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‘High and dry’ and a slap in the face
Congratulations on an excellent editorial, which hits the nail squarely on the head and provides a good background and insight, especially for younger dentists who might not be aware of the recent history of NHS dentistry. In response, I would be grateful to share my own observations, based on the experience in our practice and my involvement with the programme.
We were an early entrant into the Pilots in July 2011 and, following piloting, we were assigned to be a Blend B Practice in 2016. I was invited to join the National Steering Group in 2012 and the Evaluation Reference Group in 2017.
As you say, it is generally accepted that the Pilot/Prototype approach was well received clinically by patients and dental teams. But it required a very coordinated approach, which often presented management problems (eg if a patient cancelled an appointment within a sequence of appointments, the remaining appointments in the sequence may need to be rearranged). Coordinating delivery of treatment plans required high levels of communication and a clear understanding of the objectives within the practice.
It was also time consuming to deliver care to high-risk patients with significant dental needs. If a practice was unfortunate enough to be in an area where there were a lot of high-needs patients, it would be difficult to build up a large enough list size to be viable. When every patient is valued the same by the NHS, this was a disincentive for practices to take on new high-risk patients. The ideal scenario, of course, would be lots of low-risk patients, who could be recalled less frequently, thus allowing a large patient base to be built up. The demographics of the patients in the catchment area of a practice therefore had a big impact on the likelihood of success. Unfortunately, there was not enough allowance for this in the remuneration mechanism. Weighting of patient capitation rates was not something that was extensively tested in the Prototypes, and I think this factor was underestimated, and not sufficiently accounted for, by DHSC. Any reformed system should make it attractive for a practice to take on new patients with high dental needs, which are typically the patients most in need of dental care.
Given that most NHS activity in general practice is delivered by associates, one of the initial challenges was the payment mechanism for them. During the piloting stage, our system was based on capitation list size and hours of NHS activity. When we went into Prototyping, this was modified and consisted of a capitation payment for the majority of the remuneration, and an element of activity, based around the anticipated proportions of delivery. This was very difficult to calculate and required evaluating practice running costs, hours of activity, proportions of private/NHS work, and these were combined to establish a nominal capitation rate for our practice, but it seemed to work to everybody's reasonable satisfaction for us, as far as I was aware.
I am not sure how other practices funded associates, and this was never properly explored in the ERG. The NSG deemed that this was outside the DHSC remit and was for practices to decide for themselves. I later became aware that some practices were paying their associates by UDA activity, which seemed to me to be a conflict of incentive. I think one of the main obstacles for practices was how to pay their staff, which may have led to recruitment issues.
We adjusted our business model to take advantage of skill mixing. We recruited a therapist, who was solely prescribed NHS work (the hygienists treated patients privately) and we trained some nurses as oral health educators (OHEs). The therapist and OHEs were funded by top-slicing some of our NHS payment, so the associates did not pay for them directly, and there was an incentive to refer patients to them.
I think it is true that the vast majority of the practices were participating for the right reasons: they wanted to improve the way of working in the NHS and the care they offered their patients. Their teams had worked extremely hard to try and make the system work better for themselves and their patients. These practices have adopted a preventive paradigm, and promoted a different approach to dental care. To go back to the broken UDA system, which conflicts with their adjusted way of working, will be difficult, demoralizing and may be the last straw in pushing some of them out of the NHS altogether, yet these are the very practices that the NHS should be trying to retain.
In general terms, contract reform could work clinically, but the main issues boil down to two factors: access and remuneration. It seemed to me that the DHSC couldn't quite understand that all practices are unique, and for this thing to work, it needed to be flexible enough to work in all practices. It was repeatedly said that ‘it's not a one-size-fits-all’ and ‘the devil is in the detail.’ I don't think we ever did get to the bottom of why the failing practices failed – was it patient profile and demographics? Working arrangements of associates and staff within the practice? Or simply staff shortages and recruitment problems? I don't think we will ever know for sure. One thing is for sure – the DHSC wanted to have a champagne service for beer money!
The next stage of reporting was due in 2020. Unfortunately, when COVID-19 came along, all progress pretty much stopped. In the practices, delivery surely became even more difficult. The first lockdown would have reduced the list size by 3 months' worth of patients at a stroke (probably around 5%), and coping with emergencies, and the inevitable backlog, under compromised working conditions, meant that building the list size back up was very challenging, if not impossible.
The DHSC has seen fit to pull the rug and let all the progress of the past 10 years go to waste in these dental practices. I wonder if they had held their nerve another year or two and supported the 100 practices to get through the storm, more valuable lessons could have been learned. But the cynic in me wonders whether the NHS has bigger fish to fry, and is content to allow dentistry to ‘go private,’ and let the media blame it on the ‘greedy dentists,’ as they have done before.
Although there were 100 or so practices involved, the majority of these were larger, and so several hundred dentists have been affected, probably several thousand support staff and hundreds of thousands of patients. As you say, we have been left high and dry, with an immense slap in the face to boot. The pandemic has unfortunately brought many casualties, and it seems NHS dentistry could well be another of them.