High and dry

This sorry tale might only involve over 100 dentists, but it is perhaps an example of how NHS England treats those who have spent years trying to help the Department of Health identify a better way of working/treating patients in the NHS than the UDA system.

First, a brief history of NHS dental contracts. For more than half a century, dentistry in the NHS was paid for by a fee-per-item basis, ie the more treatment that a dentist provided, the more (s)he was paid. On the other hand, the fees received a real time reduction year on year, and the scheme was often referred to as a treadmill, with ever increasing amounts of treatment being provided just to stand still regarding one's annual remuneration. However, given that the amount of treatment provided could not be predicted on a year-to-year basis (if dentists decided to work more hours, for example, or simply that more were recruited), and given that the Government wished to have a finite budget for dentistry, it became necessary to change to system to one that was cash limited. Furthermore, for the years that NHS dentistry has been in existence, the focus of the service has been mainly on treatment rather than prevention. This means that there is little visible reward for good dentists who are improving oral health and providing a service that patients like, and little sanction for poorly performing dentists.¹ Hence, in 2006, the introduction of ‘Units of Dental Activity’ (UDAs) and ‘dental contracts’ (without any piloting – some thought that this had been thought up on the back of a cigarette packet!) by which a practitioner contracted to provide a set number of UDAs for a contract fee, the so-called new contract. UDAs were awarded for three different bands of treatment, with values varying from provider to provider. The average is around £25, but the actual value varies widely. This means that the value of a Band 3 course of treatment, for which the dentist is rewarded with 12 UDAs, can range from around £200 in one practice to well over double that in another. This clearly is wrong. If the contract value is not met, the unmet UDA fee is deducted (‘clawed back’ being the nasty word for that!) Moreover, there are some clinical procedures where the banding assigned to them was perceived as unrealistic when combined with a low UDA rate. These procedures were simply not offered on the NHS by some dentists, examples being widespread, for example, molar teeth being extracted when a root canal treatment could have preserved the tooth, even if this was a breach of contract, or even negligent.