The introduction of the new Complex Care Pathways (CCPs) marks an important change in the NHS dental contract. Their aim to provide more personalised, preventive care for patients with the greatest treatment needs, is one we support.
For too long, the NHS contract has struggled to recognise the time and complexity involved in managing patients with extensive disease. The principle of moving towards longer-term care, prevention, and behaviour change is therefore welcome.
However, the success of the pathways will depend not on their ambition, but on whether they are practical, adequately funded, and workable in everyday practice.
We have secured several important changes, but significant concerns remain.
Where we secured improvements
Early proposals required dentists to use the International Caries Detection and Assessment System (ICDAS) to grade caries when starting a pathway.
Making ICDAS a contractual requirement would never have worked; it would introduce unnecessary bureaucracy without reflecting the realities of delivering NHS dentistry in busy practices.
Although the guidance still requires clinicians to record the diagnosis and depth of active carious lesions (with ICDAS cited as one example) it is no longer a mandatory contractual requirement.
Similarly, the original proposals failed to address what would happen if patients required unscheduled care during a six- or 12-month pathway. Following our representations, dentists can now claim for unrelated urgent care alongside a CCP. This was an important and pragmatic improvement.
Underfunding remains a central problem
Despite these improvements, the central issue remains unchanged.
The pathways continue to be underfunded.
While payments are generally higher than those available under traditional banded courses of treatment, they still fail to reflect the enormous variation in clinical need between patients.
A patient with five teeth with caries into dentine and another with 20 teeth requiring treatment attract the same pathway payment despite requiring vastly different amounts of clinical time.
In effect, the pathways risk recreating many of the same problems seen within the existing Units of Dental Activity (UDA) system where there is a broad block of payment that doesn’t increase as the work involved grows. If treatment need falls at the lower end of the possible range, then the payments probably cover costs, but you’re quickly back into making a loss once treatment need increases even marginally.
Dentists can’t be expected to take on this extra work without remuneration for it.
We have yet to see the financial modelling underpinning these payments, and it remains unclear how they adequately reflect both clinical costs and the significantly increased administrative burden. The CCPs have far greater reporting requirements, alongside monthly declarations to trigger credits. Dentists can’t be expected to take on this extra work without remuneration for it.
Endodontics remains inadequately recognised
One of the clearest examples of underfunding relates to endodontic treatment. The NHS already acknowledges the additional complexity of non-molar root canal treatment through the introduction of Band 2c.
Yet under the pathways, that same treatment is expected to be delivered within the pathway payment, regardless of complexity.
If laboratory-made appliances can attract concurrent payments because of their additional cost, it is difficult to understand why endodontics should not be treated in the same way within the pathways.
Who carries the financial risk?
The pathways also introduce a new financial risk.
If a patient disengages from treatment after substantial work has already been completed early in the pathway, practices may recover only a proportion of the pathway payment despite having incurred most of the clinical cost. In this case, the treating dentist would incur the costs but only receive a fraction of the payment.
This risk is particularly acute for new patients, where engagement and attendance for this cohort of patients cannot always be predicted.
Non-periodontal treatment and Complex Care Pathway 3
Some decisions to prohibit concurrent claims also remain difficult to justify clinically. Eligibility of the third care pathway is based on periodontal disease levels, and it is possible to treat other need in a separate course of treatment ahead of a CCP 3. However, if further non-urgent treatment need arises during the CCP 3, then a concurrent Band 2 claim is not permitted.
Why are broken teeth excluded?
Relatedly, even for CCP 1 and 2, broken teeth are not included in the eligibility criteria. This means that if a patient has caries in four teeth and one broken tooth that requires roughly the same clinical work as treating a patient with five carious teeth, the payments will be significantly different. NHS England says this is about the CCPs being ‘disease pathways’, but if the goal is to treat high needs patients this exclusion seems illogical. If the purpose of the pathways is to improve care for high-needs patients, these anomalies deserve reconsideration.
Dento-legal responsibilities
The pathways are described as optional, and we welcome confirmation that eligible patients may still be managed under the existing banded system where clinically appropriate. However, it has introduced new potential for dento-legal risk and does not remove the professional responsibilities placed on dentists.
As dentists, we’re required to set out and explain to patients the different ways that we could manage their needs. We must do so in a way that always puts the patients’ interests first. This means, where a patient is eligible, setting out the CCP as a treatment option for them to consider.
So, the ‘option’ is not to take or leave the pathways altogether but is a new option to discuss with patients. That inevitably creates additional administrative work and introduces new dento-legal considerations. It is important dentists document the reasons if a high needs patient is eligible but not treated under the care pathways. This is especially important as the patient charge is potentially less under a care pathway compared to a course of treatment under the UDA system for the same clinical presentation. The variation between patients, however justified, has the potential to lead to complaints.
Len D’Cruz has helpful advice on how to manage this, but a joint statement from NHS England, the indemnity organisations, and the GDC that sets out the expectations on dentists would help to manage and mitigate these risks.
Monthly declarations add complexity
Monthly declarations have been introduced to trigger monthly credits, but this introduces a new administrative burden. If this only takes one minute to check and confirm, then that is a cost of over £40 to the practice over CCP 2. If the dentist has 30 open CCPs, they are losing half an hour of clinical time per month.
While there is an ability to submit late declarations within the pathways, practices will need to spend time monitoring if the treating clinician is on top of their administration to avoid payment credits being lost.
Across multiple active pathways, these declarations represent a considerable amount of clinician time. Time that is neither recognised or remunerated.
Practices need clear and reliable reporting
If practices are going to be able to make this work, then the reporting via Compass is going to need to be clear. They need easy to interpret information to support accurate payments to associates and dental care practitioners, and to manage contract delivery.
We’ve already seen challenges with how unscheduled care data is shared back to practices. It remains to be seen exactly how the CCPs will be presented, but there has to be easy-to-interpret data that is trusted and reliable. It must be clear to practices how many CCPs are active, where monthly declarations are missed, and how the delivery of the CCPs is contributing to contract delivery.
The way forward
None of these issues are insurmountable.
The profession supports the ambition behind the pathways. But ambition alone is not enough.
If the pathways are to become the cornerstone of future NHS dentistry, they must be:
- Properly funded
- Clinically workable
- Administratively proportionate
- Supported by clear contractual and clinical guidance.
We remain committed to working constructively with NHS England to refine the pathways as experience develops.
Ultimately, the same question continues to apply, not just to CCPs, but to every aspect of NHS contract reform. Do the payments offered genuinely reflect the clinical time, expertise, and costs required to deliver high-quality patient care?
Until that question can be answered with confidence, the profession will continue to struggle to realise the full potential of these reforms.