Article
For many decades the need for reform of the general dental practice contract in the UK has been an issue.1,2,3 Changes were made to contracts in 1990 and 2006, along with numerous ongoing pilots, in order to address population and professional needs.4,5,6 The 2006 contract, which is the basis of current operations, was not welcomed by general dental practitioners (GDPs), and continues to be problematic. Performance monitoring is on the basis of ‘units of dental activity’ (UDA). The UDA is a measure of contract monitoring based on the ‘delivery of treatments’. The delivery of treatments met the need in 1948 with the beginning of the NHS when dental caries levels were high. However, today, the prevalence of dental caries has dramatically declined and, therefore, the need for restoration and treatment, as a result of dental caries, is reduced. Today, the treatment gap for repair has been filled with social aesthetic modalities.7
The skewed distribution of dental caries within populations is clear: the fact that 80% of the disease is experienced by 20% of the population has been identified.8 Health needs have changed since those early days of the NHS. Authors have discussed disease distribution in the dental literature identifying that there are two distinct populations that need care.9,10 The first population, population A, shows the majority with no dental caries and a minority with minimal dental caries; the second, population B, has multiple dental caries experience. Splieth et al stated: ‘The current epidemiologic situation of a polarized caries distribution calls for two distinctly different approaches to primary caries prevention’.10 The Common Risk Factor approach11 will suffice for the majority of the population, whereas there is an additional targeted need for those with high caries' experience.10 Richards et al had similar findings in a qualitative study of GDPs and support staff.12 For most of the population, individual and professional prevention can reduce 90% of the caries burden and keep it at a tolerable and very low level.10
While the epidemiological data on caries prevalence are focused on children, Baelum suggested that this decline has also trickled into the adult population.13 Also, treatment patterns within general dental practice suggest similar improvements in populations, and thus influence service delivery policy in Wales.14
It has been reported that these two populations require different approaches in order to have an impact on their oral health.10 To address improved oral health, effective oral health education is required. Therefore a dental contract needs to be based on the effective conversion of individuals in Population B into Population A rather than items of treatment, particularly if the majority of population A individuals need little in the way of items of treatment as they are the beneficiaries of effective primary, secondary and tertiary prevention.
General dental practice is key to facilitating an effective preventive strategy in order to improve oral health outcomes in communities.15 From this position, the funding drivers are critical to catalysing change within general dental practice business models.
The 2006 contract gave primary care organizations (PCO), local health boards in Wales, the responsibility for oral health services within their areas, and by doing so, became the funders of NHS dental care. PCOs consider delivery and monitoring of dental care on two principles: the first process being monitoring of care delivered by GDPs, the second, the provision of emergency access.16 There is little focus on the effectiveness of converting population B patients into population A patients. Using the Welsh response to the COVID-19 pandemic as an example, it can be seen that the basic principle of process monitoring along with emergency care are embedded in government/PCOs policies and management.16 While the approach is commendable in that it addresses the overuse of routine 6-monthly check-ups for population A, and also the emergency needs of population A and B, it does not address the conversion of population B patients into population A. The COVID-19 pandemic has focused on emergency care to avoid unnecessary aerosol generation; however, for population B ongoing preventive non-aerosol generating care would be beneficial.
It is suggested that PCOs consider extending the focus from process control and UDAs towards the objective monitoring of population oral health through the observation of practice profiles. Practices that have an effective preventive approach, thus improving oral health, will result in increased capacity because patients will be low risk and need less monitoring. Measuring profiles, as opposed to process, fits neatly into a behavioural approach to care. Practically, this can be achieved by monitoring an overall practice profile through measuring:
In addition, and more importantly, the retention of patients on a practice list. This can be measured by calculating the ratio of the number of patients who return regularly for care (seen within the last 2 years) for the whole practice and the 10% most deprived, with the number of patients in both groups subdivided by age (over 10 years, between 5 and 9, 2 and 4 and under 2 years of age).
Comparing the ratio of the whole practice with that of the deprived subgroup can show whether retention ratios are the same for the whole practice and the difficult-to-get group (Population B). Currently, the system does not facilitate ongoing care for those patients attending for emergency/urgent care.
