Contract reform is on the agenda again – or maybe it never left. A recent paper in the BDJ from Rebecca Harris and Rachel Foskett-Tharby of NHS England describes the problem of the current dental contract as ‘wicked’ or ‘stubborn.’
There can be very few dentists who turn patients away because the challenge is too big. Even if they can’t complete treatment themselves, they’ll at least point the patient in the right direction.
So the Government is trying to implement a new contract whilst retaining this same level of control. However, it is very difficult to envisage a system that will allow them to do that and satisfy the dental profession.
For the last few years, everything seems to have been focused on reducing spending on NHS dentistry. This can be seen with both GDS and PDS contracts. As the PDS contracts come up for renewal the LATs are taking a much harder stance and reducing values wherever they can.
There was a time, a number of years ago, when over 50% of practices had not achieved their UDA target on a regular basis and yet no action had been taken by PCTs to recoup any monies. This was certainly the case for the first five years of the current contract; however, one of the changes we have seen recently is a significantly stronger focus on performance. So that now if a practice does not hit targets, not only will the LAT recoup the money but they will seize every opportunity to reduce the contract value, either by decreasing the number of UDAs or lessening the UDA value.
Under any new contract, if there is one, underperformance and failure to achieve KPIs is going to lead to a similar situation. Whilst the latest prototype proposed contains remuneration based on capitation, the number of patients that you have registered, the work performed and some for achieving KPIs, the potential risk for missing these targets is a massive 10%. Nevertheless, a lot of the essential details here remain unknown.
In some ways the most concerning part about the change in contract is the notion it might be time limited. This completely fails to recognise the investment that dentists have to put into practices, not only in terms of equipment, but also regarding the time spent building a good dental business. To fit out a dental practice is a very significant cost, and nobody is going to do that if there is a contract that only lasts for five years – over that period one is not going to get back that which one has paid out, never mind actually make any money!
It seems, whether stated or unstated, that it is the Government’s clear intention to reduce spending on NHS dentistry. To achieve this, perhaps all they would have to do is introduce time limited contracts and there would be a very large shift away from NHS ownership towards private.
And this, in my opinion, is what the Government wants. They need to save money and whilst they talk about the NHS in hallowed terms, I’m not so sure that NHS dentistry is quite so hallowed as the rest of it.
John Grant of Goodman Grant Lawyers for Dentists
For more information call John Grant on 0113 834 3705 or email This email address is being protected from spambots. You need JavaScript enabled to view it.
ASPD MEMBER
Following similar campaigns for medicine and pharmacy, (no I hadn't noticed either), last week NHS England launched the dental call. It was trumpeted with documents with the admirable aim of improving dental care and oral health, but the large caveat is this must be done with a reducing budget and a £30 billion black hole in the NHS funding stream. One wonders if loosing dentistry from the NHS might infill some of the cavity.
We are told that the NHS dental budget is £3.4 billion per year and that private dentistry makes up £2.3 billion in provision, although some may dispute that. £653 million from patient charges is included in the total budget and is an important part of the contribution. In view of what the government is prepared to pay on other issues, one wonders why it is needed at all, but of course patient charges are a controlling factor of the demand.
Much is made of the Dental Local Professional Networks that have recently been established, but no mention of the chronic underfunding of this, which might explain why so few of us will have noticed their existence to date.
The NHS belongs to the people is the strap line, but not sure the way politicians interfere with it, make any of us feel like the owners.
The document attempts to describe many strengths in the current system and improve access. At a recent GDPC meeting I asked Elizabeth Lynam , head of dentistry at the DoH would there be funding for more patients to register if a reformed registration and capitation model attracted more than the 56% currently visiting practices in a 24 month period, no was the answer.
So if access is to increase, that too must happen within the existing budget. Not so much a call to action as a call for charity from the profession.
As a committed LDC official, I am disappointed that there is not a single reference to local representative committees, nor a mention of them being stakeholders. Perhaps with the manipulation of levy collection ongoing by NHS England maybe they won't be for long anyway?
We are asked to respond to the questions by the 16th May 2014 and that our answers will be independently analysed, we are not told by who,( I am lead to believe it may be an American institution, so much for tendering) but it will make a change for independent analysis when we are deprived that within the pilot programme. A strategic framework for commissioning will be published along with a report.
There is pride on the excellent data on disease and activity NHS England hold but those that witnessed the destruction of the Dental Practice Board will believe this information far inferior to what was previously known.
Again there is a plan to best use tax payer’s money and develop a workforce that is appropriate for the future, a bit rich after what graduates are facing in the lottery of FD placement. But world class has been replaced by exemplar commissioner so perhaps reality is dawning at Whitehall. I wonder where the "tools" to enable a consistent care pathway are being kept.
Remarkably the document admits they need to know how to measure excellence and despite telling us how good the data is they have, they admit they lack data to benchmark performance nationally. I know what I believe of these two versions on data.
In its section on health inequalities it talks about a "seldom heard" group, I got quite excited when I thought it might be the many critics of DoH and NHS England but it turns out to be patients facing barriers to accessing care.
There is a clear message they we carry out our care at times convenient to us, and that patients want extended hours after work and at weekends. Not sure what evidence base there is for this, but the direction of travel is clear.
