Changes to the dental contract in England prioritised urgent care. But, with the total financial envelope remaining the same, something has to give. Peter Ingle looks at how the UDA system means there will always be losers
Top Gear famously had a running gag about an unloved high mileage Toyota pick up truck that could be driven into buildings, left in estuaries, set alight, dropped from a considerable height, and would then - after only basic repairs - keep going.
Twenty years on, after a steady run of events that should have left it in the contractual scrapyard long ago, the UDA system is still running.
A fresh assault on the contract is looming with reports that many practices face running out of UDAs before the end of March 2027. It has provoked some speculation on the GDPUK forum on what the affected practices will do. Contractors are predicting that the pinch point will come after Christmas 2026. Connoisseurs of unintended consequences will see the irony of the recent contract modifications which were intended to improve access having the opposite effect.
The Department of Health and Social Care (DHSC) and NHS England were under enormous pressure to improve access to unscheduled care and encourage practices to take a chance on new and potentially high needs patients. The 2026 contract replaced the old 1.2 UDA rate for urgent care with a £75 activity payment, and introduced a requirement that 8.2% of their contract value must be delivered as unscheduled or urgent care activity. Offering this more generous rate of exchange for urgent care has been an effective incentive to practices, and many claims are being made for the new higher UDA courses of treatment.
This is good news for patients with toothache, and those requiring a greater volume of treatment. But since contracts still receive the same number of UDAs, this is a zero sum game, and there must also be losers. DHSC and NHS England have made little secret about who they want to see squeezed out of NHS dental care. The intention is that those pesky regular attenders who have been soaking up UDAs will be waiting a couple of years for their next exam, not 6 or 12 months.
It must not be said out loud, but there must have been an expectation, if not hope, that many would simply go private instead. After all, a significant number of those regular patients with apparently fairly stable oral health could afford to pay for their check-ups and scale and polishes.
Practices have historically been expected to manage their UDAs through the year, but there has also been the concept of capacity. It was this that saw so many practices with an NHS logo over their front door telling patients that they could be seen privately next week but that there were no NHS appointments anytime soon.
There was a huge disconnect between the information on the NHS find a dentist website and the response to a would-be patient asking if they could be seen on the NHS. This has now been ‘fixed’ with all contracting practices carrying an urgent care header on the website and the advice to 'Phone this dentist if you need urgent dental care. They will tell you how they can help or how soon you can get an appointment.' When seen, these patients will bring the practice one of the enhanced UDA rates.
Practices will not be able to just close their doors if they run out of UDAs before 31 March. Associates will still want to work, staff will expect to be paid, and local commissioners will not be happy to hear that there is a fresh access crisis.
Some patients will choose to go private. Some routine appointments will be cancelled and moved into the new financial year. Some commissioners may find some extra funds, and no doubt some practices will deliver free UDAs for fear of the wrath of their commissioners.
We can expect a fudge, and the system will limp into a new financial year, because it always does. But this constant pressure on practice owners and staff takes its toll. For team members, a less frantic and pressurised working environment will be appealing. For anyone trying to run a small or medium sized business times are hard enough. NHS dental practice owners enjoy an extra dimension of pain as they try to triangulate patient’s wishes and NHS England's demands, all while staying solvent.
As practices began to wonder how to eke out their remaining UDAs, the Nuffield Trust have released a report on what they described as the demise of NHS dentistry.
The new report notes that NHS data about the number of practices offering NHS care lacks good information and that its quality is unreliable. The researchers’ solution was to cross match the CQC register and NHS payment records.
From this they were able to conclude that the percentage of practices in England offering NHS care has dropped by 9% since 2017. This is not just a London and the South East issue, with 41 out of 42 ICBs showing a drop in NHS practices. Unsurprisingly, the number of private only practices has risen.
The Nuffield report acknowledges that other practices may retain a UDA contract care but have altered their mix to substitute more private work. The Nuffield view is that a practice dropping all NHS work is much more concerning. While it is likely that those that have completely left the NHS will not come back, if the remaining mixed practices have reduced their NHS proportion by just a few percent it may represent a greater loss of capacity than the 9% that have departed.
However the numbers are analysed, it would seem that whatever happens after Christmas, NHS dentistry will stick with the trend that sees it serving less of the population, less often.
The Nuffield trust has described the changes in the English GDS as 'the great extraction'. Those once NHS, but now private practices reading about the latest UDA lunacy might describe their own journey as the great escape.