High and dry

This sorry tale might only involve over 100 dentists, but it is perhaps an example of how NHS England treats those who have spent years trying to help the Department of Health identify a better way of working/treating patients in the NHS than the UDA system.

First, a brief history of NHS dental contracts. For more than half a century, dentistry in the NHS was paid for by a fee-per-item basis, ie the more treatment that a dentist provided, the more (s)he was paid. On the other hand, the fees received a real time reduction year on year, and the scheme was often referred to as a treadmill, with ever increasing amounts of treatment being provided just to stand still regarding one's annual remuneration. However, given that the amount of treatment provided could not be predicted on a year-to-year basis (if dentists decided to work more hours, for example, or simply that more were recruited), and given that the Government wished to have a finite budget for dentistry, it became necessary to change to system to one that was cash limited. Furthermore, for the years that NHS dentistry has been in existence, the focus of the service has been mainly on treatment rather than prevention. This means that there is little visible reward for good dentists who are improving oral health and providing a service that patients like, and little sanction for poorly performing dentists.¹ Hence, in 2006, the introduction of ‘Units of Dental Activity’ (UDAs) and ‘dental contracts’ (without any piloting – some thought that this had been thought up on the back of a cigarette packet!) by which a practitioner contracted to provide a set number of UDAs for a contract fee, the so-called new contract. UDAs were awarded for three different bands of treatment, with values varying from provider to provider. The average is around £25, but the actual value varies widely. This means that the value of a Band 3 course of treatment, for which the dentist is rewarded with 12 UDAs, can range from around £200 in one practice to well over double that in another. This clearly is wrong. If the contract value is not met, the unmet UDA fee is deducted (‘clawed back’ being the nasty word for that!) Moreover, there are some clinical procedures where the banding assigned to them was perceived as unrealistic when combined with a low UDA rate. These procedures were simply not offered on the NHS by some dentists, examples being widespread, for example, molar teeth being extracted when a root canal treatment could have preserved the tooth, even if this was a breach of contract, or even negligent.

UDAs, since their inception (and before²) were widely vilified. As a result, it was decided that an investigation into the so-called new contract was needed: this was duly established and led by the widely respected Professor Jimmy Steele, who, sadly, did not live to see his report¹ bear fruit. The report¹ stated that the reaction to the new contract was particularly hostile, with the anger from the profession being summarized as follows:

Among the report's recommendations were:¹

I do not apologize for presenting these recommendations in some detail, because I believe that they should form part of any new contract, if that is ever forthcoming, and, given that younger members of the profession in the UK may not be aware of these recommendations. In short, the report recommended a capitation payment for each registered patient for ‘routine care’, blended with payments for activity and quality. Regarding the latter, a return to collection of tooth-level data was proposed – this could be amended to provide a level of quality, for example, disease reduction/how long restorations last. Some recommendations have come to pass, such as the computerization of NHS dental practices, but much of the rest has been mired in the recommendation that changes, quite correctly, are piloted, which UDAs were not. This duly happened, with piloting starting in 2011 in order to test the key elements of reform needed to design a new system. These pilots ran from April 2011 to 31 March 2016. Learning from the pilots included:³

As a result, prototype dental practices were established, 82 in total initially, (58 of which were former pilots) with these practices (including three community dental clinics) being split into Blend A and Blend B, as follows, with capitation forming the majority of payment in both blends:³

The number of prototypes eventually rose to over 100. It goes without saying that the practices involved in these prototypes had to change their modus operandi on several fronts, such as patient information and measuring oral health, as well as collecting extensive data that would be used to establish whether the prototypes were viable, their effect on oral health, and, perhaps most importantly, patient and dentist acceptability of the schemes. In a presentation in 2016,³ it was stated that ‘from 2018 to 2019, it may be possible to begin nationwide roll out’. However, the results indicated that all was not well on several fronts, for example:

These findings are summarized in a letter dated 11 November 2021 from the Chief Dental Officer England that stated:

It goes on to add:

I wonder if the reduction in patient charge revenue might have been the blow that finally killed the prototypes.