Much is made of the OFT report of 2012 despite massive criticism from the profession and the BDA. So not much notice taken there then, and of course they trumpet this call to action process is being supported by the BDA. Damned if you do and the same if you don't .
There are also indicators to the shape of general practice of the future, they want to move away from working in isolation and support larger teams in the interest of better care, and develop special interest in primary care. The end of single handed practice and tiered delivery of care for those with the badge to do it is just a review away perhaps?
It is followed by a list of questions deliberately moulded to either restrict answers or get the ones they want, but none the less I would encourage all to let them have the "action" by going to
www.england.nhs.uk/ourwork/qual-clin-lead/calltoaction/dental-call-to-action/
Whilst I understand enthusiasm for this is not great and we are being herded along with the medics, we should not under estimate the importance or messages contained.
Eddie Crouch
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Twitter @ChallengeDoH
Challenge on Facebook
Any new system must concentrate its efforts on delivering –
· Improved oral health for the population as a whole
· An oral care system that patients understand and can trust
· A profession that can take pride in its work
These are the simple but important features of a successful contractual arrangement between the dental profession and the Government.
In addition, CHALLENGE would say that the following issues are just as important -
· A system where the roles of the state and of individual service providers are crystal clear
· A system in which the NHS and non-NHS system work in combination, not in opposition
· a system in which the profession is encouraged and empowered to act professionally
Whatever emerges from the discussions between the profession and the NHS must be able to demonstrate that it has matched these issues with due sensitivity to the needs of both sides. Both sides need to recognise the need for fiscal control and integrity and both sides need to understand that if high clinical standards are required then the funding has to be there to support those standards.
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Twitter @ChallengeDoH
Challenge on Facebook
Chief Dental Officer for England issues a ‘Call to Action’ to the dental profession to help find workable solutions to the contractual problems that have beset the NHS general dental service since the introduction of the last set of contractual changes in 2006.
You’re a bit late getting to the party, Barry, but now you are here you will be pleased to know that your old adversaries CHALLENGE have been resurrected and are looking forward to joining a robust debate alongside you.
Barry, you will remember, but for those who are too young to recall, CHALLENGE was a political pressure group set up in the wake of the 2006 contract debacle. They argued long and strong for major changes early in the life of the new contracts. They even made a significant appearance in front of a Parliamentary Health Select Committee back in 2008. The three founder members were Eddie Crouch, John Renshaw and Ian Gordon. These are well known names with a long track record of standing up for GDPs in the one-sided battle with the Department of Health. The same three professional leaders are still the face of CHALLENGE.
The call for action from the CDO provides us dentists with quite an intriguing headline, especially coming from one of the most obdurate supporters of the status quo. Barry Cockcroft comes to the vexatious arguments over the way the NHS GDS and its various contractual formats work for patients and for dentists after telling anyone who would listen - for years on end - that the service is in great shape and patients are deliriously happy with the way they are treated.
Well, if Barry wants to hear from the profession, CHALLENGE is willing to take up the cudgels once again to promote and articulate the message we hear coming from all the GDPs we listen to on a regular basis. In the near future we will be running our own listening exercise to gather up data on how you see the contract and how you feel you have fared in the eight years since it began. We also need to know your concerns about the pilots being run at the moment and the possible shape of a new service that may emerge.
If we as a profession are to make any real impact other than making a lot of noise and blowing out a lot of hot air, we need your input to validate what we are saying. When that chance comes along please take the few moments it will require to put down, for our benefit and for the benefit of all your colleagues, exactly how you feel about the situation you find yourself in.
If Barry wants action, CHALLENGE says let’s give it to him!!
John Renshaw
CHALLENGE
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Twitter @ChallengeDoH
Challenge on Facebook
Nearly all men can stand adversity, but if you want to test a man's character, give him power.
Abraham Lincoln
Ok its crunch week, and the quote I have used here seems apposite to the issues at stake in Wimpole Street this Friday, 21st Febrary.
The Probe carries its coverage of the Big Lie discussions which carry on from Dr Kilcoyne’s leading campaign . The letter in the Daily Telegraph stirred the waters.
The effect of The Probe is to relight the fires of this burning issue in a very welcome manner. The consistent spin of the official replies is becoming eye crossing.
There is general worry that the tripartite comfy zone that is the table around which the BDA, the DH and NHS England sit is looking increasingly as though it is actually a defensive set up to protect their interests, at the cost the care of the patient by dentists.
And so this Friday, as BDA Members YOU have a chance to make YOUR voice heard.
If you cannot attend this EGM, please ensure you vote by proxy. Crack on now because it is a carefully defined legally binding process. You cannot just phone a mate the day before.
Now is the chance to fire up your Representative Association. Put a rocket up their collective arses if you will.
There will not be a second chance before Contract Reform hits you between the eyes.
It is a well worn quote of Napoleon Hill, but still, it applies.
“Whatever you want, oh discontented man, step up, pay the price – and take it.”
Good luck to our illustrious and historic Profession – it is not too dramatic to say that a large part of the future of the present generation of GDPs hangs on what happens this Friday.