With the NHS prototype practices now a few months into their trials, Practice Plan met up with Eddie Crouch, Charles Major and Paul Worskett to discuss their thoughts on the current fees being paid out to prototype dentists, what they would like to see in the future, and the potential repercussions if fair remuneration is perceived to be absent from any future revised NHS contract.
PP: With prototype Blends A and B* now being trialed across the UK, what is your perception of how practices are faring? Is there a difference between the experiences of practices depending on which blend they are working?
Eddie: For dental teams that have come straight into the prototypes from the 2006 Contract, they seem to be finding the transition beneficial, because they’re moving away from 100% UDA targeting into part capitation and part UDA. I also think, however, that some of the practices that were previously within the parameters of the pilots have found it a retrograde step, because they are facing an element of UDAs once again, which were absent from the pilots. Overall, I think those where only Band 3 is measured as activity (the B-type prototypes) are finding it a little easier.
Charles: I have heard that a number of prototype practices are struggling to hit their Contractor’s Expected Capitated Population targets [this is the number of patients for which the prototype practice is expected to provide care]. This is because they have been set higher than was expected, having moved from weighted capitation population targets to actual capitation population targets.
Paul: I think the pilot practices have probably had an easier transition through, as the prototype pathway isn’t significantly different from what we were doing in the Pilot’s. Having said that, I suspect it has also probably been easier for the blend B Practices, as this is more aligned with the way we worked in the pilots. Blend A has more emphasis on activity and I can imagine that, for Blend A Practices, they may have had their focus move back towards keeping an eye on their overall activity, which is not necessarily a good thing. I believe that for UDA practices it’s probably been quite challenging coming into the new system and it’ll take a few months for that to settle and get used to the new philosophy, the different way of working required and how to deliver it.
PP: The dental profession have expressed a concern about the level of remuneration for dentists within the prototypes. In your opinion, is this is a valid worry?
Eddie: I think there’s a lot of uncertainty for participants. Whilst the Department of Health (DOH) is not going to penalise them this year under the Dental Quality and Outcomes Framework (DQOF), eventually it will be implemented. It is true that the potential for remuneration is exactly what NHS dentists were offered previously; however, in reality they may well fall short of that figure given the unknowns involved in trialling a prototype.
Charles: At our practice we had the choice of either failing to hit our targets with the existing team or employ more dentists and DCPs to maintain our contract level. We chose the latter but the effect is that the overall level of remuneration for our dentists has fallen and the practice is less profitable. So, I consider this a very valid worry.
Paul: It is a real worry in the current financial climate. I think purely NHS practices are likely to struggle, because their income is fixed, whereas mixed practices are in a better position, because their private income can subsidise the NHS treatment. Practice running costs continue to rise; there are now a lot more regulation and compliance requirements, which incur additional expenses that we didn’t have only a few years ago. Of course, these affect all Practices, not just prototypes. But introducing radical change in a Practice against this backdrop could bring on additional concerns.
PP: What would you like to see a future contract offer in terms of remuneration?
Eddie: My ideal would be to give the dentists the money and allow them free rein to look after their patients to the best of their ability and in the best interests of the patient. I would like good practices to have the ability to take on more patients and increase the amount of capitation proportionally.
Charles: The ideal contract from a dentist’s point of view would be one that provides sufficient money to be able to offer a high standard of dental care and make a profit, but that is unlikely. The best one could hope for is official recognition that there are insufficient funds available to provide a full service and instead to concentrate on an NHS core service, remunerated partly by capitation and partly by fee-per-item.
Paul: If we accept there is no more money, the structure of the charging system and/or the remuneration scheme should change. For instance, the patient with high treatment needs is difficult to accommodate financially in a lot practices; for those patients, I think there should be a separate fee or registration charge to cover that work. I also think the present banding system should also be scrapped. I think basic treatments, such as restorations, simple extractions and non-surgical perio, should be provided under capitation; and advanced care i.e. RCT’s, surgery related treatments and current band 3 related work (which incurs a lab fee) should be item of service, with patients paying a percentage.
PP: Whatever the form of a new contract, there are likely to be winners and losers in terms of remuneration, but how do you see average remuneration being affected?
Eddie: If practices were going into a new system and were going to be financially disadvantaged then I can see a lot of people giving serious thought to whether they take the contract or not. I think it’s important that we have some sort of transitional arrangement so that practices are not destabilised financially, otherwise you will see practices pulling out of the NHS or suffering bankruptcy.
Charles: Dentists are resourceful individuals and they will look at the new contract and ask, “How can we make this work?” I suspect that average remuneration will fall and some dentists will decide to move away from the NHS. Others will continue by adapting to the new contract – albeit, perhaps, at a lower level of remuneration.
Paul: The overall NHS pot is going to stay the same; I can’t see it increasing significantly. But as long as it’s ring-fenced then the same money should be dispersed through the whole of the NHS dental budget. Practices that are able to maintain their lists pretty well should be okay. I do feel that practices with high turnover of patients, unstable lists, and large numbers of high-need patients are the most likely to suffer.
PP: If you could offer dentists concerned about the remuneration aspect of the contract one positive or constructive piece of advice, what would it be?
Eddie: I have spoken to dentists who believe that by taking on lots of new patients ahead of a new contract they will actually be better off at the end of it. However, the DOH will actually calculate what capitation levels should be for a particular practice and then dictate the number of patients that they are capable of looking after. Dentists who think they can get ahead of the game by taking on lots of additional patients would be wise to think again.
Charles: The only advice I can give is that it is important to try to maintain the quality of care offered despite the level of remuneration received. If this becomes impossible then it is time to consider leaving the NHS.
Paul: In any given situation, you can either look at it positively to try to make it work, or you can find an objection to it. Look for the opportunities within your own practice to see how you might align yourselves with the direction that the NHS is going in and aim to make it viable for your Practice. The way forward is to try to make it work, and identify what you need to do to adapt to change, because change is certainly coming.