Select Committee on Health Written Evidence


Memorandum by Dr Ashish Dhopatkar (DS 11)

NHS DENTAL CONTRACT REGARDING THE EFFECTS OF IMPLEMENTATION OF THE CONTRACT ON ORTHODONTIC SERVICES

  Orthodontics is the branch of dentistry that looks at and manages irregularities of the teeth and jaws. Treatment aims to correct dental and jaw abnormalities and provide the patient with a healthy and well functioning dentition for the future. The ideal time for dealing with such problems is usually in children between the ages of approximately 11-14 years of age.

EXECUTIVE SUMMARY

    —  My full name is Ashish Avinash Dhopatkar and I wish the Commons Health Select Committee looking at the implementation of the new NHS dental contract to be aware of and take into account how the changes have affected many orthodontic practices in the country which have been classed by the Department of Health (DoH) as new or growing practices for the purposes of transition to PDS from the old contract.

    —  I am aware that the committee cannot look into individual cases but I make this submission to highlight the effect that the national framework set up by the Government for implementation of the changes has had on new and growing orthodontic practices using my case as an illustration.

    —  I have personally and unsuccessfully disputed the treatment of my practice and therefore its local child population through the NHS Litigation Authority (NHSLA) and via an application for Judicial Review but I have been unable to make any progress which would allow my practice to continue to provide the level of service which is clearly required in my area.

    —  I am also aware that many specialist colleagues faced with similar situations have instead opted to leave the NHS completely which, in a specialty that had already been identified by the most recent Government commissioned workforce survey as having a manpower shortage, must be considered an undesirable consequence and a mismanagement of available resources.

    —  I submit to the committee that in the transition to the new PDS contract the DoH essentially created an environment where all "new or growing" orthodontic practices were classed as providing services which were surplus to the requirements of their local child patient population whether this was the reality or not. This was brought about by providing PCTs charged with commissioning appropriate service levels in their area with virtually no flexibility in their budgets to account for and correct miscalculated contract values for growing orthodontic practices which were based on unrepresentative historical data.

    —  I therefore submit that PCTs such as mine, Birmingham East and North (BEN PCT), in such circumstances, failed to discharge their duty to commission services based on an assessment of the needs of the local population.

    —  The consequences in Birmingham have included: longer waiting times for treatment, children unable to get treatment from a local orthodontist even when there is one available and specialists who had been committed to NHS service provision and who had been trained using NHS funding being forced to consider leaving the NHS and being actively prevented from providing a service despite a need.

    —  I believe the implementation of the contract has sadly failed many children who deserve and require excellent quality NHS orthodontic treatment. I therefore welcome the Commons Health Select Committee's review of the new NHS dental contract and would be happy to provide further evidence if required.

1.  BACKGROUND

  I am a qualified dentist and a registered specialist in Orthodontics. I qualified with my dental degree (BDS) from King's College London in 1992 and am a Fellow of the Dental Faculty of the Royal College of Surgeons of England (FDS RCS, 1995). I completed an MSc in Orthodontics at King's College London in 1998 and a PhD in Orthodontics at the University of Birmingham in 2006. I have carried out an approved specialist orthodontic training programme at King's College London which led to the clinical specialist qualification (MOrth) of the Royal College of Surgeons of Edinburgh (1999). This qualification allows me to be registered as a specialist on the General Dental Council's specialist register. I have also completed further clinical training up to NHS Consultant level which is assessed by the Intercollegiate Specialty Fellowship Examination of the joint Royal Colleges of Surgeons (FDS Orth, 2003). I am currently a part time Clinical Senior Lecturer and Honorary Consultant at the University of Birmingham, School of Dentistry. Previous research I have carried out is referenced in the PDS contract in relation to monitoring standards.

  1.1  I own the practice known as Sutton Orthodontic Centre at 27 Coleshill Street, Sutton Coldfield, Birmingham, B72 1SD. The practice falls within the boundary of the current Birmingham East and North PCT ("the PCT") area. The practice was first established and set up in 2001 and was fully funded in its initial period by the NHS because the area was identified as having a need for orthodontic provision. The number of patients in need of treatment in the area and length of waiting times were both high. This is still the case today.

