Summary of: Clinical decision making by dentists working in the NHS General Dental Services since April 2006

Key Points

• Dentists can be affected in their treatment planning decisions by financial pressures.

• Highlights the potential for conflict between a dentist's need to operate profitably and the quality of the clinical care that they deliver.

• Illustrates some of the challenges presented by one system of remuneration and discusses some of the tactics used by dentists to overcome them.

Abstract

In April 2006 a new contract was introduced that governed how NHS General Dental Practitioners would be funded for the services they provide. This study looks at the impact that the contract has had in the three years since its introduction, evaluating its influence on the clinical care that patients receive and the clinical decisions that dentists are making. This qualitative service evaluation involved interviewing 12 dentists representative of a range of NHS dentists working with the new NHS dental contract using a semi-structured approach. We found evidence that the new contract has led to dentists making different decisions in their daily practice and sometimes altering their treatment plans and referral patterns to ensure that their business is not disadvantaged. Access to care for some patients without a regular dentist can be compromised by the new contract as it can be financially challenging for a dentist to accept to care for a new patient who has an unknown and potentially large need for treatment. Cherry-picking of potentially more profitable patients may be common. The incentive is to watch borderline problems rather than to treat if a treatment band threshold has already been crossed and treatment may be delayed until a later course of treatment for the same reason. Dentists often feel that complex treatments (for example, endodontic treatments) are financially unviable. Some dentists are referring difficult cases that might previously have been treated 'in house', such as extractions, to another provider, as this enables offloading of costs while potentially retaining full fees. Younger and less experienced dentists may be further pressured.

Main

B. J. B. Davies and F. Macfarlane British Dental Journal 2010; 209: E17

Editor's summary

The imposition of the latest 'new' contract for NHS Dentistry in April 2006 was a cause of huge concern and anxiety for the dental profession in the UK. Dire warnings that it would not work were countered by political assurances that it would, given time and that it would enable a greater emphasis on prevention; a long hallowed goal in general dental practice.

While the direction in which the contract's effects were going necessarily took time to become apparent, since research also takes time to perform, report and publish this snapshot is based on interviews recorded a little over two years into the process. Yet they provide supportive evidence to both the pre-implementation warnings and the early subjective comments that the system of Units of Dental Activity (UDA) payments would skew the way in which dental care was provided, and not always for the best.

I commented in my first ever BDJ Editorial over six years ago (written on the kind invitation of the then Editor) on the inherent complexities of third-party payment systems and how any such arrangements, however carefully constructed, have inbuilt drawbacks that limit their ability to deliver unbridled oral care.¹ The qualitative approach used in this piece of research elegantly reinforces those observations with the real life experiences and reactions of those charged with working within the system.

With the next 'new' contract currently being wrought in the Steele-works of the Department the hope is that lessons will have been learned and a more rounded and objective arrangement will emerge. It is in everyone's interest that it does so. Whatever the outcome, the role of the BDJ as an archival repository as well as a contemporary vehicle of science, information and opinion will, I am sure, sediment this layer of NHS dental care as a rich seam from which health care historians will mine evidence for years to come.

The full paper can be accessed from the BDJ website ( http://www.bdj.co.uk ), under 'Research' in the table of contents for Volume 209 issue 10.

Stephen Hancocks, Editor-in-Chief

Author questions and answers

1. Why did you undertake this research?

This research was prompted by a desire to explore some of the largely anecdotal observations expressed by friends and colleagues working in or around the NHS GDS since 2006. Personal observations suggested alterations in referral patterns may not have been solely clinical and we wanted to explore this in a structured manner also. There seemed to be many complex angles to each question that we posed and many confounding and conflicting considerations. It was apparent that achieving scientifically robust quantitative research of the topic was unrealistic and hence the qualitative methods used allowed us to explore the more complex questions that arose with the aim of presenting these potentially sensitive and emotive issues with balance.

2. What would you like to do next in this area to follow on from this work?

This work aimed to sample a broad spectrum of the dental population. It is however acknowledged that dentists represent one end of a wide perspective, which in itself has massive variation in factors such as geography, patient bases, personalities, experience, training and practice. It is difficult to generalise across such differences and perhaps focusing research onto smaller subsets of the profession would be valuable. Furthermore, there is potential for other stakeholders in NHS Dentistry to see things very differently. A larger sample representing groups such as patients and commissioners could offer further insight and potentially contrasting perspectives that may further illuminate the subject.

Commentary

It has long been believed that payment systems influence clinical decision-making. The previous government proclaimed that the Item of Service' payment system encouraged excessive treatment. Whether one believes this or not, there is a widely held view that the 'New Contract' has the opposite effect, encouraging practitioners to do the smallest amount of work they can. This paper researches attitudes and effects of the New Contract to ascertain whether the belief that the new system has changed treatment prescribing by GDPs is actually the case.

It is very difficult to demonstrate changes in prescribing patterns, which prompted the authors to question a selection of dentists who work in the NHS and included some community and hospital dental personnel as well as GDPs. The interviews took place between August and December 2008. To some extent the new system was still rather raw and in an evolutionary state at that time, but certain themes did emerge.

There was disappointment that the promised shift towards prevention was not realised and there was a strong feeling amongst GDPs that 'short-termism' in planning dental care was being encouraged. The tension between the needs of the patient and the financial viability of the practice was being brought to the fore in a way it had not been previously. There was also agreement that the driver seemed to be towards 'simple' treatment and that the pendulum had swung too far away from complex treatment on the NHS.

The increase in referral of patients to both hospital and community services was ascribed to the financial implications of undertaking some forms of treatment but there seemed to be a relationship between treatment planning and the intended length of stay in the practice. Those who intended to remain for some years would take a more philosophical view that undertaking the initial work may bring a short-term loss but would reap benefits over the longer term – but, there are limits.

There was general agreement that there needs to be a much clearer definition of what practitioners are expected to provide under the NHS for the benefit of both patients and GDPs.

Reading the paper will bring greater insight into attitudes.