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The NHS Reform

As you’re reading this, the UK is no doubt still shrouded in political uncertainty. Unsure of what the future holds causes obvious public anxiety and the government are well aware of this.

Similar themes run through the NHS policies and the dental community. So, what are the facts? The NHS contract reforms started in 2011 and has drawn constant criticism for the contract’s failure as a feasible business model for a dental practice. Last year the NHS announced that changes to the contract, which is set to expire on the 31st of March 2020, will be in place by April 2020.

The NHS were hoping to attract more dental practices to join the scheme but any new legislation will depend on the Government pushing it through parliament.

As you will be aware, if you’ve turned on the news in the last 3 years, the Government are a little preoccupied with Brexit and other obligations they deem more pressing. If the new legislation is not passed, there is so clear indicator of what happens next.

However, if you read one of our most recent articles on Dental Groups you will see the market is still very active right now.

We chatted to some respected experts in the dental field to ask their opinion.


Jonathan Jacobs – Head of Healthcare at AN Law

The current GDS contract has run its course and as is a well known fact was due to be overhauled in 2013, some 6 years ago.

The reality has been however, that reforming the provision of dental services by the NHS has not been the top priority of the government. Never mind the fact that in between 2013 and the present day, we have had 2 General Elections and as a result, the issues surrounding the resolution of the GDS contract going forward were “kicked into the long grass”.

However, on taking soundings, it seems that there is a desire to have a replacement for the current system in place for April 2020. As to what the “new” contract will comprise remains to be seen. We have experienced Pilot Schemes followed by Prototype Models, both of which have taken elements of the current GDS contract but have been supplemented to form a blended offering. The pilots were based on capitation and quality, with care being provided through a preventive care pathway. The approach was popular with patients and dentists, but resulted in a decrease in access for patients in most of the pilot schemes. In 2015 the Department of Health introduced the prototype remuneration model. A small number of dental practices have, since 2015, been testing versions of a possible new system.

These are not the only changes afoot in the dental profession. The employment status of associates is being carefully looked as is the issue of vicarious liability on the part of Principal Dentists. The insurance/indemnity industry is already going through a significant change with the BDA now offering its own insurance scheme and a government consultation ongoing as to the future of the indemnity market. In all likelihood, indemnity will no longer be an option, to be replaced by a compulsory requirement for all dentists to be properly insured, which of course will require an amendment to current legislation.


Julian English - Editor-in-Chief of Dentistry Magazine

It was announced irrefutably in October last year that the new NHS general dental services contract is to be rolled out from April 2020. And if it doesn’t then we are all in trouble because the legal framework for pilots and prototypes runs out. So, the contract will have to be adopted by 1 April 2020 or the whole thing dropped. What a potential waste of everyone’s time and effort and angst trying to make these prototypes of blends A and B work.

The good news is that the clock is ticking for NHS England and the Department of Health. The bad news is that no one can hear the tick tock over the deafening ding of Brexit. Indeed Eric Rooney, deputy chief dental officer confirmed the problems too, saying: ‘We are working towards this timetable, and it is our intention to roll out the contract reform, but it is not definite and depends on the ability to amend the regulations (get legislation through parliament) to be able to proceed.

The new minister for Dentistry Seema Kennedy will have some tough calls to make in less than 12 months’ time. Regulations underpinning the current system of prototype contracts are due to run out on 31 March 2020. The prototypes are testing new ways of providing NHS dental care to see what works best for all stakeholders, but on the ground, they still do not work for dental practices. Just to remind you, there are two prototype blends. Both include a capitation element (a payment per patient registered and regularly attending).

The new minister for Dentistry Seema Kennedy will have some tough calls to make in less than 12 months’ time. Regulations underpinning the current system of prototype contracts are due to run out on 31 March 2020. The prototypes are testing new ways of providing NHS dental care to see what works best for all stakeholders, but on the ground, they still do not work for dental practices. Just to remind you, there are two prototype blends. Both include a capitation element (a payment per patient registered and regularly attending).

In ‘Blend A’ prototypes, this capitation element covers Band 1 care only – any treatment required under Bands 2 and 3 is subject to patient charges. ‘Blend B’ prototypes extend the capitation element to cover Band 1 and Band 2 care. Practices are expected to deliver all necessary care to each patient on the list within their overall contract value.

However, many prototype practices have had to invest in additional clinical staff to make it work. A new wave of prototypes aimed to sign up 50 more practices by March 2019. But it is too early to see how this has gone. Success or failure in this new wave of prototypes will be a litmus test for appetite for the new contract. We eagerly await results.

But for now, dentists continue on with the UDA contract and all its idiosyncrasies.


