Memorandum by Sarah Elworthy (DS 18)
COMMENTS ON THE NEW DENTAL CONTRACT
1. SUMMARY OF
In my opinion the new dental contract is unable
to provide patient centred effective dental care for children
1.1 The UDA does not measure effective patient
1.2 The "banding" system for payments
does not reward dental practices for effective patient centred
1.3 The PCT does not have the ability and
structure to work with dental practices to set appropriate financial
and clinical targets to achieve patient centred effective dental
I am a general dental practitioner of 20 years
experience. I own a small three surgery practice in the market
town of Cranbrook in Kent. The practice was established 12 years
ago. We treat adults as private patients. Children under 18 years
of age are offered NHS care. We achieved IiP status in 2000 and
the BDA good practice scheme in 2001
The practice mission statement of "integrity,
choice and value" underpins our objective of providing effective
patient centred, evidence based dental care. We feel we have achieved
this under the new dental contract. However we have been unable
to achieve our UDA target and are under threat of significant
financial penalties. This will means we will have to compromise
our standards of care or opt out of providing NHS care for children.
I would like the committee to understand why the new contract
is failing our practice and therefore our patients. I hope this
may be of some use in sorting out the current debacle.
3. OUR OBJECTIVES
FOR NHS CARE
To provide the appropriate care and advice to
minimise and treat dental disease, and to provide the skills and
knowledge to remain dentally fit for life.
Effective prevention advice
to our patients and their parents from pregnancy onwards.
Provision of effective preventative
treatments ie fluoride varnish, fissure sealants.
Early detection of dental disease
with appropriate but minimally invasive treatment.
Patient friendly appointments
to encourage regular attendance and efficient treatment.
Fast access to emergency care
to minimise distress and maximise treatment success.
Education in dental health to
the wider community.
Careful consideration of the DoH reports NHS
Dentistry: Delivering Change by the CDO (England) July 2004
and the Framework Proposals for primary dental services in
England from 2005 gave us encouragement that the above strategy
would be valued by the NHS.
Training of current staff and engagement of
therapist to provide effective team to support the dentist
We engaged with the PCT well in advance of the
new contract to ensure the PCT supported our aims
We utilised our IT systems for information on
patient numbers, treatment needs and surgery hours
We utilised our IT system for efficiently and
effectively providing flexible appointments, quality control and
Support from the PCT in funding via the new
contract, and other direct grants from Government initiatives
for training and investment in dental surgeries and Oral Health
6.1 An adequate regular monthly income has
given us the financial security to continue successful and effective
strategy for child dental health in Cranbrook.
6.2 The removal of fee per item has given
us the flexibility to prioritise surgery time and care to those
with greatest need.
7.1 The wrong measuring stick (UDA)
The UDA measures treatments provided. It does
not measure effective or patient centred care. We have increased
the number of children that we care for before the new contract.
We continue to conform to the principles of best practice as laid
down by NICE and The Royal College of Surgeons We have provided
a better level of service and equivalent surgery hours as we did
before the new contract. We provide treatment that prevents dental
disease, reduces repeat procedures and reduces referrals to (costly)
secondary care. Unfortunately this is not valued and does not
equate to the required levels of UDA's. If the government wants
the PCT's to be responsible for the provision of dental care that
is sensitive to patients needs a more appropriate measuring stick
7.2 Banding; a disaster for patient centred
The system of banding discourages dentists from
taking on new patients with high dental needs, as greater surgery
time for multiple treatments is not rewarded financially. The
UDA's can be maximised by forcing patients to book appointments
spaced two months apart. We prefer to see children promptly if
they need treatment thus limiting disease progression. We want
to encourage attendance and so offer convenient appointments after
school and increase availability in the school holidays. Most
children are dependant on their often busy, working parents to
ensure they attend for dental care.
7.3. Poor management
The PCT's need to have a good understanding
of dental practice in order to work effectively with dental clinicians.
The PCT's need to have clear objectives and strategies. These
need to be effectively communicated to the dental clinicians.
I have had a number of meetings with various PCT managers. Their
level of knowledge on dental practice appears to be limited to
their own (limited) dental experiences. Factual knowledge on the
dental needs for the area appears negligible, and they have no
obvious strategies or objectives other than in terms of the UDA
and rewarded by the "banding" system. Although I can
appreciate the desire to promote competition between dental practices
in tendering for contracts, it is the patient care that will suffer
if the measured `units' are not appropriate for the patients needs.
Our successful dental care has resulted in increased
demand from parents for NHS children's dentistry at our practice.
Increased demand has not been met with increased
funding. We have spare capacity and would be very happy to provide
more NHS care for children. We would be able to work our surgeries
more efficiently if we could expand our NHS care for children.
The framework proposals 2005 encourages PCT's to support larger
more efficient practices that utilise therapists,hygienists and
oral health educators. We are saddened that the dental health
of the children on our waiting list is being further compromised
by these restrictions. Is this because we are in a reasonably
affluent area and the PCT do not consider it necessary?
7.5 Removal of patient register
No registration results in lack of continuity
of care. Building up a good long term relationship with the patient
(and for children, with their parents too) is a major part of
effective preventative dental care.
7.6 Conflict of interest
The PCT appears to have two conflicting roles.
To manage the provision of dental care, and to award the contracts
for the provision of dental care for all the NHS providers in
the area. I cannot imagine a business situation where a manager
is working for multiple business that are in competition with
each other for contracts issued by the managerial staff. Combined
with targets that are not sensitive to patients needs
7.7 Private/NHS partnerships
There appears to be reluctance for mixed practices.
However with limited funding and regional socio-economic variations
this would be something to be harnessed rather than ignored.
From my experience most dentists do not opt
for private dentistry for purely financial gain but to enhance
patient care and regain professional satisfaction.
Can the government (or rather the tax payers)
afford to provide dental care for the whole population? Should
the politicians decide the priority groups, and the funding available?
The managers and clinicians can then set realistic and achievable
objectives for the provision of adequately funded dental care
for those groups.
I sincerely hope this brief over view is helpful
to the committee. We have provided the dental care that the DoH
proposed in their reports and implemented the new contract in
the same spirit. We have succeeded in providing effective patient
centred care. We have not achieved our UDA target and have been
threatened with significant reductions in funding.
Sarah Elworthy BDS