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Kevin Lewis column
11th Jan 2007
Kevin Lewis predicts what the profession has to look forward to in 2007 and beyond. So here we are at the start of a new year. For the first time in many years we are not bracing ourselves for a watershed of some kind in the 12 months ahead. Instead, we are probably re-grouping after a year of spectacular change, and maybe taken the opportunity to consider our options over the holiday period. 2006 polarised the profession in a way that no previous year had done and, as astonishing as it may seem, we are only 28 months away from April 2009. Whether or not it will mark the end of the world as we know it – as widely predicted – remains to be seen. But I hardly sense an air of confidence in the ranks of the profession. So how has the profession changed during 2006? I am struck by the difference between perception and reality. The raw evidence suggests that NHS dentists have collectively changed their prescribing habits quite significantly in a short space of time; the BSA needs no second invitation to produce new ‘exception reports’ to highlight some profound differences between prescribing patterns pre-nGDS and after it. While some PCTs will no doubt find these differences staggering and inexplicable, others will have been able to predict which of their providers would be responding in just the way things have turned out. There will be talk of ‘the usual suspects’ and the inability of leopards to change their spots, no doubt. But if you ask individual dentists, as I do whenever I get the opportunity, most of them feel as if they have swapped one treadmill for another – exactly what the 2004 BDA survey predicted – and they are simply making the best of a system they never wanted in the first place. More significantly, however, they feel that they have much less control over the new treadmill than they had over the old one. Mission accomplished, the cynics will suggest. But the real danger is that desperate situations will breed desperate responses. There is a sense in which the government has provided NHS dentists with a length of knotted rope, a chair and a blindfold, leaving some individuals to kick the chair away from under themselves without even realising they had done so. Do we seriously believe that in the process of converting ‘old’ GDS activity into UDAs, the default position wasn’t to round the required UDA targets up, rather than down? We have now heard of many situations where far too many UDAs were demanded as being equivalent to ‘old’ GDS income, as a result of some glitches in the logic underpinning the conversion calculations. How many scenarios have you come across where too few UDAs were being asked for in return? Precisely. This, coupled with the absence of any pressing time imperative for submitting forms, and the surprising scale of the delays in BSA processing of UDA claims, made it a racing certainty that many dentists would appear to be under-delivering UDAs when the scoreboard was checked in October, based on (at best) September figures and (in some cases) August figures. Having been given a bit of a hurry-up by their PCT at the mid-year stage, those same dentists may well find themselves in real danger of over-delivering UDAs by the end of March unless they throttle back sharply. Let’s face it, the Department has been very canny. By basing contract values upon 12 months of ‘full’ schedules rather than 12 months of ‘activity’, and by aligning UDA targets to full-year income, the Department had designed a cushion for itself from the outset, because dentists would only ever have nine or 10 schedules of nGDS activity in year one. Anyone who actually meets their UDA target in the first 12 months of the new contract would probably have delivered at least 10-15% more UDAs than they were being paid for – the extra UDAs being ‘in the system’ in just the same way as the apocryphal ‘NHS sausage’ that ‘old’ GDS dentists had effectively offered to the Department as an interest-free loan for the previous 50 years. The perceived wisdom today is that the assumptions, in all the above respects, favoured the government. UDAs delivered but not claimed, or claimed but not yet processed and scheduled, still incur fixed and variable overheads. In the case of extensive Band Two or Band Three treatment, these overheads can be quite disproportionate to the income. But looking back at 2006, and when talking to dentists, it is already clear that the new currency of NHS dentistry is UDAs. Not profit, not turnover, not quality of care, not oral health, not necessity, nor equity or fairness, but UDAs. UDAs are already re-shaping appointment books and driving professional relationships, payment systems, treatment decisions and prescribing, practice valuations and a lot more too. Looking ahead to the back end of 2007, the ‘test year’ will soon become a distant memory. The stresses and strains of UDA values that can be widely different for the same gross, or contract values that are widely different for the same number of UDAs, must surely start to invite more questions than they did in 2006. Ironing out these bumps is the next challenge, but with no additional funding overall, dentist X can only be paid more if the PCT recovers some contract value from dentist Y. And while the flavour of the month is still accommodation, rather than confrontation, this still remains a difficult circle to square. By the end of this year, the April 2009 watershed will only be 15 months away. And, interestingly enough, the next general election might follow just a month after that. That’s the price that politicians pay for postponing the kick-off twice, I guess. But this is the year in which the future of NHS dentistry will be shaped to a large extent by what happens in the surgeries up and down the country. A Happy New Year to you all.
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