Orthodontic contract procurement: ‘NHS orthodontic practice is not sustainable in the long-term’

orthodontic contractRichard Scarborough speaks to Guy Deeming about the orthodontic contract procurement process.

The wrangling over the procurement of NHS orthodontic contracts continues to throw up different challenges and issues across the country.

Most recently NHS England is abandoning procurement in the Midlands for the time being.

These challenges prompted the BDA in the run-up to the last general election to call on the government to end competitive tendering across the NHS.

To find out more about what has been happening and the impact on both patients and the profession, I spoke to Guy Deeming, specialist orthodontist and former trustee and director of clinical practice at the British Orthodontic Society (BOS).

What is the general perception of the contracts on offer?

Guy: The orthodontic contract in and of itself is essentially the PDS contract, broadly speaking, in the terms published in 2006.

Although, with this round of commissioning, there’s been some additions in terms of performance indicators and quality metrics. But, I think, on balance, many consider these reasonable, fair and achievable for the majority of providers.

I think it is also fair to say that there is widespread concern about the (in some cases) significant reduction in the UOA value. Especially with the smaller contracts. Here the total orthodontic contract value is relatively low. In essence, the NHS is asking for a lot more for quite a lot less.

They’re asking for more access, they’re asking for, quite rightly, all the appropriate governance and health and safety measures to be in place, and they’re asking for specialist teams. But they’re not putting a financial structure in place that’s going to allow that to be easy. Or even possible in some situations.

One would postulate that a lot of providers are going into procurement with a view to securing market share and building a private practice alongside their NHS contracts. There is very little, if any, safety in terms of profit margin within the NHS structures at the moment.

We are now in a position that an NHS orthodontic practice is not sustainable in the long term. Mixed practice is the only way forward.

Whilst that sounds very obvious, what has become apparent throughout this process is that there are a significant number of orthodontists who completely commit to the NHS and who deliver fantastic quality NHS care, over the last 10 or 20 years, or longer, and who are no longer able to do so. That’s because the financial envelope doesn’t allow them to. It’s incredibly sad and a tragic waste of a valuable workforce.

At the BOS Conference 2019, you mentioned that some providers are giving their contracts back. Can you give any insight into the scale of that and the reasons behind it?

Guy: One of the challenges that we have is that there is relatively little information forthcoming. However, there are reports of situations where providers, for a number of reasons, have not mobilised contracts. Or, indeed, they have mobilised but have then handed the orthodontic contracts back.

There’s a number of reasons that could explain this. Such as an inability to provide the workforce to service those contracts. Or it may be due to reassessment of the harsh financial viability of running those orthodontic contracts.

Those would seem to be the most likely short-term reasons that providers choose to discontinue providing, or fail to provide, those contracts.

In the longer-term, the risks would be about ongoing financial vulnerability (or failure to deliver over-ambitious business plans). Along with the natural attrition of the workforce, with people choosing to leave and a resultant inability to fill that gap.

There’s a lot of workforce issues in orthodontics at the moment. They are having an impact on the ability to mobilise contracts. At the same time, servicing the wind down orthodontic contracts can require an additional workforce over and above what may be available at the time of mobilising.

Do you have any updates on how procurement is going in the different geographical regions? For example, the recent abandonment of the process in the Midlands.

Guy: In the Midlands they have had issues with the marking of the responses from orthodontists. As a consequence of which they are unable to proceed with the procurements. So NHS England is abandoning the process. They will be issuing a new procurement timetable at some point in the future but they’re not saying when.

All of the time, effort, cost and inconvenience incurred up to the point that a practices wins the orthodontic contract, is at your risk. And that, sadly, is clear within the tender documentation, but it is a very, very bitter pill to swallow.

Because they had gone so far through the procurement process, they had issued feedback to unsuccessful bidders. This told them why they were unsuccessful before subsequent abandonment. It is clear that this turn of events represents a huge blow to providers and potentially patients. I know the BOS and BDA are desperately keen to establish what happened and why, lessons learned and what happens next. It is easy to forget the human aspect of these events on the dedicated small providers who are wrestling to save their livelihoods at every turn.

