Will skill-mix be enough to save NHS dentistry?

Will skill-mix be enough to save NHS dentistry?

A letter from Sara Hurley, chief dental officer for England, issued on 19 July, announced what were labelled as the first changes to the contract in 16 years and supposedly, the first stages of contract reform.

The letter outlined a variety of measures, including a commitment ‘to address misunderstandings around use of skill mix in NHS dental care, whilst removing some of the administrative barriers preventing dental care professionals from operating within their full scope of practice’.

In a recent webinar for Practice Plan hosted by sales and marketing director, Nigel Jones, dentist and GDPC member, Shiv Pabary and dental practice group MD, Chris Groombridge shared their thoughts on how much difference this would make to the state of dentistry at the moment.

Big supporter of skill-mix

NJ: Shiv, you’ve said, that workforce is the nub of the issue, and that’s what we need to address. Chris, do you have a view on what the tactics might be to address the workforce issue?

I’m including bringing in overseas dentists and, the skill-mix points, and whether or not actually therapists and hygienists could make a material difference?

CG: I’m personally a big supporter of skill-mix. But I think the problem with the current proposal is, they’re trying to put a square peg in a round hole. And what I mean by this is, there isn’t enough clarity. The Department of Health, NHS England, have not given enough clarity.

There’s also whether it’s economically viable. A therapist can do about 2,000 UDAs. A dentist can just come out of FD (Foundation Dentist) and do about 4,000. So, it isn’t economically viable if you’re going to try and use therapists to service your UDA contract. It just doesn’t stack up.

I use therapists in my practices to create time in dentists’ books, so they can do more complex NHS work. And they can do some private work. It’s about creating space, and that’s how we use the therapists. That’s why I’ve sat on the idea of using therapists more, because there’s a lack of clarity on how it is going to play out. I will look at it again, come March next year.

Current purposes

But I also think the timing’s not brilliant, as this is a primary time when UDAs are being delivered. So people are not going to change their business model right in the middle of their prime time.

I believe there are enough therapists for our current purposes. I think if the NHSE does its homework, it’ll find that the numbers of therapists they would need for their suggestions, if everything went well, would take about seven years to deliver, more likely 10, to get where they want to be. It would take too long.

So, there are enough therapists, and I have one final factor to add in. There will need to be a lot of support if they want them to do more, because a lot of therapists have been de-skilled, and have done a lot of hygiene work only. And now you’re asking for a sea change. It’s not a quick fix.

SP: Skill-mix is interesting. The first thing to say is that I think it’s a good thing to have. I’ve worked with therapists and hygienists for years, and they’re a very important part of the team. The problem is, it doesn’t work within the UDA system, and it never has.

We were part of a pilot practice for three-and-a-half years, and we worked with the therapists, it worked really well. We worked with a hygienist, who could see the three-monthly recalls within the scope of practice.

And I just don’t get why from the 1st of October, with the changes, you now have to put in the GDC number of the DCPs that have worked on that course of treatment. So, in theory, you could have a fluoride nurse who’ll put some fluoride on, a therapist who did some fillings, and a hygienist, who did some perio. And you’ve got to put all three GDC numbers on.

Look at the implications

I’m not sure what the point of that is, apart from them getting a feel of what the DCP usage is out there. They’re not on the performance list.

And really, my personal view is that I still think the dentist should be the clinical lead, and the treatment plan and the prescription should come from the dentist, and then the therapist works within the scope of practice.

There is an issue with direct access. If Chris was my therapist and I said to him, ‘Listen, work within your scope of practice, see the patient that comes in. If you need me to pop in for endodontics, or for extractions, I’ll come in and do another exam’.

The problem is whatever treatment Chris does, I carry vicarious liability for that. I would be responsible for it. And that’s why the indemnity organisations are quite worried about this.

So, you would have a performer, the therapist using the performer number, and claim the treatment of that performer. But who carries the liability for that?

So, I think we need to really strip this out, and look at the implications of skill-mix. Nobody’s against it. I think it’s very difficult, financially, for the reasons Chris just gave. We had a practice in the Northeast, which had four therapists in the NHS, and worked quite well, to an extent. And what they did was, they top sliced the UDA.

So, if your UDA value was £25 as an associate, they’d take off £1, and everybody gets £24, and then you can send the patient to the therapist without any cost. And that’s part of the problem. Associates don’t like using therapists because it costs them to send them.

And what happens? A lot of the therapists work as a hygienist, and they’re de-skilled, just like Chris said. Within the UDA system, it really is difficult to make it work economically with therapists and hygienists.

Different business model

CG: That’s what I meant by a square peg in a round hole. The therapists will be great in a different business model. For instance, if you did 70% capitation, 30% activity, that’d be a great model. But they’re trying to put the therapist into the wrong business model.

NJ: The overall sense I’m getting from you is that there are three fundamental issues that need to be addressed simultaneously, which are: a new contract, workforce, and additional funding. It feels that if any one of those are missing, the stool will fall over.

The point about skill-mix, seemed to be trying to address the workforce issue, and I totally take the point about the square peg in a round hole, in terms of the contract.

The letter spoke about the need to clarify misunderstandings, but from what you’ve just been saying, it doesn’t sound like misunderstandings, but rather some important, legitimate points of concern, that need to be addressed. But even when they’ve been addressed, from what you were saying earlier, Chris, it would take years before we got sufficient numbers to make a material difference.

Side effects

CG: Workforce was raised again at a GDC Conference recently. Finally, they’re going to start looking at what is the true situation with the workforce. Obviously, looking at therapists should be part of that, and finding out what the true numbers are.

I think, if Section 60 comes through, more dentists will come into the UK before the number of therapists ever hits the market in time. And if we’re working in the current business model, then practices will inevitably use dentists. Because it makes sense, as far as hitting our UDAs.

I’m not saying that’s the right model, going forward, because we all know it’s a failed contract. I’m just pointing out, if the government’s unwilling to reform the current contract, then that’s possibly one of the side effects of it.

SP: One of the BDA’s concerns, as well, is the pace of change. It is taking so long to have discussions, and decisions. And every day, people are walking away from NHS dentistry. People are making choices; dentists are voting with their feet, and they’re converting to mixed practice and private practice.

We’ve seen contracts being handed back. We talk about dental deserts, and in my neck of the woods, Cumbria, we’re really struggling.

We’re trying to get FD training, just so that we can get FDs in some of these areas, where they stay on. We’re trying to look at alternative ways of working within a large practice, having a number of FDs that might stay there, and trying to give them a really reasonable contract.

So, we’re trying very hard. But the problem is, and we keep coming back to this, we need to do something fundamental with the UDA system. It just isn’t working.

NJ: Thank you all for your thoughts. Yet again, we’ll have to wait and see.

For more information visit www.practiceplan.co.uk.

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