Shedding new light on contract reform

Nigel Jones discusses Sara Hurley’s recent briefing into the workings of NHS dentistry with Eddie Crouch and Paul Worskett.

Earlier this year, I was among a number of key stakeholders invited by Sara Hurley, chief dental officer for England, to a briefing that offered insight into the workings of NHS dentistry.

A number of issues were on the CDO’s agenda, including the extent of her own department’s influence within governmental echelons, the financial and political landscape of NHS dentistry, and what the future might hold for a reformed contract. You can hear everything that was said in our Bodcast, the business of dentistry podcast, at

I thought it would be interesting to ask some respected members of the profession for their thoughts. Among those party to the discussion were dentists Eddie Crouch and Paul Worskett, who offered their views on contract reform. Amongst his roles, Eddie is vice chair of the British Dental Association Principal Executive Committee, while Paul heads up a prototype B practice as part of the ongoing NHS contract reform process.

In conversation: a fresh perspective

Nigel: Eddie, if we can start with you. Sara Hurley emphasised that it was important for the NHS contract currently being prototyped to be patient-focused, with the aim of increasing access and supporting proactive prevention. What are your thoughts about that?

Eddie: There was nothing covered that the profession hasn’t known for some time; prevention is not quick and easy. Prototype practices are spending extra time and resources to achieve what’s required. This is an unsustainable business model, and the policy makers need to realise it.

Nigel: The CDO also said: ‘This reform is about having a contract that meets the health needs of patients. I’ve heard it so many times referred to as a new contract for dentists. It isn’t; it’s a new contract for patients.’ How do you feel about that?

Eddie: A contract that works for patients will be of no use if it doesn’t work for the profession. Dentists have seen significant falls in income in the last seven years and, the further reform is delayed, the more dentists will decide their future isn’t in the NHS. I do believe the patience of the profession is being stretched and a crisis similar to that which affected General Medical Practice is not far away. In fact, I have heard many stories of contract holders finding it increasingly difficult to recruit new dentists.

Nigel: Paul, Eddie brings up a very important point regarding the time it is taking to finalise a reformed contract, and the potential implications of that. Do you think there is anything the profession can do to influence effective change in a timely manner?

Paul: Although the delay in progress is frustrating, it is, perhaps, a little reassuring that the policy makers are not rushing into making wrong decisions. As a profession, this gives us the opportunity to make alternative suggestions and present them to the relevant departments. It is imperative that the experiences of the prototype practices are considered before the contract is finalised.

Nigel: Sara also spoke about the need to create a contract that would meet the needs of a growing 24/7 population, alongside supporting proactive prevention and learning interventions. How realistic do you think this is?

Eddie: To the best of my knowledge, the Warburton 8am to 8pm PDS+ has not been popular in attracting significant numbers to appointments outside of the ‘usual’ 9am to 5pm surgery times. What’s more, growing populations and any demand for additional hours would need significant additional funds, as running practices at extended hours, of course, comes with large increases in wage bills for unsociable hours and business running costs.

Proactive prevention is something that the profession desperately wants but, unfortunately, having a UDA element in the prototypes is a retrograde step. The Department of Health and NHS England need to understand that prevention is activity, and is a sound investment for the oral health of the nation. Unfortunately, access is still king in the minds of the commissioners.

Nigel: It was interesting to hear from the CDO’s team that the blended model of remuneration is being tested to try to identify the right blend in the right clinical circumstances. So, for prototype blend A, about 60% of the fund is released in capitation payments as band one activity, with UDAs for band two and band three. Then, for blend B, 83% of the final value is paid on capitation. As a prototype practice, what are your thoughts on remuneration, Paul?

Paul: We are a blend B practice and, in our first complete year, we found that our activity dropped below the minimum target level and we had to increase our list size to compensate. The overall balance for us was more like 90% capitation and 10% activity, rather than 83% capitation and 17% for band three treatments. It will be interesting to see how other practices fared in comparison and particularly blend A practices, where the remuneration balance is more heavily weighted towards activity.

Nigel: Eddie, do you feel issues relating to budget/funding of NHS dentistry and their influence on contract design was adequately addressed?

Eddie: The CDO clearly understands that clawback is increasing, is a drain on the available budget, and a further sign of a failing 2006 contract. Without additional resources to balance the issues clearly evident from the prototypes, contract reform will be continually delayed.

Nigel: Speaking of additional resources, Paul, what’s your view that there is a need to reduce the burden on dentists by making fuller use of DCPs?

Paul: The use of DCPs as part of skill mixing certainly has some value, but it does make the business model far more complicated to implement and manage. There is more variability in the way treatment can be delivered to individual patients, which means treatment planning must be very clear so that there is no confusion amongst team members and patients.

Nigel: This might be more difficult for smaller practices, I would imagine. How might they be able to cope with the idea of having a more flexible team?

Paul: It has been suggested that smaller practices could group together and provide collaborative services at different locations, but I do not think this will be acceptable to patients or practices. Patients tend to want to see dental team members with whom they have built rapport and trust, while teams prefer to keep patients in-practice, to ensure continuity of care and effective communication. It’s something that smaller practices will certainly struggle with, if a greater skill mix is needed to deliver treatment based on a reformed contract.

Nigel: Thank you so much to both of you for offering such invaluable insight into the CDO’s briefing. Armed with as much information as possible, it seems an appropriate time for the profession to reconsider how best to take control of their future in light of the uncertainty surrounding the NHS contract, albeit tempered by good intentions by Sara Hurley and her team.

Next month I will be sharing the talking points of my conversation with Simon Thackeray and Tony Kilcoyne, again based on the CDO’s briefing, but this time considering issues including how the CDO and her team are placed to make a difference moving forward, the sustainability of any new contract, how to engage hard-to-reach patients, and the possibility of prescription exemptions for dental hygienists and therapists.

Practice Plan is a specialist provider of practice-branded patient membership plans. To find out more visit

Eddie Crouch works in two practices in Birmingham. He is vice chair of the Birmingham Local Dental Committee, vice chair of the British Dental Association Principal Executive Committee and past chair of the Central Counties Branch of the British Dental Association.

Nigel Jones is sales and marketing director at Practice Plan, a specialist provider of practice-branded dental plans.

Paul Worskett has been the principal of Amblecote Dental Care in the West Midlands since 1988. Paul has extensive experience of dentistry and has a special interest in cosmetic and implant dental care.

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