This says it all. The prototypes involved a group of committed individuals and teams who adopted structured ways of working to make the prototypes work, such as employing therapists and training dental nurses to become health educators, and who possibly disapproved of the UDA system and were determined to improve on it. To say that the failure to devise a new contract may be disappointing is an understatement for those dentists in the prototype pilots. Many in this group will not wish to return to the old system, which they sought to improve. Paul Worskett, one of the prototype dentists stated, on his web site:

How will Paul and his team reconcile going back to the old scheme?

These prototype dentists have been thinking long and hard about the contract and what they would like to see implemented. They have been committed to what was, essentially, a research project, but when the results didn't work out as hoped, they have been left high and dry. Where will they go? It is interesting to note that if one searches ‘NHS Dental Contract Reform’, the site to which one is quickly directed is that of a company that sets up individualized capitation plans for dental practices. They obviously have scented an opportunity. I am sure that other private capitation schemes will be there to help the thinking prototype dentists.

In this regard, David Westgarth wrote,⁴ 18 months ago, when quoting data on the fall in net government expenditure on services in England of £550 million in real terms since 2010, while charges levels have increased by over 30% to plug the gap and patients have been delaying treatment for reasons of cost, it is not beyond the realms of possibility to come to the conclusion these data show a ramping up of NHS dentistry privatization.

For years, I was a predominantly NHS general dentist aiming to do my best for my patients. There is no question that the old schemes (fee per item and UDAs) are no longer fit for purpose and need serious revision as patients become ever more dentally aware and oral health has improved in many parts of the country. Therefore, something had to change. The Steele Report demonstrated that eloquently, but that was 13 years ago. Might it now be too late? It saddens me to read of the numbers of dentists who are considering getting off the treadmill. It saddens me to read of the stress levels reported by NHS dentists in a BDA survey.⁵ And it saddens me more to see that it has taken such a long time to NOT get a new contract organized. And, at what cost to the Exchequer? That would be interesting to know! I am also sad for the dentists who put their energies into contract reform, only to have been left high and dry, facing a return to the system which, years ago, they decided was not fit for purpose, or to leave the NHS for a private scheme. In history, indeed recent history, there are examples of peoples being abandoned to their fate. The numbers involved in the present discourse are not large, but they provide a marker of how well the dentists who have striven to help the NHS improve its contract have been treated. What about the rest? Might they also be left high and dry?

What next? As far as I can glean, governments across the world have encountered difficulties in working out methods to pay for prevention, be that in medicine or dentistry. Prevention is not readily quantifiable, at least not until the long term. The Steele Report gave us a foundation for what might be a good starting point, and, 16 years on, it is well worth sticking with. Capitation or routine care (which includes prevention) would provide the foundation to the scheme, and, once in the capitation scheme, patients would pay their annual fee in a way similar to how I pay to tax my car.⁶ I could envisage a cash-limited fee-per-item for advanced cases and new patients (to get them dentally fit so that they can enter capitation). This would allow dentists who wanted to expand their NHS practices (and improve access as a result) to bid for these additional monies. The fine detail of how this would work needs some deliberation, but it would be a way of keeping government on side and for NHS dentists to once again be able to offer a top class service to their patients. I previously argued that progress on reform has been slow because complaints about the UDA system had dissipated.⁶ However, this is no longer the case, with dentists reported to be leaving the NHS and high levels of stress and dissatisfaction.³ As a result, patients are also being left high and dry.

PS Apologies to readers outwith England, to whom the bulk of this editorial applies. Nevertheless, the findings of the Steele Report provide, in my view, a potentially viable template for new dental contracts throughout the UK. PPS I make no apology for publishing two articles, and a letter, on CBCT in this issue. The papers had risen to ‘the top of the publication pile,’ and initially I thought of delaying one of them. However, on reviewing both, I realized that they were complementary, hence their publication. This also reflects the growing importance in CBCT in diagnosis in many areas of dentistry.