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Kevin Lewis column
22nd Nov 2006
Kevin Lewis is concerned that the UDA target-driven state of the dental profession could lead to the best practices being squeezed out of the NHS. Four years ago, Options for Change sought to trace the shape of the future of the NHS. It explored key principles and themes, many of which have since come to fruition. It wasn’t long, however, before ‘Options’ became singular rather than plural, and the emphasis was more upon the change itself than any options as to its possible shape. Options for Change had pointed to the potential inefficiencies of the slightly ad hoc ‘cottage industry’ feeling of the GDS. It hinted at a consolidation of practices into larger units, each having a more cost effective critical mass. As the plot unfolded, there were voices offstage to the effect that the natural habitat of the greater crested (and lesser spotted) associate would quickly come under threat, especially for the associate who elected not to exercise his or her right to have an individual provider contract. In some cases, of course, this decision was made by the practice owner who wanted to hold a practice-based provider contract which swept up any associates and morphed them into performers. In such cases, the associate either went along with the change or left. So, far from practices consolidating into larger groups, we are already witnessing the unfamiliar sight of larger practices (and even multi-site practices) consolidating or downsizing. This happens for two reasons – either because the practice is moving towards the private sector and shedding patients along the way, or because the practice has found that its UDA allocation is easier to meet than originally anticipated, to an extent which persuades the practice owner that it can be met by fewer dentists, or possibly by a workforce of a different shape. In some cases this involves using hygienists and therapists in surgeries previously occupied by associates. When this happens in isolated cases, it is accepted as being part of the natural business cycle. Businesses expand and others contract in any changing market. But is there something a little more important happening here, under the surface? In the past, practices expanded because they took on more patients, or because the relationship between need, want and demand put pressure on the ‘supply’ side of the equation and waiting lists started lengthening and accessibility/availability became a problem. A fee-per-item remuneration system, if anything, made this more likely. A cash-limited, locally commissioned block payment system, on the other hand, can have precisely the reverse effect. There is no guarantee of additional money for additional work, and in some PCT areas the successful practices cannot expand (at least not on the NHS) because the PCT can’t fund any such expansion. Unless, of course, other practices contract. The great danger of this significant new dynamic is that the best and most successful NHS practices can’t expand within the NHS (and may feel that their only option is to expand into the private sector). Meanwhile, the least successful NHS practices will still be able to preserve their contract value by maintaining their UDAs, so they will tend to maintain the status quo (rather than contract). Over time, the best practices are squeezed out of the NHS while the weaker practices are protected. It was never going to be easy to interpret the early data emerging from the Business Services Authority (BSA), because only now is anything like the true picture starting to appear out of the mist. It was inevitable that the BSA, once deprived of the historic day job of counting and comparing widgets (in the shape of item of service claims), would quickly create a whole new industry of counting other things instead. Of course, they can only count what’s on the forms that are supplied to them, so it doesn’t take the brain of Einstein to work out what they would be counting. Having said that, even Einstein would have been a tad impressed with some of the ingenuity being displayed by some of our colleagues. Additional UDA claims made in circumstances which lead to the ‘continuation of treatment’ or ‘guaranteed treatment’ or ‘prescription only’ boxes being invoked, are high on the hit list, not least because too many UDAs are being clocked up with no patient charges. On the grapevine one hears tales of practitioners who are somehow achieving the majority of their UDAs in this way. And before you ask, I have no idea either. Any system which measures performance or activity, or which impacts upon remuneration, is open to the possibility of ‘gaming’. And let it not be suggested for a moment that gaming is the sole preserve of general dental practitioners. Politicians, hospitals and PCTs – not to mention the BSA itself – are no slouches themselves in these dark arts. This is a busy time, then, for both poachers and gamekeepers. While the poachers are still on the lookout for rabbits, the gamekeepers are desperately trying to seal up the holes through which patients’ charge revenue is escaping while UDAs are multiplying like, well, rabbits. Additional resources, briefing documents and a series of seminars up and down the country are hurriedly taking place to brief PCTs about the latest ‘gaming’ hotspots, and how to differentiate between genuine poachers and hardworking country folk who just get up earlier in the morning than their colleagues.
Author
Kevin Lewis
Kevin Lewis is renowned for his vibrant and influential writing, where he imparts his unique insight into UK dentistry. In his 20 years in full-time general practice, Kevin developed special interests in preventive dentistry and practice management. He has been involved with Dental Protection since 1989, initially on the board of directors, then as dento-legal advisor, before being appointed dental director in 1998. Kevin is also a popular speaker, lecturing on a variety of issues at many different events worldwide. He has contributed to two CD training programmes on infection control, and a BDA A12 Advice Sheet. In 2003, he became a member of the Council of the Medical Protection Society.
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