Matt Hadman looks at how contract reform could impact the clinical roles within a dental practice…
Reform of NHS dentistry will have an impact on everyone in the practice team. If you hold an NHS contract, at whatever level of commitment, there will more than likely be a change to your UDA and capitation targets, and the way you deliver treatment.
Throughout 2019, Practice Plan has held several events, called What Next for NHS Dentistry?, which have given dentists the chance to hear from and question a panel of experts about what the future may hold for them.
At these events, it has been clear that much remains up in the air – there has been no official definitive declarations around the how and when of contract reform roll-out.
And, although there has been talk recently about the potential of using a weighted capitation system based on patients’ age, postcode, etc., that model has not been trialled as yet. The two business models that have been trialled over the past few years, known as A and B, are a different mix of capitation and activity, which is still measured by UDAs.
From what we have heard at these events from those involved in reform, either through involvement with the BDA or directly as the owner of a prototype practice testing one of these models, both bring with them a new way of working and, often, the need for a new mindset.
It became clear, not least from questions from the audience, that many people in different roles want to know what changes they might be facing.
To look at this in more depth, I have looked at what insight we’ve gleaned about how reform may affect the different clinical roles of the dental team.
As it stands, it seems as if practice owners will be given a choice of whether they stay with their existing UDA contract or choose one of the prototypes being tested. Therefore, practice owners and contract holders need to consider what contract will best suits their practice and their patients.
Currently two blends are being tested: Blend A where band one treatments are paid for by capitation and bands two and three are paid for by activity, and Blend B where bands one and two are paid for by capitation and three is paid for by activity.
Much of the feedback from those who have already been delivering the prototype contracts is that a team of a wider skill mix is vital.
In order to treat patients via the contract’s care pathway, which involves an Oral Health Assessment (OHA) that assigns a Red, Amber or Green (RAG) status to patients, prototype practice owners said there was a greater need for therapists, hygienists and Extended Duties Nurses (EDNs).
This then raises some further considerations for practice owners looking at their future.
For instance, do you already have a wide cross-skilled team or will you need to recruit and how easy will that be? Do you currently have the physical space in your practice for a therapist or hygienist or will you need to/can you invest in creating such a space?
Another aspect to think about is whether you have the opportunity to introduce private treatments or increase the income you already generate from private dentistry.
That’s because many of those involved in prototypes have said that their private income increased, sometimes due to having more motivated patients because of positive engagement with the care pathway, sometimes due to having more time available to explore private options and sometimes due to a feeling of needing to spread the sources of income.
These are just some of the considerations practice owners may need to think about in advance of the roll-out of a reformed contract, whenever that may happen.
At several of the What Next for NHS Dentistry? events held in 2019, the discussion around the need for a wider mix of skills within the team often led to talking about how the role of associates may change.
Associates may find work that they have previously done now being carried out by therapists and hygienists as the full scope of their skills are more fully utilised.
This can mean a change of mindset is needed by associates about their role. And, with remuneration in both prototypes being weighted more heavily towards capitation (around 60% for Blend A and 85% for Blend B), there’s also potentially the need for a refocussing from delivering UDAs to growing the patient list.
The move to a blend of capitation and activity targets raises some questions regarding the most effective way of remunerating associates under the reformed contract. There has been some suggestion that options such as sessional payments could have implications for the self-employed status of associates.
As mentioned above, under the reformed contract currently being trialled, treatment is delivered by a care pathway in which patients are given a RAG status following an OHA, which prototype dentists have said can take between 20 and 30 minutes to carry out.
So, associates who find themselves working under a Blend A or B contract will potentially have a new way of delivering treatment to adjust to. Some have suggested this may offer new opportunities for associates to learn new skills, and others have also said a lot may well depend on the individual contract of employment that the associate has with their practice.
As previously mentioned, the role of dental care professionals (DCPs), such as hygienists, therapists and EDNs, looks set to grow in scope as a wider skill mix team seems to be an important element of working cost-effectively within the care pathway.
The pathway is focused on prevention (meaning that it has been widely embraced by the profession and patients), and that may well enable hygienists and therapists to have a more significant role in providing clinical treatment that addresses oral health issues early on.
Hygienists and therapists in prototype practices have been used to carry out work previously done by dentists, while EDNs are able to do oral hygiene instruction and interim assessments, allowing dentists to concentrate on more complex work. This makes for a more cost-effective model for the practice.
There has been widespread agreement among those involved in running a prototype that a wider skill mix team is key to successfully delivering the contract. So, DCPs may well find their profile rising in line with this and the longer-term view of the NHS which seems increasingly dependent on hygienists and therapists.
However, as is often the case, how fully utilised they are may often vary depending on the practice and team they work with in terms of how much their colleagues understand about their scope of practice.
It is also worth noting that while it may be efficient, some may say such an approach could lead to a fragmentation in the continuity of care for the patient.
That is a brief overview of how different clinical team members may see their way of working change under contract reform.
However, there may, of course, also be an impact on non-clinical members such as those managing the appointment bookings. With many saying that carrying out the OHA means appointments are taking longer, and that there is a greater focus on growing their patient list, the front desk team may need to revise the way they manage appointments and consider implementing zoning etc.
With the details of reform still feeling blurred around the edges, it is difficult to predict exactly what the future looks like and how it will practically impact those who will be working within its parameters. Much will depend on the individual practice you work in and the path they choose to take, in terms of the contract on offer, and the path that reform takes as it continues to be tested and revised.