Contract reform remains a source of uncertainty and one of the issues that is still unknown is what level of financial risk dentists may face when, or if, it is implemented. A measure of success of the prototypes is whether the new pathways being tested deliver appropriate high-quality care and access for patients (as well as delivering value for money).
Achieving all of the required indicators, particularly those mentioned above – has an impact on the financial risk for the practice, in terms of the potential for claw back and the possibility of needing additional resource to meet the contract’s needs. To gain some insight into how the practicalities of working under a new contract effect the level of financial risk, we turned to Paul Worskett, who runs a prototype B practice, and asked:
How much financial risk is involved in the new contract?
Paul Worskett: There are always risks associated with running a business, and the same general risks associated with running an NHS dental practice in the UDA system also apply when running a prototype practice. However, there are also some additional risks and differences that apply to prototypes. The discussion here only applies to practices in England, as Wales has its own version of the prototypes, and it should also be noted that there is an evaluation process in progress to assess how the prototypes are performing. Some of the views expressed here are personal, based on our own experience as a prototype practice.
In the UDA system, there is a tolerance of -4% to +2% of contract value (CV), but below 96% claw back is unlimited. The only measure of activity is the UDA, so with only UDAs to count, this makes it easier to monitor and manage. In the prototypes, there is still the same tolerance (-4% to +2%) but claw back is limited to 10% of CV. So if a practice only delivered 85% of their contracted agreement, they would still receive 90% of CV and only be penalised for the remaining 10%, which would be clawed back. However, it’s not just UDAs to monitor, list size under capitation is also measured, making it two variables to manage.
One of the rules of the prototypes is that you can increase your list size above target, to compensate for reduced UDA activity, but you cannot compensate for a reduced list size by doing more UDA activity. In our prototype practice, we have found that our UDA activity has reduced naturally, but we have compensated for this by increasing our list size. UDA activity tends to follow new patients, so by taking on more new patients, you are more likely to achieve target list size and also have more UDAs to deliver. So, the name of the game is to manage the list size well. Also, the list size has a greater impact on monetary value – capitation comprises a larger percentage of the overall CV. Of course, if you over deliver by more than 2%, you are treating patients without being funded for it, yet still bearing the costs of delivery.
There are also other risks that affect finances and should be considered. Most significantly, we have found that it takes more clinical time to deliver the pathway and we have needed to work additional NHS hours in order to deliver the contract. This places a financial burden on the practice, as the clinical time and extra resources needed to deliver the additional hours inevitably incur costs for the practice, with no additional funding.
“Most significantly, we have found that it takes more clinical time to deliver the pathway and we have needed to work additional NHS hours in order to deliver the contract.”
For the same reason, appointment book management is becoming a significant problem, as our appointment books have become cluttered and we are booking much further ahead. This can slow down the throughput of UDAs and courses of treatment inevitably take longer to complete, therefore increasing the likelihood of under delivery of UDA activity. The delays in appointments also mean that some patients may go elsewhere because they have to wait too long. The practice then receives no reward if the patient is no longer on the capitation list at year end, yet valuable clinical resources have been used during the time the patient has been treated at the practice.
Against the risks, of course, we must balance the opportunities and benefits. There is no doubt in my mind that, despite the risks, the clinical objectives of the care pathway are better for patients, who are receiving a better service than under the UDA system; and it is better for practices too, because dental teams have the opportunity to provide care for patients with the emphasis on prevention rather than items of treatment and the target is to improve patients’ oral health, rather than just deliver units of treatment. The incidence of dental disease has changed significantly over time and the UDA system is totally unfit for purpose. In my view, the main problem with the prototypes at the moment is that the system of remuneration is still based on UDAs and, until that changes, the financial risks in the current format of the prototypes may outweigh the potential benefits for some practices.
“It should be remembered that the prototype is not the finished article, but is still a work in progress. Many prototype practices appear to be working successfully, but many do not and more work is needed to improve the business model of the prototypes, to reduce the risks involved for practices and increase the likelihood of successful rollout.”
As far as evaluation of the prototypes is concerned, we are awaiting the publication of the official evaluation report. It should be remembered that the prototype is not the finished article, but is still a work in progress. Many prototype practices appear to be working successfully, but many do not and more work is needed to improve the business model of the prototypes, to reduce the risks involved for practices and increase the likelihood of successful rollout.
Thanks to Paul for once again sharing his experience and insight into the realities of how a prototype practice operates. Whilst the aims of the new clinical pathway are laudable, and it seems those currently trialling them can see some positive benefits, the importance of the financial stability of practices cannot be underestimated…particularly if reform is to result in the ‘golden triangle’ of working for patients, practices and the NHS.