Nigel Jones talks to Nishma Sharma, clinical adviser for NHS England, and Martin Woodrow, chief executive of the BDA.
It scarcely needs saying again that the past nine months have been turbulent and highly challenging for the profession.
Whether you are in a position where you feel you have finally got back on your feet and into a new rhythm of working, or whether you are still struggling with what has happened and what is to come – the resilience and adaptability of the profession has again shone throughout.
The behaviour of the profession during this time and as we move forwards is something I recently discussed with Nishma Sharma and Martin Woodrow. We also talked about how the way the profession acts now could impact the reform of the NHS contract. As well as what the timescales are to implement this.
Since the pandemic the slowness/lack of communication from the powers that be was a source of frustration. How did you feel about that?
Nishma: My sole role at the Office of the CDO is as the voice of the practitioner on the ground. There are people working at decision-making levels around the table who have not done a UDA in their life. They wouldn’t understand how much a band three is worth.
I feel like my purpose over the past few months is to pass on what is happening on the ground. And my frustrations were well and truly known and felt!
It wasn’t a frustration with my colleagues at the Office sitting around postulating and not doing anything. It was that the hard work was being done, but it just wasn’t cascaded through because of the way in which the system operates.
I saw it first-hand, the frustrations and constraints the CDO had to work under. It was horrible. That’s why other methods need using, such as speaking to magazines, going online or using social media.
All I was concerned about was getting the communication out there about how we get back to work safely. It was frustrating not getting through, but it was not for lack of trying.
Martin: I think we’ve all felt similarly frustrated to Nishma about the pace of things coming out of NHS England at times. It’s not necessarily the people dealing with it either in the Office of the CDO or within NHS England. But the machinery of government just takes a lot of time to churn through. And it’s not dentistry specifically – it’s for all of the professions.
Nevertheless, we’ve been able to work effectively with NHS England, to point out the challenges and restrictions facing practices. We also have to be realistic in terms of what we can expect them to do from a contractual point of view. And they’ve taken that on board.
The framework we’ve got at the moment is fair. It recognises the limitations that are on activities going backwards to the period before the 8 June, where practices began providing care again.
Then there was a long discussion about the abatement. So the reduction in their contract value reflected the expenses that weren’t occurred around things like lab bills at that time and materials.
It was a really long, painful process to get that particular piece of work over the line.
At the end of May, just before we did come back to routine face-to-face care, there’d been a piece of advice. A prompt to prepare as the CDO called it. That had been sitting around for eight or nine days that they tried to get it out prior to that and hadn’t been able to. That was hugely frustrating.
And quite rightly, the profession. Gets upset in a period of time where they’re already under stress and strain.
What do you think that the future holds, particularly when it comes to the reformed NHS contract? What can the profession do to influence this?
Nishma: I think the way forward for our profession is to engage as much as we can. To do that we need to learn the rules of the game. Figure out who does what, because that way you can have an intelligent debate and negotiation.
I also think when it comes to moving forward, it is about behaviours.
Just do what’s right by the patient within your own capabilities so that we can prove that capitation works. If we don’t, it does go back to the UDAs. Which, as we know, is a completely broken system, incentivising bashing out widgets.
If a crown was clinically required and necessary six months ago, why isn’t it now? Why is there this drop all of a sudden if you’re able to carry out AGPs?
If you are and you’ve got through your backlog of pain patients and incomplete treatments, there’s no reason why you can’t start seeing children and more routine or high-needs routine work.
We need to not try to play the system. We need to behave and do the right things.
Where you can do it, do it. We will reap the reward from that as we come to a reformed contract that works better for everyone.
I have faith in that system. I have faith that something will need to change because we can’t go back to what we were. But it’s a very real threat if the indicators show that we can’t be trusted or a few bad apples spoil the cart.
We just need to work together on this.
Martin: It feels as if since 2011, there’s been a very conservative approach to contract reform; a real reluctance to take a leap of faith and move ahead. There’s been constant reinvention of the process of prototypes and, before that, pilots.
Could this be the thing that breaks the logjam? Necessity is the mother of invention. At the moment we’ve had to design a contractual framework at very short notice.
