Experiencing NHS dentistry – the truth behind the contract
David Houston, Paul Worskett and Charles Major share their experiences of working within NHS dentistry with Practice Plan, and reflect upon the results of the NHS Confidence Monitor survey, which offers insight into the profession’s confidence levels.
Practice Plan (PP): How do the results of Practice Plan’s NHS Confidence Monitor survey to date reflect your own feelings about working within NHS dentistry?
David Houston (DH): The Confidence Monitor, when considered as a whole, indicates that an overwhelming majority of dental professionals are lacking confidence in many aspects of NHS dentistry, which supports my view of the situation. This is because my interpretation of the very concerning data contained therein is that it clearly demonstrates a profession that genuinely and almost completely lacks any residual belief in the system they are working within. As a result, dental professionals have become demotivated and lack confidence that any realistically workable solution is imminent.
I think that these results also illustrate a profession that has become demoralised, requiring the government to reconnect with us and show understanding for our current plight by entering into meaningful dialogue with respected professional leaders who are not disconnected from the workforce and appreciate our very real concerns.
As a general dental practitioner in mixed practice for over 30 years I have experience of ‘life before the nGDS contract’, when remuneration was based upon an extensive range of fee per item payments. Whilst this was certainly not a perfect system, it had the merit of rewarding productivity and popularity; thus allowing popular practices to grow, develop and prosper.
This opportunity has been removed from those now forced to work under the nGDS contract’s terms and conditions. The target-driven, ‘numbers game’ dentistry system that I believe the nGDS contract has become does not inspire the dental profession to work hard, develop their skills or careers, and fails both to promote excellence and reward investment.
Paul Worskett (PW): The results don’t really reflect my views. We’ve been a pilot practice for the past four years and we are now a prototype practice. Because we have been involved in the contract reform process, we have a slightly different slant on things compared to many other dental professionals. I would say we, as a practice, are cautiously optimistic.
Charles Major (CM): I agree with Paul on this one. My team and I are not quite as pessimistic as most in this survey.
PP: What are your thoughts on the prototypes and how you perceive your future in light of their content?
DH: I concede that advocates of the prototypes would argue that they are in their infancy [they began on 1 January 2016] and must be given time to provide meaningful feedback from the data collected. However, my opinion is that because they are based upon a flawed concept and working premise they are a ‘tinkering’ rather than a true realistic root and branch reworking of a discredited and unworkable base model that has not proved to be worthy of further consideration, never mind prolonged pursuance.
With regret, having originally been pleased and proud to join the NHS in 1985, I now believe that my personal future must be primarily outside of the NHS sector as I desire to have a degree of control over my professional career. Additionally, I would like to be able to control my practices’ growth and development. Only the private sector would appear to offer me these facets of career and business progression.
I do sincerely hope that I am not ‘playing into the government’s hands’, since progressing outside of the NHS may simply be satisfying an ulterior motive to create a marginalised NHS dentistry element of a centralised national healthcare system.
PW: I think things are heading in the right direction, but I’m concerned about the activity requirements, especially for ‘blend A’ practices [see www.bda.org/contractreform for details on the two prototype ‘blends’].
I’m also unhappy with the patient charging structure, which is still based on bands one, two and three. I think it needs to be proportional to the amount of work a patient is having done. So, for instance, if they need one filling they should be paying less than someone who requires, say, half a dozen fillings.
There are challenges ahead; there are no two ways about that. The future depends on how a practice adapts to change. If practices are reluctant to change, then it’s going to be difficult for them. But if practices are more adaptable then they’ll probably make more of a success of it. I do think the way NHS dentistry is moving forward will be more suited to larger practices or corporates because the way you need to organise your practice to deliver the preventive approach will require the engagement of a skill mix.
CM: I think that whilst the prototype is an improvement over the old UDA system, NHS dentistry remains underfunded. Looking to the future, this seems unlikely to change due to the country’s fiscal challenges.
PP: How are you facing the potential for change within NHS dentistry, in terms of your practice, your team and your clinical skills?
DH: At present, whilst the current uncertainty pervades, our practices’ growth and development is primarily in the private sector, particularly the expansion into specialist care provision and the ancillary market of facial aesthetics.
Our NHS-based expansion and ‘future proofing’ is by means of purchasing other local practices with nGDS contracts, closing them at their original locations and transferring the care provision to our own, much larger site where economies of scale and reduced overheads make the continued provision of NHS care just about practical and realistic.
We have engaged the services of dental therapists, although we are currently utilising them as dental hygienists, in order to be ready to alter the bias of our workforce, should this prove to be necessary to continue to operate within any new arrangements enforced.
PW: We have a therapist and have trained some of our dental nurses to be oral health educators, and that allows us to give that emphasis to prevention. I think the dentist’s role is more in terms of diagnosing and treatment planning, as well as directing treatment, which is then delegated to dental care professionals whenever possible. The dentist can then focus on what you might call the more specialist areas, such as advanced treatment.
