Memorandum by Sandwell Local Dental Committee
1. Dentists have always enjoyed a good relationship
with their patients. Indeed it is a fundamental requirement in
order to do the job. There has to be a high trust environment
and the number of long-term patient/clinician relationships that
do prevail supports this.
2. The new GDS contract appears to have
been designed to disrupt this relationship as shown by the following
(a) The Chief Dental Officer was quoted on
Radio 4's You and Yours as saying that patients wanting to see
a Dentist should contact the Primary Care Trust and NOT Dental
practices. Dentists provide dental treatment not PCTs.
(b) On Midlands news television in an item
on the new contract, one of the presenters said that it was important
to have a good trusting relationship with a regular Dentist as
you would with your Doctor or even your hairdresser. West Midlands
Strategic Health Authority were then quoted as saying that "Patients
need to get used to not seeing the same Dentist each time they
attend." That does not support the further development of
the Patient/Dentist relationship.
3. There are other areas where we believe
that the new contract is causing problems and not delivering its
Dentists can no longer sell their NHS practices
to whom they choose. They cannot even give a value for the practice
as the PCT have complete control over the contract. In all sales
of which we are aware in our area, the PCT have reduced the contract
There is no guarantee that the PCT will award
a contract to a purchaser if it is contrary to their plans. Funding
is likely to be squeezed in 2009 when ring fencing of the Dental
budget ceases and contracts may be trimmed accordingly. A practice
owner will have built up the practice over many years taking mortgages
and financial risks to provide an NHS service. The PCT have made
no investment and provided no service. In 1948, the Government
bought out the goodwill of General Medical Practitioners. Dentists'
goodwill has been stolen.
4. The Unit of Dental Activity (UDA) is
an ill conceived and artificial construct. It delivers no health
gain and is only a measurement of quantity. It is even a poor
measurement of that, when complicated and time consuming treatments
such as root canal therapy attract the same UDA value as the simplest
of fillings. There is no recognition of or reward for quality
in this system. Instead we have a new treadmill based on hitting
a target number of UDAs. We believe that the targets are artificially
high, but we are not allowed to challenge the methodology that
produced the targets. The new system encourages Dentists to concentrate
on achieving UDA targets or risk financial penalty. The contract
could be withdrawn by the PCT as a Dentist is in breach if the
target is not met. Patient care is not addressed by this system
and may well suffer as a consequence.
5. In the run up to the Contract, Practices
were informed by the PCT that all the UDAs generated by all the
Dentists in a Practice would count towards the Practice UDA total.
Eight months into the contract a notice was posted, on a not well
advertised DoH website, that this was no longer the case. Information
of this significance should be made available by the PCT. Not
all Practices have Internet connections. It now appeared that
UDAs generated by first year qualified Dentists (Vocational Dental
Practitioners) would not count towards the Practice total. This
is unfair and inequitable. A VDP is a Dentist providing patient
services like other Dentists. It is plainly wrong to discount
this Dentist's UDA total after two thirds or the year. In one
local training Practice the year-end UDA total was 104% of target
if the VDP's UDAs were included. Without those UDAs the Practice
achievement was 92% of target. Consequently the Practice now has
to repay some £36,000.
6. The CDO spoke of "a basket of measures"
around year-end negotiations and that UDAs need not be the sole
measurement. Quality issues such as good Clinical Governance should
be taken into account. Not in Sandwell. The PCT have offered that
Practices can make up any UDA shortfall in the second year. This
is often not feasible as it only increases the treadmill effect.
7. This contract was meant to improve working
conditions and to free up time for Dentists. Not in Sandwell.
Dentists report that they are working harder than before the contract
came into force and that there is no free time dividend.
8. Regular patients, who are far and away
the majority in Sandwell, are financially penalised by the new
system. They will generally receive occasional intervention; the
odd lost filling or crown, rather than extensive treatments. The
amount they now pay is over 100% greater for crowns and around
200%-400% greater for a filling. Perversely, high need infrequent
attendees get huge value for money for extensive treatment within
a neglected mouth. These patients only generate the same number
of UDAs as a patient who needs a single treatment item within
the equivalent treatment band. If a Practice takes on several
of these high needs patients it runs the risk of being unable
to reach its UDA target.
Time is a vital factor under the new contract.
If a patient needs several fillings over four appointments lasting
two hours in total, three UDAs will be generated. The general
target for an individual Dentist is six or more per hour every
hour. So there is an immediate time and UDA deficit. Time is impossible
to make up.
9. Patient charges collected by many local
Dentists show a significant increase from the period before the
new contract. However, the PCT have not collected as much revenue
from patients as they expected. This is entirely the fault of
whoever designed and engineered the contract at the DoH. If you
impose a completely untried system that has not been piloted or
tested, as the DoH have done with the Dental contract, it cannot
be a complete surprise to discover major problems.
10. Dentists were promised that the new
contract would simplify matters for patients and dentists, offering
a guaranteed regular income for less clinical work in an atmosphere
of clarity. This has not been the case. End of year reconciliation
between payments made to Practices and UDA achievements have led
to clawback and adjustments well into the following year. Should
a Practice hit the target early there is no incentive to continue
an NHS service for the remaining time as it actually costs the
Practice to provide this out of what is now a finite budget. Needs
could be addressed under the old system but not now.
11. We were promised the opportunity for
increased prevention, but this is impossible to carry out if UDA
targets are to be met. There is simply no time to practise prevention.
12. The scrapping of the Seniority payment
mechanism seems to be cruel and petty. It has long been recognised
that the output of older Dentists declines. The Seniority payment
system sought to redress that balance and to reward years of dedication
to the NHS.
13. Superannuation calculations are a nightmare,
especially if adjustments have to be made at year-end. Even PCT
finance officers do not seem to understand the system fully.
14. There is a definite shift in relations
between the PCT and Dentists. It has become a master and servant
arrangement, which mirrors the situation between the DoH and our
BDA negotiators. Our locally democratically elected BDA representatives
inform us that the DoH approach is extremely unpleasant and dictatorial.
We do not find the PCT unpleasant, but they
do dictate and if put into a position where a decision is necessary,
will ignore the possibility of local discussion with the profession
and follow the DoH hard line.
15. Finally, the new system has managed
to introduce rationing and waiting lists to NHS Dentistry for
the first time. Perhaps this brings us into line with the wider
If the Select Committee is interested in improving
NHS Dentistry, we would urge them to revoke this new system and
to work with the profession to seek out a proper way forward.
Sandwell LDC believes that the new Dental contract
has satisfied none of the criteria that it hoped to achieve. Working
conditions for Dentists have not improved and the promised benefits
for patients have not materialised. There is no incentive for
Dentists to carry out preventative treatments and the fear of
financial penalties is dictating the way Dentists practise, with
the treadmill of chasing UDA targets being the priority.
This submission is made after consultation with
local Dentists and on behalf of Sandwell Local Dental Committee.
Dr D M Gingell
Dr D Cooper