  1.2  I took over this practice and have been running it since February 2005. Prior to this Sutton Orthodontic Centre was experiencing considerable management problems of which the PCT was well aware. When I took over the practice, the waiting list for treatment was approximately 18 months. Before the dental contract changes introduced in April 2006 I had turned around this practice and reduced waiting times to 6-8 weeks. In the process I also increased the number of patients seen and receiving treatment at the practice. Throughout this period I used the now mandatory Index of Orthodontic Treatment Need (IOTN) criteria to prioritise need and treatment was not offered inappropriately. This is important to point out because the Government in its defence has stated that they have taken their stance with growing practices to avoid funding practices who were starting inappropriate or unnecessary treatment in an area where their service was not required, presumably for financial gain. Unfortunately whilst taking this hard line approach against what they clearly consider rogue practices, they completely failed to devolve any additional funding to PCTs to help fund ethical but growing practices in areas where their service was required (despite the sentiments outlined in the above letter). As a result my PCT needed to make a case that they did not need our service in order to justify their not commissioning our ongoing service at the level it was just before the contract changed in April 2006.

  1.3 Sutton Orthodontic Centre between February 2005 and March 2006 provided an improved service to patients and referring dentists alike and this was reflected in the steady increase in the number of referrals to the practice, a trend which has since been maintained. We had in that period also been able to support local hospital departments such as Good Hope, Burton and the Birmingham Dental Hospital where waiting times for treatment were already high before the contract changed and we helped provide earlier treatment to children who would have otherwise been on those waiting lists for some considerable time. The new contract has had the effect of driving up waiting times even further, because capacity in practices such as mine has been drastically cut. The average waiting times in those local hospital departments now for treatment is over 3 years.

2.  THE NATURE OF THE PROBLEM

  I entered into a Personal Dental Services (PDS) Agreement ("the contract") which was served upon me on 24 March 2006 in respect of the provision of orthodontic services in the Birmingham area. A dispute arose between myself and the PCT relating to what is called the CAAV (the calculated annual agreement value of the contract) which is too low and incorrect in the light of my patient caseload and the local population's orthodontic needs.

  2.1 The ongoing contract values, namely the CAAVs, for orthodontic practices in the new PDS arrangements have been calculated by looking at payment history for the practice from Dental Practice Board (DPB) records in the index period (October 2004 to September 2005). As I only took over the practice in 2005 this essentially meant that my CAAV was calculated based on the first 6 months of my practice being set up. This is clearly unfair as no new practice is likely to start generating representative payment records in the first months of operation. Furthermore, for orthodontic work in the old General Dental Services (GDS) contract there was a huge time lag between undertaking treatments and receiving payment. The bulk of the payment was not made until treatment was completed which for an average case takes 18 months. Clearly therefore my CAAV did not include any completed case payments at all—only start of treatment assessments in the main which is a small proportion of the cost of orthodontic treatment. As a result my CAAV was far too low to continue providing anything like an adequate service level to local children.

  2.2 Although the payment history did not show this, the practice was providing a far more considerable and valuable service to the local population in the run up to the new contract. This fact has since been confirmed by the so called "close down" figure which was the value of the work in progress at the practice on 1st April 2006 which the NHS had not yet paid the practice for. The total value of this work transpired to be nearly 10 times the calculated CAAV. This shows quite clearly that the commitment of my practice to the NHS and the local service it was providing before the contract changes had been grossly undervalued by the methodology used by the PCT under direction by the Department of Health (DoH). The DoH has acknowledged that the methodology for calculating the CAAV was flawed in this respect (Hansard 1st March 2006 Part 10) but does not point out that all remedies suggested to PCTs in such cases merely involved methods of "paying off" the practice in question to finish the existing case load rather than by enabling the PCT to fund additional service where there was a need. This is because virtually all funding devolved to PCTs was already spoken for in terms of previous historical service levels and there was no facility at all for additional funding for PCTs unless they diverted this from other services within their own budgets. The DoH seem to have been working under the assumption that any practice that was growing or new in the run up to the new contract was not likely to be providing a valuable service that needed to be maintained in the long run and failed to provide PCTs with enough flexibility to enable this in the event that it was actually necessary. It is also clearly inaccurate to state that there was no practicable way to get more up to date data for new practices as these data were readily available from the DPB or directly from the practice if they had wanted to use them.

  2.3 Therefore my practice, in common with many others caught in this DoH trap, has been severely disadvantaged by the DoH's decision not to take into account the value of work already approved and under way in the GDS for which payment had not yet been received in the index period. This is despite the strong assurances by the Department of Health previously that they would take into account the currently unpaid work when calculating ongoing contract values.

