’re not going to receive some of the advanced treatments available until they address it. That’s made very clear to them at the start.

‘That is very empowering for the dentist as it can actually help when it comes to dealing with patient complaints.’

The need to spread your source of income

NHS practices not having ‘all their eggs in one basket’ was a view that all the panel agreed with.

Daniel, who is now in a predominately private practice, said, ‘You need to think about whether you can make your practice work within this kind of model. For some of us, this could just look like too much hassle, and if you’re not mentally prepared to go down this route, there are other options such as moving private or into a mixed practice.

‘Often, one of the concerns is that you won’t be able to make it work, especially if you’re not in an affluent area. But if you’re providing a good level of care, good customer service and believe in what you’re doing, there’s no reason you can’t be successful wherever you are.’

Ben agreed that his private income also increased, as due to the NHS care pathway, they had more time to explore options with patients. He said that as patients became more motivated about their dental health, they often chose private treatment.

A wider skill mix in your team

To deliver the care pathway, under both blend A and B, Ben and Ian agreed that a wider skill mix was needed and potentially a change in mindset and behaviour of the profession. For example, there was discussion about how therapists can be used to deliver the interim care appointments as the course of treatment has already been opened and no new exam is needed.

However, while some practices may already be embracing this type of business model, many aren’t. This is potentially due to the size of their practice and the ability to create space for utilisation by therapists, hygienists or extended duties nurses. Indeed, a question from the audience about how this could be done in a two-surgery practice in a terraced house, highlights that many in the profession are not currently set up for the changes that may be required.

Ben suggested that one of the challenges in making these contracts work is that there is a need for behavioural change in terms of the make-up of the dental team and which treatment is delivered by which clinician, i.e. therapists doing work that was previously carried out by associates.

Ian said that in his view, the contract could be delivered with a 50/50 split in the team between dentists and therapist, and that this could potentially be done in a two-surgery practice by one dentist and one therapist.

Eddie added, ‘Some of the practices that are making it work are the ones that have the ability to fit into the model. They have up to 12 surgeries, not two to three. The model can’t work if you don’t have somewhere to put your nurse to do the oral hygiene and prevention. Some of the really successful practices have varied income streams as training practices, etc.

‘Lots of people have pulled out of the reform process or been removed due to falls in access, and more are scheduled to pull out at the end of March, and are going back to the UDA system. That’s a sad indictment.

‘I’m happy it’s working for some practices but it has to work for everyone otherwise there’s no point in rolling it out. It’s currently not a gleaming success otherwise they would have been rolling it out much quicker.’

I’m happy it’s working for some practices but it has to work for everyone otherwise there’s no point in rolling it out. It’s currently not a gleaming success otherwise they would have been rolling it out much quicker

All of the panel encouraged NHS dentists to seek the information they need now so they’re prepared for the choices they may soon need to make.

To do this, you can get in touch with your local BDA groups and LDCs, read further blogs about the NHS and contract reform and also attend future What Next for NHS Dentistry? events.

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