The ethical limit
The difficulty with defining ethical dentistry is that when asked, nobody ever feels that they are acting unethically.
A clear set of rules over what is available within NHS dentistry would certainly help, but the actual guidance here is remarkably sparse. For almost any given situation there are a range of legitimate clinical choices, however the overwhelming financial incentive placed on dentists is to pick the best option with the lowest cost and chair time.
The currency of the NHS system is units of dental activity (UDAs) and the rate at which UDAs can be earned varies significantly between treatments. For example, when treating an abscess a dentist can earn three UDAs for root canal therapy, or the same for an extraction that takes a fraction of the time to complete.
The ‘ethical limit’ is not a number but more of a concept, the concept being that any practitioner working ‘ethically’ can only muster through a certain number of UDAs within any given time.
If I were to suggest a number I’m sure there would be those who could explain why I’m wrong, of course; different dentists work at different rates or perhaps have other practitioners working under their performer number, such as hygienists or therapists – but surely there must be a limit.
Figures revealed to me by the NHS Business Services Authority (NHSBSA) under a freedom of information request, indicate that the highest number of UDAs (claimed by 17 dentists in England in 2013-4) was recorded as an astonishing 18,000+, a figure that hugely exceeds what I would consider to be the ‘ethical limit’.
But looking beyond these exceptional figures, a quick internet search of dental associate jobs available indicates a number of available positions offering 8,000+ UDAs available on a full-time basis with ‘great private potential available’.
One particular advert states: ‘High performer required with 9-10,000 UDAs available. Great private potential’, with another stating: ‘Dentist required starting as soon as possible working Monday, Tuesday and Thursday. Offering 6,000 UDA’s at £10 per UDA.’ Whilst both of these adverts do not represent a crime, I would argue that it would be hard to meet the terms of the adverts without committing one. This is of course a personal opinion and not necessarily representative of Dentistry.co.uk.
Ultimately what I am concerned about is the bashing of the NHS system and the abusing of one’s right to make a claim in order to meet an arbitrary target loosely linked to healthcare need. This doesn’t in any sense exculpate those in government who have decided to award unrealistically high targets without any form of due diligence as to how those contracts would be performed.
An open debate
Unlike the previous dental contract, the current system has a budget ceiling, so any UDAs awarded to dentists and subsequently claimed for through unscrupulous practice will tend to divert resources away from their intended use. Whilst this may benefit the Department of Health in terms of creating favourable performance figures, it takes away funding from dentists trying to practise ethically, as well as besmirching the wider reputation of the profession.
I strongly believe that we need an open debate on what the ethical limit should be.
As a profession we don’t need to look any further than the largest ever patient recall at Daybrook Dental Surgery to see what sort of issues excessive claiming causes. An NHS contract report showed Mr D’Mello’s two-person practice in Daybrook was contracted to complete 29,000 UDAs in 2014-15. How on earth anyone can think that this could be achieved in any ethical sense is truly astonishing.
Setting a limit wouldn’t necessarily provide a solution to a failing system, but rather it might limit the damage that could be afflicted upon the profession.
In truth, someone claiming 1,000 UDAs per year could just as equally be committing an act of fraud as someone claiming 18,000+. However, when we think of the logistics involved with providing 18,000+ UDAs per year, alarm bells must start ringing. Assuming the dentist were to work five days a week and take seven weeks’ holiday annually, this would require 80 UDAs per day to be achieved; assuming an average UDA rate of £25, this would gross £2,000 per day under the NHS alone.
The impact of this doesn’t just have massive implications for patient care, but also has wide reaching implications on the business of dentistry as a whole.
The obvious impact is through an overall dilution of UDA values, but perhaps less obvious are the secondary effects such as rising General Dental Council (GDC) fees, indemnity costs or younger dentists unable to secure vocational training places due to insufficient funding.
For far too long those with vested interests have turned a blind eye to how UDAs have been completed.
The Department of Health has passed the buck to providers, who in turn have contracted out to associates. There are of course many examples where this works well, but when it fails more often than not the GDC is left to pick up the pieces, creating bad news for everyone.
I’m sure that there will be those that would take umbrage with setting a limit of UDAs per performer, but we as a profession have a choice: either we support and actively promote an ethically driven approach to NHS dentistry, or alternatively we can bear the burden of any repercussions that result as a consequence of a target-driven system.