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NHS Dental Crisis Worsens

The implementation of the new Dental Contract is causing considerable chaos. Because of an error in the leaflet about the charges being paid for dentures the whole batch of leaflets about the new system have had to be withdrawn and reprinted. The Dentists Computer system is also not currently available which means that PCTs will encounter a cashflow problem as they will be unable to clawback charges. John Hemming MP said, "The DoH have budgeted for a 30% increase in charges to patients. They will have a cashflow problem if they cannot claim these back from the dentists. Their cash situation is particularly tight at the moment."

Documents leaked from the Department of Health that have been obtained by John Hemming MP show that the Department of Health is having considerable problems handling the developing NHS Dentistry Crisis

"The leak shows the Department are having a lot of problems handling the NHS Dental Crisis. One of the key changes is getting all the information centralised at the Department of Health. The notes say:
'For the introduction of the new contract a system of reporting from PCT to SHA to Department comms has been suggested so the Department can answer media questions without having to contact the PCT. The Department will produce a proforma for information requested, probably on a weekly basis for the next few weeks. It will be the sort of information the PCT should have anyway to answer local enquiries. Any good news stories or positive case studies would be welcomed by the Department.'
"This shows that the Department of Health are desperate for some positive stories to come out of the gradual phasing out of NHS Dentistry."

"The Department are also admitting problems with Polish Dentists ", said Mr Hemming
The Notes say:
'v. Funding for Polish dentists
Any funding for Polish dentists is part of the PCT’s allocations and if any dentist leaves before or after the three year contract then the money will remain with the PCT
There has been some difficulty with some Polish dentists underperforming and how this will relate to the new GDS contract.'

John Hemming said, "Although clearly as part of EU Enlargement people can move around the EU, It does worry me that government organisations are particularly targeting replacing UK dentists who have gone into debt to train as dentists en masse with cheaper dentists from Poland (or any other country). Polish dentists may be willing to work at £70 a day which is a lot cheaper than a plumber, but this approach is not a long term sustainable approach to providing reliable dentistry services. As people find out the costs of living in the UK they will stop doing this work and we end up in an unstable situation. The document leaked from the DoH makes this clear."

"The tightness of the finances are shown by the department's refusal to pay loss of earnings for Continual Professional Development training unlike the past."

"The Department are rightly preparing for large numbers of dentists not signing up to the contract. Their decision to allow people to sign the contract "subject to dispute" means, however, that there will be further bureaucratic nightmares that will seize up the arbitration system. It is a very unusual thing to have contracts signed where the terms are not actually agreed. This, however, will reduce the problems on 1st April.", said Mr Hemming.

"The contract itself is odd in that the PCT can cancel the contract at under a month's notice, but a Dentist has to give the PCT 3 month's notice or more."

"At 16th March only 1,648 Dentists out of the 6,007 who have agreed the new contracts actually know how much money they are being paid."

"An interesting decision of the department is that shortage of finance will not be permitted as a reason for refusing a contract. With PCT budgets being topsliced and the PPA withdrawn this will cause a further difficulties in that the PCTs have less and less control over their expenditure."

