While England returned to increasing UDA targets in the recovery from the COVID-19 pandemic, Wales remained UDA free. Welsh practices' only volumetric was a manageable new patient target with a simple request from the CDO Dr. Bridgman, to treat those patients that needed care the most. This true embodiment of the ‘high trust' environment gave dentists professional freedom. Morale soared as patients could be treated the way dentistry is taught. For the first time in my 25-year career, NHS patients' dental health was at the forefront of NHS provision.
What was lacking for the Welsh Government was granular control – that needed to be re-exerted. Contract Variation in April 2022 was rolled out with just one month's notice in the absence of a new CDO to replace Dr. Bridgman. A one-year contract variation with a non-weighted capitation landed without consultation. Practices received a New Patient (NP) or Historic Patient (HP) credit for the completion of an examination with the Welsh need and risk assessment tool, ACORN. Not until December were mitigations introduced, but only reconciled AFTER year end. Clawback levels skyrocketed, and Health Board measures created a huge variance across Wales. Morale dropped off a cliff and with it record levels of contract hand backs were seen.
Every year since then Welsh Government have tweaked the contract package targets with practices having to adapt every April. Additionally, the Cabinet Secretary for Health linked the annual contract uplift to ‘progress towards policy aims' – additional contractual conditions imposed to receive the below true inflation contract uplift.
2026 new contract
Remit to negotiate with the British Dental Association's negotiation body – the Welsh General Dental Practice Committee (WGDPC) was granted in 2023. This was to be a ‘ground up' dental contract – bespoke for Wales. Initial hopes were high with shared aspirations of a contract with fair remuneration, providing good access to quality dental care, responsive to population needs, promoting prevention and skill mix. During 20 meetings over the course of a year it became apparent that a heavy Government inertia existed, with suppositions of current ways of working as the basis for the new contract. The old hang up – CONTROL – rearing its head.
The Cabinet Secretary Mr. Miles MS frequently speaks of the ‘concluded' negotiations. ‘Not everyone gets everything that they want, but it is an improvement for everyone'. The reality is that the negotiations were terminated by Welsh Government with multiple red lines for WGDPC remaining.
The implementation
One year after terminating negotiations the public feedback from the consultation on the Government's proposals meant several contentious aspects were shelved. As the clock runs down on 2025 there is still little more than sketchy information with the recent publication of the Vignettes.
The secondary legislation for the new contract will be laid in early February under a negative procedure. This means that members of Senedd will have 40 days to choose to accept, reject or abstain. Welsh Labour Government is a minority government, but it seems highly unlikely that opposition parties will scupper this new contract.
Full contractual details are expected to be released at the same time the legislation is laid in early February. This means Welsh dentists won't have time to provide their three months' notice to 31 March, should they reject the detailed offer of the new NHS contract. The Cabinet Secretary for Health intends to impose the new contract as a contractual ‘variation' with 14 days' notice.
The prospects
What is set to roll out next April is a segmented contract. Undisputedly there are positive elements. Urgent access for non-registered patients remains, and 7% of the Annual Contract Value (ACV) will be for these New Urgent Patients (NUP). At a guaranteed £75 for a half hour slot at face value this seems quite reasonable. But factor in multiple appointments if treatment cannot be completed, plus a 1-year guarantee on urgent treatment at the practice's expense, and that value could change drastically.
Care packages replace volumetric targets (and shadow UDAs) with proportionate recognition of more complex care. However, the whole contract is rebased onto untested metrics on a time-to-treat basis. On that basis eight fillings equate to just under six minutes per filling to achieve the purported £150 per hour with a strong steer to using composite materials rather than amalgam. Routine treatment carries a two-year guarantee at the practice's expense. This becomes problematic when extended to patients who refuse appropriate treatments or denture patients who decide they dislike the colour of their new teeth.1 The outcomes could mean defensive dentistry – we can all guarantee our extractions for two years and beyond…
The biggest issue remains the fixed financial envelope. While NP and NUPs gain access, the ‘half a cake' of funding simply gets cut differently. The capitation of 3% ACV is a pitiful sum to see all the green patients at their recall exams.
Conclusion
The reality is that WG are trading on the brand that is ‘NHS dentistry'. Providing access to NHS care for ‘more' people is a laudable goal. The public perception of what it means to be an NHS dental patient is often rose-tinted. But the trades to allow access must happen in the open, with appropriate consultation and testing. The reality is the level of care in Wales will not come close to the expectations without the dentist's own wellbeing and practice finances bearing a heavy strain. It is this general prospect that will undoubtedly be too much for many practices with the Government's juggernaut approach to full implementation in just a few months' time.
This text was originally published as a feature in BDJ in Practice (Volume 39, Issue 1 page 20)
