A winter’s tale
Some of the profession’s leading voices have warned that although the government may not be planning a move to core NHS dental services, private practice may still be the only option for most dentists.
The revelations came at a debate held in Westminster last month that rounded off a turbulent year in dentistry.
The debate, sponsored by leading capitation scheme provider Denplan, saw a panel of highly influential stakeholders put their heads together to discuss some of the issues facing today’s NHS dentists.
Chairing the event, David Phillips OBE explained: ‘We are here to discuss the current dental climate – which, like the weather, is a bit chilly at the moment!
‘The purpose of today’s debate is to look behind the political rhetoric surrounding the profession at the moment and see if we can provide some food for thought.’
To this end, he asked the panel to consider three main points:
• Do the government’s actions amount to nationalisation of the NHS by stealth?
• Does the economy in the current financial crisis have the capacity to bail out the banks and the NHS?
• What is the best way forward for patients, the dental profession, and the NHS?
With panellists ranging from Denplan’s chief dental officer Roger Matthews to Dentistry columnist and dental director of Dental Protection, Kevin Lewis, the event was not short on stimulating debate.
Representatives from the British Dental Association, as well as the chief dental officer Barry Cockcroft, had been invited to attend but both sent their apologies. Clashing engagements left empty seats – but gave a little more room for the jostling taking place at the debating table.
Failure to deliver
David Phillips started proceedings by referring heavily back to the Options for Change proposals, and asking the panel to consider how the profession arrived at where it is now. It was little purprise to see Eddie Crouch address the issue head on. Dr Crouch – whose judicial review challenging aspects of the new contract was upheld in the Appeal Court two days after the debate – laid the blame squarely at the door of the new contract.
Highlighting some of the issues, he said: ‘The new contract immediately disenfranchised the local workforce. It gave Primary Care Trusts (PCTs) and dentists all the problems of the previous system but none of the proposed solutions.’
He was scathing about its effects, adding: ‘Complex treatments under the NHS have dropped like a stone, and I don’t see how that’s good for oral health.’
Nigel Carter, chief executive of the BDHF, went even further, saying: ‘We no longer have a National Health Service in dentistry; we have commissioning by PCTs, which is hugely variable.’
Citing his biggest disappointment as the lack of the promised move towards preventive care, he pointed to the Department of Health’s refusal to acknowledge the need for change as a major problem.
The panel was united in its indictment of the new contract, pointing to its failure to deliver on its
promises – but agreeing that the desire for tighter control of the NHS was one of the driving forces behind it.
Kevin Lewis said: ‘There is no provision for quality in the new contract; dentists are given the same amount of money whether they deliver prevention or not. I think that the government wanted control over the spend on dentistry first, second, and third.’
Taking inspiration from this talk of governmental spend, the discussion moved swiftly on to the emotive subject of goodwill and UDA values.
Roger Matthews neatly summed up one of the biggest issues facing the profession, saying: ‘Control of goodwill has passed from dentists – we have lost that protection, and I think it’s that which has upset so many people.
‘Some PCTs have devalued goodwill by putting contracts out to tender – and in some instances, awarding them to the lowest bidder. There are grave concerns that the value of goodwill is being undermined.’
Kevin Lewis lent his voice to those worried about the effect of April’s changes on UDA values.
He said: ‘The PCTs are not short of equipment – and come April, they will be able to bring the full weight of their negotiating power to manipulate who they contract with. Some UDA offers are already changing; PCTs may be offering more money to dentists, but it comes with so many strings you could start an orchestra.’
Derek Watson, CEO of the Dental Practitioners Association (DPA), agreed that dentists have had their goodwill ‘stolen’, but suggested that market forces would out.
‘The general opinion on UDA values is that there will continue to be an excess of demand over supply’, he said. ‘When dentists go private, they take perhaps a third of their patients with them, leaving behind the majority of their patients with a demand for NHS treatment.’
But he added: ‘There is no time being left for planning. Anyone being offered a poor UDA value will have to appeal to the NHS litigation service, which has a history of finding against dentists.
Eddie Crouch expanded on the issue of planning, saying: ‘Part of the problem lies in the capabilities of the PCTs to deal with dentistry. They have all the tools, but they haven’t got the workers to take the tools out of the box.’
Nationalisation by stealth?
It did not take long for one of the driving reasons behind the debate to come up, when David Phillips questioned the real motives behind the new contract – and the impending changes due in April.
Is the government merely trying to nationalise NHS dentistry by stealth, he asked?
Anthony Halperin, appearing in his capacity as chair of the Patients Association, said: ‘I think the main consideration was keeping a very tight budget on NHS dentistry.
‘I don’t believe the government explicitly set out to create a core service, although strict budgeting and neglect may lead to it.’
Derek Watson said: ‘The government may not want a core service, but by turning a blind eye to the collapse of provision, it will leave us with a system that it doesn’t want.
‘I think we are most likely to be left with a “core patient” system, where a few people have full NHS service, but the majority are unable to access care.’
He offered little hope that the credit crunch will help the situation by driving patients back to the NHS.
‘That isn’t going to happen,’ he said. ‘People aren’t going to return to a broken system just
because there are problems elsewhere.
‘Capitation schemes are probably the only systems that align the objectives of oral health and the dentist.’
Kevin Lewis argued that in terms of private dentistry, ongoing monthly payment schemes would be the big winner in the current economic climate. He explained: ‘Access is a big issue – patients very much want access to “their dentist”, and this sort of relationship has a definite value in times of financial crisis.’
Dr Halperin was quick to recommend the benefits of payment schemes, saying: ‘I think capitation schemes in general are a good way forward for patients, although they do need to be more accessible in terms of monthly outgoings than perhaps they are now.
‘These schemes need to be tightly regulated too – practices running their own services have a great deal of incentive to embark on their own policy of supervised neglect.’
Roger Matthews supported this idea. He said: ‘It is essential that there is some form of quality assurance in any capitation scheme. And quality assurance accepted by the profession is far better than anything imposed on it.’
Eddie Crouch advocated the idea of a pay monthly plan too, saying: ‘Capitation schemes are probably more affordable for most people.
‘Reducing the cost of the highest band of NHS treatment has not helped patients – as most of them would not pay that top price anyway. Many people are now paying more for their care.’
A not so bright future
Two hours of discussion threw up many interesting points, not least of which included Kevin Lewis’ light-hearted suggestion that: ‘If we subscribed to conspiracy theories we might think that Gordon Brown was involved with the credit crunch to keep dentists in the NHS!’
All joking aside however, everyone agreed on one aspect.
‘Come April, I think we can expect a small pop rather than a big bang’, said Roger Matthews.
‘There is a great deal of uncertainty, and that’s not a good thing. There is no dialogue with PCTs yet, suggesting that apathy will win the day – which can only drag out the agony. The
PCTs appetite for developing innovative contracts still remains to be seen.’
Most panellists agreed that a mass exodus was unlikely come April 2009, but Derek Watson made an additional qualification. He said: ‘I think it will produce two types of dentists – those who are able to thrive under the contract, and those who cannot. Unfortunately, I think most dentists won’t like the contract.
‘The vast majority of dentists – particularly those my age – will struggle to work this way. It is hard to get to grips with the language and skills that you need to be familiar with to benefit from it. These types of dentists will be on the margins of the service, which is a shame – particularly for NHS provision.’
It was left to Denplan’s chief dental officer to close the debate with sombre food for thought.
‘We are facing a definite period of constraint in health spending’, said Roger Matthews. ‘It is the unknown, and it is not a bright unknown.’