Introduction – Aversion to the UDA?
With the talk of the new contract going around for years now, it has been speculated that there isn’t going to be a ‘big bang’ effect like with the 2006 contract and that this reformed contract would be rolled out for a gradual and symbiotic transformation. The BDA has been vocal about discrediting the UDA system and replacing it with an item of service tariff, especially since this would incentivise taking on high-needs patients. The Department of Health and Social Care (DHSC) states that it is not possible for it to conduct the necessary analysis for this ahead of a 2021 roll-out, and therefore want to delay any change to the activity measure until after the initial roll-out. There are concerns that a non-capitated activity (NCS) measure is still going to be a part of the final financial arrangements. The government needs to acknowledge that with the newly appointed goal for prevention, it would take more time and thus needs to reduce the capitation quotas.
Background
The field of dentistry in the UK is widely operated under the National Health Services (NHS) which strives to actively provide top-notch dental treatments to the whole population. While a respectable reach of the NHS for the majority of the Brits still remains a crucial motive with dentists continuing as contractors to the NHS, many private practitioners tend to be more popularized due to their contrasting roles and task ethics as seen from NHS dentists. Many people prefer private non-NHS affiliated dentists to seek treatments from due to a wider range of commercial treatment handled by them, especially in the wing of cosmetic dentistry and also being motivated by a better value for money.
Introduction to the 2006 contract
The infamous NHS Dental Contract of 2006 created a huge storm in the dental industry with its drastic modifications to the old contract. Prior to the reformed contract of 2006, the dentists contracted under the NHS were paid as per every filling, extraction or other work. The contract of 2006 established that the NHS would rate the performance as per the item of service through which a regulated payment was issued. This incentivised fillings and extractions, but not preventative work. When the Department of Health decided to cash limit NHS primary care dentistry, both the dental professionals and patients experienced a downturn in opportunities.
Changes brought on by the 2006 contract
In April 2006, NHS dental services in England and Wales began operating under a new General Dental Services (nGDS) contract. Three major changes were implemented with the force of this whirlwind of a contract:
A shift in financial resources and dental commissioning
Following the devolution of financial resources for the NHS Dentistry to PCTs in England and LHBs in Wales from the National Budget, a brand new sure kill start to the contract modules began with the local dental commissioning.
Introduction to a new patient charge system
Over 400 NHS dental charges were reduced to 3 broad bands that govern over the incentivization of the treatment program. This system was set with a desire to simplify patient charging and sever the direct link between a dentist’s remuneration and individual items of treatment activity.
The 3 broad bands were:
- Band 1: Clinical examination, radiographs, scaling and polishing, preventative dental work, such as oral health advice – 1 UDA
- Band 1 (urgent): Treatment including examination, radiographs, dressings, recementing crowns, up to two extractions, one filling – 1.2 UDAs
- Band 2: Simple treatment, like fillings, including root canal therapy, extractions, surgical procedures and denture additions – 3 UDAs
- Band 3: Complex treatment, which includes a laboratory element, such as bridgework, crowns, and dentures – 12 UDAs.
New contract currency, UDA
Unit of Dental Activity (UDA) is a unit of currency for measuring the type of clinical activity expected from a dentist within a 12-month contract for a certified financial value. Dentists have continually condemned this form of treatment program citing inequality regarding improperly regulated varying UDA rates and sums, and a target-focused approach.
UDA and its impact on dentistry
The 2006 NHS Dental contract in England and Wales brought on with it a targeted approach whereby a dentist was given a target of a number of treatments to be performed within a 12-month radial span measured in the form of ‘UDAs’. A UDA is a Unit of Dental Activity which is an actual value set by the local NHS Primary Care Trusts (PCTs) in England and the Local Health Board (LHB) in Wales.
The purpose of a UDA was to measure a practice’s activity from which they could ensure that the correct amount of patient’s charges was collected. In case these goals were missed, the contract holder and the practice could be financially penalized (commissioners could issue breach notices and require claw back for under-achievement of targets).
In this convoluted system, a course of treatment involving one filling (3 UDAs) would attract the same fee as one containing five fillings, a root treatment and an extraction (also 3 UDAs). Dentists discovered infinite loopholes where they could shorten the treatment plans in order to gain greater value of UDAs over a minimal treatment practice. Due to this reason, this period saw a rapid increase in the extraction cases as extracting a tooth would retrieve the same number of UDAs as would a comprehensive completed procedure to conserve it. Due to this contract some dentists even have had to go part time and do locum work to meet their UDAs.
Pilot and prototype testing
The current dental contract implemented in England and Wales in 2006 remunerates dentists solely based on activity and has been deemed unfit for purpose by many health care professionals as well as the Chief Dental officers of England and Wales. The Steele Report of June 2009 affirmed that the dental profession’s prime goal was to improve oral health and emphasised that better health outcomes through prevention was a much needed change.
Elements of a reformed contract were first piloted in 2011 in England and the Welsh Dental Pilot Program was developed in 2011 that ran through 2015. The pilots were based on capitation and quality, widening access, improving quality and incentivising prevention. In 2015, the Department of Health introduced the prototype remuneration model, with a small but growing faculty. New prototype programs then started in two waves, the first in October 2018, and the second in January 2019. As of April 2019, there were 102 practices from England and 92 practices from Wales that were taking part in the Dental Prototype Agreement Scheme. They strived to test for new ways of providing NHS dental care to the masses with an increased emphasis on preventing future dental disease.
