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Meeting 13th June 2018

LOCATION

THE HUNTINGDON MARRIOTT HOTEL

DOWNING ROOM

WEDNESDAY 13th JUNE  2018

7pm Arrival for 7-30pm Start

MINUTES

  1. Attendees:

Jaco Craig - LDC Chairman

Patrik Zachrisson - LDC Treasurer

Mariana De Villiers - LDC Administrator

Amiras Chokshi - GDPC Representative

Julia Hallam-Seagrave

Claire Jackman

Marlise De Vos

  1. Apologies:

Bharpur Sanghera - LDC Secretary

Gawain King

Peter Mullins

Maria Ross-Russell

Guests:

Tom Norfolk - LPN Chairman

Nick Stolls - GDPC Representative

  1. Minutes of previous meeting held on 28th March 2018 were agreed as true and correct record.
  1. Jaco Craig – Chairman’s Report:

The LDC is currently in the process of recruiting new members.  It was agreed that the LDC constitution be amended to include self-nomination of an eligible candidate, supported by two eligible practitioners form his or her constituency or electorate.  An eligible candidate must have a performer number and be included on an NHS list.

The LDC is currently in negotiations with Maria Ross-Russell (Head of Deanery) looking at funding some of the Continued Professional Development (CPD) Courses offered by the Deanery.  It was suggested that the Postgraduate Centre would send out information regarding these courses. 

The CAMBRIDGESHIRE AND PETERBOROUGH LOCAL DENTAL COMMITTEE are hosting a 3 hour verifiable CPD Event:

Dentists and NHSE: how do they work together in this region?

Presentation on Wednesday 17th October 2018.

Venue: The Huntingdon Marriott Hotel

Kingfisher Way, Hinchingbrooke Business Park, Huntingdon, PE29 6FL

Registration at 7:00 with hot food buffet and drinks. Presentation at 7.30pm.

Speaker: Tom Norfolk.

GDP, Lead Dental Practice Adviser NHSE Midland and East (East), Chair of the Local Dental Network East Anglia, NADA Exec member.

An overview of Performance management, support for dentists and an update on NHS dentistry in the County. 

There has been much in the dental press recently over the NHS National Performers list.  Have you wondered what 'the list' is, how you get on to it and how you might manage your details once you are on it?

Also, there has been a greater emphasis on the NHS locally managing our performance when concerns are raised about our clinical skills. What is the process and what support can you expect should you encounter problems?

These questions and many more will be addressed by Tom in what promises to be a great evening from one of the region's most knowledgeable and informed dentist 

Aims:

  1. Explore the entry and removal from the Dental NHS Performers List
  2. Teach the various aspects of conditional inclusion on the NHS Performers List.
  3. Discuss various aspects of Performance Management of NHS dentists.
  4. Update on NHS dentistry in the region. 

Objectives:

  1. The speaker will explore the entry and removal from the Dental NHS Performers List.
  2. The speaker will teach the various aspects of conditional inclusion.
  3. The speaker will discuss the Performance Management of NHS Dentists.
  4. The speaker will update on how NHSE works with GDPs

Outcomes:

  1. Understand the basic principles of entry and removal from the NHS Performers List
  2. Understand conditional inclusion of the NHS Performers List
  3. Highlight the various methods of Performance management of dentists by Dental Practice Advisers within NHSE
  4. Understand how to work effectively with Dental Practice Advisers and NHSE.

We trust the evening will be both informative and uplifting. Presentation with plenty of time for questions and discussion.

Attendance to be confirmed by E-mail to:

Mariana De Villiers, LDC Administrator, marianadv@hotmail.co.uk, by 26th of September 2018, as limited number of places are available.

Orthodontics

Cambridge Orthodontist Andy Parker is to retire on 26th June 2018. Andy Parker informed the Local Area Team 3 years ago of his pending retirement. No formal arrangement from the Area Team to accommodate Andy’s patients is in place. Orthodontic provision and care for his patients in the midst of treatment or still in supervised retention is still unclear. Although it is understood that the said patients will be reassigned to local nominated orthodontic practices in the area, orthodontists are not enthusiastic about taking on these patients.  Valid barriers include Lack of Capacity, Remuneration Structure Issues and Lack of Orthodontists.

