At the 2016 BDIA Showcase, Practice Plan was delighted to bring together a number of key opinion leaders for two live events, one to discuss the results of the fourth NHS Confidence Monitor and one to answer audience members’ burning questions on the future of NHS dentistry.
Practice Plan now has the pleasure to share the perceptive and sometimes heated discussions that ensued between valuable contributors at the two events – young associate dentist David Bretton, wet-fingered dentists and BDA representatives Eddie Crouch, Len D’Cruz and Judith Husband, principal of the Houston Group of practices, David Houston, cosmetic dentistry specialist Tony Kilcoyne, solicitor Andrew Lockhart-Mirams, and principal of a prototype blend B practice, Paul Worskett.
Offering essential insights
Over the past 18 months or so, Practice Plan has commissioned a set of surveys – known as the NHS Confidence Monitor – asking dental professionals to rate their confidence levels in the future of NHS dentistry. The survey’s purpose has then been to track these confidence levels, as information is released, about the NHS contract reforms, which has revealed confidence is low across the profession.
Each survey has been followed up with a meeting of key opinion leaders in the form of an Insights Panel to explore the results in greater depth. On this occasion, at Dental Showcase in front of a live audience, Nigel Jones, Sales and Marketing Director at Practice Plan, started the event by summarising the results of the latest NHS Confidence Monitor survey, as well as placing them within everyday practice context. To this end, he shared with the panel and audience his view of Andrew Marr interviewing Chris Hopson, the chief executive of NHS providers, recently on the BBC.
Nigel commented: ‘What I thought was particularly interesting was the kind of language being used by Chris Hopson as a representative of the NHS about the need to sacrifice services, to make difficult choices, to start rationing. I think that is the kind of environment where financial pressure on the NHS is intensifying to a very high degree.’
‘I think that is the kind of environment where financial pressure on the NHS is intensifying to a very high degree.’ – Nigel Jones
Picking up on the theme, David Houston added: ‘I think confidence is low because you cannot plan for or predict the future given the current contract and financial climate. Dentists may well be better off taking their future in their own hands by at least combining NHS and private work, if not trying to use their NHS access issues to guide people to the private sector using plans and more manageable ways of offering affordable dentistry beyond the Government’s control.’
Adding to the hot topic of the potential for a revised contract and the prototypes, Eddie stated: ‘The Department of Health is about to do a six-month review of what’s been going on in the prototypes. From what I understand, some are finding it difficult because there are three different elements that they’re trying to balance: patient numbers, activity and quality indicators. The worrying thing is that very few of the prototypes seem to be managing to keep their patient numbers high. Sadly, time and access don’t really match up. A lot of people participating in the prototypes are potentially facing a significant claw-back at the end of this year. Some of them are even thinking of pulling out before that happens, so the repercussions will be somewhat reduced.’
‘The worrying thing is that very few of the prototypes seem to be managing to keep their patient numbers high. Sadly, time and access don’t really match up.’ – Eddie Crouch
Continuing the discussion about claw-back, Andrew said: ‘It’s certainly our experience that the flexibility that commissioners allowed a couple of years ago has fallen away. In minute terms, we’ve been dealing with a case where the contractor has been pursued vigorously by NHS England because they missed their target by 0.03%. That isn’t a confidence winner.’
There was also speculation as to when any revised NHS contract may come to fruition. Reflecting on this, David Bretton expressed frustration about the lack of clarity: ‘I don’t think the Government has a clue, to be honest, and if they have they are certainly not sharing. It’s as clear as mud.’
Nigel added: ‘One of the things we’re trying to address is this lack of communication, to help as much as we can, to clear the mud by getting expert opinions and canvassing people who are running prototypes.’
Looking beyond the prototypes
An event complementary to the NHS Dentistry Insights Panel was facilitated to enable the audience to ask questions of our experts, which were ultimately posed to both our Insights and Burning Questions panels to provide clarity on the key issues and concerns facing dental professionals.
In light of the different pilots, what is your best guess of the structure of a new NHS contract, how might it be remunerated and when could it be brought in?
