Following confirmation that the contract reform process will rumble on for another two years, with fresh calls for new practices to join the prototype programme, I caught up with two dentists already involved.
Len D’Cruz is a dentist and practice owner in a prototype B practice, and Claudia Peace is an associate in a prototype A practice.
I spoke to both to find out more about how their experience in the programme so far informs their opinion about contract reform and the future of dentistry.
Nigel Jones (NJ): Based on your experience in the programme, how realistic is it to expect the majority of practices to make a success of either prototype contract?
Len D’Cruz (LD’C): The business model has not been shown to work satisfactorily to my mind and therefore rolling out the contract now would be a disaster. How to manage both capitation and UDA targets in a practice with multiple associates on a monthly rolling basis is a challenge that has taken our practice a long time to overcome. We have been successful largely because we have spent more time and resources delivering the contract by increasing our working hours, but for the same contract value. That is a cost that seems to have escaped the Department of Health. Many of the prototypes have kept their heads above water with a similar injection of resource.
Claudia Peace (CP): In my opinion, dentists are bright people and will find a way to make it work. One of the advantages of contract reform is that the advice and prevention we give creates patient responsibility and the changes we see them making is motivating and rewarding.
NJ: ‘Expressions of Interest’ to be in the next wave of prototypes are now open, what would be your advice for anyone thinking of putting themselves forward?
LD’C: They need to think very carefully before they launch into it. If they are achieving their UDA targets each year, I am not convinced they will benefit from moving into the prototypes. There are bigger financial risks and there is no leeway given by the commissioners if you start to under-deliver when you previously hit your UDA targets.
CP: I’d say think ahead as to how to use skill mix successfully. Think about whether you have spare surgery time and how to effectively apportion it, with a view to being flexible about changing working hours. Set clear targets for associates, bring the whole team into the concept of what contract reform is trying to achieve and spend time in training every member as to how they will contribute to the success of delivering the contract. Accept that this is all going to take time and effort!
NJ: It’s interesting to hear your views on the future of the prototypes in terms of the next wave. What kind of future do you see for NHS dentistry as a whole? Bearing in mind that the most recent NHS Confidence Monitor survey showed that 70% of NHS dentists don’t see themselves within the NHS in five years’ time and the BDA recently reported a ‘recruitment crisis’.
LD’C: Whatever emerges as the definitive reformed contract, it will always be a compromise since the three stakeholders, the patient, the Government and the profession, want different things. How significant that compromise is will influence the direction of travel and the success of the contract in the end. The limiting factor will be funding and whilst the Government can conjure up more money for the wider NHS and agrees to awards of 4% for NHS staff pay, their failure to increase the primary care dental budget will mean the service will wither on the vine as the years go by. Patients are already contributing 70% of the funding of primary care dentistry through patient charge revenue so it won’t be long before all the funding comes from patients.
CP: Contract reform is based on much more patient education and prevention, which is another of its strengths – it really works and patients like it. The introduction of ‘skill mix’ is a smarter way to work, but I think we have to be really careful that standards don’t drop in adopting this new way of delivering the contracts and a watchful eye is needed.
The cost of the NHS, generally, is a headache to the Exchequer. Without higher taxation, I don’t see how it’s sustainable to keep offering all treatments on the NHS and it may well be that only a ‘core’ service can be afforded in the future. I’m worried that there is a possibility that these ‘smarter’ ways of working, which are obviously cheaper, will lead to de-skilling and less professionalism. I think the procurement process for NHS contracts may well favour the corporates and I can see NHS dentistry becoming commoditised with a concomitant race to the bottom for service provision. The danger for the NHS is that standards may well be driven down to below that of the level of the Regulator.
If I’m absolutely honest, I would probably advise younger colleagues that they may well have a more satisfying work/life balance in private practice, particularly if they wish to be a principal; the goal posts constantly change in the NHS and I also suspect that NHS contracts will not be as secure as they have been in the past.
NJ: What do you see as the long-term role of dentistry within the NHS?
LD’C: The NHS is still failing to serve the most needy – young children who end up having extractions under general anaesthetic and older people stuck in care homes and in their own houses, unable to access a dentist because the funding that was there for these ad hoc services prior to 2006 are no longer there. It would be some comfort to taxpayers to know that the NHS was there for the most vulnerable in society and when they need a dentist when in pain or for basic treatment, but I am not really convinced even that can be guaranteed anymore.
CP: I really don’t know. There are big political questions to be asked about what can be afforded as a country. At the inception of the NHS in 1948, penicillin was a cure all, but advances have been made that are relatively much more expensive and are an expectation. An advanced society should have health care provision for all, but I think it should also inform the public about healthy lifestyle choices with an expectation for individual responsibility. The NHS is currently looking for pilots to reach out to the homeless and to nursery groups which I believe are important initiatives and should be prioritised. As a nation we are improving our oral health so dentistry should become cheaper, but whether advanced cosmetic work can or should be afforded on the NHS is an issue for the politicians, not for me.
NJ: Thank you both for sharing your views, it has been a very interesting discussion.
If you would like to share your own views on the future of dentistry please take part in the latest Confidence Monitor Survey.