General Dental Practitioner Committee Report

General Dental Practitioner Committee Report

6th October 2017

Summary:

• Statutory levy collection is a problem in many areas due to the BSA only able to collect a single amount from the NHS England local team area. A discussion with the BSA will take place to find a solution and/or change the computer system that handles this.
• “Check by One” has been launched as from July 2017 and a UDA claim can be made for seeing a child under one even though an “examination” hasn’t taken place.
• “Starting well” initiative being piloted in 13 area. Funding will different in the various areas but there is no national policy on extra funding.
• Contract reform will roll on with prototypes continuing for another 2 years with additional practices being taken on as prototypes. Widely accepted that blend A is failing but blend B has some workability.
• DDRB will have evidence supplied to them to attempt a greater than 1% pay rise for 2018, however due to the relaxation of pay restraint in other public sectors there is worry that NHS workers’ pay could be used to fund this.
• The GDPC will implement some changes to the committee’s working practices to reduce the stress or worry of newer, younger members joining. This would include reform to the associate’s group to include associates that have never owned a practice.
• Hepatitis B vaccinations are short in supply and advice is that staff members must have full immunisation with a titre proof prior to working chairside.
• The relationship between the GDPC and CDO has become frosty. Highlighted with a lack of consultation prior to the CDO office undertaking their record keeping survey to practitioners
• Some NHS England local offices have acted on practice shortcomings due to PCSE (Capita) failings with performer list addition implementation prior to national guidelines. Those dentists put out should request a local review of their circumstances in light of national guidelines.
• Draft papers for the implementation of Tier 2 endodontics and surgical extractions have been released but they have been poorly accepted by the BDA with many failings evident. Least of all legal defence questions which go unanswered.
• BSA have published a summary of £60 million clawed back from underperforming contracts in England last year.
• GDPC has signed off all the agreed motions from the LDC conference and feedback from actions generated by them will be filtered back through the year.
• The GDC have been challenged on the ARF being kept at the same high level from last year with no response to date.
• NHS superannuation is under review from the assessment the 2015 year. An overall employee contribution of 9.8% was required from all the NHS staff in total, however 9.3% was achieved. It is widely believed that no benefit or contribution change will occur with this review.

Dental check by one scheme is one which aims to encourage attendance among children under one years old. It was clear that this was a positive policy initiative but the office of the Chief Dental Officer has been unable to confirm that guidance on UDA claiming for pre-cooperative children would be published before the scheme was launched. It was felt that this matter was one of many areas where there had been a lack of engagement and consultation on a number of areas. These concerns will be raised at the next meeting of the Strategic Dental Quartet.

Starting well launch events took place on September and early October in 13 local authority areas. The programme involves practices being offered additional funding to target children under five and fully implement delivering better oral health. Practices would also be able to apply for funding for outreach work.

With contract reform there have been issues with the current prototypes and it was clear that many prototype practices were struggling with the business model in particular. A quarter of wave three prototype practices had been subject to clawback and this raised fundamental questions about whether a roll-out would be viable. There has been a meeting of the department of health finance working group, which had agreed that desktop modelling of different patient weighting and capitation registration periods would be undertaken. There were also carious other financial matters relating to the contract reform process and roll out, such as a computerisation allowance and rent reimbursement, that might form part of the negotiations.

The view was that weighting should seek to reflect the time taken to treat patients and that age, sex and deprivation might be appropriate indicators of this. Tying weighting to individual patient’s RAG status would be inappropriate and a cohort weighting should be used. In addition, there was a risk in basing dentists’ pay on the behaviour of patient over which they have little control.

The use of UDAs in the new contract were discussed and that if the contract is to be similar to the Blend B prototype then an item of service could be used for the activity element of the contract making it easier to treat high needs patients. There remains concern that preventative advice is not valued in the way activity (fillings and crowns) is and there is a question over the oral health and financial sense of this. There is also concern about the department of health asking dentists to prevent the need for treatment while also measuring treatment and setting targets for treatment levels.

