NHS contract reform: part one

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Oral health regulation, prevention and dental contract reform, Dental Review reports

During the Westminster Health Forum Keynote Seminar in early July the panels both addressed issues and raised questions about the next steps for NHS dentistry, and the direction its long awaited contract reform might take. Some tough words were spoken, and a clearer idea of how the final contract might look came under the spotlight

In this first of two in-depth reports we hear first from session Chair Lord Colwyn, Vice Chair of the All Party Parliamentary Group for dentistry and oral health. He is followed by Peter Howitt, Deputy Director of the Legislation and Policy Unit, NHS Group, Department of Health, and finally Henrik Overgaard-Nielson, Chair of the General Dental Practice Committee at the BDA.

Shocking statistics

Lord Colwyn opened proceedings by highlighting stark regional and social inequalities in oral health which he deemed “unacceptable”. 44% of 15-year olds had decay in England compared to 63% in Wales and 72% in N Ireland. These he described as “shocking statistics” that are finally forcing Parliamentarians to “wake up to the fact that oral health deserves much more attention”.

He warned that the gargantuan task of organising “Brexit” would be likely to dominate the political agenda for years to come, and wondered if it might result in dental reform being “kicked into the long grass” while more pressing matters are addressed.

Full capitation “a swing too far”

Peter Howitt discussed the mechanics of putting contract reform into practice. He admitted NHS dentists didn’t need a contract that rewards drilling and filling. His unit would rather see a model that encourages prevention while also taking time to teach the general public how to take responsibility for their own oral health. He agreed that the current UDA/activity-based treadmill doesn’t work for dentists. It throws too much focus onto activity and not enough on doing the right thing for patients’ teeth.

Taking time to get the new contract right is important. An NHS dental budget of nearly £3billion, he said, might seem a vast sum of money but it still needed to be spent as effectively as possible. The previous two contracts, introduced in the early 1990s and 2006, were flawed, done in haste, and saw dentists walk away from the NHS because there was a real cut in their incomes and morale. That can’t be allowed to happen again. The new contract will need to be robustly tested and proven before it can be rolled out nationwide.

The key principles of contract reform follow guidelines put forward by Professor Jimmy Steele’s review in 2009, and will involve a preventive clinical pathway. The model has cross-party support, and, to answer Lord Colwyn’s concerns, the current turmoil created by Brexit should not derail the process of reform.

He said pilot practices have told him the new model is great. Patients have become more focused on keeping their teeth healthy and dentists are doing what they were trained for. The principal quandary is in agreeing the remuneration system. Switching from UDAs to a full capitation mechanism was, he explained, “a swing too far”. The new prototypes are testing a model that supports complex work where needed but also provides time for a focus on prevention.

In the pipeline are two “Blends” of remuneration through which the majority of cash flow will be tied to capitation. Blend A replaces Band one UDA activity with capitation, but Band two and three treatments will still be remunerated with activity payments. Blend B utilises capitative payment for Bands one and two and activity for Band three. In a nutshell: Blend A will see something like 60% of dentists’ work rewarded by capitation. For Blend B that figure will rise to 85%.

When will it take place? 2016 will see the first full year of prototyping concluded and an evaluation by Christmas. If that proves positive a full evaluation should be completed by autumn 2017. Assuming that is also positive the NHS should then be in a position to make a decision regarding the timing for final roll-out.

No repeat of 2006

Henrik Overgaard-Nielson wanted to thank the 82 practices currently engaged in NHS contract prototyping. Somebody, he said, had to stick their heads above the parapet and test what it’s all about. He noted the “huge” decline in access at the very beginning of the original pilot schemes and observed that 21 of the prototype practices have come into it straight from UDA contracts. He suggested there was a need to check how those 21 practices perform. If problems with access happen again with these fresh players there might be a need for a rethink about the model.

Problems with access probably happened due to the extra time spent following clinical pathways, performing oral health assessments and discussing preventive measures. Patients were happy, dentists were happy, all the required treatment was carried out – the only problem was those numbers for access. No matter how many tick boxes and targets we’re given, he said, it’s not going to solve that access problem.

Another concern Overgard-Nielson raised about the prototypes was with the phrase “where appropriate, high quality care” which included a qualification regarding treatment volumes. He said the only way to decide if treatment volumes are correct is to look in the patient’s mouth – not by looking at it on a cohort basis or through a computer programme at the BSA (Business Services Authority).

Why capitation? Simple, he said. If we want prevention link it to a capitation system. Dentists will do as much prevention as possible because that means they won’t need to spend time doing treatment. And if dentists are to be given a cohort of patients to care for he hoped to see the end of tick boxes and targets, there should be no need for them. Another advantage, if patients are paid by the volume of patients they see they have a great incentive to see as many as possible which should address that access situation and put a smile on politicians’ faces.

“I hope,” he said, “this is going to improve professionalism.” Professionalism is up to the patient and the dentist and not subject to tick boxes and targets; he hoped capitation might improve that situation. And remuneration weighting needed to be right, reflecting the time spent on patients. Whether seeing high need or low need patients a dentist’s time must be rewarded appropriately. The UDA system currently in place meant patients who require the most care are least welcome in practice. And there will always be rotten apples in any barrel, observed Overgard-Nielson. There was a need for practices to be properly monitored and he posited that dental reference officers should be reintroduced, or something similar.

He saw the need for some kind of transitional funding during the new contract’s roll-out to protect any practices that might be destabilised during the process, and he mooted the removal of the existing cap on dentistry. He said, “At present we are seeing 56% of the population. The worst case scenario for the Treasury would be if we started seeing more, but in my mind that’s what NHS dentistry is all about.”

He concluded with these words, “We need the Department of Health and the Treasury to understand that prevention is activity and prevention takes time and prevention needs to be remunerated properly. We don’t want a repeat of 2006.”