  2.4 According to DoH guidelines a PCTs decision to commission or otherwise "additional services" from practices where the adopted methodology resulted in an undervalued CAAV needed to be underpinned by a Needs Assessment exercise to determine their local population's needs. A relatively small uplift was offered to my practice and presented as an adjustment for an undervalued CAAV in the first instance. Unfortunately this uplift bears no resemblance to the local needs situation and the PCT has not to date explained why it felt this was the appropriate level to commission from us. In addition the PCT also applied a lower unit of treatment (UOA) value to this additional work and this essentially means that my practice has to do more work for the same funding as everyone else commissioned to carry out orthodontic work in the BEN PCT area, including dentists with no specialist qualifications at all. I submit that the PCT did not undertake sufficient consultation of the needs of the community prior to making its decisions regarding my practice and that these decisions were based purely on the allocated funding devolved to the PCT budget in the immediate run up to the new contract. In defence of this statement I would submit the following evidence (all of which was also submitted to the NHSLA):

  2.4.1 The practice which I took over in 2005 was actually set up and funded by the NHS in 2001 following a needs assessment exercise which showed a need for increased specialist orthodontic service provision in the area. If the practice had been managed differently from the start then by the time the new contract was brought in it would have been well established and have been treated more fairly by the transitional arrangements. However, the available DPB data show that the practice only started fulfilling the objectives for which it was set up following the management change in 2005. During the intervening time there is certainly no evidence that need for the service had reduced in the area—in fact all available waiting list data show that the need for our service was actually greater in 2005-2006 than in 2001.

  2.4.2 The PCT in its defence against my case to the NHSLA initially represented a draft and incomplete needs assessment as a finished work in order to show that it had commissioned appropriately. As far as I am aware this document has still not been finalised but certainly was not in a state to inform the PCTs decisions in March 2006. The current document at that time was the document which led to the practice being set up in the first place.

  2.4.3 The Consultant in Dental Public Health who is charged with providing advice to the PCT was instrumental in my decision to take over the practice in 2005 as she advised me at the time that this was an area of need and this is supported by the fact that she also re-iterated this in a letter supporting our plans to expand the practice in July 2005. Furthermore the draft document which the PCT submitted to the NHSLA in actual fact showed an inequality of service provision in Birmingham and that my PCT in particular has under-commissioned orthodontic services for its local population. This was simply not addressed by the NHSLA.

  2.4.4 I also submitted evidence to the NHSLA that showed that the PCT did not seem to know exactly how much orthodontic provision it had commissioned. I provided testimony from dentists whom the PCT stated were providing the service in my area but by the dentists' own admission this was not the case.

  2.4.5 Finally but perhaps most importantly, I provided representative testimony to the NHSLA from a parent of a patient of my practice who had been told by PCT representatives that if my practice could not provide the treatment they could be redirected to another practice by the PCT—but all alternative practices suggested were in fact a long way from the patient's home and were in-fact within another PCTs borders. Is this not tantamount to an admission by the PCT of failure to provide the necessary local service to its population.

3.  SUMMARY

  I have tried to illustrate with reference to my own case how orthodontic service provision in some areas has been jeopardised as a result of the way the new PDS contract was introduced. I believe that very similar arguments and reasoning have been used to justify such decisions by PCTs across the country and that these decisions stem from the lack of funding flexibility provided to PCTs by the DoH in the transitional arrangements to the new contract. As a result it seems that it is at least possible that PCTs may have been making commissioning decisions without proper consultation and without due regard to the needs of the local population. I have provided the committee with some evidence in this respect in relation to my own area. In addition it is interesting to note that even the DoH was referring to the incomplete and highly controversial needs assessment exercise carried out in Birmingham as a completed work and an example of good practice at a time when this work was still in draft form. Furthermore the actual findings of that draft assessment were also being misrepresented to justify the commissioning decisions.

  3.1  A major consequence of these decisions has been that waiting times for treatment have drastically gone up. For example, in the case of my practice the methodology adopted to determine our contract and therefore our activity level basically reduced our activity level from approximately 500 cases (which was the number in active treatment at the practice at the point of transition) to approximately 80 cases per year. Also as a result, children are having trouble finding orthodontic treatment locally and specialists who had recently moved into an area where their services were required but have suffered due to the transitional arrangements for new practices were forced to consider leaving the NHS or to try and provide a service in hampered and increasingly stressful circumstances.

  3.2  I believe the implementation of the contract has sadly failed many children who deserve and require excellent quality NHS orthodontics. I therefore welcome the Commons Health Select Committee's review of the new NHS dental contract and would be happy to provide further evidence if required.

Dr Ashish Dhopatkar

PhD BDS MSc FDS MOrth FDS(Orth)

December 2007





 
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