All change at the prototype practice

All-changePaul Worskett spoke exclusively to Practice Plan about his experiences thus far of running an NHS prototype contract practice, shedding light on what this might mean for the future of NHS dentistry.

Practice Plan (PP):  Why did you get involved in the prototype?

Paul Worskett (PW): We began as one of the original pilot practices in 2011 and there were three reasons really. Firstly, I felt that some of the principles behind the pilot are the right way forward; ie, the prioritising of prevention as a main driver in dental healthcare and the concept that at least some of the delivery would be capitation based. However, I do not believe that 100% capitation is the right model and some measure of activity is necessary.

Secondly, it got us out of the UDA system, which I think is an inherently flawed and broken system. Thirdly, I thought it would give us the opportunity to contribute to making the system better and, hopefully, being able to ‘make a difference’.

It was natural for us to continue as a prototype, as we were able to make a success of the pilots; however, there is more financial risk with the prototypes than the pilots. For example, as a prototype 10% of our contract value is at risk if there is under-delivery of patient numbers and that risk wasn’t there in the piloting process. However, I do think the care our patients receive is better as a prototype than it would be back as a UDA practice.

PP: How did you prepare the practice for the changes?

PW: We attended the training sessions organised by the Department of Health and our software company, Software of Excellence, all of which made us realise that a massive change was required in the way the practice operates. We recognised that we needed to get the whole team on board and went ahead with a lot of in-house training to educate the staff. We had to change the way the appointment books were managed and the roles of various members of staff. We also created some information leaflets to explain the changes to patients.

PP: You mentioned changing the roles of some staff to meet the needs of the prototype. What were those changes? 

PW: We have gradually introduced a greater skill mix into the way we deliver care and treatment. We trained several nurses to be oral health educators (OHEs) and introduced therapy sessions with a dental therapist. The reception team also needs to be aware of how the care pathway works.

PP: Your team seem to have adapted well to the impact the change had on them. How did you go about communicating the change to

PW: Communicating the changes to patients was one of the biggest challenges. Some patients like to read things, others like to talk – it’s a matter of identifying the best methods in each case. Repetition is often necessary and it is all very time consuming.

PP: So far, what have you found to be the main changes to the way you practise dentistry?

PW: The emphasis on prevention is the main one, and rightfully so. We try to engage with patients so that they can take responsibility for their own oral health. We aim to support them and then keep them motivated.

Our dentists plan the treatment for the care pathway, and then delivery of that care is delegated wherever possible. We adopt a minimalist approach to clinical intervention, and the therapist can therefore perform a lot of the necessary treatment. Interim care, in which prevention and maintenance is carried out between oral health reviews, can often be done by OHEs or the therapist, and recall times can be extended. This team approach means effective coordination and planning is essential and, in turn, communication needs to be very clear and precise so that everybody knows what to do.

PP: How have your patients responded to this change?

PW: It was difficult to start with, as it was very different to what most patients were used to; there has been some resistance in a small number of cases. At the end of the day, it boils down to effective communication.

PP: What elements of the prototype are you most excited about and why?

PW: We are seeing improvement in the oral health of patients who take the message home and improve their oral health significantly. The staff can also improve their job satisfaction levels.

For instance, an OHE can take ownership for his/her contribution to improving the oral hygiene and lifestyle of a patient, and feel a sense of achievement in that. The therapist is also able to use the skills he/she was trained to perform.

PP: Are there any elements of the prototype that you would prefer not to have to test?

PW: It’s a shame we are still operating within the UDA framework for activity and the patient charges system, but that is because of legislative requirements. I am still unsure about some of the quality indicators, upon which some of the contract payment depends.

PP: Has anything surprised you about the process and/or the prototype?

PW: We definitely underestimated the amount of work required to implement the changes when we became a pilot practice in 2011. It required a complete shift in our business model and it has taken time to make the changes.

For new prototypes coming on board from UDA practices, they have the benefit of tapping into the learning that was gained from the pilot practices, but there are still big changes to make that will require a lot of hard work for them to be successful. The admin workload is greater and the systems we have set up are more structured than when we worked to with the reformed 2006 contract. I am grateful that I have a great team of people at the practice who work very hard to make the system work.

Practice Plan is a specialist provider of practice-branded patient membership plans in the UK. For further information on the NHS Confidence Monitor, visit

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