Select Committee on Health Written Evidence


Memorandum by John Mills (DS 08)

DENTAL SERVICES

  1)  My name is John Mills. I worked in a mainly NHS dental practice for over 40 years, but have recently retired, which allows me to give an opinion which is not biased by motives of personal gain. However my wife works in the management of a dental corporate body, so I have continuing interest and knowledge. The observations made here are anecdotal, without statistical basis. However they are relevant observations about the development and introduction of the New Dental Contract, introduced in April 2006, and its effect on dentists, patients and the provision and quality of NHS dental care. Most of these observations relate to finance, but then dentists in practice are running businesses!

  2)  It is essential to understand how the New Contract evolved and how it works in order to understand why it is failing to deliver the increase in availability; however it is a complex area to comprehend fully.

  3)  It is also essential to understand that the only income that a GDS practice receives from the NHS is from the Contract Value, as described below, (or from the fee per item under the previous system). They do not receive a salary or any contribution to the running costs of their dental practices, which are typically around 50% of gross practice income. The only income that the dentist receives is the "net profit" from the running of the dental practice.

  4)  Although there was a consensus view that the existing GDS contract had many shortcomings, there was no great demand for change, certainly not for very radical change. Although the previous contract favoured treatment rather than prevention, the "fee per item" system did give a direct link between work done and reward (piecework!) and a mechanism for reflecting variations in expenses (eg. price of gold or recent requirement to regard root treatment instruments as single-use) through the periodic review of the fee scale by the DRSG.

  5)  A new alternative, the PDS system was piloted on a small scale, then rolled out more widely before it had been properly evaluated. This was the basic model used in development of the New GDS contract.

  6)  It was evident at an early stage that the new contract was being developed entirely by the DoH and that input from professional organisations or individuals was not welcome. Both BDA and GDSC were disenfranchised from the development work.

  7)  The new contract seemed to have only three key aims:

    a)  Organisation and control of GDS treatment was to be devolved to PCTs which would have a responsibility for provision of NHS dental care within their areas.

    b)  The PCTs would be given a fixed budget for this purpose, based on historic cost. This budget would be "ring-fenced" for dental treatment until April 2009, after which the PCTs have the discretion to divert part of their dental budget to other areas of perceived need.

    c)  The new patient charging system was to be simple for patients to understand and was required to raise at least the same amount of revenue as the old system. The existing system was linked to the fee per item scale, such that patients paid 80% of the cost of their treatment up to a maximum of £360. This seemed fair and was not complicated for dental practices, especially as most are computerised. For patients it was actually no more complicated than understanding the till receipt from the supermarket.!

  8)  Above items 7a and 7b resulted in the "Contract Value" which was allocated to each "provider". This was calculated by reference to NHS income in 2004-05 (Test Year"). The need to measure the quantity of treatment provided in exchange for the contract value resulted in the concept of the UDA (Unit of Dental Activity, or as it is unaffectionately known, the "udder").

  9)  Using data supplied by the DPB, the level of treatment activity in the test year was established and converted into UDAs. This was linked to the contract value, thus giving a monetary value to the UDA for each dentist or practice. A new unit of currency had been created! The UDA values varied widely between practices and PCT areas. The range is as low as £13 to above £30. Average £19-20. PDS practices, having recorded relatively little treatment during the test year, had very high UDA values.

  10)  Dentists would be expected to achieve their target number of UDAs annually in order to maintain their contract value. Shortfall would result in reduction in the contract value whereas over-achievement of UDAs would not produce any addition to the contract value.

  11)  The problem of patient charges was difficult to resolve. A committee eventually recommended a three tier system.


Band 1:£15.90 Simple treatment (eg. exam, xray & scaling)
Band 2:£43.60 More complex treatment. (eg. Including filling(s).)
Band 3:£194.00 Complex treatment. (including any treatment incurring laboratory charges. But including all necessary treatment)

This over-simplified system has resulted in serious anomalies.


