Health Forum hears strong criticisms and concerns for future contracting

Pilots of a new dental contract based on capitation are proving successful, but more time is needed to evaluate how they can effectively replace the current UDA system, delegates from across the dentistry sector heard today.

Speaking in central London on Tuesday July 5th at a seminar of the Westminster Health Forum, which seeks to unite the views of practitioners with those of policymakers, Dr Susie Sanderson, chair of the BDA’s executive board, said the biggest challenge for the new contract was finding a way to improve oral health and patient confidence, and deliver prevention, while eliminating perverse incentives,
writes Jonathan Gilbert, GDPUK's special correspondent.

The UDA system came under fierce criticism from Dr John Milne, chair of the BDA’s General Dental Practice Committee, who said that target-driven contracts have created a “moral hazard” for dentists under extreme pressure to treat patients in order to guarantee their income.

Dr Milne said the ‘drill and fill treadmill’ that was encouraged by the item of service system has not been eradicated by UDAs, which he called “corrupted and malign”.
“The current contract puts targets ahead of health,” he said, adding that, since the system was not properly piloted, a relationship of mistrust has developed between the profession and the Department of Health.
The move from UDAs to a capitation model, which will require changes to legislation and which, subject to Parliamentary approval, will be introduced in April 2014, was also welcomed by Dr Paul Batchelor, senior lecturer in dental public health at University College London, whose comments were well received by the audience.
He said the change could “liberate the dental profession”, but that the new contract was still lacking detail. “It’s a promising start,” said Dr Batchelor. “But we need far more information about how the private and state sectors will work together.”
Dr Batchelor also raised concerns about how quality will be measured under capitation, and called for the Department of Health to raise standards by ensuring increased patient mobility and improved access to treatment for high-needs patients.
Oasis Dental Care, which operates 200 practices in the UK, is piloting 32 contracts aimed at providing new access to treatment for patients in areas of high deprivation.
The pilots are based on a capitation and quality payment system in which dentists have greater freedom to use their clinical judgement. Practitioners are not restricted by UDAs, but must adhere to a Quality and Outcomes Framework (QOF).
Justin Ash, chief executive of Oasis Healthcare, said the pilots, the longest of which has been running for 18 months, have been successful. He said the quality incentive had been well-received by dentists and that colour-coding patients as red, amber or green means high-needs patients get better access to treatment.
“There has been a rapid increase in access to care,” said Mr Ash. “In areas where the population had no previous access, we now see numbers of 1,800 patients per dentist.” He said that appointments are longer than under the UDA system, which is much valued by patients, and that the QOF is uncomplicated.
But Dr Sanderson warned the pilots have not run for long enough and that dentists would have to wait for a proper evaluation to be carried out. She said practitioners were wary that results may be manipulated and that a move to capitation would signify a “paradigm shift” in which dentists should have a say.
And speaking to GDPUK, Mr Ash also indicated that the pilots need more time. He said: “We have shown the new contract will be good for both patients and dentists, but there are still a great number of challenges to overcome.”
Dr Sue Gregory, deputy chief dental officer at the Department of Health, told the audience that the pilots were not testing a discrete contract model, but rather the key elements of a new system, including clinical pathways and QOF.
She said that under capitation patients would be more relaxed about access to dentists and, speaking to GDPUK, spoke of her desire to see the new contract succeed. “This is an opportunity for the NHS to build a truly great product that could threaten the private sector,” she said.
Delegates said they would be concerned about the price of new software if capitation were introduced. But Janet McLaughlin, director of Dentistry@BD4, told them the investment was needed and that, despite the cost, it would be an “entirely appropriate transformation”.
Care Quality Commission
Debating the topic of over-regulation and the role of the CQC, delegates were cautiously optimistic following a declaration by Amanda Sherlock, director of operations at the commission, in which she insisted the CQC would consult with dentists before implementing regulatory frameworks.
The CQC had been berated by Dr Henrik Overgaard-Nielsen, chair of the Federation of London Local Dental Committees, who said dentistry had been subjected to “an onslaught of new bureaucracy, red tape, onerous legislation and downright silly measures” over the last few years.
Chris Morris, a dental lawyer and former dentist, said the relentless monitoring had made work akin to Big Brother for practitioners.
Dr Overgaard-Nielsen claimed dentists’ lives are being made “unbearable” by over-regulation and argued that the CQC registration process was a waste of time, triggering a chorus of approval from the audience. He also criticised the CQC for requesting information that practitioners already provide to other bodies and said that an “eagerness for unimportant detail” is a hallmark of the commission.
A furious Dr Overgaard-Nielsen said the HTM 01-05 and the Information Governance Toolkit are a big enough strain on dentists, adding that they are not fit for purpose since their requirements are often not evidence-based.
Delegates backed Dr Overgaard-Nielsen by calling for a return to clinical regulation and, specifically, dental reference officers, rather than the box-ticking exercises they feel will be implemented by the CQC.
But, speaking from the audience, Lord Newton said it was important not to rubbish the commission. He pleaded with delegates to work with the CQC in order to improve it and make its measures proportionate.
Ms Sherlock assured delegates that the CQC was only concerned with improving patient care, not with imposing “torturous regulation” upon clinical practices.
She also insisted that the commission will talk to dentists. “I am committed to reopening the dialogue to improve regulation,” she said. “Let’s start having some conversations about how to regulate.”
Ms Sherlock said a ‘thanks but no thanks’ attitude to talks would be unacceptable and that dentists’ views would not be discarded, but taken into account in a proper consultation. She also apologised for the incompetency the CQC has shown during registration, calling the process “ropey”.
Dr Overgaard-Nielsen told GDPUK that practitioners will have achieved “a hell of a lot” if the CQC does open up a dialogue. “If Ms Sherlock does start talking that would be brilliant,” he said. “But we will wait to see what happens.”

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