Memorandum by John Mills (DS 08)
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
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
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)
|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
|Patient A||Requires 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 B||Only 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
|Patient A||Regular 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 B||Irregular 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.
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