Complaints should be forwarded to NHS England, Complaints Department.

British Fluoridation Society

The British Fluoridation Society contacted LDCs, asking to help support local fundraising efforts. 

Dental Media Training

Nick Stolls is organising a Media Training Day for Dentists on 11th October 2018, offering general media skills for ongoing proactive and reactive media work. There have been lots of interest from dentists. Places are limited which has resulted in looking at organising a second day event at a later date.

Well-being and Work-related Stress of Dentists:

The BDA carries out a range of research on work-related stress and well-being among dentists, and dentists' working conditions. The BDA's research programme in this area covers three main themes:

Dentists' mental health and burnout: The BDA Research team is currently engaged in research on dentists' mental health and burnout in the profession. This builds on the BDA's previous research on work-related stress. To learn more about this research project and the BDA's work in this area, then please visit the BDA Website – Dentists’s Well-being and work- related stress.

Dentists' personal well-being: Since 2012, the BDA has been monitoring dentists' level of personal well-being using a set of indicators developed by the UK Government to track levels of well-being in the UK population. For more information about the BDA's research on dentists' well-being and BDA reports on this topic please visit the BDA Website.

Work-related stress and dentists' working conditions: In 2013 and 2014 the BDA carried out research to identify levels of work-related stress among UK dentists and the determinants of high job stress. For more information about the BDA's research on work-related stress and BDA publications on this topic, please visit the BDA Website.

Self-employment Status of Dentists

The validity of the status of Associates as self-employed business people for tax and other purposes is under scrutiny. The recent UBER and Pimlico Plumbers Employment Tribunal Cases have brought the issue of tax status to the fore again causing alarm in some dental quarters. 

In each of these cases so called self-employed business people were classified as “Workers” and were therefore not deemed to be self-employed. These cases were pursued by the workers, rather than by HM Revenue & Customs, and focused on holiday and sick pay entitlement rather than whether or not PAYE tax should have been deducted from earnings. 

The tax status of Associates in the eyes of HM Revenue & Customs was clarified shortly after the introduction of “New” NHS Contract in April 2006. At that time an urban myth grew up that the new GDS Contract changes spelled the end of self-employed Associates.  The apprehension was that Associates would receive a set payment each month for NHS work. This would look like a salary payment which should be subject to employment taxes under PAYE.

Thankfully these concerns proved to be unfounded and, following representations from Bob Cummings of Morris & Co, HMRC updated their guidance manuals to recognise the new contract. This guidance remains unchanged despite yet another scare in 2007 caused by an article published in the Times Online suggesting that associate dentists were about to be targeted by HMRC. At that time HMRC advised Morris & Co that ….. “the new standard general dental Associates contract which came into force on 1 April 2006 did not affect our existing published guidance stating that, where standard forms of agreement for associate dentists which have been approved by BDA and GDPA are used and followed, the associate dentist is regarded as self-employed for tax and NI purposes”.

As things currently stand HMRC guidance contained in the “Employment Status Manual ESM4030 Particular Occupations: Dentists” states:

“It should be noted that there are standard forms of agreement for ‘associate’ dentists which have been approved by the British Dental Association (BDA) and the Dental Practitioners Association (DPA) (sic). These agreements relate to dentists practicing as Associates in premises run by another dentist. Where these agreements are used and the terms are followed, the income of the associate dentist is assessable under trading income rules and not as employment income. In these circumstances the dentist is liable for Class 2/4 NICs and not Class 1 NICs.”

However, the BDA reported in March 2018 awareness that Her Majesty's Revenue and Customs (HMRC) has written recently to a number of associate dentists indicating that they are reviewing the employment status of associates.