Eddie: They are all good questions that are a challenge to answer! What I can say is that the current prototypes have been going for six months, and the evaluations have started. My own personal feeling is that it’s far too early to reach any conclusions. Some people are saying that a revised contract is likely to be issued before the next general election. As for what the contract may look like, I hope it would be a heavily dominated capitation-type contract with as few targets as possible, so that dentists are given the flexibility to look after patients in the most appropriate way.
Andrew: Although this is perhaps best answered by those involved with the negotiation of arrangements for the pilots and the prototypes, I would have thought that it is inevitable that we will see a greater emphasis on capitation – we can but hope, Eddie!
Len: Adding my view to capitation, if I may, having spent the last three years in the pilots and the prototypes, I perceive that the direction of travel is heavily weighted towards capitation with a light sprinkling of UDAs thrown in to monitor activity. Timing-wise, the general thought is that the roll out will start in 2018-19, however not as a big bang but rather a gradual ramping up of the contract across England.
‘I perceive that the direction of travel is heavily weighted towards capitation with a light sprinkling of UDAs thrown in to monitor activity.’ – Len D’Cruz
Paul: I would opt for predominantly capitation of 75% to 85%, with some activity measure. There are two principles that need to be recognised. Firstly, the system needs to be flexible because, to use a well-worn phrase, one size does not fit all and, secondly, the incentives need to be aligned with the objectives.
David B: If I can pick up on what Eddie was saying about the dentists’ flexibility to look after patients, my understanding is that the new NHS system will work primarily on risk assessments, which will allow care to be delivered in a more individual way by a mix of the dental team. In terms of when a contract might come out, I don’t think anyone really knows. My best guess is 2018 but I think it could be as late as 2020.
David H: I agree that’s a real possibility. I think that the process is slow and laborious, and there are rumours that the powers that be are not happy because access appears to be an issue, since the traffic light system of examination takes so long to complete. So, I believe that will be changed in order to focus on improving access and numbers of patients receiving care. There will have to be a fundamental change before any contract is rolled out.
Judith: For my part, I think it’s imperative that the prototypes are permitted to run their course and assessed appropriately before any major changes occur. It’s important for us to have an open mind and rigorously assess what’s actually going on, because the pilots were very different, as are the two prototypes. There were some grave concerns with respect to single-handed practices and high-need populations, and it seems clear that these are two areas that need a lot more work and consideration.
‘I think it’s imperative that the prototypes are permitted to run their course and assessed appropriately before any major changes occur. It’s important for us to have an open mind and rigorously assess what’s actually going on.’ – Judith Husband
Tony: Given past patterns of Department of Health behaviours, I think it is likely that no new dental contract will happen before the next general election in 2020, so 2021 is the earliest. And given that Brexit will be a major distraction between now and March 2019, we are likely to see dentistry priorities being kicked down the road into post-2020 government agendas.
Will NHS dentistry as we know it exist in five years’ time?
Tony: That’s difficult to answer. The main problem is that nobody seems prepared to admit that NHS dentistry is now a limited system. It struggles to see half the population once every two years. Only when the Government admits publicly that it’s a limited service can we then focus upon delivering limited objectives well, rather than everything spread too thinly. There is, of course, a great need for an NHS dental service, but more focused on the most vulnerable. We have children in hospital beds with rotten teeth, a vulnerable and growing elderly population, and oral cancer is on the increase. We need the NHS and private sector to work in harmony rather than as competitors, meeting different types of need.
Len: I think that in five years’ time things won’t be same, with an over reliance on activity targets. This will result because the Government knows that the public will not accept a reduction in access or a narrowing in the scope of the treatments available.
‘The main problem is that nobody seems prepared to admit that NHS dentistry is now a limited system. It struggles to see half the population once every two years.’ – Tony Kilcoyne
Eddie: I’m not so sure that NHS dentistry will be there for everyone in the future, however I don’t see any radical change within the policies of any of the political parties over the next five years.
Judith: The country is under significant financial pressures and we are likely to face even greater uncertainty as we move towards Brexit, but I don’t think that NHS dentistry will change much over the next five years.
