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New Contract: Not April '06 but April '09!
11th Jan 2006
Julian English goes deep inside the new contract, exposing the hidden and shocking truth. The hype surrounding the new contracts, promoted equally by both government and dental press, labels 1 April as D-day. It is not. It will be three years later in 2009, or even sooner if the National Audit Office or Parliament’s Public Accounts Committee or Select Committee on Health gets a whiff of the inevitable scandal. In 2009 it will be back to Bloomfield. It will be a managed, means-tested, core service for lower income and exempt groups provided by those with mixed dental skills. What is the evidence of this three-year period of grace? It is the Health Minister’s statement that ‘dentists’ NHS incomes are guaranteed at current earnings levels until 2009’. (Hansard 22.11.05). Rosie Winterton could reasonably claim ‘Apres-moi la deluge’. Edward Samson’s dictum that dentists cannot see the writing on the wall because they have their backs to it is wrong. Dentistry readers do face the wall but are too absorbed in minutiae. Thousands of column inches in the dental press are currently being devoted to charging for failed appointments, posterior composites and children-only contracts. Nobody looks at the big picture. It is irrelevant that funding for dentistry has dropped from 5% to 3.5% over the past 10 years. What is of greater importance is that, after four years of unprecedented spending, the NHS as a whole is getting deeper into debt. Wards are closing, operations are being delayed for the maximum permitted time and, more to the point, GP contracts are costing the Department more than it expected. PCTs might soon be run by private health care companies. There is a government white paper on alternative personal medical services for family doctoring. Instead of having private providers operating at the margins of primary medical care, they will be able to work with the NHS on a level playing-field. From 2008, PCTs will no longer provide services such as community nursing and community hospitals or health visiting, and will become mere purchasers of those services. Nobody knows from whom, except perhaps from opportunist US-baked corporations. NHS dentistry may be protected by ring fencing but what happens to the fence in 2009? History teaches us that dental prescribing patterns are not value free. Change the goalposts and the whole game changes. The Ministry of Health got their sums wrong in 1948. The Department of Health got it wrong again in 1990. GDP clinical behaviour is like a mobile hanging from the ceiling with only one constant. Replace just one suspended object and the whole spatial arrangement of all the objects alter. The one constant factor is the psyche of the GDPs. UK dentists are intelligent, hard working, resourceful and endowed with a unique ability to read the small print. Their favourite bedtime reading is the Statement of Dental Remuneration. They love words such as ‘normally’, usually’ and ‘reasonable’. A recent three-year longitudinal survey found that 36% of 133 recently qualified graduates regarded dentistry as more a business than a profession. The one common factor of the 11,500 practitioners not presently in PDS or the corporates is that they want to run their own show. They do not want to be controlled. It is not part of their entrepreneurial culture or that of their financial advisers. Furthermore, unlike family doctors, whose patient lists were effectively nationalised in 1948, GDPs still regard practice goodwill as a saleable asset at retirement. Nevertheless, in spite of the control, there are fantastic opportunities for the next three years .The National Health Service (General Dental Services Contracts) Regulations 2005 are as much an open cornucopia as the 1948 and 1990 contracts. The clue can be found in two paragraphs. The first is paragraph 14(2)(a) on page 14 which defines a mandatory service as being the care that a dental practitioner usually undertakes for a patient and that the patient is willing to undergo. The second is paragraph 20 on page 31 which lays down that a dentist under contract shall not prescribe where the cost or quantity is in excess of that which is reasonably necessary for the proper treatment of the patient. Another clue is that, unlike the interpretation section in the existing 1992 regulations, there is no definition of oral health. Dentistry considers it pure speculation if this is deliberate or not. What is also interesting is that in the interpretation section of the nGDS , mandatory services are defined as the services described in regulation 14. It is a zero sum game. As John Renshaw told the 51st annual conference of LDCs, the government will simply not address the crucial question on defining what and what is not available. There is nothing in the contract that prohibits a single tooth implant where clinically necessary. There is also nothing in the contract that contradicts the shortened dental arch notion of five-to-five in both arches, as advocated by 39 references on Medline. Perhaps PCTs will support practitioners in not considering bridgework as a mandatory service in heavy smokers. After all, East Anglia PCTs refuse hip and knee replacements to the obese. This lack of definition and the epistemology of words makes the nGDS very flexible. The Statement of Dental Remuneration goes into the dustbin of history. The SDR was never meant to be just a fee scale. It was far more important. The SDR defined item of treatment by means of provisos. It was the machine that drove the DPB’s probity department. The definition of mandatory services is like Alice in Wonderland asking; ‘How long is a piece of string?’ ‘How long would you like it to be?’ replies the Mad Hatter. As the acting CDO said; ‘Dentists will be able to use their clinical judgement rather than be restricted by a set of rules and prior approval’. Derek Watson in The GDP (Sept 2005) is probably closer to the mark when he said ‘manipulation will be rife’. What is going to replace the monitoring and policing system when all the Business Service Authority has is a charge band and patient statutory contribution? It will have to be the PCT. Can anyone imagine 300 PCTs having the knowledge, experience and professional backup of the soon-to-be abolished Dental Practice Board? A National Audit Office report in November 2004 also questions whether PCTs are competent. While the nGDS might give PCTs control they there will have to be several stages before they can impose the ultimate sanction. If FPC, FHSA and HA experiences are anything to go by, each case (and it must be done on a case-by-case basis) will take at least 18 months. Then there are the appeals. By that time it will be 2009. It is worth noting that Schedule three, Part nine of the nGDS regulations that deals with variation and termination of contracts takes up 12 pages. It is not dissimilar to a pre-nuptial agreement. The most marvellous thing about the new contract is that changes in prescribing can be supported by best practice guidelines. BDA News (Oct 2005) suggests that ‘once patients become aware of their entitlement to dental treatments, there is an incentive for a patient to maximise the amount of treatment per charge-paying visit’, and goes on to suggest that a practitioner’s judgement may be regularly challenged on the basis of value-for-money consumerism. Their concern is flawed. The practitioner will have enormous flexibility. The fact that a patient with a single missing incisor wants a bridge (12 UDAs) and not a removable lump of plastic (12 UDAs) is irrelevant. What is wrong with a removal lump of plastic? It would be a brave PCT manager to suggest that it was not reasonable or failed to do the job for which it was intended. They would have similar difficulties with the provision of a preformed stainless steel crown (12 UDAs). Based on the past behaviour of high street dentists, Dentistry believes that the steady drift to non-NHS practice of the under-55s will continue, but not at a much higher rate than would have occurred in any event. Practitioners who presently derive 70% of their income from NHS fees (inclusive of patient contributions) will regard the nGDS as a three-year breathing space for a gradual conversion. They and their defence organisations, can be expected to go through the contract with a fine tooth comb. During this interregnum they will profile and pace their treatment plans so as to reach their target UDAs by the required date. Disputes, sanctions and terminations will end up as an administrative nightmare for PCTs. Consultants in dental public health will hover in the background, giving opinions on possible breaches of contracts. Treatment plans giving rise to concern will be shuttled between the Healthcare Commission and NICE and eventually the Secretary of State. Policing of the system will cost millions. The over-55s will run with the nGDS and quit in 2009. NHS dynamised superannuation, itself an anomaly for those who profess to be independent, is far too valuable to ditch. Accountants estimate that a similar pension requires 17% of income to fund. The great unknown is how patients will react to the new system. It is understood that the Department is working with consumer groups in promoting clarity for patients by means of waiting room posters and brochures. This is not a new innovation. It already existed under Para 31 of the 1990 contact. The Department failed to supply them. Para 34 (1)(b) of the nGDS confirms that; ‘The contractor shall ensure that there is displayed in a prominent position in the practice premise information relating to NHS Charges.’ Leaving aside the required transparency of higher patient charges demanded by the OFT, what effect will this have on with demand? The promise of three years protected income may not materialise if demand/activity falls below that level at which block payments have been calculated. Nevertheless, for any constantly busy practice with a large proportion of exempt patients, it would be foolish to turn down the offer. Levels of activity will easily be reached. Dentistry readers need to be reminded that it will only last three years.
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