Welsh Government: Consultation to reform the GDS Contract

The Welsh Government has recently launched its consultation on a reformed NHS dental contract. While it will have no direct impact on provision in England, does it provide any indication of the potential direction of travel we may see in England? In this blog we will look at some of the key points from the Welsh Government consultation. 

The background to the consultation is much as expected. There is an emphasis on the issues with the UDA contractual system and the perverse behaviours it encourages. There is an overt statement on the purposes of reform: “The proposals set out in this document clearly show how prevention and access for children are incentivised from a financial perspective.¹” But are they?

The Welsh Government also clearly acknowledges how NHS payments have not kept pace with private fees leading many practices to focus on the latter provision, especially in light of ever increasing costs. 

There is, however, the old trope of recall guidelines underpinning access plans. The consultation is clear that the Welsh Government considers that many patients are inappropriately on six month recalls, having little or no disease. It considers dentistry perverse as a service which sees “well patients”. The proposal is to have contractual measures enforcing strict adherence to the NICE recall guidelines. This contradicts previous statements in the document which focus on prevention and ignores the fact that dentistry is not just about treatment of disease but prevention of disease and that oral disease is predicated on a range of patient risk factors and behaviours. 

This is not to say that there are no patients who could be on longer recalls, but it is to say that a focus on extending recalls, which is simply a way to use the same budget to see more patients, is a short term budget focused plan, not a plan in the best interest of patients. Patients who are assessed as being on a recall of more than 18 months would be put back into the Dental Access Portal system. This is to free up space at the practices and allow a central system to allocate space based on need. If those patients require urgent dental care in the meantime the system will guarantee them access to the original practice. 

That said the consultation’s objectives for dentists appear admirable²:

• “Reduce administrative burden
• Introduce a fairer and more transparent remuneration system
• Encourage dentists to commit more of their time to providing NHS services
• Enable skill mixing and making full use of the dental team
• Have clearer contractual controls to manage underperformance”

The contractual changes proposed include splitting the allocation of budget according to different priorities, Care Boards will be able to vary the distribution³:

•  “10% is allocated for urgent treatment for new patients – definitive treatment is mandated and in cases where definitive treatment is not possible it is expected that the patient is offered an additional appointment to complete the definitive urgent treatment. Practices must provide appointment slots at time required by the health board on a rolling six monthly basis. All patients will be supplied via the health board’s urgent access arrangements and the urgent fee is paid even if the patient fails to attend.
• 10% is allocated for new patient assessment – all new patients will be supplied by the health board from the Dental Access Portal with specific exceptions e.g. children where their parents are already NHS patients at the practice
• 70% will be available to provide care packages
• 5% is allocated for a prevention payment – This will require full compliance with Delivering Better Oral Health (DBOH), Fluoride application as per current variation requirements, prevention conversation and the provision of a tailored care plan based on risk and need
• 5% is allocated for local/national priorities – This will be specified annually, usually through negotiation, and could include elements such as Audit / Quality Improvement activity, Annual self-assessment, high needs areas/retention.”

The reformed fee scale is an interesting proposition. Fee for Item was considered and dismissed as too focused on activity over prevention and instead a new banded system with 14 scales is proposed, with an additional 5 for children⁴. The highest treatment bands Posterior RCT and Crown/Bridge work will be limited to 10% of the 70% allocation for care packages. Patients with exceedingly high needs “(defined as requiring ten or more interventions e.g. fillings/extractions, which include endodontic (root canal) treatment)⁵” will have their own pathway through the CDS. 

The timeline for submitting claims will be reduced from 62 days to 20 days to speed up end of year reconciliation. The Welsh Government argues that 90% of claims are submitted within 7 days so apparently this will not increase administrative burdens. 

Patients who miss appointments are a perennial issue for practices. The consultation makes it clear that this is tricky to solve without creating other problems and proposes that patients referred to a practice through the Dental Access Portal who miss 2 appointments for their initial appointments will be put at the back of the queue. This doesn’t help the practice directly but is hopefully an incentive to keep appointments and also directs the patient to the Care Board rather than the practice for an explanation. Patients in the midst of treatment who drop out or miss appointments will similarly be at the back of the Dental Access Portal queue and the practice will be paid a proportion of the work carried out to that point. 

In order to incentivise closer collaboration between practices there is funding for practices to meet four times a year. This will also be a contractual requirement, with failure to engage resulting in contract breach. 

Patient charges will be moved to a central online system administered by the NHS BSA and taken out of practices. Patients would receive a text or email after treatment. The proposal is also to reform the payments so patients will pay between 50 and 60% of the cost of care. This will result in some increased costs, but also some decreases. 

There are a lot of innovative ideas in the consultation, more than have been outlined here. Some appear good, such as moving patient charges to a central authority and out of practice (though we must be wary of digital exclusion for solely online payment systems), but some are going to be very difficult to manage such as a centralised appointment system which holds patients rather than practices. This fundamentally changes the nature of the patient/clinician relationship and it is not entirely clear why. Is it really likely that a central administrative system is going to be more efficient at managing patient flow than a practice if the system is using the information as provided by the practice itself anyway? 

We look forward to seeing how our colleagues in Wales manage these proposals and what eventually is implemented, and look forward with baited breath to see what happens in England next. 

1. Page 9 ↩︎
2. List below is from page page 10 ↩︎
3. List below is from page 12 ↩︎
4. Page 12, fee scales on page 13 ↩︎
5. Page 15 ↩︎