David H: I disagree to some extent. I think NHS dentistry as we know it is unsustainable and I don’t think any government would be going through this exercise without seeing change as the end game. We must anticipate and expect change, but perhaps not within a time-scale of five years.
‘I think NHS dentistry as we know it is unsustainable and I don’t think any government would be going through this exercise without seeing change as the end game.’ – David Houston
David B: I guess it does depend on whether the new contract will have been rolled out by 2021, David [Houston]. But, in general, I foresee the same demands from patients and more complaints.
Andrew: Really, it is impossible to predict what sort of contract will be available. However, I cannot help but feel that the overall provision of NHS dentistry will be scaled down with an increase in patient charges for those who are not exempt, which ties in with what David [Bretton] is suggesting the future may hold.
Paul: If I could just add, I believe it is going to take more than five years for all UDA practices to move into the new system. Patients will need to have a greater understanding that they have a responsibility to care for themselves if they wish to be entitled to state-funded healthcare. The NHS cannot afford an open cheque book for patients. I also think we will see more skill mixing, with patients seeing a team of people for their dental care, much the same as is already happening in medical care. There will also be a drive towards more specialist skills development, as the advanced care pathways evolve.
Free treatment for the over 65s?
With patient satisfaction high on dentists’ agenda, the following question was posed by one dental professional with strong feelings about free treatment for older patients, asking: ‘The unemployed and those on benefits get free treatment on the NHS, yet pensioners have to pay the full cost. Shouldn’t we at least provide a subsidy for those in their 60s and older?’
David B: My opinion on that is that this is a much wider issue than NHS dental services. But in terms of the over 60s, I’d have to say ‘no’ to a blanket subsidy. You need to look at the distribution of personal wealth statistics. Yes, some are in dire straits but we also know that the age group that holds the most wealth in this country is 55-plus. So means testing, rather than age, should be the yardstick for subsidised NHS dental treatment.
Judith: I’d like to consider this in the much broader concept of the NHS and contributions, much like David [Bretton]. We have accepted that NHS dentistry is not free at point of service and that a contribution is made. We are tax collectors, in effect, as dentists offering primary NHS care. I personally don’t think that merely age should warrant free care, but I do think that we need to have a sensible conversation as a profession and with the Government as to what we want to offer and who gets extra support and focus.
‘So means testing, rather than age, should be the yardstick for subsidised NHS dental treatment.’ – David Bretton
Len: I totally agree with you both. Yes, there are sound financial and moral reasons to extend subsidies to older patient groups but it should be means tested because age does not automatically mean poverty.
Eddie: Absolutely. There are very wealthy pensioners out there and there are very poor pensioners out there. I would certainly like poor pensioners to continue to get free treatment, if that’s possible.
David H: We’re definitely all warming up to a theme here! Because those people on benefits are assessed by a form of means test, it could be argued that it is a legitimate subsidy. A broad-brush subsidy for pensioners does not make sense.
Paul: Like probably all NHS dentists, we see patients who are less well-off than others, and those for whom I have sympathy are just above the benefits threshold and therefore not entitled to free treatment. These patients struggle financially and cannot afford essential treatment. Some of these patients may also be pensioners. As my colleagues have said, I concur that a fairer system of means testing should be used to determine exemption from charges, rather than age.
Tony: I disagree. I think it may be time to consider making NHS dentistry true to the core NHS principles laid out in 1948: meeting the needs of everyone, free at the point of delivery, and based on clinical need, not the ability to pay. It needs to be the same as visiting an NHS GP. How many people would be put off if they had to pay £53 or even £200-plus to see their GP?
Look out for the second part of this thought-provoking panel discussion in January, within which our team of experts will answer questions relating to the evolution and sustainability of mixed dental practices, and the prospect of time-limited contracts.
Read the second part of this panel discussion for more insights. For detailed results of the NHS Confidence Monitor surveys, as well as to gain access to the discussions from Practice Plan’s previous Insights Panel meetings and interviews with the panel members, click here.
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