The NHS contract: talking points, part 1

We have heard many times from health minister Earl Howe and from the department of health that the new contract will remove dentists from a ‘treadmill’ and introduce more education, more prevention and some form of capitation.

But no-one really knows what’s going on in pilots definitively. No-one really knows what the end product will look like by the time it reaches the hands of dentists’ solicitors. No-one really knows if there will be more money allocated to dentistry or less. And there are many more intriguing and unanswered questions.

Here, we feature the first in a series of personal opinions of some well-known and influential commentators who have been through this kind of thing before.

Chief dental officer Barry Cockcroft has kindly revealed the government’s thinking about the new contract and that strong opening leads on to many contributors’ discussion on this new contract.

Part two, next week.

A light touch approach

Chief dental officer, Barry Cockcroft, reveals the government’s thinking

The coalition government has made specific commitments regarding oral health and dental services; to continue to improve access and to further improve oral health with a particular focus on children.
To support these aims, the government is also committed to introducing a new contract and to pilot aspects of the new contract prior to implementation.
Given that the structure of the NHS has undergone significant change over the last few months – and the 150 PCTs that were autonomous organisations have been replaced by 27 area teams, which themselves are part of one larger organisation, NHS England – it is also important for all parties that the new arrangements are not over bureaucratic or cumbersome.

This reorganisation also gives us an opportunity to achieve greater consistency in commissioning and use contractual arrangements in a more strategic way. The biggest change in the 2006 reform was the introduction of a commissioned service that gave the NHS much greater influence over the availability of services, as well as a degree of financial certainty. The fundamental aim of the development work is to align the incentives within the contractual arrangements with both the government’s aims and those of the profession and the needs of the population. Access has improved and it would clearly be unacceptable for any new arrangements to put at risk improvements already achieved, or the potential for more.

Pilot testing
We know the overall approach with the pilots, with a focus on prevention and based on working with patients to prevent disease occurring, resonates with clinicians already engaged in the process. We have also learnt that, to make best use of the pathway approach, practices will need to fully use all the dental team.
One of the major differences between now and the changes introduced in 2006 has been the significant clinical engagement we now have in the process. The BDA has representation on the National Steering Group as do pilot practices, the NHS and patients. The government has already said it wishes to introduce a contract based on registration, capitation and quality and has further committed to the care pathway approach.

‘Light touch’ approach
We know that no system can be developed that does not have the potential for creating perverse incentives. But I want to see a contract develop that provides the right incentives for the vast majority of dentists who will always act in the best interests of patients. We also need sufficient information to enable us to identify anomalous practices as history tells us this is bound to occur in a relatively small number of cases. If we can get this right, then NHS England, in its direct commissioning role, would be able to take a much more ‘light touch’ approach to managing most contracts.

Decision makers
Learning from the pilots has already shown that a system based on capitation with identified quality indicators can work. The adoption of a care pathway approach is popular with both clinicians and patients and has the potential to ensure that clinical decisions are not only supported by an evidence base, but also that significant elements of evidence-based prevention of care can be provided by other members of the dental team.
I think one of the most important aspects of the pathway approach is to recognise that it is to support clinicians when they make decisions and not actually to make decisions for them.
The key element of the pathway approach is a comprehensive oral health assessment, as this is the gateway to care. Again, many clinicians were involved in its development. All clinical treatments should be based on an accurate diagnosis and assessment of needs of the patient and, sometimes, the treatment delivered may vary over the passage of time, depending on how the patient responds.

Litigation reduction
Potentially, there is another really significant benefit that emerges from the pathway approach. There has been a significant rise in complaints and litigation in relation to dental treatment but, by following best practice in treatment planning and treatment as described within the pathways, I believe there is a real opportunity to reduce the risk of litigation.
The fact that all dental services will be directly commissioned by NHS England gives us an opportunity to develop a really integrated service and also means that, for the first time, we will be able to look at the whole patient pathway, whether that care is delivered in primary care or the acute sector, and develop contracts that encompass the full range of services and facilitate this integrated approach.

