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Will we see more prevention and less UDA counting post-Covid?

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  Posted by: The Probe      23rd October 2020

“Possibly!!!” says former CDO Barry Cockcroft

A period of disruption and uncertainty like the one we are in at the moment can sometimes lead to positive outcomes in the long term.

Although oral health is much improved overall from when I qualified, the majority of dentists and their teams still spend the major part of their working days treating diseases that are almost entirely preventable, or repairing and maintaining previous treatments.

For years now, the National Health Service has based the remuneration of clinicians, both in the dental world and beyond, on a measurement of activity, be it measured in sessions, treatments or numbers of patients cared for with adjustment for needs where possible. The Green Paper published last year has suggested a move, at long last, from an NHS focused on treatments and a simple measure of life expectancy to a service focused on health and quality of life. The paper refers to Quality Added Life Years (QALYs), finally recognising that quality of life is just as important as length of life.

This is very significant for dentistry.

Soon after I joined the Department of Health, as it was then, Ian Philp, the older peoples’ Tsar at the time, published a paper, which suggested that for those older people not suffering from significant illness, the most important factors in making them “feel well” were healthy feet and teeth – not things we often hear doctors discussing. Dentists need to make clear to everyone connected with healthcare that oral health is not just important because it is potentially linked to other systemic diseases but because it plays a key part in maintaining a good quality of life.

Dentistry has changed significantly, and we now spend a significant proportion of our clinical time dealing with patient wants as well as patient needs.

This gradual change of emphasis will continue as caries rates continue to reduce but the growth in monitoring of periodontal health and the ongoing treatment of caries and maintenance of restorations will continue to be a major part of our working days for years to come. As somebody who worked in a practice that delivered two GA sessions a week until 2000, I understand how depressing these sessions could be, especially when you are aware that the problems are avoidable just by patient (or parent) action.

I have heard people say that the current move away from UDA-based contract monitoring is great and points the way for the future. I agree with this but there are some significant issues to overcome before everybody can move on. I led a PDS pilot from 1998 which was based on capitation as a method of remuneration for care that was carried out in practice, which did not require any laboratory work. In a perfect world this is certainly the way forward and is replicated in the Blend B prototypes.

The stumbling block was, and still is, the £900,000,000 that is raised from dental patient charges every year in England. A move to a capitation-based system significantly reduces patient charge revenue (PCR), we saw this in our pilot and it is also seen in the prototypes as dentists and their teams focus more on prevention where it is appropriate and do not feel pressured to deliver a certain number of courses of treatment. The clinicians liked the pilots and prototypes, the patients liked the more preventive approach and outcomes improved overall. Clinically, this is clearly the way forward but somebody will have to have a tough conversation with both DH and NHS England finance if there is going to be a permanent change.

Change to a capitation-based system would not need any significant change to primary legislation if it were agreed, as it is with the prototypes, but to impose a change would need primary legislation and any change to the current patient charges system would also need primary legislation, which would also involve a full public consultation.

We have already seen that the pilots and prototypes work best when there is greater use of the wider dental team, especially in the delivery of prevention. It has happened in the wider “unreformed” world with the number of courses of treatment in general practice including an application of fluoride varnish increasing from 0 to over 5,000,000 courses per year since 2007, but it could be even greater. 

Government will have to decide whether it is willing to foot the bill for the shortfall in patient charges and also fund a level of capitation payments to practices, which makes practices viable if we are to see rapid progress.

Moving to a more preventive capitation-based system would be better for everyone but would come at a cost. Somebody somewhere has some tricky decisions to make.


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