Practices functioned with two main targets, maintaining a level of patient access, and activity measured by UDAs. The pilots ran smoothly before any financial risks were involved with the new policy of health assessment focus and extra time. There was no need to hammer home the UDAs and dentists seemed to be all-around content with the pilot phases. However, when these pilots were upgraded to prototypes, the same effect could not be pursued, what with the decreased access and activity. Although this could be ‘fixed’ with a grand increase in funding to the health sectors by the government, expectations of such sorts in the current climate seem unlikely to take place.
The prototypes seemed to be what works best for the stakeholders, but on the ground, still do not work for the dentists. The two ‘prototype’ practices (Blend A and B) were decided on and will remain on the new contract without the return to using UDAs.
The Reformed contract
The 2006 NHS contract was met with immense criticism by the dentists streamlining mainly on the target-driven approach which was centered around them generating the desired UDAs. Dentists are looking forward to a radical overhaul of the current contract that the profession so desperately needs. Dental professionals have long called on and lobbied the government to reform the policy. As a response, at the end of 2019, NHS England declared regulations underpinning the current system prototype contract due to be rolled out nationally in April 2020, after years of testing through a pilot scheme and then a prototype program with vast testing variations.
Speculations of the new reformed contract
In April 2020, the official new contract is anticipated to come into force and the calamities that it may bring with it. People are ruminating about how the current turbulence surrounding health policy will see a grand transformation and are skeptical about seeing an entirely altruistic attitude from the government.
The basic expectations out of the reformed contract stem from unsatisfactory remuneration, inability to manage patient expectations, and with a gleam of hope of working within agreed working hours and without feeling stress and burnout have been widely depicted with the existing contract regulations.
NHS England reported considering a range of changes to the existing contract in order to keep it up-to-date and relevant, fitting correctly with the new legislation. Some of the expected key policy changes are:
Expectations of a new blended remuneration system
It has been speculated that a new remuneration system will be laid out following the roll-out of the reformed contract. A practice’s contract value for general dentistry is split into:
- Capitation: The number of patients that the practice is expected to have on their list at the year-end.
- Activity: The minimum level of activity that the practice is expected to deliver.
It has been universally understood that the practices will upkeep the same UDS contract values and will continue to be paid 1/12th each month. However, 10% of the contract value is at risk if the adequate activity and capitation presuppositions are not met.
Two different prototype blends are also being tested:
- Blend A: Payments are made 60% capitation and 40% activity. Activity is paid for Band 2 and 3, and capitation payment covers all activity that would have been under Band 1.
- Blend B: Payments are made 85% capitation and 15% activity. Activity is paid for Band 3 and capitation payment covers all activity that would be under Band 1 and Band 2.
There has not yet been a set decision on whether blend A or B of the prototype would predominate the reformed contract, which would give us a clue about how much care could be covered by capitation and how much by UDA activity. Some favor blend B where the UDA target is minimised, although it requires maintaining a certain number of Band 3 treatments. Others favor blend A as there are more UDAs to target and the associates can get paid easily. There is hope that the dental practice would be given a choice between the two blends, but it is unlikely to happen. There may however, be a choice given whether to sign into the new contract or remain with the ‘06 regulations.
Implementation of an oral health pathway
Throughout the pilot and prototype programs, the policy of Oral Health Assessment (OHA) has been invariably appraised. The contract may see the same oral care pathway that strives to educate, motivate and improve the oral health of the public. In this policy, patients are given an Oral Health Assessment which generates a Red, Amber or Red (RAG) status or score that would aid in determining the intervals at which the patients are seen.
This allows the dentists to spend more time with their patients and evaluate each case individually without having to meet a certain target. The patients are then given a RAG score for the four main clinical domains and the dentists tailor a treatment plan with the patient’s best interests in mind. Having more time with the patient allows the dentists to build a strong rapport and ease the patients into the treatment program. This specialised care pathway was designed by dentists for dentists that does not use an activity model and encourages the prevention of dental ailments.
Aversion to the UDA? – UDA 2.0.
With the talk of the new contract going around for years now, it has been speculated that there isn’t going to be a ‘big bang’ effect like with the 2006 contract and that this reformed contract would be rolled out for a gradual and symbiotic transformation. The BDA has been vocal about discrediting the UDA system and replacing it with an item of service tariff, especially since this would incentivise taking on high-needs patients. The Department of Health and Social Care (DHSC) states that it is not possible for it to conduct the necessary analysis for this ahead of a 2021 roll-out, and therefore want to delay any change to the activity measure until after the initial roll-out. There are concerns that a non-capitated activity (NCS) measure is still going to be a part of the final financial arrangements. The government needs to acknowledge that with the newly appointed goal for prevention, it would take more time and thus needs to reduce the capitation quotas.
Eddie Crouch, Vice-Chair of the BDA’s Principal Executive Committee informed, “The inequality of the UDA that has been around since 2005 will be eliminated in reform. That’s because they are going to give the same value to the non-capitated activity, which is what they’re calling the UDA in the reformed contract, for every patient across the country.” The dentists expect an anti-UDA charged treadmill state of work for their future endeavors and hope for a system that stands better than just a watered-down version of the old contract.
Skill Mixing & Appointment zoning system
Under a reformed contract, there may be more scope to utilise Dental Care Professionals (DCPs). Patients may be given a further stage called an Interim Care Management appointment which can only be delivered by a DCP. By implementing a rigid appointment zoning system, the dentists will have set slots for emergency cares, private treatments and check-ups which would ensure that they hit their target and fulfil their contract over the year. However, skill-mixing may be difficult for smaller premises and practices.
When it comes to the future of working in an NHS practice, there is no confirmed date for the execution of the new contract but the belief is that it wouldn’t be a big bang approach, but rather ‘ink spotting’, that is rolling out in spots across the country and gradually weaning the dentists off the old contract formula. The exact changes of the 2020 contract are currently unknown.