Searching for the goalposts
 

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Searching for the goalposts

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Searching for the goalposts

 

Searching for the goalposts

Kevin Lewis reflects on the original principles of the new contract and can’t help wondering where they seem to have disappeared to.

Has anyone seen the goalposts? I’m sure they were there in 2004 and 2005. I accept they had already been moved several times by March 2006, but now they seem to have disappeared altogether. The last time goalposts went missing on this scale was back in 1991 and 1992.

History does seem to be repeating itself, because here we are just nine or 10 months into the ‘new’ NHS contract. It was at precisely the same moment following the 1990 ‘new’ contract that the rules starting changing then, and the lesson from history is that only one year after that – in July 1992 – many of the most attractive tenets upon which that contract had been ‘sold’ to the profession were decimated, leaving mostly the bits that the profession hadn’t wanted in the first place. And let us not forget that the salt in those wounds was the 7% fee cut, nor the fact that April 2009 is just 26 months away.

The smoke signals from general medical practice are hardly encouraging; stories of medical GPs ‘earning’ £200k-£300k per annum are being widely trailed in the media, with Ministers readily available to be quoted as saying that this was never the intention, and all the extra money that had been put in had been intended to improve patient care, not to line the pockets of doctors. It is all a hauntingly familiar pattern.

A review of GP earnings has already been commissioned and we should keep our ears and eyes closely tuned to events on that front. The verdict and sentence is depressingly inevitable, I fear, but the evidence for the prosecution needs to be garnered just the same.

Much has been spoken about the ‘like for like’ underpinning principle of the new dental contract – the same money for broadly the same activity. Some PCTs have liberally interpreted this as meaning that they expect the same mix of treatment (in terms of referrals, or the provision of laboratory-related items like crown and bridges for example). Other PCTs have even tried to insist that practitioners continue to see and treat the same ‘list’ (sic) of patients. Which section of the regulations is missing from their copy, one wonders? Other PCTs are putting on the pressure to maintain the same balance between adults and children amongst patients receiving dental care.

A noticeable skew away from adults and towards children is already being reported and this could knock a big hole into patient charge revenue. Certainly not what the PCTs want to see. Blind Freddie could see from the beginning that a patient charge revenue (PCR) shortfall was potentially the most problematic outcome of the transition to the new contract. Hence the recent preoccupation with the prevalence of ‘continuation of treatment’ and ‘overlapping’ causes of treatment in particular. There are also concerns regarding ‘prescription only’ courses of treatment and ‘urgent treatment’ – all of which are yielding too many UDAs for too little PCR.

It is worth remembering that the ‘test year’ income, and hence contract value, was based upon the forms scheduled in the test year. Not the work that was actually carried out in the 12-month period of the test year, because some of this related to incomplete courses of treatment, and completed courses of treatment that were in the system (i.e. they hadn’t been processed, scheduled and paid for until after the end of the test year). But included within the forms scheduled in the test year was activity carried out in the months prior to the test year. In a normal year, the hope would be that the two would balance out.

No allowances were made for dentists who only started practice at the commencement of the test year, or midway through it. Irrespective of when any work was actually done, if the form wasn’t scheduled in the test year, then it (and the monetary value it carried) didn’t count.

It is particularly alarming, therefore, to see the underlying intention of the plans that have recently been agreed between The Department of Health and The Dental Practice Division of the BSA, regarding how the UDAs for the first year of the new contract will be calculated and reported.

In a true ‘like for like’ situation, the contract value would be paid in return for the UDAs scheduled before the end of March 2007. But the revised game-plan is that if you actually complete a course of treatment by 31 March, it will be credited to your 2006/2007 reporting year – in terms of both UDAs and PCR – if the BSA has scheduled it by 31 May 2007. There is even a further 10-day window – to 10 June 2007 – to extend the inclusion time in the case of forms that contain some administrative error that needs correcting.

The intended effect of these arrangements is to shoe horn another two months of patient charge revenue into the 2006/2007 year, and to squeeze 12 months of ‘activity’ out of what may not have been a full 12 months of activity (and hence, income) in the test year. This is actually quite good news for dentists who are struggling to meet their UDA targets, but not for those who will already have exceeded them. In the latter case, most of the UDAs scheduled in April and May 2007 will no longer count towards their 2007/2008 activity, and the net effect is that they will have carried all the overhead on these ‘excess’ UDAs out of their own pocket.

Sir Kenneth Bloomfield, when reflecting on the first two years of the 1990 contract, referred to the ‘perverse incentives’ that rewarded the wrong kind of behaviour. Seventeen years later we see the most committed dentists being penalised, and the talk is still not about quality but about trying to control the GDS and its cost.

In 2004 and 2005 practitioners were promised a ‘high trust’ system, but trust needs to work both ways. The language of the BSA’s technical guidance on end-of-year reporting is more adversarial than high trust in its flavour, and this doesn’t help. If the BSA’s stance is anything to go by, a moat is already being dug around the high trust system and the crocodiles will be following shortly. Any search for the missing goalposts may soon be called off, and a new search party sent out to locate the playing field itself.

 Posted on : Thu 8th - Feb - 2007

 

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