This means that if you won the bid, or you were the preferred provider, you would not have had the privilege of feedback. Whereas, if unsuccessful, you receive information on how to make your bid better.

So, if they re-run the process, they’ve got inequity. Some people have the privilege of information and others don’t. This means they have a really sticky problem in terms of how to level that playing field.

There was a judicial review taking place in the north. We have just found out that there has been some resolution of that. We hope to see some progress there relatively soon.

There are lots of separate issues and NHS Enalnd will assess the merit, or not, of those independently within each area. They are independent processes with their own nuances. So the questions and marking processes in the various areas are slightly different. Just because NHS England is abandoning the process in the midlands probably doesn’t have any bearing on the north or the south, etc.

That said, clearly, neighbouring areas will take a very keen interest in the nature and merit of any challenge in their colleagues’ patches. There will be learnings and opportunities for them to adapt their approach.

And what impact is this having on the patients?

Guy: There’s not complete clarity because there is no central repository or log for patient queries. And, perhaps unsurprisingly, commissioners are clearly quite reluctant to share this information while the situation is still so fluid.

That said, there is significant risk to patients with any process of this nature. We are aware of noise from patients that are going through to the NHS England and commissioners, with pushback also going into the practices.

We haven’t yet seen big patient volumes with a service gap yet. Although we have certainly seen some delays where new providers have failed to mobilise on time. But, for the most part, existing practices have treated their existing patients to completion. This has smoothed the process significantly.

The area where there’s been most controversy is around the management of waiting lists, particularly with electronic referral management systems. It seems to be that one of the main problems has been the loss of ‘metadata’. This is the information relating to the patient status and the time stamps on the various different events that have taken place.

That’s meant that providers have been given a list of patients. But they haven’t got too much of an idea of what those patients are for. Or, indeed, how long they’ve been waiting. That has created some confusion and certainly some concern that patients, in effect, would then be put into a completely homogenous bag with no regard for how long they’ve already served on a waiting list.

I understand from NHS England that there have been some learnings from that experience, and that it is something that they are watching extremely closely, and that that particular situation was resolved.

But there are some very high-risk patient data transfer situations when you’re looking at the management of waiting lists. And I think there was perhaps an assumption of simplicity, about that when this process started.

What has been the impact of all this on morale of the profession?

Guy: It’s disastrous. It’s harrowing. I wonder if it comes back to a perception amongst providers, that NHS England are out to drive them down to the cheapest deal, and that, on behalf of the commissioners, the orthodontists are seeing the NHS purely as a revenue stream. Neither in my view are true. The vast majority in both roles want the best for the patient. But seeing the world from a different perspective; it is very easy to lose this message amongst the stress and uncertainty of procurement.

The ultimate impact of this is that we’re forcing the two sides of NHS commissioners and providers into their respective corners.

The profession is completely demoralised with significant numbers seeking early retirement. We’ve seen significant numbers of young members of the profession seek opportunities elsewhere in the world. Others seek to move into the private sector to the detriment of the NHS.

What that means is you’ve got a brain drain. A brain drain of some of the most caring, ethical and committed NHS providers and performers. That’s really, really sad on a professional level.

On the human level, worry and distress surrounds principals’ lives, to the point of illness. There’s been widespread concern that those that haven’t had the business acumen, enthusiasm, or foresight to build a private practice, are at risk of bankruptcy or worse if they don’t win their orthodontic contracts.

I understand that the process is a blunt instrument. Contracts need procuring, and the rules of the game are not designed for this situation.

But the sad bit is that we lose the ability to empathise. Not just with our colleagues and peers within the profession, but between different stakeholders of commissioners and providers with working relationships risking damage beyond repair. I look forward to a new chapter beginning and the professions starting to rebuild confidence and relationships to establish a fresh focus on the fantastic and rewarding patient care for which the profession is rightly recognised and proud.