It now appears that the department of health would be open to different models of remuneration within a reformed contract. The GDPC would need to determine which options it would support being included as possible remuneration models. It would also be necessary to ensure that the choice over which remuneration model is used is decided by the provider and not commissioners. Providers should also have the flexibility to change between remuneration models. It is agreed that it would not be tenable for the current UDA system to remain an option within the new contract.

It is felt that the department of health’s stated aim is “to improve access, quality and appropriateness of care and improve oral health, within the current cost envelope, in a way that is financially sustainable for dentists” is incoherent. It would not be possible to do more, whether that is increased access, activity or quality, within the same funding in a way that does not reduce dentists’ incomes. It was not viable to expect practices to provide that additional investment needed to make a reformed contract viable. There is also the possibility that NHS England would seek to negotiate a new, rather than a reformed contract. It was felt that through these negotiations the BDA should also seek occupational health, 24 hour retirement, the ability to transfer contracts more easily, support with the costs of indemnity, changes to the tolerance on delivery, protected time for enhanced CPS and clinical audit.

A meeting was held with the department of health on 30th August 2017. At which further efficiencies were discussed. The DoH wishes to find £22billion in efficiencies across the NHS, which is what was agreed between the DoH and the Treasury (HMT) in exchange for an additional £8 billion in funding. As part of this £2.2 billion is required from primary care. NHS dentistry has delivered well on its expected efficiencies; seeing more patients within the existing budget, however pharmacy have done better. If the 1% pay cap was removed they NHS England would still be expected to find this loss of efficiency from elsewhere.

The increase in patient charges had replaced a lowering of expenditure on NHS dentistry but the increased revenue of £200 million has not been sufficient to deliver the required amount, so it is likely that increases will continue. The DoH do not see it as a problem that more and more practices will be finding the patient charge revenue will be greater than their UDA value.

In regards to specifically orthodontics, the DoH has confirmed that NHS England does intend to develop a new orthodontic contract but this process had not started yet. NHS England would first decide what they wanted to achieve with a new contract and would then approach the BDA and BOS. They believe that the current contract wasn’t fit for purpose, even though the BDA did not feel this was an accurate portrayal of its position.

There has been development and drafting of an accreditation process for a tier 2 level for endodontics and surgical dentistry. However there is no mention of where funding would come from or the remuneration level for the dentistry. The definitive “accreditation of performers of level 2 complexity care” guides are due out very shortly. In the meantime, the BDA has responded:

“The BDA has submitted detailed comments in the spreadsheet provided however some of our comments will not fit within that pro-forma. This document captures those comments as a supplementary document to be considered with the comments in the spreadsheet.

We are particularly concerned about the lack of clarity around paediatrics and special care dentistry particularly when there are NHS England speciality commissioning guides for both. The provider document mentions paediatrics but not special care. As these documents stand it is not easy to see how community dental services, which are often commissioned to provide level 2 and 3 services, would easily fit in with the arrangements. Would such services, being specialist led not need to gain performer accreditation for level 2 provision? Most CDS dentists are currently undertaking some or all the level 2 procedures but it would not be easy for them to put together the evidence for paediatric or special care dentistry level 2 competencies to the degree that is being proposed for endodontic and periodontics care. Many community dental services are under contract that would not be re-tendered for up to another 10 years making it impossible for the MCN to influence the services specification to aid dentists in achieving tier 2 accreditation.

Also, there seems to be a requirement for the MCN to develop the accreditation panels. How will this be funded? Will the member of the panel be appropriately remunerated? The panel will need significant amount of administrative support and time to fulfil its function. There is also a requirement for consultants from other areas to be involved, again this will require a large commitment of time. This cannot be provided on goodwill. In areas with few consultants and specialists (as is the case with paediatrics and special care) how will these panels be staffed? Will this role be included in the job plans of those involved?

The recently circulated documentation around the formation of MCNs indicates that they can be specialist led, therefore they may not have any consultants. Will this be taken into account for the accreditation process and those applying?

The panels need to be open to scrutiny and a conflict of interest policy and register of declarations of interest will be required. There also needs to be an outline of the appeals process for unsuccessful performers and support to allow them to achieve the missing requirements.

