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Kevin Lewis column

5th Apr 2007

On the first anniversary of nGDS, Kevin Lewis explains how some people now need to look at things from a different perspective.

Does my contract value look big in this?

As the majority of general practitioners collapse over the line into Year Two of nGDS, they find themselves one year further away from the historical and arithmetical accident of the 2004/2005 ‘test year’, and one year closer to the watershed of 31 March 2009, when local commissioning and local contracting starts in earnest. In many ways, the basis upon which both contract values and UDA targets were reached has simply perpetuated many of the inequities of the previous system. In some respects it has exaggerated and compounded those inequities, but while these anomalies are acutely painful and acutely personal for those most closely affected by them, they are often invisible to others. For example, I would be the first to confess that, until recently, I had not fully appreciated the plight of our primary care colleagues in special needs dentistry. They are treating patients who present massive challenges by virtue of their physical, mental and/or systemic condition. The difficulties of treating them would be beyond many of us for practical, logistic and commercial reasons, let alone the fact that this is specialist care requiring an exceptional degree of skill and competence. Is it not staggering, therefore, that they are forced to justify their existence and performance on precisely the same UDA basis as the rest of primary care dentistry? Can you imagine how long our special needs colleagues will need to spend in Band Two in order to collect the same three UDAs as the rest of us? Or the practical and physical obstacles that they regularly need to overcome in order to achieve just one UDA? This is plainly a ludicrous situation. At the other end of the scale, one of the criticisms of the ‘old’ GDS system was the fact that the same fee was paid for outstandingly good dentistry that lasted a lifetime, as for less spectacular dentistry that lasted only long enough to claim another fee under the ‘Replacements without Patients Charge’ provisions. We may not appear to have made quantum leaps to correct this bizarre set of perverse incentives, but this is actually one of many areas where things are not quite as they might seem at first sight. The apparent freedoms of the ‘high trust’ nGDS are designed along the same lines as a spider’s web. It serves its purpose well, and the spider stays offstage and out of sight until breakfast is served. Right now, ‘outlier’ practitioners can enjoy a few more months of claiming high levels of ‘continuation’ courses of treatment, ‘guaranteed’ treatment and other charge-exempt courses of treatment, but every such claim is adding to the evidence for the prosecution. At the same time ‘outlier’ prescribing profiles may be tolerated for the time being (albeit by some PCTs more readily than others), but the clock is running down towards the moment when the spider will announce his presence. With a finite budget and infinite need, PCTs will increasingly be forced to choose with whom they wish to contract, and on what basis. That is the moment when the PCTs will reflect upon the value that each provider contract has been delivering since April 2006. A PCT will have a pretty shrewd idea by late 2008 – if not already – who is ‘at it’ and who is genuinely doing their best within the system to provide a level of service to patients that the PCT might wish to commission. It is a fair bet that many PCTs would prefer to have a better geographical distribution of practices across their patch, rather than the historical pattern of dentists climbing on each others’ shoulders in one area, leaving voids of under-provision elsewhere. PCTs have already shown themselves to be eager to address this problem, when contracts change hands, and it is very much on the main agenda of the Department of Health. In the past, practitioners have never really needed to consider how they looked from the PCT’s end of the telescope. The transitional provisions at the time of the implementation of nGDS ensured that existing contactors would be offered a contract if they wanted one. But it will not always be thus. There are some big contract values out there that the PCTs would love to get their sticky paws on in order to commission what they really need and want, where they really want it and where patients really need it. For two more years they are still forced to commission what they may not want and need, in places where the supply/need equation is least favourable. On the first birthday of nGDS, we are inching our way towards an internal market in the provision of NHS dental care, where the real teeth of local commissioning and contracting will be seen, and where there will be active competition between local providers for a greater share of the local PCT budget. I am not convinced that this penny has dropped as widely as it might have done. During the past year, patient charge revenue (PCR) has been viewed very much as a PCT problem. In fact, it is very much our problem, because the legacy of a PCR shortfall from one provider contract is actually less money available in the PCT kitty for other providers who are delivering their notional PCR (and more) and who need additional funding to cover the cost of over-delivering UDAs. People ask the immortal question ‘does my bum look big in this?’ because what we see in the mirror is not quite the same view as others get of us. There is a lesson in there somewhere. Please log-in to post comments or register here.

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