While what we’ve got as a current temporary arrangement can persist, we are discussing with NHS England ways to change that.
I think that there will be a gradual change across the second half of this year.
Necessity means that from April 2021, we will actually need a new contractual framework. In the current environment, the UDA, apart from being deeply unpopular and really not fit for purpose, and a contract based on chasing activity, simply doesn’t work. So, we have to do something different.
Across the backend of this year, I think we’ll see a fairly simplistic framework and a bit of change there. That will give us a bit of room to have something from April next year.
Now, normally you’d say that’s just not going to happen in six months’ time. But given the circumstances, it actually is more likely than it was previously.
It may be something that needs developing and needs to be iterative. But my hunch is that we’ll probably see things develop that way and that we may well, by necessity, need to move relatively quickly.
Martin, what’s your sense of optimism that the government will accept the recommendations of the recent Short Life Working Group (SLWG) report into the resilience of mixed and private practices?
Martin: Private dentistry’s left in the same place as lots of other businesses. In some senses, dentistry is in a worse position given that associates rely on private income. If they earn more than £50,000, they were struggling to get even self-employed support. It’s a real problem.
We’ve made the case time and time again to the Chancellor that there needs to be more support.
The report by the SLWG makes a number of recommendations to support dentistry. Particularly private or mixed practices.
For example, it says there should be an extension of the original job retention scheme for the sector. It makes recommendations about repayment terms for the business interruption scheme and business rate relief for dental practices. This is one of the real bugbears that we’ve had during the pandemic.
We’ve long articulated the argument that NHS dentistry provision relies on the private sector. More than 50% of the money in dentistry patients spend on private care. And there is a huge interrelationship between the two parts of the dental sector that cannot be unentwined easily.
The issue is that, important as we think it is to the health of the nation, we are one small business sector, and it is difficult to have a voice.
What is easier for us in the sector is to influence the people that we can influence. Those that we have a relationship with. Such as NHS England and the Department of Health.
We’re in a different environment now. The Treasury has had intense lobbying over the last few months from groups of MPs raising the issue of the status of private dentistry. Very unusually, even when a group of 20 plus MPs wrote to the Chancellor, they didn’t get a reply to that letter. And that’s hugely unusual.
I think it just demonstrates the amount of pressure that the Treasury has been under, as we all have been.
But that is a concern. We won’t let up on it, we’ll continue to persist and badger them on it.
I’m an optimist. I’m not saying that we’re going to get something out of it, but we will make every effort that we can to do that.
And Nishma, how optimistic and positive are you about the potential silver linings of this very big cloud we’ve been living and working under?
Nishma: There are so many positives. One is that there was collaboration between these huge organisational beasts that govern the profession. So I hope this will end siloe working.
Pre-COVID-19, a piece of policy would take nine months or a year to put into place; during lockdown we were whipping it out within weeks.
When you focus, when you collaborate, when you know you have to do it, we can do it. It shows the power of people working together is much greater than people doing things in bits and duplicating efforts.
There is a whole world of dentistry outside of the four walls of drilling, filling, suction, repeat over and over again. There’s this whole political arena. And I don’t think enough emphasis is placed on training dentists into knowing what that arena is and how it works.
It’s a game of chess. If you don’t know the rules of the game, you don’t know what you’re playing, you’ll never be able to checkmate. And I do think it suits decision makers, keeping dentists in the dark. That way they can checkmate us over and over again. You think you’re getting somewhere, but you’re not.
So, it’s time for the profession to engage, and there’s the silver lining. People now know who these organisational bodies are, who the CDO is, what the commissioners do and the difference between them all. It’s about educating yourself beyond clinical dentistry.
From the ashes rises the phoenix and I think we’ve finally got a voice. People have galvanised, started lobbying and it’s gained momentum – and that’s what we need. Private dentistry finally has a voice.
I can’t praise enough the local dental networks and their chairs; they’re all acting like mini CCGs that are influencing local and regional policy. They will just become stronger and more pertinent as time goes on, especially if we have local lockdowns.
And lastly, the country saw a world without dentistry and it was rubbish. Elected officials, the NHSE and most importantly, patients are finally starting to notice us as a profession. They value us again!