It has been well over half a year since Lord Darzi was called upon to diagnose what was wrong with the NHS for the new Government.
His report echoed the position of two Health Committee inquires, the Nuffield Trust, Prof Jimmy Steele’s review, and this profession itself. It noted "If dentistry is to continue as a core NHS service, urgent action is needed to develop a contract that balances activity and prevention, is attractive to dentists and rewards those dentists who practise in less served areas.”
Diagnosis in hand, the next step was meant to be writing the prescription.
We are going to hold this government’s feet to the fire. We need urgent and ambitious change, but the latest hearing in parliament gave us more dither and delay.
Real reform will not wait, so as the newly elected chair of the General Dental Practice Committee (GDPC), I want your help writing the prescription.
Making the UDA history
Step back to 2023 and the Health and Social Care Committee said: “The current UDA-contract system is not fit for purpose, and urgent reform is needed to boost recruitment and retention in NHS dental services.”
We have been telling anyone who will listen the same thing for a generation.
Depressingly, we continue to see in dentistry today what the Steele Report noted three years after the imposition of the 2006 UDA contract. It observed that “so long as we see value for taxpayers’ money as measured by the production of fillings, dentures, extractions or crowns, rather than improvements in oral health, it will be difficult to escape the cycle of intervention and repair that is the legacy of a different age.”
Successive governments of all political persuasions have ignored this excellent advice and now the public are paying the price. 13 million patients in England are without access to an NHS dentist – that is over one in four of the adult population.
So, that is the state of play. What is the solution?
We are calling for a fundamentally reformed contract for NHS dentistry that is prevention-focused and patient-centred. A blended contract, predominantly based on a capitation payment weighted by need, but with other types of payment to reflect different treatments and patient cohorts.
The pressure is building for negotiation to begin in earnest, so I wanted to take this opportunity to set out what the GDPC has been proposing, and to seek your views from the front line on the fundamental questions about how NHS dentistry should be rebuilt.
I am launching a major consultation with all General Dental Practitioners to ensure that your voice is at the heart of how we change NHS dentistry.
Whether you are an associate or practice owner, experienced clinician or new graduate, BDA member or not, I want to hear from you.
Fair capitation, weighted by need
In a fundamentally reformed contract, a capitation payment would be the predominant part of the remuneration received by a dentist, and would in effect be a fee paid to the practice for each patient on their list.
We think this would work best for children and most routine adult patients. This capitation fee would be based on a national value to remove practice-by-practice inequalities that we see in the UDA contract.
It is important to say that capitation payments would be weighted for patient need to ensure that practices receive appropriate payment for the work they do. Patients with higher need would attract a higher capitation payment.
In addition to this, recognising the reality that new patients often have greater need, we believe that the capitation payment must include a new patient tariff that reflects the additional work required.
We also believe that the prevention-focused clinical pathway developed for and tested by the now-ended prototypes programme should underpin clinical delivery and decision-making.
Oral health and the patient-dentist relationship
An NHS dentistry contract fit for the future must put the relationship between dentists and patients back at the heart of NHS dentistry.
The Steele Report said that “dental care is most effective when delivered over time and as part of a trusting dentist-patient relationship.” To be frank, we cannot afford to continue to fail to prioritise the benefits of a long-term relationship between dentist and patient, and we know this is what patients want too.
Read the Healthwatch research on what people want from NHS dentistry.
A weighted capitation system is the means to achieve this ongoing relationship, and to focus it on preventing disease, rather than treating it once it arises. Contracts that only contain activity-based payments mean that it is not until the patient already requires dental procedures that the dentist is paid to intervene. Capitation means that our efforts to support patients to maintain and improve their oral health are rewarded throughout. We finally need to break with the ‘drilling and filling’ treadmill that the Steele Report said belonged to a different era a generation ago.
All dentists have a professional commitment to tackling oral health inequalities, and there is clear benefit to local and national Government in tackling the shocking variation in oral health found across the UK. The pilots and prototypes, testing a system based around capitation, showed the benefits of focusing on patients’ oral health improvement, rather than chasing targets.
High needs patients
While the vast majority of care should be funded via the capitation payment, we believe that patients with very high treatment needs should be under a ‘pathway to capitation’ in which their treatment is remunerated using non-UDA activity payments. There remains significant unmet treatment need within the population and activity payments offer a means to effectively treat this, before moving to a preventive approach. Once the patient’s oral health has been stabilised, they can enter the capitation arrangements.
Urgent care
Alongside this, urgent care should be delivered using sessional payments. This model has proven effective when implemented locally by Integrated Care Boards, and we think it should be how urgent care is delivered nationally. It buys time, which is the key issue in delivering urgent care, and ensures that there is a fair balance of risk between dentists and the wider NHS.
A vision for reform
This is what we are seeking from a new contract for NHS dentistry.
These proposals and the detail underpinning them has been developed in an incremental, collaborative way by the GDPC, with input from grassroots GDPs, over more than 15 years.
As I start my role as chair of the GDPC, I want to hear from you about these proposals. Please do take a few minutes to respond to our survey.