Time to end mixed messaging on NHS dentistry
Dr Martin Skipper, Head of Policy for the LDC Confederation highlights major discrepancies in the Government’s strategy for dentistry during the pandemic.
On 22 December general dental practices operating under NHS contracts were finally informed of the contractual requirements for the final quarter of the 2020/21 financial year. They would have to achieve 45 per cent of their usual contracted activity for the final three months. The announcement came a day after London had been put into tier 4 and shortly before infection rates began to skyrocket, with new stricter measures put in place and the public was told to avoid all unnecessary travel. Despite this context of uncertainty, the 45 per cent activity target remains unchanged.
When it comes to NHS dental services the Government is relaying mixed messages. On the one hand we, the public, are being urged to minimise our interactions, to avoid all social contacts and to do what we can to safeguard precious NHS resources. On the other hand, the NHS is sending the message that dental services are operating as normal, though they may have to prioritise urgent care.
While the country is still in the grip of a pandemic we should not be encouraging the public to seek routine dental care but should instead focus on prevention, so that we may free up limited resources for those who require face to face interventions. The Chief Dental Officer appears to agree, she recently stressed the need to prioritise care for urgent patients. Despite this, the NHS persists in sending the message that practices are open as normal and introduced a seemingly unreasonable activity target.
It may not be immediately clear where the contradiction lies, however. Surely if appointments are made, treatments are carried out and care provided then the target will be met? There are significant numbers of people whose care has been delayed and whose oral health continues to deteriorate. Patients are responding to the Government's message of staying at home and they are cancelling their routine dental appointments, but often those appointments are filled by urgent cases and referrals from NHS 111. If the patients are there, how can there be a problem?
Dentists are allocated a certain number of Units of Dental Activity (UDAs). Each band of treatment credits the dentist with a certain number of UDAs which are deducted from their target. A Band 1 course of treatment, such as a regular check up, credits the dentist with a single UDA against their target. A Band 2 course of treatment will be slightly more complex and time consuming, including things like fillings or extracting a tooth and will therefore credit a practice with 3 UDAs against their target. A Band 3 course of treatment involves items which require laboratory work such as crowns, bridges etc. take a lot of time and credit a practice with 12 UDAs against their target.
One would think if people are not attending practices for Band 1 treatments (1 UDA) then practices will be mostly performing higher Band treatments, accumulating more UDAs and so will meet their target faster. This, however, is not the case. If a patient does not normally attend the practice but is in urgent need, there is a separate Band which credits a practice with 1.2 UDAs. This would not be an issue if the urgent treatment took the same time as Band 1 treatment, but it doesn't. Many dental procedures require the generation of an aerosol. To ensure that this does not represent a risk to staff, dentists and their teams wear full face protection masks with filters and other personal protective equipment following recent infection control guidance. This is exhausting and mentally draining for team members day in day out.
The result is that practices will be busy. They will be meeting the pent up demand and unmet need caused by the reduction in access due to the pandemic. It means that they will be mostly providing care which takes the time of a Band 2 or 3 treatment but not getting credited Band 2 or 3 UDAs. Instead, they will spend as much time on a patient as required and be credited as much as if they did a simple check up. Under normal circumstances urgent courses of treatment do not make up much of a practice's activity, so the expectation on practices and how they work has also changed while the system of accreditation has not.
Under those circumstances the time available, the treatments required and the infection prevention protocols mean that a target is neither realistic nor helpful.
But it is not the target per se, which is the problem. Rather it is the impact of missing the target on future dental provision. A practice will be busy seeing people in need, providing care in difficult circumstances and miss its target. As a result they will have to pay back all allocated funding to the NHS as though they had not provided care, or they will somehow have to increase their activity in the new financial year as if the pandemic was over. In the worst scenario a practice could find itself in breach of contract and in danger of having its contract removed for no other reason than because, during a pandemic, it could not meet an activity metric which in 2008 was identified by the Health Select Committee as not fit for purpose.
At the start of the pandemic the NHS committed to continuing funding for dental practices with an NHS contract in order to maintain the service. That commitment appears to have been lost, if contracts are removed after April 2021 access to NHS dental services may be in genuine crisis. Practices could go bankrupt or dentists simply decide that they can no longer provide care under while stifled by an activity driven contract – one more concerned about counting artificial credits (UDAs) than people's health.
If action is not taken to protect NHS dentistry then there is a real danger that many communities will lose access and their oral health will suffer. And all because an arbitrary target, following a discredited system, was missed during a global pandemic
What is the solution?
If the NHS will not abandon the target requirement, then they could accept all urgent courses of treatment at 3 UDAs rather than 1.2 UDAs to reflect the fact they take up a lot of time and resources. The NHS could make it clear that “breach of contract” notices will not be issued to contractors for simple under-delivery of UDAs. Repayments could be phased over a longer time frame, until the pandemic situation is stabilised and care timeframes can return to normal. If action is not taken to protect NHS dentistry then there is a real danger that many communities will lose access and their oral health will suffer. And all because an arbitrary target, following a discredited system, was missed during a global pandemic.
Longer term, dental services need to be considered in tandem with continuing reforms to the rest of primary care. The formation of Primary Care Networks and the development of Integrated Care Systems presents an opportunity for truly holistic care where dental services can help people eat, speak and socialise with confidence.
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