Once data are available, then comparisons can be made within and between sites. This will show which populations are being served by sites and which are retaining those from Population B. This demonstrates effective prevention where it is needed. Hypothetical examples of two different practice profiles resulting from different approaches to the delivery of care are shown in Table 1. It would be expected that PCOs would value the profile of Practice B. Here, the community is represented, the numbers of ‘registered’ patients are greater (facilitating coverage of the population), and emergency patients (patients B) are converted into regularly attending patients (patients A) on a similar ratio to the whole practice.
| Area | Practice A | Practice B | ||
|---|---|---|---|---|
| Deprivation profile, area and practice | 50% least deprived | 54% | 70%a | 40% |
| 30–50% most deprived | 46% | 30% | 60% | |
| 20–30% most deprived | 31% | 25% | 35% | |
| 10–20% most deprived | 24% | 15% | 25% | |
| 10% most deprived | 12% | 10% | 15%b | |
| Cost per patient per contract | Annual contract value/number of patients seen within a 2-year period | £35 | £40c | £25d |
| Percentage retention for whole practice by age group | >10 years | N/A | 15% | 15% |
| 5–9 years | 20% | 20% | ||
| 2–4 years | 25% | 25% | ||
| <2 years | 40%e | 40%f | ||
| Percentage retention for most deprived 10% of practice by age group | >10 years | N/A | 5% | 15% |
| 5–9 years | 10% | 20% | ||
| 2–4 years | 10% | 25% | ||
| <2 years | 75%e | 40%f |
Weighted profile on least deprived;
weighted profile on most deprived;
lower capacity;
higher capacity;
emergency access with low retention;
emergency access with high retention.
There is much in the literature suggesting that contracts stimulate both positive and negative behaviours in general dental practice.17,18,19,20 Training packages can be developed to help those practice owners and practitioners who wish to develop their practices in leading teams and delivering prevention to become more effective. This monitoring will provide the necessary outcome expectations required by PCOs, which can evolve with time. It will also move away from procurement on an equal ‘delivery of treatments’ basis. PCOs can then demonstrate equitable procurement. Then, the penalization of those practitioners who wish to operate on a health model of care is avoided.
The Welsh approach to a funding mechanism that is not based on treatments (UDA) is a welcome change. This provides the GDP with a contract value that is independent of UDA generation. Therefore, the GDP can direct activities towards health generation without affecting their funding stream. There would be freedom to operate dental teams delivering prevention rather than teams of GDPs delivering treatments.
Post-COVID-19 contract monitoring in Wales has now provided GDPs with the opportunity to choose UDA monitoring or a contract focused on process control within practices through micro-management, often of the ‘delivery of treatments’, for example, fluoride varnishes. Both options have generated discontent within GDPs. We argue that a system of outcome monitoring that shows the effectiveness of the retention of patients that will show the conversion of Population B patients into Population A patients could impact positively on social inequalities in oral health, as population B correlates with deprivation, but that does not exclude a minority of non-deprived individuals. There will be many practice owners and practitioners who would value the opportunity to do this and in so doing, would feel a sense of professional satisfaction.
While not all GDPs would find a totally health-driven practice attractive, this approach would offer practice owners (including corporates) the opportunity to secure appropriate funding from PCOs to deliver health improvement. It would also allow establishment expansion through non-health aesthetics if so desired. Those who would prefer to operate solely on a business model based on items of treatment servicing population A and aesthetics could do so within the marketplace. This equalizes the financial balance between health and beauty for practice owners and practitioners.
The equitable apportionment of funding could provide the support to practices that are totally or partly focused on health. This allows those GDPs to deliver care as they wish, receiving appropriate pro rata public funding, thus facilitating effective coverage of the whole population as suggested by the Alliance for a Cavity Free Future (ACFF).21 Currently, both populations A and B are finding access to services difficult post COVID-19.
A new generation of outcome monitoring could provide a win–win for all concerned: patients, GDPs, PCOs and government. To quote Stephen Hancocks:22 ‘The treasury, as well as collecting a tranche of income from patient charges, does also pump billions of pounds into dental NHS. We should not forget this’.