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The Unit of Dental Activity (UDA) remains the currency by which dentists operating in the NHS system in England and Wales are paid. Introduced in 2006, it took only three years before a report roundly condemned these as an inappropriate method for paying dentists.1
I have to report that, sadly, the Chair of the group who produced the report, Professor Jimmy Steele, recently passed away and his untimely passing has stolen, from UK dentistry, one of its cleverest, most clear-thinking minds. Our thoughts and prayers are with his family. This sad event has removed a person who sought to devise a more equitable system for paying dentists in England and Wales and it is to be hoped that the momentum for change will not be stalled by his passing.
We like case studies in Dental Update. Here I report three related to UDAs. First, I saw a patient who had been injured when a car reversed into her as she attempted to cross a road. Her UL1 was avulsed, and UL2 fractured. There was a family wedding shortly after this unfortunate incident so, quite rightly, the dentist whom she attended made the patient (who was exempt from payment) a one tooth partial acrylic denture: 12 UDAs, minimal laboratory fee. The UL2 was, in my opinion, restorable (large composite or, at worst, a crown) but, shortly after the wedding, it was extracted and a new partial upper immediate denture was placed: another 12 UDAs, minimal lab fee. Two months later, the patient complained that the denture was loose and another was made: another 12 UDAs, minimal lab fee. When I saw the patient, her teeth were covered in plaque and there were heavy calculus deposits in many areas. On being asked, the patient advised that she had not received any scaling and polishing or oral hygiene instruction during the three courses of treatment in which the dentures were made: all that seemingly mattered was the multiple gathering of 12 UDAs.
In the second case, a patient (again exempt from payment) attended a dentist who worked for a large corporate. She was surprised that she had been unable to see either of the previous two dentists who had previously treated her and with whom she had built up a good relationship. She was advised that both had left. Despite attending for a routine ‘check-up’ with no symptoms, the new dentist advised that she was suffering from temporomandibular joint problems and prescribed a soft night bite guard (NBG) for the upper arch: 12 UDAs, minimal lab fee. She never wore the NBG but, on re-attending for a subsequent course of treatment, she was prescribed a further NBG guard for the lower arch: another 12 UDAs, minimal lab fee. One could ask why the patient did not question the dentist more regarding her treatment or, indeed, confront him regarding this overtreatment: all that happened was that she contacted me. I hope that cases 1 and 2 are isolated incidents, as I am sure that the majority of dentists continue to work in an ethical way, despite the system.
Case study 3 relates to an ethical dentist who had a child-only NHS contract, this being unusual at the present time, I am told. She has worked hard on prevention for her child patients, and employs an oral health educator. She has been successful in her preventive strategy, so has ‘generated’ a shortfall in her UDA target because the majority of her treatments achieve 1 UDA because her patients require no treatment, rather than achieving the 3 UDAs which are awarded when restorations are needed. A totally perverse incentive which needs fixing.
Sadly, there is now a whole generation of dentists who think that UDAs are the only currency by which dentists are paid for their treatment of NHS patients. By coincidence, I wrote about this in the pre-Christmas issue of Dental Update two years ago, 2 writing ‘Perhaps the new contract will seem clearer a year on’. This is not the case, even after two years. Pilots for a potential new system of payment have been amended and are still ongoing. The Government are not in a hurry to change how dentists are being paid: they manufactured a cash-limited system, which is what they wanted. They see no need to hurry into a new contract, when few are complaining and (some) dentists are making massive amounts of money from treatments, as described in the first two cases. The ethical dentists are doing their best but some, as described in case study 3, are suffering. I apologize for discussing a system which relates only to England and Wales, when many readers are not from there. For those of you not afflicted with the UDA system, count yourselves fortunate, and resist any moves, wherever you are working, to change to a system which bears even the slightest resemblance to this method of payment. The UDA system has always been broken and remains thus.
As we approach the end of another year of Dental Update, it is my pleasure to wish all readers, everywhere, Season's Greetings and a happy and, above all, peaceful 2018. But also to thank you, the readers of Dental Update, for continuing to subscribe to our journal – I hope that you have enjoyed this year's issues. I also wish to thank the Editorial Board for their input and wisdom, our superb authors for sifting through the copious dental literature and telling us what it means by way of the review articles that they write, our peer reviewers for their advice and, finally, all the excellent team at Guildford, ably led by Angela Stroud, Lisa Dunbar and Stuart Thompson, for producing each super issue.