Select Committee on Health Written Evidence

Memorandum by Dr Amolak Singh (DS 35)



  The Dental NHS began life in 1948. The system was based on a fee for each item of treatment. There were over 400 items of treatment. It was free at the point of delivery. Dental disease was rampant after the war years and the system served the population well. Very soon patient charges were introduced. These charges commenced at £1, increasing over the years to a little under £400 just before the current new contract (2006). At the same time there followed successive fee cuts. This resulted in a treadmill system. The system was no longer fit for the 21st century. Morale was at an all-time low early this century. A new system had to be found. Consultations began for "Options for Change". No change was no longer an option.


  The consultation process was on "Options for Change". All sorts of options were discussed. None of the discussed options formed the basis of the current contract which is based on "Units of Dental Activity" (UDAs). The UDA contract was imposed without any meaningful consultation or pilots. Dentists were given just days, less than a week, in many cases. We were told "take it or leave it". Livelihoods were at stake. Dentists signed under duress and over two thousand signed with the words "under dispute". In law, to be valid, a contract must be entered into without force, pressure or deceit.


  The contract value for a practitioner was based on the gross earnings of the practitioner for the period 1 October 2004 to 30 September 2005. This is called the reference year. Provisions were made in the contract for those general dental practitioners (GDPs) who had an atypical reference year to make representations to their Primary Care Trust (PCT) to have their contract value amended where justified. Most PCTs refused to make any amendments regardless of the evidence submitted on the grounds that they had no funds. The PCTs willfully negated the very provisions in the contract for those with an atypical year. They could, at their will, thwart the intentions of the legislators. Complaints of ultra vires action by the PCTS went unheeded. The Department of Health was not interested, nor was the Secretary of State.


  PCTs simply referred dentists to the NHS Litigation Authority (LA). This body is an arm of the Department of Health and cannot be seen to be an independent authority. There is a conflict of interest. Hence it is not surprising that almost 99% of the appeals were rejected. In my case, when I asked for reasons, I was given a sharp rebuff and told in no uncertain terms that I must not communicate with the LA and if unhappy with their decision I could go for a judicial review (JR). I simply decided not to fight the system but to increase my private work. The LA forgot that the whole process was one of "dispute resolution". In law, not giving reasons for a decision is tantamount to not having any reasons to give—as if the decision is arbitrary!


  For the past few years PCTs have been receiving additional money from the Department for two specific purposes. The first sum is for Access, Quality and Choice (QCA). For 05/06 such a fund had a label attached to it, to specify how the sum should be used. For 06/07 and for 07/08 it was ring fenced. In spite of this PCTs have used this money to reduce their overspend. When a complaint was made to the Department and to the Secretary of State, no one appeared interested. A copy of the complaint was also sent to the then Prime Minister. I specifically asked the Secretary of State if her intention for the QCA funds was for PCTs to reduce their overspend. She did not answer this question. Her reply was non committal, ambiguous, incongruous and unintelligent. The PCTs action was ultra vires. It was abuse of power. There was no respect for the rule of law. Even the Health Ombudsman appeared uninterested as if this did not constitute maladministration.

  The second fund was called "Capital Funding". Most PCTs paid this fund to GDPs, though not all PCTs did so. Those who did not pass on this sum to GDPs have again abused their power.


  Goodwill is an asset. Practice owners paid for their goodwill when purchasing their practices. The law of the land (Human Rights Act 1998) and the Convention on Human Rights of which we are signatories since 1951, makes it clear that no one should be deprived of his/her property without due compensation. Yet clause 12 of the new contract says "the contractor shall not give, sell or assign, or otherwise dispose . . .." Worse still, GDPs who deleted this clause in the contract are told they cannot do so. I ask, "are clauses deleted in the contract, being forced on us?" Is this a contract of our free will?


  The Secretary of State said that the new contract would increase access, prevention and quality of treatment. The reality is that the new contract is the biggest hindrance to access. Those with very low contract values will not accept any patient, new or existing, once they have achieved their contracted UDAs. If they did, they will be passing on to their PCT the patient charge revenue collected, and this will be deducted from their contract value. In short such GDPs will have to fund patients themselves. It is no different than the Government telling GDPs that they should not take on more NHS work, even if they wished to do so. This contract has stifled growth, obstructing access. The system is seriously flawed and needs urgent review if access is to be increased. Prevention cannot be achieved without UDAs being allocated for prevention. Nor will quality improve as the old treadmill has been substituted for a UDA treadmill.


  From over 400 items of treatment, each with its own price and patient charge, Harry Cayton and his team have so over simplified treatment bands and patient charges, that the present system is unfair to both patients and dentists. Professor Wade, the father of English Administrative Law, says that, "administrative convenience and fairness can never be good friends". For some patients the charges are now almost three times higher. This itself is a deterrent to access.


  PCTs are adding or amending contractual clauses. Goalposts are changing. Greater regulation, greater burdens and more monitoring has become the order of the day. Dentists have always been asked do more and more for less and less. Some PCTs are beginning to lower the UDA values of dentists, which means that dentists have to again work on a conveyor belt system. Such a state of affairs cannot continue. Such action is unacceptable, unlawful and will never raise standards.


  Dentists in the NHS feel frustrated. They feel they are unable to provide standards of care that they were taught and that which patients deserve. Some just cave under such pressure and decide to go private, often for reasons that under a private system they can provide higher standards and treat patients more ethically, even if they earn less!


  GDPs are self-employed. Before the new contract they could charge patients for a failed appointment. The new rules prohibit them from charging patients for failed appointments. The Department goes on to broadcast this to patients in their patient information booklets. The result is that patients now can blatantly miss their appointments without fear of being charged. This is irresponsible action from the Department. There are no UDAs for failed appointments. I ask are GDPs self-employed or are they employees of the Department or PCTs !


  The contract forbids a dentist to refuse to accept a patient on the NHS due to the status of the oral health of the patient. This means that if a patient presents with loads and loads of treatment needs, (several fillings, root fillings, extractions, periodontal disease, crowns, and partial dentures) the dentist is obliged to accept the patient. The dentist must carry out all the treatment for a fixed maximum value (12UDAs), even if it takes 10 visits, spans over a six-month period, or his laboratory costs exceed what he is paid. I see this as onerous since during the reference year a GDP could refuse to accept such patients on the NHS.


  PCTs can make clawbacks in cases where dentists have not done the contracted amount of work. However, such clawbacks have to be made by following certain set procedures. PCTs do not follow such the procedures.


  PCTs simply do not understand how discretion must be exercised. They think discretion means they can do what they like or as they deem fit. They do not take relevant facts into account. They act in an arbitrary manner. Such behavior is unlawful.


  London is one of the most expensive cities to work and live in. Almost everyone working in London receives a London Weighting Allowance. The Review Body for Doctors and Dentists Remuneration has expressed surprise that GDPs do not receive London Weighting. The Department, in its response said that the contract would be one based on local commissioning and such matters would be addressed in the 2006 contract. Sadly, GDPs have once again being misled.


  The new contract is riddled with unreasonable and inequitable clauses. It is an obstacle to access quality and prevention. It needs urgent changes.

Amolak Singh MBE

15 December 2007

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