NHS dentistry must work work for patients

Mike Hedges, MS Swansea East 

There are problems with getting an NHS dentist and dental practices are reducing and, in some cases, terminating their NHS contracts, including for children.

I along with many other people would like NHS Dentistry to be available to everyone who wants it.

Along with other Members of the Senedd, I met with Morgannwg Local Dental Committee which represents dentists and dental practices in the Swansea Bay University Health Board area.

Following that meeting I have requested, that the Minister directly engages with the representative body of NHS dentists (British Dental Association Wales).

Those dentists carrying out NHS work are committed to the principles of the national health service.

The issues they raised included the new contract and that dentist signed up to the contract without the detail which emerged later. This was meant to be a lenient learning year, but that does not appear to have happened.

There is a need for a new dental school in Wales, and I have suggested Swansea University as a possible site, though I am sure people in the north will suggest Bangor.

I think it is important that we have another dental teaching centre at a site where we already have a medical school. If we do not have enough dentists, I support training more to fill the vacancies.

Issues have emerged which are affecting dental care and may mean that many dentists exit their contract. Around 75 per cent of dentists surveyed by the British Dental Association said that the contract was not working for them.

The co-production meetings on the contract have increasingly lacked co-production.

Fundamental principles

In 1948, NHS Dentistry was introduced as part of the newly formed National Health Service. There were three fundamental principles: no-one should ever have to worry about being unable to afford necessary medical care; care would be provided free at the point of delivery, and care would be based upon clinical need.

The Dental Contract has gone through many changes. The original payment system was fee per item, where dentists were paid for each treatment they provided and this was used between 1951, when Patient Charges were introduced, and 1990, and the system worked well for both patients, dentists and the government.

The system was changed in 1990, involving dentists being paid a fee for each treatment, as well as an allowance for registration of adult and child patients.

The Units of Dental Activity (UDA) were introduced in 2006. The contract involved dentists being paid for a set number of UDAs per year, with each band of treatment assigned a certain number of units.

This was not trialled and was flawed from the start.  This meant that a treatment containing 1 filling was paid the same as a treatment that required 10 fillings – what retail outlet would charge the same for one lightbulb as ten lightbulbs?  Surely a recipe for financial disaster.

Furthermore, the value of a UDA was different for different practices, sometimes by more than £10.

The system worked against both dentists and patients – patients with high needs (lots of fillings needed) were finding it difficult to get treatments done.  It has been recognised from the outset of this contract that it was not fit for purpose which resulted in the trialling of alternative contracts.

Prototype

The prototype A B system was introduced in 2011 as a trial for a new contract system. There were two prototypes in Wales. One was the quality and outcome pilot, and the second, a children and young people’s pilot.

Both removed the unit of dental activity and gave clinical freedom to make clinical judgment on what is best for the patient.

The latest contract system started in 2019 and is called ‘Contract Reform.’ Every time I hear the term ‘reform’ or ‘modernisation’, I break out into a cold sweat.

Under the system, dentists are paid for a set number of units of dental activity per year (25% of their Contract Value) with other Key Performance Indicators making up the other 75%, with the emphasis on preventative care and patient outcome, which is good, but clawback has generated huge concern for dental practices.

There is also confusion in the local dental workforce as to how the metrics work, how they have been derived and the evidence of their validity – some metrics are impossible to meet for some practices e.g. there is a target number of historic patients to be seen in a contract year based on a percentage of contract value, some practices’ numbers of historic patients are lower than the target, which is therefore impossible to achieve.

The dentists suggested some solutions: dental contractors are paid the same rate for each item of treatment they deliver; a weighted capitation scheme needs to be considered, remember, we used to have that, and dentists should be rewarded for seeing higher risk patients more regularly and for providing more complex treatments which take up more time.

Everyone, patients dentists, and politicians, wants NHS dentistry to work for patients.