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Welsh Government’s Dental Contract Reform

 

The current General Dental Services Contract introduced in April 2006 remunerates dentists an annual contract value in return for providing an agreed level of Units of Dental Activity (UDAs). It is well documented that General Dental Practitioners (GDPs) are not happy with the current contract as they feel working towards an activity target is like ‘being on a treadmill’. Also some GDPs are reluctant to accept new patients because they don’t know the extent of treatment patients may require. UDAs are allocated based on courses of treatment and dental treatment is categorised in the various bandings, so for example a dentist would receive the same number of UDAs whether the patient needed 1 filling or 5 fillings.   Also UDAs are the main measurement of dental performance but does not give assurance of the quality of the service.

 

Cwm Taf University Health Board (UHB) is supportive of Dental Contract Reform and 3 dental practices were approved for the 1st phase in September 2017 and at least 1 additional practice will commence later this year. Therefore 10% of dental practices in the UHB area will be operating under Dental Contract Reform this year.

 

The UHB is currently reluctant to approve more dental practices as reducing contracted UDAs by 10% also reduces the amount of patient charge revenue (PCR) the UHB receives; the dental allocation is given to Health Boards net of PCR any shortfall in income has an impact on the UHB’s financial position. Additional funding has been agreed by Welsh Government should Health Boards approve a minimum of 10% of dental practices. This additional funding only funds the estimated shortfall in PCR for 4 dental practices so it is a risk to the UHB’s financial position should it approve more. Any significant reduction in PCR will have impact on other primary care dental services.

 

One of the criticisms of the current GDS Contract is that it wasn’t tested before its introduction in 2006.Therefore the UHB consider it important to pilot Dental Contract Reform on a small number of practices so lessons can be learnt not only in relation to any risk around funding but also the risk assessment process, to which there have already been several changes since Phase 1 was introduced in September 2017. There also needs to be the ICT infrastructures in place to support the new way of working and currently not all dental practices are computerised.

 

If the % of UDAs is further reduced under new contract a decision is required on how dental contracts are to be monitored to ensure probity and value for money. When the current contract was introduced it took several years before a process was fully agreed and implemented. GDPs need to be fully aware of what is expected from the start in order to avoid any misunderstanding.

 

The emphasis of Dental Contract Reform is prevention and also use of a different skill mix of staff within the practice. However, feedback from some dentists is they are concerned how this will work in a single surgery or small practice, where they may not have sufficient space to accommodate other practitioners. When the UHB initially sought expressions of interest to participate in Dental Contract Reform, very few practices were interested. Therefore a barrier for extending the number of practices will be convincing dentists that they will be able to work effectively under the new arrangements.

 

As the number of practices working under the new contract increases, there also needs to be a public awareness campaign. If the new ways of working are not publicised then it is a concern that there is risk of an increase in patient complaints.

 

 

How ‘clawback money’ is used

 

The General Dental Services Contract states that a Provider is only able to carry forward a maximum of 5% shortfall in UDAs to the following financial year, therefore any breach of contract greater than 5% requires repayment of funding to the UHB.

 

From the mid-year position in each financial year (i.e. 30th September) the UHB closely monitors activity, comparing actual performance each month to the expected levels of achievement. As the current contract started April 2006 the UHB now has 12 years of trend data to aid the monitoring process.

 

The UHB communicates with Providers during the financial year when there are concerns that the practice is likely to under achieve against their contract. Occasionally Providers will inform the UHB that they are expecting to fail to achieve 95% of UDAs and will agree for funding to be withheld during the financial year. This allows the UHB to offer the withheld funding to other dental practices or to invest in other dental services during the financial year so funding is not lost to NHS dentistry.

 

However, the majority of dental providers do not agree to a temporary reduction to their contracts during the financial year, even when the UHB considers that they will almost certainly not meet the contract target. As the UHB has 12 years of trend data, a judgment can be made during the year on the likely financial outcome so a decision can be made whether to invest in other dental services during the financial year.

