Is contract reform important? Yes it is!News
Posted by: The Probe 5th July 2019
Barry Cockcroft, former Chief Dental Officer, explores the nature of contracts.
When I first entered general dental practice in 1975 serious concerns were being raised about the then NHS dental contract which was based on item of service remuneration. There was a high profile television programme with the headline grabbing title Drilling for Gold, which suggested that dentists were filling teeth unnecessarily just to maximise their incomes. I am sure there were a very small number who were playing the system in this way but the vast majority of dentists, like now, were just getting on doing the right thing for their patients and were appalled by the behaviour of a small number of their colleagues.
As time progressed the BDA became concerned by the pressure to ‘drill and fill’ that the item of service system potentially created. I joined my local LDC and later the General Dental Services Committee of the BDA, primarily because at a time when minimal intervention and prevention was being seen as the way forward, I thought a system based on payment for individual items of service created the wrong incentives. If you look back at the BDA evidence to the Doctors and Dentist Review Body between the mid eighties and 2001 you will see countless references to the ‘item of service treadmill’.
At the same time that more dentists were becoming unhappy with their payment system the Government was increasingly coming under political pressure to do something about the high profile national issues of access to dentistry but without any local budget for dentistry the NHS was virtually powerless to do anything about it.
Out of this situation came the Options for Change working group and subsequent report which was published in 2001 and is probably the first time the profession, their representatives and the government were able to agree on anything related to dentistry – it was not to last!
The report suggested the introduction of local commissioning with the local NJHS having a budget to tackle access issues for the first time although the uneven distribution of existing funding was to cause issues for years to come.
Any commissioned system needs a currency and given the then Government’s urgent political need to introduce reforms the new currency was based closely on the previous item of service system. This was probably the most difficult part of the whole process, an ad hoc working group was set up to advise on contract currency involving three participants from the BDA and three from the DH, this group came up with the concept of courses of treatment weighted by complexity (the UDA system) but the BDA were always clear then, as they are now, that they are happy to discuss but will never negotiate or agree. I don’t think any of us thought that it would be so difficult to move on in the way it is beginning to look like we might be on the verge of now. Dentists have more security now; without primary legislation changes there should be no challenge to contract values or the non time limited nature of contracts and if it does not look attractive then I suspect that staying with the current system would be an option.
I had piloted a capitation based system under PDS arrangements since 1998 but we had excluded those treatments which are now included in band 3 as it was impossible to include them fairly in a capitation based system. This looks uncannily like the blend B prototype which hopefully will be on offer as the process proceeds and which has not really changed for years.
The success of the reforms will clearly be determined by what level the capitation payment is set at. At this point we will clearly know whether there is a serious commitment to reform.
I was surprised to read that at the recent LDC conference the “special adviser” to the BDA seemed to suggest a return to item of service payment might be the way forward. Setting aside the history of this payment system, anyone who has looked at the data on caries prevalence and projections for the future would realise that this would be an economic disaster going forward.
In terms of aligning clinical needs with the remuneration system, the Blend B pilot looks attractive but as always the devil will be in the detail. The fact that it is inevitable that a contract involving just a changed currency does not need primary legislation means that the ‘big bang’ approach which happened in 2006, and which I had argued against before joining the DH, will not be needed.
Encouragingly, the oral health of the majority of the population has continued to improve so a capitation based system will become even more attractive over time but now that the NHS has the power to invest in dental services, which it did not before 2006, will it invest before we are again faced with images of queues round the block to see a dentist, as we did in Scarborough in 2004?
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