Reena Popat – Managing Partner at Carter Bond Solicitors

More than 3 years of deliberating, retracting a testing and we are still nowhere near seeing a conclusive policy. You would be forgiven for thinking we are talking about Brexit. Instead we are discussing a major NHS reform that is still yet to be decided amid an upcoming 2020 implementation date. NHS Dental Contract reforms have been part of the Conservative manifesto since 2016 and after numerous pilot studies it seems no end is in sight for the final version.


Increased waiting times, reduced availability

The contract introduces a requirement for practitioners to carry out a full oral health assessment for their patients. At present this takes over 20 minutes. While this will only apply for patients at the start of the contract and then after reasonable intervals, it indeed creates a problem of increased waiting times and reduced availability.


True self-employment?

As most in the dental profession will admit, the goal of most dental practitioners is to work on a self-employed basis having the freedom to choose when and where to work. With a system that is built on capitation and activity renumerations, this takes away the control self-employed dental practitioners will be entitled to in respect of running their practices how they see fit.


Time-limited contracts

In 2015 the Treasury released a report that suggested practices would have to re-tender contracts every 5 years. This policy was introduced to be in line with EU regulations. Following the United Kingdom’s plans to leave the EU, this policy could still be removed in the final UK policy. The truth is, even those in the dental industry are not sure what the new changes will be or what they will even mean. A source told us that “they have been running new pilot schemes since I was in University, we are still unsure what the final outcome will be and if it will even happen by April 2020”.


Nicola Lomas – Senior Associate at Brabners Law

It is always difficult to second guess the NHS, particularly when there are so many different variations on the pilot schemes out there. However, as we have always known, the current system does not reward the contentious dentist who concentrates on prevention. The calls to move towards a mixed capitation/activity system are getting louder. Dentistry seems to fall behind on the political agenda all too often and reforms are now overdue.

From the perspective of a lawyer dealing with sales and purchases of practices, it is important that we keep a fluid system for practices changing hands, whether this be by way of the partnership route or perhaps something more transparent.


An Article on Dentistry.co.uk that speaks to Joe Hendron, a year after he withdrew his practice from the prototype.

The dental profession has been promised that roll-out in 2020 will be gradual and practices will be able to choose whether to sign up. They will not be able to choose which blend (A or B) to operate under but there will be an expectation, no doubt, on NHS England commissioners to sign up a minimum number of contracts year on year on the blending that the commissioners choose. As time goes on, the ability to sign up to the prototype style contract or stay with the 2006 contract will become restricted with eventual phasing out of the 2006 rules.

I very much doubt that there will be a ‘big bang’ as software companies and NHS England will be unable to cope with the changes that will be required. Training in the new scheme is essential both in the new ways of working, the new regulations and the IT changes in claiming and monitoring. Making time to get the changes right will make for a more successful transition – this is simply common sense. This government and their commissioners, however, have shown time and time again that this is not an attribute they possess and their impatience to push through policies and, in particular, procurements, leads to unsatisfactory outcomes for all parties involved.

Practices with stable patient lists will fare better than those with a higher turnover. Access targets will probably be set using the numbers of patients seen between 2016-2019, so knowing these figures at this stage and maintaining them up to the point of embarking on the new contract, will be a big help.

Practices which meet their UDA targets easily every year will fare better than those that struggle to do so. Do not be succumbed into thinking that the reduction in UDA targets in blends A and B will be the panacea to avoiding clawback. There is the more challenging access target to balance as well, as the three waves of prototype practices have found over the past eight years. All these practices were considered successful before signing up, achieving their UDAs year on year, but a significant number found themselves subject to clawback for the first time and still struggle to make the targets.

How to make it work? We need more time to provide the care for which we were trained, to develop a collaborative approach in our skill mix, and to get the preventive message out to those who need it. Reducing access levels by 10-15% will allow the time we need to do the job properly. In time, as oral health improves as a result, we will be able to increase the access – but there is no point in putting the cart before the horse.

The expectation for dental practices to do more for less must end. The money must follow the patient and all clawback should stay within dentistry. Investment in contract values is essential if the profession is to provide a safe and effective dental service which is capable of delivering the care that the population of this nation expect and deserve.


Conclusion

At Pluto Partners we pride ourselves on experience. Although no one can predict the future, with over 60 years of combined dental experience, our Directors aim to give you the most informative advice possible. That said, we believe current long-term NHS contract holders should consider executing their exit strategy. If you haven’t made a plan or aren’t aware of the current value of your practice, now would be a great time to give Max, our Director of Practice Sales, a call! As April 2020 looms, we expect a decrease in goodwill values as inevitable uncertainty will spook certain buyers. Although we might see an increase in dentists looking to sell their practice, it’s uncertain if the demand will match. Pluto can provide a comprehensive valuation for you in 48 hours. Amongst uncertainty, be informed and let us be part of your journey.

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