Do we really need contract reform?
NewsPosted by: Dental Design 29th October 2021
…or do we just need to see more use being made of the existing flexibilities?
This may sound like defeat to some people, but it is simply being realistic. There was no mention of contract reform in the recently published Health Bill and, with another health bill likely to be several years away, people should now be trying to make the best of the legal framework that is already in place. One of the problems is that some people are willing to write or speak in public on issues they don’t actually understand.
I have written about flexible commissioning many times and remember attending an education day at the Faculty of Dental Surgery several years ago where the minister with portfolio responsibility for dentistry at the time was a speaker and made a positive reference to flexible commissioning. After the minister had departed, a speaker from the floor, an “eminent academic”, informed the audience that the concept of flexible commissioning was promising but that it first required some sort of contract reform to enable it to go ahead. This was complete rubbish but went unchallenged. Flexible commissioning is completely possible within the existing legislative framework. If I was being cynical, I might think that it would be very convenient for the majority of the secondary care providers present if this were true as flexible commissioning, done properly, would certainly lead to a greater proportion of services being provided in primary care with an overall cost saving for the NHS, care closer to home for patients and better career opportunities for those working in primary care.
The other thing I often read is that contract reform might have a negative impact on the viability of practices, especially those largely with an NHS focus. Again, this is not correct, current legislation means that the open-ended nature of the majority of dental contracts cannot be changed without agreement and neither can the contract value be reduced unless the provider has failed to deliver 96% of their contract in each of three separate years. I rather suspect that some of this uncertainty around NHS contracting is being created deliberately by those with an interest in encouraging people to move away from the NHS. As overall oral health continues to improve and patient demands and needs change, there will inevitably be more growth in the private sector as more treatments, which are quite rightly outside the scope of the NHS, become available and requested. The majority of adult orthodontics, purely cosmetic treatment, and more expensive treatment options that are not clinically necessary are certainly outside that scope.
Perhaps the most important section of the legislation, though, is not related to contracting.
The 2005 legislation, implemented in 2006, places a legal duty on the NHS to provide or commission NHS dentistry to the extent it considers necessary to meet the need in its area – clearly something it is now failing to do – and access to NHS dentistry is becoming a significant issue again. I saw some extensive media coverage about this issue on the local BBC news in the West Midlands. The problems being caused by the growing lack of access, exacerbated by the pandemic, were well articulated by patients, local dentists, and a representative of the BDA, but nobody mentioned that the NHS was now in breach of its statutory duty in many areas.
The NHS being in breach of its statutory duty is a very serious issue and nobody seems bothered.
The cause of this breach is not down to “the contract” but it is simply that those in high office now have consistently failed to address the emerging dental workforce issues. I recently wrote to the (now ex) minister with responsibility for dentistry and her reply referenced the Advancing Dental Care programme, which has just been published and clearly will do nothing in the short term to improve the situation. In more rural areas, this shortage is now affecting both mixed and fully private practices. Workforce issues are often only addressed when there is a crisis and there is a political need for short-term solutions, but it is essential to also look at the long term. In 2004, we looked to the EU for a short-term solution and expanded student numbers in England and more DCP engagement with a view to the long term. There seems to be no plan, or even effort, at the moment to tackle this issue in the short term. Or is that the plan? Ignore the problem and let more people provide or receive care outside the NHS and therefore reduce the NHS spend on dentistry.
The ministerial reply also conceded that the GDC could do more to address this issue. I think that is a gross understatement. If you look at how the GMC and the NMC are supporting the recruitment of doctors and nurses from overseas to tackle short-term issues and compare that with the total lack of interest in workforce issues shown by the GDC, then it rapidly becomes clear that the new Chair of the GDC has some serious work to do and needs to do it quickly.
About the author
Dr Barry Cockcroft CBE is the former Chief Dental Officer for England and current chair of the British Fluoridation Society.
