Close encounters of the fourth kind

The Department of Health and Social Care has missed an opportunity by repeating exactly the same model in the next wave of prototypes, Kevin Lewis says.

There’s no mistaking the irritating sound of a can being kicked down the road, especially after more than a decade of hearing the same can being kicked down the same road. So, the recent (mid-February) announcement by NHS England and the Department of Health and Social Care, inviting expressions of interest for participation in yet another wave of prototypes, involving practices in testing models for NHS dental contract reforms in England, was always going to be somewhat underwhelming.

The fact that this latest (fourth) wave is to test the same model as the third wave, made a very limp reception inevitable. Persisting with the same model means, naturally enough, that the third wave model seems to be delivering more of what the Government wants than what the profession wants.

Heaven forfend the possibility that the Government really believes that it is bearing down on the model of choice, but the profession’s patience is wearing as thin as the can itself, and the kicking has to stop at some stage.


The festering sore at the heart of the existing shambles of a contract, is the increasing likelihood and scale of clawbacks. Setting yourself up for a financial penalty has become the unlikely new norm of NHS general dental practice – either because you are chasing unattainable UDA targets, or because you are offering to provide UDAs at a knock-down value, which guarantees that many of those UDAs will incur expenditure way beyond the income they produce (or both, as one is often linked to the other), or because you need to make a range of additional investment to satisfy the various requirements of the contract, but even this still yields no return.

It is palpably of little concern to the Government that for some practices the prototype business model is effectively unviable, and will probably be equally unviable for some in wave four – depending on the selection criteria and process. Indeed, the Government positively welcomes the fact that one GDS practice in every four currently ends up handing money back, despite (in many instances) having incurred higher fixed and variable costs generating ‘activity’ and delivering ‘quality’ (sic) en route to ultimately falling short of their contractual targets, despite their best efforts.

The ability to surreptitiously recycle all this dental money is great news for a cash-strapped NHS. Not only does it allow the Government to redeploy the money elsewhere, but it still allows the myth to be perpetuated that NHS dentistry remains alive and well.


The BDA’s GDPC chair, Henrik Overgaard-Nielsen, struck exactly the right note when reaffirming the urgent need to find a suitable replacement for the current lamentable dental contract, but stressing that it must be one which takes the needs of the profession and patients just as seriously as the aspirations and objectives of the state. Patients are not well served by any system that results in fewer dentists feeling able to continue providing NHS care and treatment.

But the Department’s adherence to an unviable business proposition in this latest wave of prototypes is the surest way to ensure that dentists and practices lose confidence that there might yet be a light at the end of this long, dark, can-strewn tunnel – and vote with their feet.

Henrik aptly describes it as a wasted opportunity, and indeed it is. A wasted opportunity not just to test an alternative model, which builds constructively on the good bits and improves the problematic bits, but also to regain the profession’s confidence and trust in the Department’s good faith. Meanwhile, don’t throw away those ear protectors – that can will be bouncing noisily down the road for a while yet.

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Timing is everything, and I was inevitably struck by the juxtaposition of the above, with the Government’s bullish stance that people (like Carillion, Virgin Trains, Capita, etc) and their shareholders should bear the consequences of having entered into unviable contracts and ending up in difficulties.

More fool them, seems to be the mantra of the day. Shame on those on the other side of these contracts, reaping all the financial and political benefits of parasitic commissioning and procurement processes and deflecting all of the ensuing blame, I would reply. Yet other companies like Serco successfully tendered at rock bottom prices for the unfulfilled Carillion contracts and one starts to wonder if any lessons at all were learned.

Yet in a world where NICE applies a measure of ‘cost effectiveness’ to the question of the interventions that a national healthcare system like the NHS should fund, it is surely neither reasonable nor equitable that the state can legitimately decline to provide interventions that do not deliver an appropriate return on investment, while simultaneously commissioning services on its behalf in the certain knowledge that the provision of those services represents commercial suicide for the provider. How can that be right?

A BMJ article published as recently as November 2017 questioned whether NICE assessments and decisions should take into account future care costs for the life of the patient (which are currently excluded).

Short-term financial gains secured through clawbacks from dental contracts might similarly be viewed very differently in the context of driving dental providers and performers out of the NHS for ever.

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