NHS choices

Practice Plan considers what the current dental contract has to offer and takes a look at what changes could be incorporated into NHS dentistry when the revised contract is fully rolled out.

In 2006 to much fanfare – on the Government’s side at least – a new NHS dental contract came into force. At the time some dentists chose to leave the NHS altogether preferring the private route, some created a mixed practice but the majority stayed put, believing in the provision of dentistry to those in need.

Over the following years, again, some have changed the way they practise; but still a large number have continued to operate within the parameters of the contract while others have joined the NHS. Statistics released by the Health and Social Care Information Centre tell us that 23,723 dentists performed NHS activity during 2013-14. This is an increase of 522 (2.2%) on 2012-13, and 3,563 (17.7%) more than 2006-07.

With a revised contract on the horizon, what does the 2006 contract offer and what might we reasonably expect the next one to deliver?

John Milne Chair of BDA GDPC once said: ‘How can a system improve oral health, deliver prevention, continuing care and advanced treatment, whilst paying dentists adequately, fairly, and provide an environment where all this can be achieved with minimal perverse incentives from any direction to enable the patient, the government and the profession to have confidence for the future?’

Remuneration

As we know all too well, the contract to which the majority of NHS dentists are working operates on annually targeted UDAs (the exception being those on the piloting scheme).  This has, of course, raised some financial issues; a popular view is that dentists have not been receiving fair remuneration for their work in more extensive cases. It should be noted, however, that, committed as they are to patient care, the vast majority of dentists who have stayed in the NHS have worked hard to provide a quality service.

The contract currently being piloted shuns UDAs and instead a capitation system is being tested. Essentially, capitation provides payment according to an agreed number of patients seen during a specified period of time. Three are being piloted:

• Type 1 – guaranteed remuneration for guaranteed NHS commitment

• Type 2 – weighted capitation payments applied within tolerance of contract value with capitation payment covering all care

• Type 3 – weighted capitation model applied within tolerance of contract value with capitation payment covering only routine care and remaining contract value attributed to complex care guaranteed.

Weightings are applied to the registered population, which aim to reflect the workload involved in meeting patient needs. In the report ‘Dental Contract Reform Programme. Early Findings: Opportunity to give feedback’, the following example for a hypothetical practice treating 100 patients was provided:

• Twenty high-need patients: £10 per patient = £200

• Fifty low-need patients: £5 per patient = £250

• Thirty medium-need patients: £7.50 per patient = £225.

This provides a weighted capitation of £675.

With these pilots ongoing, which of these three options are achieving success is unknown, but it seems fair to suggest capitation is likely to feature in some form. 

It would be remiss while on the subject of finances to move on without considering the forthcoming contract’s affordability for the government. Contact reform offers an interesting conundrum; you might achieve happy patients and dentists but realistically only at a cost that would be unacceptable in a wider roll-out. For example, the new approach involving a preventive pathway takes more time and means longer appointments than before, which is why patients tend to like it. Within the pilots, the dentists are happy as they have had their income ring-fenced so they can essentially take as long as they want without incurring any financial penalty. In addition, that all means that access has dropped and fewer patients are being seen which, given that has been a priority for successive governments, won’t be deemed acceptable. There seem to be three possible solutions to this – making more money available (which, let’s face it, is never going to happen in the current economic climate), finding a way that forces individual dentists to improve access for the same money or to accept lower access per dentist but pay individual dentists less.

Quality

There’s little to be written about the 2006 contract and quality treatment that you haven’t already heard or read many times over. Suffice to say, it constrains care to providing treatment to achieve oral fitness and little else; this is a system that does not easily lend itself offering a high level of care and NHS dentists remain the unsung heroes for achieving high quality results. Considered by many as an incentivising scheme gone horribly wrong, we all look to the future with great expectations.

The (hopefully) forthcoming contract aims to deliver high-quality, prevention-based care based upon three indicators:

1. Patient safety

2. Clinical effectiveness

3. Patient experience.

This is where the much talked about Primary Care Clinical pathway approach comes into play. The clinical pathway begins with a comprehensive oral health assessment, recording information on caries, periodontal disease, tooth wear and the soft tissues. Needs and risk are then assessed based upon both clinical information and that obtained from the patient. A preventive plan is then created and shared with the patient and dental team. Lastly, a review date is set according to risk and NICE guidelines.

Advanced care pathways are also being piloted in endodontics, periodontal care, indirect restorations and metal-based partial dentures.

All of this is being supported with the use of software provided by one of three software companies.

Thus far, overall the concept has been considered to have a sound basis but, again, things are still being ironed out so while the future looks to be preventive based there are no guarantees.

Registration

Under the 2006 contact, formal registration with a dental practice, which had been introduced in 1990, came to an end.  In essence, nowadays no-one in England and Wales is registered on the NHS with a particular practice although, in truth, this is not on many patients’ radar. However, access appears to have been a problem for some patients, with pre-pilot figures indicating that 24,292 patients received emergency dental treatment in hospital casualty departments in 2009/10, compared to approximately 17,400 in 2000/2001. These statistics certainly do suggest that fewer people were getting the dental treatment they needed between 2000 and 2010.  
 

The future contract, meanwhile, promises provide a formal system of patient registration, ensuring patients will receive ongoing care as and when clinically needed. We don’t know much more than that, but it sounds like a good plan to improve access and long-term oral health.

Tentative hopes…

So here we are; the majority of practices are still working within the confines of the 2006 contract and the minority piloting the next contract. The possibilities are tantalising but there is still so much that we don’t know.  When will the pilots end? How will the general election affect NHS dentistry?  And last, but by no means least, how will the government, whatever their affiliation, work within the confines of national finance to deliver what is being promised? We have hope that the resources available can be used to best effect.

Practice Plan is the UK’s number one provider of practice-branded dental plans. They have been supporting dentists with NHS conversions since for over 20 years, helping them to evaluate their options and, for those who decide to make the change, guide them through a safe and successful transition to private practice. So, if you’re thinking about your future and would like some expert advice you can trust, then call 01691 684120 or visit www.practiceplan.co.uk/nhs.