We’ve found that the majority of patients are quite positive about what we’re doing, but there is a challenge in communicating what you’re aiming to achieve. You have to find out what type of communication works best for patients; some like to have something to read and others prefer to have a conversation. The prototypes offer some leaflets, but I think we could probably do with more help from the Department of Health on informing patients about the changes. That said, different practices have different needs so we must be self-directing to some extent.
I think if patients come along with the same expectations that they’ve had in the past then they’re going to be surprised or, perhaps, challenged by that. For instance, if patients are used to going to the dentist every six months and having a scale and polish, then that’s not likely to happen so much on the prototypes. It is possible that they will be seen if they’ve got a healthy mouth over a longer period of time – perhaps 12 months – for a check-up. And the treatment that is given to them will be specific to what they need rather than what they might expect.
CM: We are expanding our team, making full use of the skills of our dental care professionals. We are also capitalising on referral within the practice, thereby delegating treatments to complementary members of our team. There is, of course, no opportunity to further develop the NHS side of the practice due to the fixed contract but this does mean that we can focus on building the private side of the practice.
PP: What would you like to see a reformed contract offer both the dental team and patients?
DH: Utopia! However, realistically in the inevitable absence of contractual perfection, I would at the very least hope for a restoration of trust and confidence between the profession and the government. I would like to see this linked to an ability for dental professionals to be able to plan for the future of their career or business with certainty and predictability. Patients would gain access to a clearly defined and well understood level of care that satisfied the need to provide good basic dental health at reasonable charge levels, whilst allowing the profession to ‘mix’ the types of treatments offered without fear of ‘gaming’ accusations or complaints about supplying restricted services despite the constraints of economic realities.
PW: I think as far as the dental team is concerned, job satisfaction, feeling valued and being remunerated adequately for the work that they are doing need to be addressed. The prototype doesn’t necessarily offer that. For example, the annual increase that the NHS gives us doesn’t reflect the increase in costs that we have to endure.
For patients, they ought to be clear about what their expectations are, which might need to change from what they’ve been in the past. I think the new way forward is to improve overall health and patients need to take more responsibility for that rather than just going to their dentist and expecting them to put everything right. Patients also need to perceive they are receiving value for money for their dental care.
CM: In an ideal world, we would receive better funding to improve access. The only limit on patients in our practice is the contract value. Sadly, we have reached the target of NHS patients we are allowed to accept. In the new contract I would like to see commitment to increasing funding if the practice could demonstrate a local need.
PP: Where do you see yourself in 10 years’ time?
DH: Given my age, I will inevitably be retired! For those younger members of the profession, I genuinely hope that our cohesive reaction and solutions to the current dilemmas ensure that they will be practising with confidence, enjoying their roles as front-line care providers, offering high-quality, well-remunerated treatments at the cutting edge of technology in modern, state-of the-art practices, of which the nation can be proud.
PW: Given that I’m 55 at the moment, I hope I will be spending a little more time on holiday! But retirement is a long way ahead yet. I’m still enjoying my dentistry and as long as I enjoy it I’ll carry on as I am. Having said that, at the practice we do place an emphasis on treatments beyond that which the NHS typically offers, such as implants and orthodontics.
Elsewhere, all things being equal, I can perhaps see the NHS becoming more focused on certain types of practices such as the corporates and larger practices, and smaller practices might have to be more bespoke and, perhaps, private. I think change is a good thing as long as the profession as a whole is able to meet the challenge by means of
CM: The plan is to build the practice further. Expansion will all be on the private side of the business. In 10 years’ time I would hope that I will not be working at all!
The third forum of key opinion leaders was held in March and included Eddie Crouch, Andrew Lockhart-Mirams, Sarah Franks, David Houston and Paul Worskett. Information on their thoughts will be released soon.
Practice Plan is the UK’s number one provider of practice-branded patient membership plans. They have been supporting dentists with NHS conversions 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.
David Houston is the joint principal of the Houston Group of dental practices, offering both NHS and private treatment. He is a wet-fingered dentist five days a week, as well as lecturing and writing for professional journals. He is also the former clinical governance lead dentist of North Somerset Primary Care Trust. David is a key member of Practice Plan’s Insights panel, which meets twice a year discuss the results of the NHS Confidence Monitor in depth.
Charles Major trained at University College London, qualifying in 1985. He practised in London and Suffolk before establishing his own practice in Cambridge in 1997. He moved to Fowey in 2011, practising dentistry at Noah’s Ark Dental Practice, where he offers both NHS and private treatment. Charles is a general dental practitioner but has developed an interest in implant and cosmetic dentistry, and taken further training in these areas. He is also a member of the ADI and BACD.
Paul Worskett qualified in 1983 and has worked in London hospitals specialising in oral and maxillofacial surgery. After gaining experience in general practice, in 1988 he became the principal of Amblecote Dental Care in the West Midlands, and has expanded and developed the practice ever since. Paul has completed numerous courses on advanced dentistry over the years and was awarded a masters degree with distinction from the University of Birmingham in Advanced General Dental Practice. Paul has extensive experience of dentistry and has a special interest in cosmetic and implant dental care. In March 2016, Paul joined Practice Plan’s Insights panel.