GDPUK.com opinions:: Michael Watson - Can UDAs be made to work?
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Heart Your Smile, the dental charity with a mission to find innovative ways to promote oral health and regular dental visiting, has devised a Market Index which charts the growth of dental activity and patient uptake across the spectrum of dental care in the UK. This is based on industry figures for sales of dental treatment gloves and dental local anesthetics, providing a proxy for the volume of dental visiting actually taking place.
Michael Watson’s career started in the army and continued in general dental practice, before going to the BDA as their political adviser. He also edited both the General Dental Practitioner and BDA News. Since leaving the BDA he has written extensively in the dental press, lecturing and giving advice on a consultancy basis. Most recently he co-authored the book Understanding NHS Dentistry.
The Health Select Committee report1 published at the beginning of July is a wake-up call not only for the Government, but for commissioners of dental services and the dental profession itself.
Politicians, the media and dental organisations have been universally negative for instance the chair of the BDA's executive board said: “This is a damning report which highlights the failure of a farcical contract that has alienated the profession and caused uncertainty to patients”.
And yet the mood of this year's Annual Conference of Local Dental Committees was that the profession should work with the Government to improve the contract. The Chief Dental Officer, Barry Cockcroft, tells everyone who will listen that he is opening new practices all the time and there are some Primary Care Trusts (PCTs) which are working well with their local dentists to improve services to patients.
Units of Dental Activity (UDAs) are often cited as the main reason for the failure of the contract to deliver its promises. But there is much confusion and some misinformation about how the UDA system was developed and the reasons for introducing it. Early in 2004, the Department put its Framework Proposals2, to the profession.
They were emphatically rejected by the profession in a BDA ballot, but the Department of Health decided to proceed. However the BDA insisted that there should be some form of monitoring of activity. Of the three measures of activity used by the Dental Practice Board (DPB) only courses of treatment could be used once registration and item of service were abolished.
Both the BDA and Department of Health did some work on using 'weighted' courses of treatment as a measure of activity, assigning points values to each course of treatment depending on its complexity, the points eventually being known as UDAs. The different weightings had to correspond with the banding system for patients' charges.
UDAs were not new items of service but part of the accountability for delivering services. They have, however, been used both by PCTs and dentists as items of service, a job they are totally unfitted to do. The new contract was supposed to abolish item of service, instead it has been perpetuated through UDAs with the perverse incentives and treadmill associated with that discredited system.
UDAs refer to activity and therefore can be said to cover the extra costs incurred when a surgery is in operation, including payments to the dentist working there, materials and laboratory costs. The non-UDA element of the annual contract value would cover the practice's fixed costs, those that have to be paid whether a surgery or surgeries are in operation or not. Some element of the contract value also needs to be available for incentive payments to deliver agreed outcomes and to for pay for additional services.
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This points to a fixed UDA value across the country, in much the same way as there is a fixed value for Units of Orthodontic Activity. UDAs could be tied more closely to patient charge bands and made to equal the charge itself. This should remove the UDA value bidding wars which perpetuate the treadmill effect of the old contract.
Whatever changes are made to the current arrangements, they should incorporate the principle of a contract value where dentist and PCT can identify its make-up eg fixed costs, UDA element, incentive payments. The UDA element could be used to pay the performers for the work they do in the surgery plus paying for laboratory costs and materials.
The non-UDA element would in effect be a practice allowance and could be used to cover overheads, including staff costs, incentive payments and practice profit. It would mean that a PCT could reward a practice for taking on new NHS patients, carrying out specialist treatments, and non-UDA treatments such as domiciliaries and sedation. The practice would need to produce a business plan to justify these payments (some of which could be negotiated with the LDC). But the PCT would have funds to reward commitment and achievement; it could lead to more intelligent local commissioning.
The use of the UDA as the sole currency of the contract merely prolongs item of service which the Department said would be removed. The penalties for non-performance should be clearly written into the contract and should relate to the element of the contract value where performance has not been met.
The Chief Dental Officer Barry Cockcroft, speaking at a BDA seminar one year into the contract called for a 'basket of measures' with which to judge the contract, so has the BDA itself, so did some witnesses to the Health Committee. Nothing will change while the PCTs insist on regarding the UDA as the only indicator of performance.
[1] House of Commons, Health Committee: Dental Services, Fifth Report of Session 2007–08; July 2008
[1] Framework proposals for primary dental services in England from 2005: Department of Health, Gateway ref 2755 published February 2004.
UDA systems are unworkable as we are realising! Dentistry is an art-form and, as such, we should be best paid for effort - and each job is different! Architects are paid according to the size of the project; painters according to the work and skill involved, a builder is paid according to the size of the project. It is 'dispiriting' to work hard and then not be rewarded directly.
Henry
Whilst I applaud your recognition of UDAs as an unsuitable measure of "items of service" provided, I feel UDAs are so invalid scientifically and statistically as to be no use for anything, except perhaps a crude measure of NHS patients charge revenue.
UDAs don't measure health or needs or delivery of care in any shape or form AT ALL.
UDAs intrinsically detract from Professionalism and even the principles of the NHS itself - as such they should be totally rejected/scrapped :idea:
They shouldn't be meddled with or adapted, just scrapped - another system of remuneration should be introduced, even if it's under the cover of the "basket of indicators", should those who imposed NHS UDAs be too embarrassed to admit that which even the Health Select Committee could recognise, that they were wrong :!:
Yours pragmatically,
Tony.
Could this move the emphasis from fewer large 100% NHS practices, which require maximum fixed cost funding to many predominantly private practices, where fixed costs are largely covered and a small amount of UDAs are produced at each? Cost savings would have to be weighed against the difficulty of maintaining control of many small rather than few large providers.
Close to neutral costs by removal of the fixed cost element and patient charges equalling UDA value could be appealing to PCTs, unless this market effect is prevented by HMG instructions.
Another point: UDAs produce a very distorted reflection of variable costs. They require significant polishing to adequately match costs and thereby eliminate distortion effects.
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