The following are extracts from the:
Senior Dental Leadership meeting – 16 March 2006
Notes of meeting
Devolving funds
There are at present two national pots of funds to be devolved worth £1M each
i. Travel and subsistence – a fact sheet soon to be available
ii. Audit money for Local Assessment Panels
These funds are from central budgets and there is no confirmation as to whether these will be paid next year but likely.
At present CPD and VT courses are claimed via the DPB, from money paid to them by the Department. In future this will be devolved to the PCTs. There will be a new FP84 form for dentists to claim travel (pegged at 23p per mile) but no longer loss of earnings payments. PCTs will have to have a system to pay dentists on the FP84.
Contract implementation
i. Progress in agreeing contracts
The numbers are going up rapidly, some are in dispute. If dentists are holding back, PCTs will need to have contingency plans to handle last minute decisions. Assurance to the public will also need to be available. SHA should hold a key role in solving the PCTs financial concerns.
ii. Progress in loading contracts
There should be no problems uploading the contracts with the DPB (BSA) but it is important it is done as soon as possible, otherwise problems will occur. At present 6,007 are in the system, of these only 1,648 have money values attached. Financial information has to be in the system by 31/3/06 otherwise dentist will not be paid. If money has yet to be agreed but a contract is to be issued, then send detail of contract as soon as possible and add money later. Please enter figures at 2005/6 prices on the contract as the uplift will be added automatically by DPB. (Even if sending post DDRB announcement on annual uplift). If this is not done the figures will be uplifted and create a financial risk to PCTs. CDO will be issuing information on payments to practitioners in the transitional period. Finance directors have been sent this information.
iii. Dispute resolution
Next week an advice sheet will be published on the PCC site as to how PCTs are to handle disputes. Local resolution is the first and most important step but can go to Litigation Authority. PCTs have to be open, clear and reasonable on any contracts in dispute and be able to defend their reasons (main disputes are over UDAs). It is very advisable not to say that a contract is not being issued due to lack of money from the Department. The Litigation Authority will not accept this as a legitimate reason for refusing what should be a strategic planning decision. PCTs may set themselves up for a financial risk if they argue the reason is lack of money. It would be helpful to have Board endorsement for any decision taken on refusal of contracts due to a strategic decision. SHAs should also be supporting these PCT decisions. Any dispute against primary legislation will not be accepted by the Litigation Authority (e.g. no audit payments made as none were paid in the test period).
iv. Replacing lost capacity
The tendering process is worthwhile, for value for money, if significant contracts are to be offered.
If a child only contract is being offered to a practice previously accepting all categories of patients (although not advisable) this can be done on a limited basis, so not locking the practice into a long term contract. Also the UDA value does not have to be the same. There would be a need to provide elsewhere the lost adult provision.
v. Changes being made to the model contract
There have been some changes made to the model contract by the Department and the BDA have been informed. None materially affect the contract, just a tidying up process. For contracts signed a variation order will be put on the web site for PCTs to issue.
Dentist to dentist referrals
The number of referrals will be monitored by the BSA.
Regulations only allow for referral for an entire course of treatment where the dentist accepting the patient will collect the patient charge and UDAs. If a dentist has seen a patient and made a decision after examination to refer, as they can not do the treatment, then the referring dentist will receive 1 UDA for the examination and collect the corresponding patient charge. The patient will be then seen as a new patient by the accepting dentist and start a new course of treatment at whatever band is appropriate.
Only with advanced mandatory services are split treatments allowed. The referring dentist would then collect the patient charges and UDAs. The accepting dentist would also be able to claim UDAs. This will only occur in cases such as surgical extraction of difficult teeth. Problems may occur in cross boundary referrals as patient charge revenue will be lost to the PCT doing the work. The BSA will be able to monitor this and the PCT may have to have an arrangement with the referring PCTs for cross charging if the sums are large. The SHA should be able to monitor this.
Replacement of lost appliances
Replacements will be charged at one third of band three. If a patient can not afford this there will be a form to fill in and the BSA will make a decision as to whether the replacement will be free (as in prior approval now).
Missed appointments
Good practice on how to handle missed appointments will be posted on the PCC web site. PCTs should agree how dentists should handle this.
Financial issues
i. General
It is recognised that budgets are tight. A number of PCTs are still holding back money for a) patient charge revenue, b) disputed contracts, c) dentists hold out on signing contracts. SHAs will look at redistributing any money PCTs do not commit.
ii. Forthcoming AWP
Previous AWP had some missing columns for PDS and Section 56. These have been looked at and will be on the next AWP. SHAs will written to with the final 05/06 prices and the adjustments that have been made. A formal AWP will be issued with 06/07 prices when the DDRB have announced the pay increase.
iii. Capital funding
It is possible that some capital funding may be available for PCT primary dental services (salaried). If there are any local developments that may benefit from capital investment then the Department should be contacted. The Department is also looking at any possibility for third party payments to practices (GDS). Any suggestion as to how this capital could be used should be sent to the Department.

iv. Central budgets
How these can be devolved to the NHS is being discussed (£3.7M occupational health service money, £1M clinical audit and a small amount of KITS money). This will be either in the general allocation to PCTs or ring fenced dental funds.
Travel and subsistence comes from a different central budget but its devolvement is also being discussed.

They will probably be devolved to SHA level.

v. Funding for Polish dentists
Any funding for Polish dentists is part of the PCT’s allocations and if any dentist leaves before or after the three year contract then the money will remain with the PCT

There has been some difficulty with some Polish dentists underperforming and how this will relate to the new GDS contract. Any contract variation is a matter for the PCT to agree. PDS agreements already have a generous UDA level so care has to be taken in negotiating down UDAs. Best way of handling this is by local negotiation.

vi. Vocational trainees
After April the present VTs will be paid by the BSA on the instructions of the PCT. The SHA will be cross charged for this as the budget allocations will have been removed from the PCT baselines.

No clarity as yet as to how the Deanery will be funded for equivalence training.

1,875 UDAs are applied to VTs in practice (15% less than they are now doing, on average). Any variation will need to be discussed by the PCT but money will not be taken away. These 1,875 UDAs will be split over two VT trainees and will need to be handled locally in the transition period. The money will stay the same.
Media handling
For the introduction of the new contract a system of reporting from PCT to SHA to Department comms has been suggested so the Department can answer media questions without having to contact the PCT. The Department will produce a proforma for information requested, probably on a weekly basis for the next few weeks. It will be the sort of information the PCT should have anyway to answer local enquiries. Any good news stories or positive case studies would be welcomed by the Department.
Fluoridation
A Bill is being taken through the European parliament on fluoridation in which some anti fluoridation MEPs have placed an amendment that may almost make it impossible to use fluoride in water or foods. The Department is monitoring this.

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