How do you plan to address the issue of reduced access and reduced patient revenue if the new contract introduces longer appointment times and more prevention?
BC: The falls in access seen in the pilots can’t be taken as a predictor of what would happen with a future model. Both the clinical approach and the remuneration model have an effect on access. We have been refining the clinical model working with pilots to see what works best and adds most value. Similarly we are looking hard at what remuneration and monitoring system will best support access in any future system.
Patient charges will have to be designed around the needs of any new system of care and remuneration. The expectation is that in any new system they will be required to raise the same proportion of the total budget as now. However, that does not mean that they would remain in the same form as now. But we need to get the basis of the new system sorted out before we can understand its interaction with the patient charge system. It may then be the case that the current system will need modification or even replacing in the longer term. This will be something to be judged during or indeed after the initial prototype stage.
The Minister announced in April that the next step is an engagement exercise (which completed at the end of July) followed by limited prototyping to start during 2015/16. We are now in the process of considering responses to the engagement exercise and developing an approach to prototyping.
Is it likely that the new contract will abandon the capitation and prevention focus in favour of a fee-per-item model like the original contract and the UDA based system?
BC: The prototypes are in the process of being developed. I can’t of course pre-empt that process by discussing content .The Minister set out when announcing the prototype stage in April that the prototypes would be focussed on prevention and that a blend of capitation and activity might be considered for the remuneration. The papers that supported the engagement exercise
developed this thinking further. The papers are still available at www.gov.uk/government/consultations/improving-dental-contracts and provide a guide to the general approach and thinking.
There has been much talk of an increased use of skill mix and greater use of hygienists/therapists in a new contract. Will a new contract require practices to reorganise their entire workforce? On a larger scale, will it result in less dentists working in the NHS and an increased pressure to go private?
BC: Contractual requirements cannot require any provider of services to organise their business in a particular way.
The approach that is being trialled in the pilots focuses more on outcomes, in terms of improved oral health rather than activity and one of the recurring themes within pilot practices has been that they can deliver improved outcomes by using a different skill mix within the practices. This is particularly true with the delivery of prevention and education to patients which can clearly be delivered by members of the dental team other than dentists.
There are other factors including the growing older dentate population which would point to a growing need for the care of people with more complex needs. Essentially workforce change takes a considerable time but we need to train the appropriate workforce to efficiently and effectively deliver the right care for all patients.
In any system it is important that both dentists and the wider dental team are working in such a way that best meets the oral health needs of their patients and makes the best use of the skills of the whole clinical team. And as oral health continues to improve there is increasing scope for the use of dental care professionals alongside dentists. This direction of travel to increased skill mix – flagged clearly for example by the General Dental Council’s guidance on Direct Access in 2013 – goes well beyond the reform programme or indeed NHS dentistry.