Among the many questions that dentists have about the impact of a reformed dental contract in England, is one about whether the corporate businesses will have an ‘edge’ when it’s introduced.
It is understandable that many may feel that the corporates, due to their size, are better equipped than the average independent practice to meet the requirements of a new contract, particularly if that turns out to be one with more emphasis on activity. However, it may not be so clear-cut that in this instance bigger is necessarily better.
I asked Eddie Crouch to explore the issue and whether the post-reform playing field really will be level…
Eddie: “Most of the issues that relate to prototypes seem to affect both corporate and non-corporate practices alike. The drive to maintain access levels to see enough patients and prevent the reduction in numbers affects all practices equally, as the time taken for oral health assessments (OHAs) is the key factor in availability within appointment books.
To mitigate this, all practices are working longer hours or taking on additional staff to achieve the throughput of patients.
Whilst corporate practices may have the ability to increase capacity by shifting dentists from one practice to another, this would have a knock-on effect on the practices they have moved from. It would also not be so easy when all practices are involved in any developed contract.
“Let us remember that the amount of clawback within England has risen from £50 to £80 million in just one year.”
Let us remember that the amount of clawback within England has risen from £50 to £80 million in just one year. All practices are struggling to hit targets, so moving staff around is hardly a benefit as it increases the risk of clawback within the practice the dentists have been moved from.
It is clear that having UDAs or any activity measure within a contract is favoured by the corporates, rather than a heavy capitation model, as this allows them to remunerate associates in a manner that, they believe, rewards them in an apparent comparator to work undertaken.
In a large corporate setting, patients may move within the practice from one provider to another. In a model dominated heavily by capitation this makes patient-tracking and, therefore, paying performers simply on patient numbers more difficult. Obviously in small practices with fewer options for patients to be seen by multiple performers, this is less so.
Later entrants to the prototype programme, such as the wave-three practices (those that moved directly from UDAs in 2016), are the best comparison we can get to a roll-out. In all of these practices, knowing that access fell in previous pilot practices after entry to the prototype programme, the numbers of patients rose ahead of entry.
“10% of the wave-three practices suffered clawback”
This would seem to have been a deliberate move to mitigate against the inevitable fall that happened to all participants in waves one and two, caused by the extra time needed for the OHA. But despite this, 10% of the wave-three practices suffered clawback, and this was not limited to corporate or non-corporate practices.
What seems more relevant than the type of practice is the area the practice was located, with practices in low-needs areas finding the transition easier due to the ability to move patients to longer recalls and therefore maintaining access levels.
We must always remember that the practices participating are the keen and eager, so the figures on clawback are even more worrying. To compound the access issue, only three quarters of wave-three practices hit delivery targets on UDAs.
Those in blend B (where capitation amounts to just over 80%) had better results but again this was not related to the issue of being corporate or non-corporate.
Turning to skill mix, once again the picture is perhaps less clear than in the pilots. It seemed inevitable then that larger practices with higher numbers of staff could utilise DCPs to deliver the preventive aspect of the contract and free up, via therapist delivery, time for dentists to carry out the treatment plan and OHAs.
However, many practices seem to have changed their minds with several appearing to move back to a more traditional model of delivery, especially those in blend A with a higher element of UDA needed.
“Another issue is the ability to recruit dentists.”
Another issue is the ability to recruit dentists. Many practices in the prototypes report difficulty in recruitment due to unfamiliarity with the contract. Certainly, recent reports from some corporates show they are choosing to hand back general contracts in areas where recruitment is a problem. One such closure in Appleby, Westmorland had recent coverage in the media. This is backed up by many practices reporting increasing difficulty in recruiting suitable dentists as a much wider problem than in previous years.
In conclusion, the previous assumption from the pilots was that the contract being developed was more suitable for larger practices with the ability to be more flexible in the delivery of the contract, and hence favouring the corporate model.
We must wait for the evaluation report to be published, but from my own information, I think that position is now not so clear due to the changes in the prototypes.
“What is abundantly clear is that there needs to be changes”
What is abundantly clear is that there needs to be changes to what is being tested in order to secure a business model that works for all the parties, patients, commissioners and, most importantly, dentists – whether they operate from a corporate or not.”
My thanks to Eddie for sharing his thoughts and highlighting what we can learn from what has already happened within the prototype programme in relation to this issue. It seems that the impact of reform might not be so obviously in favour of the corporates as some might think at first glance. Of course, as with many other aspects of the new contract, the answer to this question will only become clearer once more information is revealed about the specific nature of any new contract.