Nigel Jones, Eddie Crouch and Tony Kilcoyne talk clawback, collective action and crisis as a catalyst for change in NHS dentistry…
This year saw a huge £30 million increase in dental clawback in England and another five per cent increase in patient charge revenue (PCR). In light of these events, I spoke to Eddie Crouch, Vice-Chair of the BDA’s Principal Executive Committee, and Tony Kilcoyne, member of the BDA’s Principal Executive Committee, to delve deeper into the financial pressures facing NHS dentists.
To say that the rise from £50 million to £80 million in clawback in just one year highlights the issue of dentists struggling to fulfil their contracts doesn’t really do justice to the magnitude of the increase. It doesn’t merely ‘highlight the issue’, it shouts it out loud in capital letters!
Indeed, for Eddie and Tony, and undoubtedly many others, it is yet more evidence of the UDA system being unfit for purpose. Eddie described a situation where, in some areas, 40% of practices are facing clawback. He said, ‘Even in stable practices with a core base of patients it’s getting more difficult year-on-year to deliver the UDAs. It is not an adequate measure of work carried out in a practice –some patients have greater needs and require many hours’ work, but the NHS won’t give you any credit for providing that care. They just look at whether you hit your target, and if you didn’t, the sucker-punch is taking money from you via clawback.
“Whilst clawback has long-been a bitter pill for many, it could be a little easier to swallow if that money was then reinvested into dentistry.”
‘Other contributors to the hike in clawback are the actions of the Business Service Authority (BSA) by questioning the dentist’s treatment planning and the aggressive tactics of NHS England. It’s no surprise the figure has almost doubled. Some indications suggest this year will be even worse.’
Whilst clawback has long-been a bitter pill for many, it could be a little easier to swallow if that money was then reinvested into dentistry. But, this is not the case as often it’s re-distributed across the wider NHS, and I understand that there are even some Local Area Teams who are proactively including clawback when setting their budget.
As Eddie said to me, ‘The chair of our Local Dental Network is the Deputy Chief Dental Officer and even she struggles to get funding from the area team to deliver some projects. Clawback money is being taken out of clinical care and used to prop up other areas of the health service that are significantly over-spent, whilst the spend on dentistry year-on-year is falling.’
The issues of the Government’s declining contribution to funding NHS dentistry and the increasing PCR has gained some traction in the national media this year; a Sunday Times article referred to it as a ‘stealth health tax’. However, whilst coverage like this may go some way in helping to raise public awareness of who sets the fees paid by patients, it is still largely esoteric. Many patients assume the fees they pay, and any increases to them, are the dentist’s decision and therefore it is often practices who bear the brunt of their criticism at the point of payment.
“Many patients assume the fees they pay, and any increases to them, are the dentist’s decision and therefore it is often practices who bear the brunt of their criticism at the point of payment.”
Tony described the situation where patients are paying £21.60 for treatment but the dentist is receiving £20 for carrying out that work as ‘ridiculous’. He added, ‘I never thought we would reach the point where the PCR is over 100% of the UDA amount. I think the Government will continue raising the charge by five per cent annually, which makes you wonder if this is a deliberate ploy to raise money for the NHS. If you add clawback into this mix, you’re talking about a real reduction in commitment to dentistry from the Government and I’m not sure they’ve been fully open and transparent about it. Should we, the public, tolerate this from public servants?’
Eddie concurred, ‘If clawback money was reinvested into dentistry, particularly for additional prevention projects that fall outside the remit of the contract, that would be more palatable to the profession. But the truth is it’s not. That message, along with discrepancy between what patients pay and what dentists receive for UDAs, hasn’t got through to the general public. It’s the job of the BDA to make sure everyone knows where their money is really going.’
A lot of what is happening within NHS dentistry, in terms of the pressure at the coal-face and the squeeze on funding, is symptomatic of the problems facing the entire health service. But there was some positive news for the NHS in June when Teresa May announced that it would receive an extra £20bn a year by 2023. I asked Tony and Eddie whether they thought dentistry was likely to receive a share of that particular branch of the money tree?
Tony said, ‘I remember in 2006, when they introduced UDAs, and it was a ‘boom time’ with high growth period and extra taxes and, even then, the Government’s commitment to dentistry was minimal. If it was like that in a boom time, are they really going to spend £3-5 billion a year when we’re in a period of austerity? I think dentistry will receive the minimal amount necessary to satisfy complaints from the public about the inevitable decline of quality NHS dentistry.
‘I could be misjudging them, but history tells me they are not commited to NHS dentistry and have no appreciation of what we do to benefit society. I can only conclude, therefore, that it’s a cynical decrease of commitment.’
Eddie added, ‘The last time dentistry received any significant money was just after the current contract was introduced, when access figures for NHS dentistry plummeted and extra funding was introduced through the PDS Plus contract. Therefore, it’s quite clear that if access drops, the Government will invest. But access at the moment is still high and until it falls, and until a lot of practices leave the NHS and patients start complaining, there will be no additional funding.’
“The last time dentistry received any significant money was just after the current contract was introduced, when access figures for NHS dentistry plummeted and extra funding was introduced through the PDS Plus contract. Therefore, it’s quite clear that if access drops, the Government will invest.”
This notion that it will take a crisis in dentistry to force the hand of the Government into making positive change has been a recurring theme that I have heard many in the profession talking about recently. It also suggests that it is in the hands of dentists to try and instigate change, rather than relying on the Government – a point I put to Eddie.
‘Absolutely. The BDA is the voice of the profession, and we’d like far more members, solidarity, unity and collective action, but it’s very difficult to coalesce a group of small businesses with varying elements of NHS and private.’ He added, ‘It’s more likely that practices will leave the NHS, access will fall, MP’s mailbags will fill with patient complaints, and then we will get a reaction.
‘The general medical practice is a prime example of this. It took an absolute catastrophe of patients being unable to access GPs for the Government to act and provide more funding. We’ll probably get that eventually, but we’ll have to have a crisis first.’