The NHS discussed

What next for NHS dentistry?

Nigel Jones NHS Dental Landscape, Options Out Of The NHS Leave a Comment

This is the question that, following years of under-funding, under-resourcing and increasing regulation, many have been asking for a long time. There has been a feeling among the profession for a while that things need to change. But how that will happen and who will drive it, is not clear-cut.

Some may be hoping the reformed contract due to be rolled out from April next year, will be a catalyst for the change they’ve been waiting for. However, so much is still unknown about what reform will actually look like that it can be difficult to know whether, if they continue to wait, they will be rewarded or if they will still be facing similar issues.  

It can be seen as a sign of how uncertain dentists feel about what the profession will be faced with from 2020 onwards, that 100 turned up to a panel discussion looking for the answer(s) to that question. The discussion between the panel members – Eddie Crouch, Vice-chair of the BDA; Ian Redfearn, owner of a prototype A practice; Paul Worskett, owner of a prototype B practice; and George Savva, owner of a mixed practice – as well as questions posed by the audience, revealed what is particularly troubling the profession about their future.

Rolls Royce care on a Fiesta budget

Delegates raised concerns about what reform actually means for them, with one person who has been in the profession for more than 40 years, likening the situation to ‘being asked to buy a Rolls Royce but being given the money for a Fiesta’.

There were questions around the possibility of the introduction of time-limited contracts and how much control dentists will have over the direction of their practice, i.e. whether they can choose to remain as they are or if they will have a say over which contract they take (either the A or B variations that are being tested).

Eddie responded, ‘If you’ve invested and bought into your practice on a GDS contract and that suddenly became time-limited, you could lose your business overnight, which is what’s happening now for orthodontic practices, then you need to be looking somewhere else other than the NHS.

“If they introduced time-limited contracts across the board, that would be the death knell of NHS dentistry and I just can’t see that.”

‘If they introduced time-limited contracts across the board, that would be the death knell of NHS dentistry and I just can’t see that. If that is what is offered in 2020, from the BDA’s point of view we would say “don’t do it”.’

Control over future contract choices

He added, ‘The DoH say there will be no compulsion to join one of the new contracts, but will dentists be given a choice of going into the A contract or the B contract? Who will make that decision? Will the Area Team ask you to choose or will they offer you a particular one? And, what happens if you go into a particular contract and after a year or two it’s not working well for your practice, will you get the chance to come out and go into the alternative? There’s not enough insight into the implications of the rollout yet.’

Eddie also said it was hard to know for sure how the prototype practices have fared due to the analysis. He said, ‘Worryingly, if access drops, in a practice then they are being eliminated from the system. So, when it comes to analysis of how it is going, and they’re taking out all the ones that are failing, what you are left with is a successful system. But that doesn’t mean it’s successful, it just means you’ve got rid of all the ones it doesn’t work for, and if you do then start rolling it out to 8,000 practices – what are they going to do?’

“One in four prototypes face clawback”

Choosing which contract will be best for your practice requires knowing how each one works and the impact it can have. There was discussion around the differences between the two types of contract in terms of reaching the targets, how they are measured, what it cost – both financially and personally – for the dentist to make it work and the levels of clawback. Prototype A practices generally fare worse than B – suggesting higher capitation means less chance of financial penalty – and one in four prototypes face clawback, which led Eddie to say that it ‘doesn’t look like a successful system to me’.

Ian said, ‘It’s a crazy situation where access is king. On my wish list for the future contract there would be a degree of trust with a system where the quality of your work is being looked at and measured not just in terms of activity but in terms of quality, much like what used to happen with the Clinical Reference Service.’

While Ian said he thought a practice with just one dentist and one therapist could be able to strike the right balance to deliver patient care and meet the targets under his contract, Paul suggested small practices would find it a challenge.

He said, ‘I think it would be very difficult for a single-handed practitioner to make it work due to the level of skill mixing required. There’s a lot of balls to juggle – capitation, UDA targets, the appointment book. You need a reasonable-sized team to make it work and it looks like larger practice contracts is probably the direction of travel for the wider NHS.’

A numbers game

George said the discussion around targets raised concerns around the sustainability of the NHS element of his mixed practice, ‘I feel our private work subsidises the NHS service we provide, and we’re already starting to reduce our NHS commitment by coming out of the Vocational Two (V2) training. We’ve been a V2 trainer for 20 years, but sadly, as far as I’m concerned, vocational training is changing beyond all recognition.

‘The concern is that the future will be the same old story of being a numbers game – the whole point is that you’re trying to look after patients but you’re also having to get bums on seats. It’s all about getting as much out of us for as little as possible.’

“We, as a profession, need to stand up and say is this system going to work? It’s all about access and freeing up the chair to get more people in. How does that help us as a profession to develop or maintain our skills?”

He added, ‘One of the things that concerns me is that the focus seems to be all on access and numbers…where does it allow the profession to develop? Where does it allow for the profession to do the complex treatment? Are we just moving from a UDA system, which is really, in essence, a core service, to another system that’s rebranded? We, as a profession, need to stand up and say is this system going to work? It’s all about access and freeing up the chair to get more people in. How does that help us as a profession to develop or maintain our skills?’

During a discussion about the de-skilling of the profession, Ian observed that when working with a wider skill mix, dentists were able to offer more advanced treatments and that there may be future opportunities for dentists with enhanced skills to offer level two services in a number of areas including oral surgery and endodontics.

Is the writing on the wall?

Given all this discussion around what is happening in dentistry now, and what is known – or unknown – about exactly what will happen from April 2020, the discussion turned to how NHS dentistry can remain viable in the long term.

Eddie suggested that recent news reports with comments from the Health Secretary gave a clue as to the answer to this conundrum, ‘If you look at the direction of travel in general in the DoH and then you see Matt Hancock quoted recently in the press – we assume correctly – as promoting private dentistry, that seems to be the Government saying “we can never afford to provide access to everyone, so if there’s alternative providers out there then those who can afford to pay should go there”. The writing is on the wall.’

“It was clear during the discussion and from the input of the audience that the profession is seeking answers that will enable them to understand the kind of choices they are facing and – crucially – make the right ones.”

While there may be signals and indicators for those working in the NHS about what the future holds, for many questioning what will happen next it feels like there is also lack of concrete information and clarity about what exactly the impact of contract reform will have on them. It was clear during the discussion and from the input of the audience that the profession is seeking answers that will enable them to understand the kind of choices they are facing and – crucially – make the right ones.

*The ‘What Next for NHS Dentistry?’ was held on 30th January in Solihull. The next one is in Durham on 27th March click here for more information or to book your place