Select Committee on Health Written Evidence

Memorandum by Sandwell Local Dental Committee (DS 10)


  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 evidence.

    (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 stated aims.

  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 value.

  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 NHS!

  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.

  16.  Summary

  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


December 2007

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