  12)  Having adopted this simplistic approach to charging patients, the truly fatal error was to use it as the basis for calculating UDAs for dentists. Thus remuneration for dentists became based entirely on a patient charging system that was intended only to be so simple that an idiot could understand it.

  13)  Thus the treating dentist is rewarded with UDAs as follows:


Band 1
:
1 UDA
Band 2
:
3 UDAs
Band 3
:
12 UDAs


  14)  This is where the anomalies arise, as follows:

  (For this exercise, regard a UDA as worth £26 for dentist X and £15 for dentist Y)


Band 1

Patient A  :  requires only a simple check up.
Patient pays £15.90 Old system approx £4 Not very happy
Dentist X receives 1 UDA Worth £26. Old system £5. V. Happy!
Dentist Y ditto £15 ditto Happy
Patient B:requires check up, scaling, 4 xrays
Patient pays £15.90 Old system approx £20 Happy
Dentist X receives 1 UDA = £26. Old rate £30+ Not too happy
Dentist Y ditto = £15 ditto Very unhappy

Band 2

Patient ARequires check up + 1 small filling
Patient pays £43.60 Old rate approx. £12.00 Very unhappy
Dentist X gets 3 UDAs = £78 Old rate £14.00 Deliriously happy !
Dentist Y ditto £45 ditto Very happy
Patient BOnly attends when in serious trouble!.
Requires check up, 6 xrays, scaling over 2 visits, 12 large fillings.
Patient pays £43.60 Old rate, perhaps, £120+ Happy
Dentist X gets 3 UDAs = £78 Old rate perhaps £150+ Unhappy
Dentist Y ditto = £45 ditto V.Unhappy

Band 3

Patient ARegular patient with excellent dental health, but fell and knocked front tooth out. Requires only a temporary partial denture, for 3-6 months. (May have bridge subsequently)
Patient pays £194.00 Old rate £50 Angry
Dentist X gets 12 UDAs = £336 Old rate £65.00 Embarrassed!
Dentist Y ditto = £180 ditto Slightly embarrassed.
Patient BIrregular patient with multiple problems.
Requires examination and complex treatment planning, multi-visit to hygienist for gum problems, 15 assorted fillings, 3 root treatments, 5 crowns, 1 bridge & metal partial denture.
Patient pays £194.00 Old rate £360 Patient happy.
Dentist X gets 12 UDAs = £312 Old rate £900 Very unhappy
Dentist Y ditto = £180 ditto Suicidal!
In this case, the laboratory costs alone, borne by the dentist from within the 12 UDA value (£336 or £180), would most probably exceed £350! Thus dentist Y would suffer an immediate loss of £170. But in addition a course of treatment of this complexity might easily take 20+ hours of surgery time.


  15)  Under the previous system, the patient charge (subject to the £360 maximum) and the reward to the dentist were both directly related to the treatment carried out. Under the current regime, this link has been broken. In some cases, the patient pays more than the cost of the treatment. In other cases, the dentist receives less than the basic cost of providing the treatment.

  16)  The representatives of the DoH, including the CDO, will state that although the system has changed, dentists are actually receiving the same remuneration. However the major changes were intended to result in totally different uptake of treatment and to improve access to NHS dentistry for those who did not previously have access. So treatment patterns have changed. As the DPB has been disbanded, there is no longer a satisfactory mechanism for recording and measuring the type and quantity of treatment provided, only a crude UDA count. So the DoH presumption is not only flawed, but cannot be verified.

SUMMARY

  17)  The anomalies described above have resulted in distortion of treatment patterns. Dentists are discouraged from treating patients with extensive dental problems or needing any laboratory work eg. crowns and bridges. Dental laboratories have experienced a major drop in business.

  18)  There is nothing in the new contract to encourage a preventive approach.

  19)  In 2009 the PCTs will be free to direct the "ring-fenced" dental budget into other areas of healthcare.

  20)  The "New Contract" requires urgent re-consideration, in full consultation with the profession. In its present form it is fatally flawed!

John Mills, BDS., DGDP

December 2007





 
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