Cockcroft pleads for time

Chief Dental Officer for England Barry Cockcroft has given the new NHS contract the thumbs-up despite having lost 500 dentists and nearly 50,000 patients in its first year.

Dr Cockcroft, speaking exclusively to Dentistry following the publication of the government’s first detailed assessment of its controversial reforms, said the contract provided a ‘sound basis’ for reversing the ‘long-term gradual decline’ of NHS dentistry.

But he cautioned that it would take time – perhaps until March 2009 – for the most radical changes for 60 years to deliver significant improvements to patient access across the whole country.

Dr Cockcroft said: ‘The availability of NHS dental services has been declining across the country for some time. It takes more than 12 months to completely turn it around but early signs are good.’

The Department of Health report, NHS Dental Reforms: One Year On, said Primary Care Trusts had commissioned more services during 2006/7 than were delivered the previous year under the old system. It said: ‘As newly commissioned services open and build up their capacity, this should translate into increasing levels of patient access.’

The number of dentists listed on NHS contracts at the end of March 2007 stood at about 21,000, the report said. This represented an increase of more than 2,000 compared with 2003, but a fall of 500 since the introduction of the new contract in April 2006. Many of the dentists who decided not to take up new NHS contracts had relatively few NHS patients.

The 1,050 contracts rejected in the run-up to 1 April 2006 represented ‘less than four per cent’ of NHS dental services, according to the report. In more than 99% of cases, the disputes process ended with dentists deciding to stay with the NHS. The report said patient access had ‘stabilised’ over the first 12 months of the reforms. Figures showing 47,000 fewer patients had seen a dentist compared with the previous year were described by Dr Cockcroft as a ‘minor fluctuation’ when placed in the context of the 28 million patients who had seen a dentist over the past two years.

The report pointed out that funding for NHS dentistry had risen by nearly £450 million since 2003/4, to £1.8 billion in 2006/7. Meanwhile, a £100 million programme of additional capital investment in dental surgeries had begun. Under the new system, it said, PCTs were for the first time able to bring in new services to replace those lost when a dentist left an area. But the report also acknowledged that there remained ‘discordant views’ about the new contractual arrangements.

Dr Cockcroft said he accepted that the reforms, which replaced payment-peritem with an annual contract measured by courses of treatment, had been ‘very difficult for lots of people’.

He said: ‘Dentists have had the same system for 60 years. The fear of change is inevitable. Now they are getting used to a system which doesn’t just pay them by item of service, so it’s very difficult. In some places there’s been a backlash. But I have also met a lot of dentists in some areas who say “this is working quite well for us”. We need some time for dentists and the NHS to settle down.’

Evidence of progress would not be immediate in all areas because services commissioned by PCTs in the past year would take time to get up and running. He said: ‘It just takes time for that to be put in place. By the end of next year [2008/9] we would hope to see new services developed in lots of areas. If you get a loss of service you can’t replace like-for-like instantly. It will take more than one year to sort out the long-term gradual decline there has been in NHS dentistry. These reforms offer a sound basis working to do that.’

But success was also dependent on the willingness of practitioners to work constructively with PCTs, whose role had been beefed up from administering NHS lists and handling complaints to commissioning sufficient dental services for local communities.

Dr Cockcroft added: ‘The PCTs have taken on a much more significant role in the new contracts. A lot depends on the way the relationship between PCTs and dentists develops.

‘Where people say the way to go about things isn’t to go to war but to work collaboratively together it’s better for everybody. When you see dentists and PCTs working together, as we should, there are lots of positive developments.’ The CDO, setting out his case for the new reforms, said: ‘They give the NHS control over where services are provided. PCTs have a duty to provide primary care services in their area for people who need them.’ Under the old system, he said ‘there were areas with virtually no access to adults at all’.

Dr Cockcroft acknowledged that the abolition of ringfencing in April 2009, when NHS dentistry will have to compete for cash against other parts of the health service, was what ‘most worried’ dentists.

He moved to reassure practitioners that the end of guaranteed income did not mean contracts would have to be renegotiated. He said: ‘We don’t expect a rerun of ‘06 in ‘09. The statutory duty on PCTs to provide dentistry locally won’t go away. Neither before ‘09 nor after ‘09 can either party to a contract unilaterally vary the contract value. The legislation says it has to be reasonable. PCTs know what is a reasonable contract value in their area.’

He said 2009 offered the opportunity to tackle ‘outliers’ and bring UDA values which are either well below or above the area average back in line to make the system fairer. Any dentist feeling unjustly treated was guaranteed a right of appeal to the NHS Litigation Authority.

Dr Cockcroft said he remained committed to ensuring that everyone who wanted to see an NHS dentist should be able to do so. He said: ‘I want to get into a situation where everyone who wants to get care and choose NHS care can get it. Making commitments about the availability of NHS service was difficult under the old system because the NHS didn’t control what service was available. It is much easier now for the NHS to say “that’s how much service we need and we have a responsibility to deliver it”. The new system makes it easier to meet commitments.’ But he refused to set himself a deadline for securing full access, saying: ‘I don’t set time scales for anything I do as long as we are going in the right direction.’

Dr Cockcroft declared himself to be ‘comfortable’ with the growth in private dentistry, saying: ‘There has been a very significant growth in cosmetic dentistry in the last ten years. It has gone from virtually nothing to £500 million a year. That’s a good thing. If it is purely cosmetic it is not appropriate for the NHS to provide that. The NHS and private dentistry should be complementary.’

Looking to the future, Dr Cockcroft indicated he was prepared to listen to the profession’s concerns about details of the new contract, but ruled out an early review of the unit of dental activity (UDA). While no immediate major change was on the cards, the DoH was likely to continue making minor amendments to the new system as it had done every year under the old system. But he said: ‘UDAs work if applied properly. Going away from UDAs would be a major change in policy. It hasn’t gone on long enough for us to review this.’

Asked whether there was anything he regretted about the way the new reforms were implemented, he said the Department had underestimated the number of charge-exempt patients who would seek treatment. But he said the seven per cent increase in such patients, which was almost double the four per cent forecast, had been addressed by extra funding from April 2007.

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