 

The UHB currently has GDS contracts with 35 general dental practices for the value of £13m.  Every financial year since the introduction of the GDS Contract some dental providers in Cwm Taf have not met their contract targets; the number and value of repayment has varied each year. The UHB does not look for savings on GDS Contracts but when funding is repaid, it reinvests:

 

Ø  Offering additional UDAs to other practices when funding is released during the financial year which has resulted in additional UDAs being invested in Merthyr Tydfil and in Cynon Valley

Ø  Purchased equipment in order to commence a Minor Oral Surgery (MOS) service and sedation service for anxious patients in Primary Care.

Ø  Arranging additional Primary Care MOS sessions on weekends to reduce the waiting list.

Ø  Approving improvement grants for a number of dental practices to make them more accessible for disabled patients

Ø  Purchasing hearing loops for every dental practice’s reception desk along with Sonido hearing devices for use in surgeries.

Ø  Funding three Fluoride Varnish courses and offered to all  general dental practices for their nurses to attend for free

Ø  Purchasing toothbrushes, toothpaste & drinking cup for Health Visitors to give all under 3 year old children

Ø  Resources required for the campaign “Baby Teeth DO Matter”

 

Recovery of funding for 2017/18 underperformance is estimated to be 2.2% of the total GDS Contracts but the UHB has not yet completed the end of year review process yet so this may not be the actual amount recovered.

 

Cwm Taf UHB has an approved IMTP therefore the dental budget is no longer ring-fenced. However the UHB is committed to improving the oral health of Cwm Taf patients and does not have an access problem with more than half of dental practices accepting new NHS patients. When funding is repaid due to breach of contract the UHB takes the opportunity to fund new dental initiatives, as described above.

 

Issues with training, recruitment and retention of dentists in Wales

 

Recruitment is not currently a problem for the majority of dental practices in Cwm Taf and this is probably due to its proximity to Cardiff and the Dental School. However the corporate practices have reported that they experience problems recruiting dentists and this could be due to Brexit with European graduates less interested in coming to the UK. As with General Medical Practice, it has been suggested that younger dentists seem unwilling to commit to long term or extensive NHS involvement and don’t appear to be interested in becoming practice owners; preferring part-time working so as to have work life balance. As the current GDPs retire this may become more of an issue with possibly less experienced dentists unwilling to provide treatment traditionally carried out in primary care.

 

With the introduction of Dental Contract Reform and more use of a varied skill mix in dental practices there need to be a workforce plan to ensure there is sufficient supply of these individuals to support dental practices.

 

The provision of orthodontic services

 

There are no orthodontic specialist practices in the Cwm Taf UHB area and historically patients have always travelled to the specialist practices in Cardiff. When the current contract was introduced in 2006 funding was given to the Health Board based on historic spend in dental practices rather than based on patient population. Cwm Taf UHB therefore has little influence on orthodontic contracts as approx. £750k of funding for Cwm Taf patients sits with Cardiff & Vale (C&V) UHB.

 

There are concerns over the length of the waiting times for treatment as the UHB has been informed that referral to treatment is approximately 2 years. A recent survey of the waiting lists in C&V practices show that there are over 8,000 new patients with a further 1,700 patients assessed and on review waiting to start treatment. There have been previous reviews of orthodontic services undertaken which have stated that there is sufficient provision in Wales so there will be no further investment into the service.

 

It has been suggested that these long waiting lists are due to dentists referring patients too early for treatment and an audit of new patient referrals undertaken by the SE Wales LOC in 2015 showed 15% of patients had been referred early. This is an evitable consequence of long waiting lists.

 

The Managed Clinical Network for Orthodontics introduced a referral form in an attempt to reduce inappropriate/early referrals but this does not seem to have had any impact on reducing the number of referrals to the service. Although the quality of referrals showed positive improvements. It is hoped the electronic referral management system (eRMS) to be introduced across Wales by March 2019 will continue to improve the quality of referrals but ultimately the bottleneck is in treatment capacity.