Align incentives
What we have been trying to introduce in the pilots is a system based on evidence-based prevention as set out in the Delivering Better Oral Health guidance. On the subject of prevention, I believe we are pushing at an open door: across the board, the number of fluoride varnishes provided last year went up by 63% and it is clear this enthusiasm for a more preventive approach is not confined to the pilots.
If we can align the incentives in new contractual arrangements with the right clinical outcomes for patients, we will automatically have aligned the remuneration system with best practice. Finally, when we established the first wave of pilots in 2011, we also learned a lot about the transition from one system into another and how that can be very complex, how some issues are not actually related to the system but actually to the transition process itself. So, whereas 2006 had to be implemented over one specific date because of budgetary transfers, I think it is really important we smooth out the transition process as much as possible.

A numbers game

Michael Watson, Dentistry news correspondent, talks facts and figures

Three years ago, the Coalition Agreement made a commitment to introduce a new dental contract that would ‘focus on achieving good health and increasing access to NHS dentistry, with a focus on the oral health of schoolchildren’. The new contract will be based on registration, capitation and quality, not on UDAs. Pilots were announced at the end of 2010 and were expanded in April 2013. These were based on an outline of care put forward in Professor Jimmy Steele’s review of NHS dentistry. At the heart of the new contract will be the concept of a patient pathway and the development of a dental quality and outcomes framework (DQOF). Although funding has not been piloted, it has already been recognised that a fall-off in patients charge income has been a significant problem. So, here are 10 features of the new contract…

1. Target date
When the pilots were first set up the target date for implementation was April 2014, but this is probably not achievable. In which case the May 2015 general election looms up and all bets could be off under a different government/coalition. Assuming it is implemented before the election, some questions arise. Will there be a ballot? Will the 70% of dentists who are associates have a say? Will practices be given sufficient notice of any change? There is, however, a possibility that changes could be implemented in stages or rolled out gradually, perhaps by enlarging the pilots and allowing more practices to opt into them.

2. Pensions preserved
There has been no indication of any changes to the NHS pension, which is seen by many as a valuable part of working in the NHS. However, the ways in which associates were affected by the 2006 contract changes are still being worked through seven years later. Will other members of the dental team be able to have an NHS pension?

3. Patients’ charges and private mixing
Patients’ charges will remain, although the present system, based as it is on UDAs, will need to be modified. UDAs will be replaced with capitation payments. This raises the possibility of patients having to pay to register with a dentist, something any government would resist. The pilots, like the existing contract, have charges based on courses of treatment. This could be retained after some modification. The existing ban on charging for broken appointments is likely to remain.
    NHS England has recently issued guidance on the mixing of NHS and private work aimed mainly at doctors, especially those working in hospitals. Reading across from this, it would appear dentists will be able to offer treatment privately that is not available on the NHS (eg, tooth whitening) but the existing ban on charging extra to an NHS patient (eg, using a ‘private lab’ or offering hygienist scaling privately) will remain. It needs to be said that the rules over mixing are unclear at present and this may be addressed by NHS England.

4. Most dentistry for most patients will be simple and routine
When the 25 new extra pilots were announced last year, the DH endorsed the ‘care pathway’ approach. An oral health assessment is carried out and, on this, the patient’s treatment plan is based. Until the patient has improved their oral health and reduced the risk of further decay, they will be offered a largely preventive (and simple restorative) service that can be delivered by DCPs.
     It appears as if up to 80% of patients at any one time will be treated like this under the new contract.

5. New rules for complex treatments
More complex treatment will, in effect, be rationed for clinical not financial reasons. Quite how they will be commissioned and how paid for is unclear at the present time. The most recent from NHS England paper speaks of ‘dental specialty based commissioning packages’. It is likely that, in the new contract they are commissioned separately.

6. Capitation will replace UDAs
A capitation payment will mainly cover this simple, preventive-based model. More complex restorative treatments, including lab-based work, could be separately paid for if they are not included in the capitation payment. Rather than dentists struggling to maximise their UDAs, the emphasis is likely to be on the maximum number of registered patients. As with UDAs, dentists will be expected to carry out all necessary treatment within the capitation fee.

7. Expenditure capped
At present, dentistry is no longer ring fenced and the NHS is expected to make significant ‘efficiency savings’. There is no longer a target income for dentists. Dentistry will have to fight its own corner with other parts of the NHS. Dentists can expect ‘claw-back’ if registration targets are not met. It seems likely that capitation values will be standardised, unlike UDA values that vary from practice to practice. There is likely to be a downward pressure on incomes of dentists, especially those performing more simple tasks and more replacement of dentists with DCPs.

