As the parliamentary inquiry into dentistry in England rumbles on, we turn our attention to dentists in the other home nations. Here, Louise Anderson shares her insight into how dentists in Wales are faring.
What I see when I go into practices is that morale is on the floor. The danger of the complete collapse of NHS dentistry in Wales is as imminent as it is in England. However, the circumstances are different.
The Welsh government has done something completely different from England. Here, they have introduced what they call ‘contract reform’.
I was involved with contract reform for about four or five years before joining Practice Plan, as the practice I worked in was one of the pilot practices for the contract reform study. The Welsh government wanted to introduce a new contract to be able to move away from the UDA system.
In theory, it sounded great. They wanted to encourage more of a preventative programme, making people accountable for their own oral health and service need, rather than patients visiting the practice on a six-monthly basis when there wasn’t necessarily a need for them to do that.
The initial contract reform pilot programme was a data collection exercise and the ACORN form (Assessment of Clinical and Oral Risk Analysis) was introduced as part of the process.
This proved to be very time-consuming as some of the questions were about lifestyle. So, while we know smoking, alcohol, sugar, BMI, all need to form part of a risk assessment for a patient, patients weren’t used to being asked those types of questions. Accordingly, there was some pushback. However, the Government forged ahead with it.
COVID-19 effect
However, COVID-19 meant that it became the de facto contract. Practices were still given the option to remain on the old UDA system. But to do so, they would have to accept a 5% reduction in their actual contract value.
So, they would only be paid 95% of their contract if they remained on UDAs, and to achieve 100% of their contact dentists had to accept contract reform.
Along with contract reform came a series of metrics and measures for dentists to comply with. The ACORN forms were used to categorise patients into red, amber or green. Red patients needed active treatment so dentists could start a course of treatment on them. It was a similar case for amber patients.
However, for patients in the green category, examinations should not be prioritised for them for 12 to 18 months.
This meant that patients who had previously been regular attenders, coming to a practice every six months for their routine examination, were now being told they couldn’t be seen in that practice for 12 to 18 months. And then only if there was capacity to see them. So, this was how we were to create access, by pushing regular attenders to one side.
No allowance for Wales’ high-needs patients
Another part of the metric was new patients, including a weekly target for new patient appointments, based on contract value. In some cases, that could be up to 40 new NHS patients per week.
However, no account was taken of the likelihood that a patient who hasn’t seen a dentist for, in some cases 20 years, will have a high level of need.
Patients in this cohort typically have medical health problems, mental health issues and place higher demands on a practice’s time than those who attend regularly. They often needed multiple appointments to complete their treatment.
And, as request for payment forms couldn’t be submitted until the treatment had been completed, dentists were left waiting for payment, having an effect upon their cashflow.
Another metric was fluoride application targets for both adults and children. Fluoride applications on children had always been part of our business but it was new for adults. Dentists were expected to achieve targets for historic patients, new patients and fluoride applications to achieve contract value.
As a result, by mid-year, a lot of practices had only achieved around 20% or 30% of their contract. This saw them in a state of panic wondering how they had a hope of fulfilling their contract.
Previously, health boards had described this as a learning year and that clawback probably would not take place. However, Wales’ government has issued advice that it is now up to each individual health board to decide how they administer clawback. This could lead to huge inconsistencies across the country.
Huge outcry in Wales
Contract reform works for neither practices nor patients. Some patients have been gaming the system. They know that each practice is obliged to take on new NHS patients, so they are approaching other practices to get appointments sooner.
This casts doubt on the Welsh government’s claim that 280,000 additional patients have been seen. They’re not necessarily new patients as patients have just been rotated from one practice to another, to another, to another. We’re just recycling the same group of patients. Which means practices have almost lost their patient list, which affects goodwill value.
It’s extremely challenging for practices. We’re seeing lots of them contact us to put plans into place. Some are carrying out a drip feed conversion, where they try to retain their historic patients by inviting them to become plan patients with a view to reducing their NHS contracts later. Others are converting and just pulling out completely.
Dentists are really struggling to remain in the NHS under this system. There has been a great deal of media coverage on it. Even the local dental committees have come together to give a single view on this. All LDCs in Wales are attempting to approach the Welsh government to highlight a system that isn’t working and that a better one needs to be found.
I’m seeing record numbers of practices unable to recruit associates and dental nurses because people are just leaving the profession.
If you’re considering your options away from the NHS and are looking for a provider who will hold your hand through the process while moving at a pace that’s right for you, why not start the conversation with Practice Plan on 01691 684165, or book your one-to-one NHS to private call today: practiceplan.co.uk/nhsvirtual?
For more information visit the Practice Plan website: www.practiceplan.co.uk/nhs.