Building log-books and portfolios for tier 2 accreditation will be a huge task and the size of this undertaking by individuals must be recognised by NHS England. The document does appear to set the bar at a very high standard. We don’t think that many applicants will be able to provide references from 2 consultants and have WBAs unless they have undertaken formal specialist training or possibly a master’s degree.

From our analysis of this programme of work, more needs to be done to reassure the profession that this process will be of benefit.”

The BDA have undertaken date collection from the BSA in regards to clawback form provider contracts. In 2015/16 the clawback across England was £54 million, higher than in both the year before and year before that. This is equivalent to 2% of the total dental spend. 18% of all English contracts had clawback with an average of £26,000 being clawed back from each of these practices. For Surrey and Sussex the clawback for 2015/16 was £1million form 124 practices (out of 645 total contracts in our area) and “over” delivery was just £1000 from a single practice. In previous years (2013/14 clawback was £2.7million and 2014/15 it was £3.2million)

Business and NHS team top 10 member issues: The BDA’s Business and NHS teams have received enquiries from members on a range of issues.

The most common queries recently have been:

1. Year-end performance and predominantly underperformance caused by the Capita performer’s list failings

Throughout the contractual year 16/17 some members experienced problems getting performers added to their contract and performers added to the performers list. The delays have been largely caused by Capita. In some instances this has led to issues with meeting their contractual targets.

The advice that has been given throughout the year is:

I. Endeavour to meet the contractual target by other means

II. Keep a paper trail of all contact with NHS England and Capita

Following year-end we have also been advising that members raise a formal complaint with PCSE and with their Local Area Team.

2. Orthodontic agreements where members gave notice on their agreements and were threatened with sanctions such as referral to the GDC/PDLP in one case.

Members terminate their orthodontic agreements with NHS England for a variety of reasons. Often this can cause NHS England more issues than with GDS contracts because of the way the contracts are funded. Orthodontists are paid for case starts as opposed to case completions and therefore termination with 3 months' notice means that some CoT will need to be transferred and effectively paid for twice (once to the terminating practitioner and once to the practitioner who takes on the case). In practice, the incoming practitioner will usually come to some agreement with NHS England.

The advice that has been given here is:

I. Standard PDS Agreements can be terminated with 3 months’ notice (individual agreements will be reviewed by advisors to confirm this)

II. NHS England should not refer on the sole basis that the Agreement has been terminated GDPC 2017 077 2

III. The responsibility for the patients remains with NHS England once the Agreement has been terminated.

3. Patient complaints

The NHS team receives calls on a regular basis from members about patient complaints either made directly to the practice or via internet forums such as NHS Choices. The advisors tell members to follow their practice policies and to make sure the complaint is fully investigated, communication is good with the complainant and that any lessons that can be learnt are learnt.

4. Medical history taking

Common questions asked about the medical history form include how often the history should be taken and how often the patient should sign the form. The advice given is that the history should be reviewed every time the patient attends the practice even if the patient attended recently and this is only to confirm the history is still accurate. The form should be signed each time a new form is used and initialled each time amendments are made and ideally the patient attends to confirm its accuracy. It should also be noted in the patient’s notes.

5. Storage and retention of records

The advisors are regularly asked how long records should be kept for. The below table shows the advice given:

Form Used for Keep

FP17Claim formSent to BSA & kept for 2 years

FP17DC Form Treatment plan 11 years or until the patient is 25 – whichever is longer

PR Form Patient Eligibility 2 years

6. The new data protection requirements

Members are being contacted by companies regarding the proposed new data protection requirements. The advice on the requirements is currently being developed internally however the advice stands that the legislation has not yet passed through parliament and is not yet law and therefore does not yet apply.

7. Starting a new/buying a practice

Members ask for information on how to purchase or start a practice. The advisors will talk through the process with the member and provide the written advice materials which are comprehensive.

Courses are also being planned for spring to cover these topics.

8. Breach notices for data protection breaches

Data protection breaches are also breaches of the terms of NHS contracts/agreements. Therefore where members have breached data protection regulations and the NHS is aware, it can result in a breach notice. The advice given is that breach notices, where properly served, are the correct responses as the breach cannot be remedied however steps should be taken and evidenced by the practice to ensure this does not reoccur.