8. It will remain a commissioned service
NHS England, through its area offices, will commission new services, which may well be put out to tender. There has been talk of time-limited contracts, leading to re-tendering of contracts after a few years. Corporates and large practices will be at an advantage here; there will be little or no opportunity for an individual to open up a new NHS practice. Some two thirds to three quarters of dentists who are associates do not have a contract with the NHS and will not be directly affected by the changes.

9. Dentists will be involved at a local level through Local Professional Networks
This is very much work in progress. But the intention is that dentists should be involved at local level in the commissioning process, including specialist care, though local professional networks in dentistry, pharmacy and optical services.

10. Structure of the profession
The profession is liable to changes that may be accelerated by the new contract. First is the growing influence of corporates that have shown themselves better at bidding for contracts and are backed with serious money. Secondly, the new contract seems likely to favour the employment of DCPs for the bulk of simple work. It remains to be seen whether, following direct access, the NHS will commission directly with DCPs. Finally, dentists will need to develop a career pathway to include some form of specialisation if they are to compete in this world.
If a new contract based on the pilots is implemented, this will mean a whole new way of working. Dentists and DCPs will need training in these new ways. There is also a need for certainty and lack of ambiguity in the wording of any contract. It should only be introduced with adequate notice in contrast to 2006.

Age-old problems ahead?

John Milne, chair of the BDA’s general dental practice committee, considers the needs of an ageing dentate population

It’s now approaching two years since the pilots to test elements of a new dental contract for England began. It’s probably worth re-stating some of the reasons the pilot project was begun. The 2006 dental contract came under fire almost from its introduction. This was notable in that the health select committee chose to investigate dentistry in 2008 and their report didn’t make comfortable reading. The BDA gave verbal evidence to the select committee and made plain that the UDA contract was neither improving health nor working well for the profession. As a result of the investigation, the government of the day commissioned a review of NHS dentistry – led by Jimmy Steele. His report was welcomed as a positive way forward. I can remember discussions with Professor Steele, and I made it clear it was imperative to incentivise good care.

Behind the scenes
It was encouraging that the government of the day agreed to set up working parties to consider possible routes for change, and I was pleased the incoming coalition government recognised this work would not compromise their pre-election pledge to bring in a new dental contract based on capitation, registration, and quality and outcomes. Behind the scenes, many colleagues began working on elements to consider such as a standardised oral health assessment and the development of risk-based care pathways. The BDA heralded the pilots as a ‘positive first step’ in developing a contract that works for the profession and for the public.
The pilots are beginning to show us some interesting things. Patients clearly value that they are able to become more involved in understanding their own health and also in learning how to prevent further disease. Dental teams seem to find the care pathways helpful, although there have been many difficulties and teething problems with the software systems and, not least, the fact that assessing patients thoroughly takes time and I certainly believe this cannot be ignored as we go forward. The government position is clear, they are committed to increasing access to NHS dentistry while also attempting to improve outcomes for patients. This is a big challenge for the pilots going forward.

There is a ‘but’
Data from oral health surveys show steady improvements in oral health across all ages, particularly the younger end of the population. In theory, at least, in a population where health is improving, access to care could increase as fewer interventions are needed. But there is a ‘but’, and I suspect quite a big one, and it is this. There is a large sector of the population over 50 years of age who have heavily restored dentitions, and the 75-plus age range increasingly are dentate, having received care over a lifetime that has enabled them to retain a functional dentition. This is something to celebrate, but may bring a note of caution to the table. It is possible that the needs of this ‘heavy metal generation’ are understated at present, and it is vital that we maintain a dental workforce with the necessary skills to care for these people in the future. It will probably take 30 years or more for the improved oral health of younger people to work its way though.

Good engagement
And so, at this point, it’s important we hold our nerve. There is still much to do before a new contract can be implemented, and I’ve said many times that the profession needs to see that a new way of working is feasible. Engagement with the profession has been good, and must continue. The stakes are high, both for government and for the profession. Adequate funding for the needs of the population is clearly a challenge, although we are reasonably comfortable with a mixed economy in dentistry. It’s important now that the government works with the profession on the detail, while continuing to learn from the pilots as they continue. The UDA contract continues to fail and, many within the profession, express their frustration at the slow pace of change.

I wish the new pilot practices well, and with colleagues from the BDA and GDPC continue to constructively work for change.

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