New Year: New SDR?

06 February, 2023 / editorial

Questions abound. What will the fee structure look like?
‘New Determination 1’: what about the rest? The devil will be in the detail

Will Determination 1 v2 be workable? Will it be any good? From what I can see from the notes on, there are certainly fewer items. Fundamentally, this is what people have been calling for – for years. However, being that Item of Service (IOS) is the primary payment method, it has to be suitable. Can it reflect the complexity of the work in a fraction of the codes? Will we end up with a huge discretionary fee list because it’s unsuitable?

I feel the most important factor for the Scottish Government is that dentists are prepared to accept an aggregate fee structure. I mean not all fees may make money but, overall, the money we earn will be enough, or the same, or better. This is a very difficult balance to achieve. Dentists have always struggled with any code which is not income generating. Look at the classic argument that molar endo, chrome, and gold crown fees simply don’t compensate for the time or costs involved.

I understand the aggregate argument. We have to look at the overall balance of fees, CC&C and allowances to enable a reasonable living and businesses to be profitable. The Scottish Government does have an understanding of this – however, not a good understanding. One complexity is business owners, be they private or corporate, have different income streams to associates. This puts each group at odds with the other and the Scottish Dental Practice Committee (SDPC) and the Scottish Government have to strike a balance which allows both groups to be happy. Look at the strikes we are currently plagued by in healthcare and elsewhere. There are huge variations in what’s on offer and within the deals themselves: often offering larger percentages or flat rates to those in lower levels of responsibility. Could associates end up being more rewarded than owners?

This should be done with great care. Back in the late nineties and early 2000s, associates were in short supply (cf the 200 or so empty associate positions in Scotland just now) and percentages were increased. This led to a real lack of impetus to buy practices. In turn, this forced the 2005 Action Plan to redress the balance towards ownership. If the Scottish Government and SDPC are not careful, and the workforce planning isn’t addressed quickly, there will be a very similar situation again. The fee structure in any new SDR will have to reflect that.

So, what will make it work? I believe there must be a little (and I mean a very little) more emphasis on the CC&C. This will give comfort to dentists that some fluctuation in IOS fees will be flattened out and we can expect that ‘background income’, which pays for holidays and illness and guarantees viability, to tick along. Dentists need to accept the loss of ‘Christmas Tree Codes’ like sensitive cementum, stone and smooth etc., and take responsibility for preventive advice and minimal items within that CC&C.

Once the new ‘Det 1’ fees are set, they must be trialled and proven to result in, at the very least, a ‘net zero’ situation. A pilot would test this (I’ve already called for this) and would give comfort to dentists and those paying the bill, that all will be satisfied and no one disadvantaged.

This should be at least six months. It would also allow codes to be refined, dropped or amended and some added, if proven necessary. There should be no ‘magic number’ of codes to achieve; simply a workable document.

The desire for less administration, I think would benefit everyone. The Practitioner Services Division (PSD) would get greater efficiency with less funding. However, that will only work if the codes are workable.  Fewer fees will create more requests for clarity, more difficult prior approval and backfire for PSD. Practice management systems take care of EDI claims and, as long as we code properly, it doesn’t matter whether there’s 30 or 3000 codes. More codes equal fewer provisos and fewer queries from dentist or PSD. Fewer codes mean more provisos to include or rule out instances when the code is the correct one; does that equal more opportunity for confusion and create a greater burden on the people involved to answer queries in either direction? That is more complicated, not less.

Prior approval needs an overhaul. Items, like soft splints, take longer to complete the PA for than the treatment itself. The PA cost is too low. It takes far too long and is too subjective to be reasonable. It’s an enormous barrier to proper care.

Finally, and most importantly, the other allowances need to be sorted. Generally, I feel they are appropriate.

They need some tidying up:  

Rent shouldn’t be paid to practices; it should only be paid where a proper lease agreement is in place. This would force practices to move their property into a separate entity; there is some tax benefit in this. The main point is it then makes practices comparable in terms of profitability.

GDPA has already had a little tickle, post-COVID. The cap must go. There is absolutely no evidence for it. One surgery or ten have comparable costs in terms of staff, utilities, equipment and materials. With every fee increase, more practices are affected; this is a de-facto, year-on-year cut in practice funding, especially in poorer areas.

SDAI funding should be re-introduced across Scotland to fund improvements and expansion (where a properly assessed business case is made). This would improve the dental property portfolio but keep that funding in dentists’ hands: not landlords, if rent is amended.

These are the allowances which make practice ownership viable, and the only way NHS dentistry survives in Scotland is with practice ownership, especially non-corporate ownership, being incentivised. Much work to do.

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