Can capitation really save NHS dentistry?
Or do activity payments still have legs?
Access to NHS dentistry is shockingly bad. And yet the NHS will underspend its dentistry budget this year by 13%. The Parliamentary Health and Social Care Committee lands the blame squarely on the NHS contract - particularly the payment mechanism. The Committee instead recommends a new capitated payment and patient registration model. But will it work? Capitation is just as likely to continue to under-remunerate providers and incentivise under-delivery. I ask whether we are really right to dismiss activity payments just because this activity payment model hasn’t worked. Here’s my thinking.
Access to dentistry is dire
Access to NHS dentistry is dire and the impacts are shocking. The Parliamentary Health and Social Care Committee’s Report famously noted the case of a woman who removed her own tooth with pliers because she could not find an NHS dentist. It also states that 1 in 10 Britons (10%) admit to attempting their own dental work with 36% of these doing so in the last two years. (Health and Social Care Select Committee Report) According to a Guardian report, a new practice in Bristol had queues to register that were so long that the police were called to manage the crowds. (Guardian article)
And all of this at a time when the NHS’s dentistry budget will be underspent by £400m. (HSJ Article)
“If you see a queue, someone is selling something too cheap”
My economics professor at university used to say “If you see a queue, get in it. Someone is selling something too cheap!” Well, this is not a queue anyone wants to be in - but there’s no doubt that NHS dentists are being asked to sell their services too cheaply - and we’ve known about this problem for years. The differences between the cost of private and NHS dentistry are huge. This is the second committee report into this issue and it makes no bones about the fact that the problem is the NHS dental contract - and specifically the payment mechanism, which fails to incentivise prevention and which doesn’t remunerate procedures (especially complex procedures) well enough.
Capitation and registration - The public health argument
The answer, the report says, is to mandate capitation and registration. In other words, dentists should be paid according to how many patients they have on their books - not per procedure. And patients should be encouraged to register with their dentist in the same way they now do with their GP. The idea is that this outsources public health and prevention to practices: Dentists have an incentive to promote oral health because this will reduce the amount of treatment work they will have to do in exchange for the capitated fee. In other words, dentists who do the work to cultivate healthy patients will do less work in the long run and keep more of their income.
But, if this argument is right, why isn’t the model having that effect for GPs in primary care?
Is capitation a good payment mechanism?
The core of the capitation argument is that there’s an economic incentive to prevent poor oral health because dentists can keep more of the capitated fee that way. No doubt many dentists would try this - out of a sense of moral obligation, if not wholehearted optimism. But shouldn’t we consider the fact that capitation also creates a big incentive to under-provide? And if the capitation budget is insufficient (and it probably will be), might this incentive to under-provide actually become an economic necessity?
I’d argue that, under a new capitation model, it will be impossible to tell the difference between those practices that under-provide and those who prevent - at least for some years. That’s because the first step for an expanded provision model is to reach the disenfranchised - and these patients are very likely to present with significant ill-health. So the “good” practices who reach out to these groups will see their outcomes fall - while the “bad” practices who under-provide might well measure better outcomes.
But let’s say that all dentists decide to take out loans (or work 18 hour days) so that they can provide really good levels of dentistry to their population, safe in the knowledge that, when their efforts have paid off, demand will drop and they can sit pretty and harvest the capitation payment. This relies on the idea that, once demand drops off, Government will keep paying at the same level. Will they keep paying though? Not many dentists will believe in this pay-off and, if I were a dentist, I wouldn’t be banking on that pay day.
And that brings us to the third challenge of this payment mechanism. Will need really lessen? In every area of healthcare, there is always more to validly do. Good services fill up with need.
Is capitation affordable?
There’s a big question mark around how you would ever accurately estimate the right capitated payment. You certainly can’t just divide the current spend by the number of patients being treated:
We know that prices are too low. The budget isn’t getting spent and it’s not for want of demand.
Current access issues mean that people who can’t get onto a dentist’s books are suffering from progressively worse oral health. In other words, it could well cost much more, per capita, to treat new patients than it does existing.
Even if capitation encourages prevention in the long term, you have to be able to afford to treat ill-health as well as prevent it, in the short term. Prevention costs more in the short term, even if it works in the long term.
Is UK dentistry set up for capitation?
With NHS services in decline for many years, the dominant provision model is private. And the NHS provision model is largely emergency reactive. So, what makes us think that these services are well placed to transform into a prevention-focused oral wellness service?
You might argue that dentists are no worse placed than GPs to perform this service (save for a bit of experience with the model) - but, again, is the GP model a shining example of a prevention-focused approach?
Would you want to lose patient choice?
Most of the people reading this article will use private dentistry. As do I. I had to change dentists twice before I got a good one. Registration is a big barrier to exercising patient choice. Of course, it’s not nearly as big a barrier as the current situation where choice is meaningless because of scarcity. However, if we are going to fix the scarcity problem (as we should), are we prepared to sacrifice the choice of those patients over their own dentist? Would you want to lose that right?
Why can’t we incentivise public health and activity?
The Committee’s report dismisses an activity-based model - in part because the existing model is already activity-based and has already been tweaked. But this is a model with no payments for prevention, a laughably limited pricing schedule (in the latest, expanded version, just six price points to cover all activity) and prices that everyone seems to agree are too low.
The report highlights the fact that the six price points are not enough to cover complex procedures. But the capitation model would actually replace those price points with just one - a capitation payment.
This is a patient group for whom much more treatment is and will be needed. So I am left wondering: Why can’t we incentivise that treatment directly? Why can’t we additionally commission dentists to do prevention? Why can’t we borrow ideas on activity-based payment models from private insurers, who are not exactly known for wanting treatment costs to balloon? By abandoning activity-based payments, are we throwing the baby out with the bathwater? And might we be embracing a new model which will perpetuate underfunding and under-delivery?
Extracted from Health and Social Care Select Committee Report on NHS Dentistry