 

In Cwm Taf there are orthodontic specialists working for the Community Dental Service but they do not accept referrals from GDPs. Currently CDS is managed by C&V UHB but will transfer to Cwm Taf UHB in April 2019. The service will then be reviewed as to how it can work more closely with the hospital orthodontic service.

 

Patients tend to be referred to the hospital service even though they do not meet the criteria for complex treatment as parents from the most deprived areas are not able to travel to Cardiff as no transport. This then has an impact on the hospital treatment waiting lists, particularly in Prince Charles Hospital, which is currently 2 ½ to 3 years.

 

In Cwm Taf there are 3 dentists with enhanced skills (DWES) in orthodontics who work in primary care practices. The 3 DWES work with the hospital consultants and would be able to treat more patients but are limited by their contracted Units of Orthodontic Activity (UOAs). They have a very small number of UOAs based on their earnings during the reference period prior to April 2006. 

 

The effectiveness of local and national oral health improvement programmes for children and young people

 

Designed to Smile (D2S) started in 2009 and teams visit primary schools to introduce tooth-brushing and fluoride varnish to young children. The D2S Team visit schools in the Community First areas but the UHB also funds a team to visit all the other primary schools not covered by D2S. So every primary school in Cwm Taf has the opportunity to introduce supervised tooth-brushing and fluoride varnish in schools. Unfortunately not every head teacher will agree for this oral health improvement programme to be in their school. The majority of schools participating are fully engaged with the initiative and the programme forms part of their accreditation under Healthy Schools Award.

 

The most recent survey of 5 year old children shows that across Wales there has been a significant improvement in children’s oral health in the last 10 years. However this improvement was not seen in Cwm Taf.  What we don’t know is would the levels of decay have increased if it wasn’t for the current oral health programmes in place? The UHB has made it a priority to improve children’s oral health and since September 2017 has now introduced a fluoride varnish programme for those schools not covered by D2S.

 

Since April 2017 the UHB now funds toothbrushes/toothpaste for Health Visitors to give babies/toddlers twice per year. They also provide the child with a free drinking cup to encourage the child to stop using a bottle.

 

Is it a factor that children’s oral health in Cwm Taf hasn’t improved because the number of children accessing dental services has decreased over the years? In 2009, 36,271 children attended a dentist in the previous 2 years however by 2017 that number had reduced to 35,158.

 

In an attempt to increase the number of children attending a dental practice, the UHB decided to pilot an initiative ‘Baby Teeth DO Matter’ in the Merthyr Tydfil locality (56.5% of under 5 year old children have dental decay). The UHB has not invested from the UDA contract into this initiative, other than a small amount to pay for advertising and promotion. There are currently 3 dental practices in Merthyr Tydfil involved in the pilot and they are linked with GP practices. A dentist or dental therapist visits the baby clinics to speak to parents of babies/toddlers to encourage attendance at a dentist. The 3 dental practices had their contracted UDAs reduced by 5% but their annual contract value remained the same. The 5% funding was used to pay for the dentist or dental therapist to attend sessions at the GP practices.

 

The pilot is only currently in Merthyr Tydfil but the awareness campaign has been publicised throughout Cwm Taf.

 

The pilot started in April 2017 and during 2017/18 the number of children attending a general dental practice has increased:

 

Ø  Total number of children increased by over 1,500 children (4.48%)

Ø  Total number of 0-2 year old children in UHB (target age group of campaign) increased by 16.9%

Ø  Total number of 0-2 year old children in Merthyr Tydfil (where Baby Teeth DO Matter is piloted) increased by 39.53%.

 

The most recent survey of 12 year old children shows that in Cwm Taf there has been an 18.5% reduction in the % of children with decayed, missing or filled teeth compared to the 2008/09 survey. So D2S has been effective in reducing the levels of decay in 12 year old children.

 

The UHB needs to continue with prioritizing children under 3 years of age and this will be aided by the refocus of the D2S programme. There is no one initiative alone that will improve children’s oral health but parents need to hear consistent messages from all healthcare professionals.