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The claw of the dragon: NHS clawback in Wales

Blog Author David Westgarth

Blog Date 15/01/2019

In August, BDJ In Practice presented and discussed the startling clawback figures for England. Shocking as they may be, those involved in delivering dentistry were perhaps unsurprised by the figures, not least by the scale of them.

With its own set of challenges, access problems and a constant drain on funding, is the story any different in Wales?


£20 million lost from NHS services

The BDA has analysed data on NHS budget allocated to general dentistry in Wales taken away from direct patient care in 2014-17. Via processes of clawback, handback and contract reductions this amounts to £20,645,987 of the dental budget removed in just three years.  

If a dental practice failed to achieve 95% of their targets for Units of Dental Activity (UDAs) they face 'clawback', with budget returned to Health Boards. Boards have a variety of different ways of handling clawback. Some clawback everything owing, others allow the dentist to carry 5% over to next year and only claw back the excess, some deal with dentists on an individual basis.

So what is the full picture? Data from Health Boards shows that, 31% of practices experienced clawback in 2017 which compares with 41% in 2016.

The data also reflects the level of handback, which occurs where an NHS dentist, struggling to achieve their UDA target for that financial year, chooses to give back a percentage of their UDAs to the Health Board. Handback may also occur if a dentist chooses to close their practice or if they retire, for example.

After two years of clawback such practices are then at risk of permanent 'contract reductions'. The BDA has discovered that all Health Boards were applying permanent contract reductions to a greater or lesser extent.


Lack of access for dental patients

BDA research also shows that over a quarter (26.5%) of all NHS practices in Wales have experienced contract reduction in the last three years. This amounts to approximately £4,323,078. Hywel Dda Health Board alone effected more than half of this contract reduction.

In September the British Dental Association Wales told the Health, Social Care and Sport Committee that patients across Wales are now facing a 'postcode lottery' of care – fresh analysis of data from the official NHS Direct service shows that new patients are facing journeys to see an NHS dentist, with residents in Aberystwyth facing a 90-mile round trip.

New patients in Newtown face 80-mile journeys, while even those in the Welsh capital Cardiff face a nearly 30 miles trek. In November images of locals queuing around the block in Llangollen went viral – some queued for as long as five hours, yet there is a growing frustration about the inconsistencies across the Health Boards to reinvest the money back into NHS dentistry.

BDA analysis from last year showed that only 15% of NHS practices are taking new adult NHS patients, with just 28% accepting new child patients.

In December Vaughan Gething AM, Cabinet Secretary for Health and Social Services, submitted a written statement suggesting that while progress had been made in 'improving and maintaining oral health for some group and communities', more was still to be done.

The statement read: 'Challenges remain and, despite being largely preventable, the burden of dental disease impacts adversely on too many lives in Wales, particularly in vulnerable and disadvantaged groups. It is costly for the NHS, can be unpleasant to treat and, for some young adults severely affected, it can result in the permanent loss of teeth.  Access to dental care still remains variable across Wales.'

It continued: 'I am asking health boards and the dental profession to continue to work collaboratively with Welsh Government and to step up the pace of contract reform. For practices already part of the programme, and where data supports such a move, I want to see health boards work with individual practices to go further in testing need, quality and outcome measures and in adopting prudent healthcare principles.'


What dentists need 

While BDA Wales has praised initiatives like Designed to Smile, which has narrowed deep health inequalities among young children, it has previously criticised the Welsh Government for failing to apply these effective preventive principles to wider strategy and reform of the failed NHS system and has called on the Health Boards to step up and demonstrate how they are spending clawback within dentistry.

Ministers are advocating modest 'tweaks' to the current target-driven NHS contract – which effectively caps patient numbers – rather than root and branch reform. The model has fed recruitment and retention problems across Wales, with recent official data revealing morale in the profession has fallen to its lowest levels since 2000 and more than half of dentists are considering leaving the profession.

Tom Bysouth, Chair of the BDA's Welsh General Dental Practice Committee, has previously said: 'The Welsh Government talks about prevention, inequalities and sustainability. But we require deeds not words to guarantee the future of this service and end the postcode lottery of care.

'It's utterly perverse that £20 million has been lost from local services, while some patients are travelling 90 miles to see a dentist under the NHS. Sadly, it's the inevitable result of a failed system, where officials bank on dentists missing their targets just so they can plug holes in other budgets.'

David Westgarth, Editor

BDJ In Practice

Adapted from an article by Westgarth, D The claw of the dragon BDJ in Practice 2019; 1:32