The BDA are working with dental accountancy colleagues, who are monitoring developments closely and will offer further information and advice to members as and when there is more clarity around the scope of the HMRC process.

If you receive a letter from HMRC, the advice from the BDA is to contact your accountant before responding.

The BDA would also ask to inform them as soon as possible at Advice.Enquiries@bda.org if you have been contacted by HMRC.

It would be helpful for them to have a copy of the letter you have received and an indication of your practising arrangements (e.g. NHS/private, and whether for example you work in a prototype practice).

You can scan or photograph the letter to attach it to an email and send it to the above address. Copies will be kept securely and destroyed after their work has been concluded.

The information you provide will be used to help the BDA build a picture of what is happening, and your personal information will not be used.  

Rumours are that if it is concluded that associates are employed rather than self-employed, HMRC can claim back Tax and National Insurance Contributions for up to 7 years.

Negligence of Associates

Negligence of Associates is the responsibility of the Provider, the Practice’s responsibility.  Indemnity does not cover self-employed associates. Practice owners are vicariously liable.

  1. Patrik Zachrisson – Treasurer’s Report:

The Cambridgeshire and Peterborough LDC continues to be in a healthy financial state.  The LDC supported the Annual LDC Conference which was held in Belfast on the 7th of June 2018.

  1. Amiras Chokshi / Nick Stolls – GDPC Representative Report

1. The GDPC met on 4 May 2018.

Contract reform

  1. We discussed a set of proposals on contract reform in England that the Executive had developed. There was broad agreement that the paper set out sensible proposals for developing the prototypes to ensure the business model will be financially viable for practices. This paper had been used in discussions with the DHSC and NHS England and would be circulated at LDC Conference.
  1. The GDPC continue to be frustrated by the slow rate of progress on contract reform. The prototype evaluation report for 2016-17 was still yet to be published and would now be out-of-date by a full financial year.
  1. There was debate about how activity could be measured in a reformed contract, with a consensus that the UDA needed to be removed altogether. Some members felt that a measure somewhere between an item of service and the UDA should be explored. Prevention should also be acknowledged as an activity. It was felt that there should be better remuneration for endodontics, but NHS England would likely ask what dentists should be paid less for if endodontics or other treatments were to be made more rewarding.
  1. In Wales, the CDO is piloting a different approach to contract reform where practices have their UDA target reduced by ten per cent to support them to conduct an oral health risk assessment. The Welsh CDO was said to be open to other changes that would focus on prevention and provide incentives to treat high needs patients.

Contract values

  1. We also discussed whether practices in a reformed contract should receive the same payment for providing the same treatment to the same patient. This would ensure that inequalities within the current contract were not carried over into the reformed contract. This could only be done on the basis of practices receiving the same contract value who would be given enough time to increase patient numbers if they needed too. This could be done through a minimum practice income guarantee and a long implementation period. The national tariff would also need to be weighted by age, sex and deprivation and could also have a geographic weighting.
  1. On the basis of seeking the highest national values and ensuring protections on financial viability, we agreed that a patient being treated under a reformed contract should attract the same payment for the same treatment, regardless of which practice they choose to be treated in. An itemised account for treatment with equal capitation values. However, it will be difficult to manage band 3 activity as there are lots of different elements in Band 3.

DDRB

  1. Along with representatives from other BDA committees, the Chair gave oral evidence to the DDRB in April. This session would normally take place in November, but instead had taken place more than a week into the current financial year. The session went well and it appeared that the DDRB had been persuaded by the arguments we put forward regarding recruitment, retention and morale issues. We expect the report to be published at the end of May or June and for any uplift to be implemented later in the year and backdated. The BDA has made clear to the DDRB that the delays to the process are unacceptable.
  1. In Northern Ireland, BDA staff had identified an error in the calculation of the 2017-18 uplift and as a result it had been increased from 1.13 to 1.5 per cent.

NHS England

  1. There are a number of difficult issues currently under discussion with NHS England and a number of reasonable proposals that the Executive had put forward had been rejected.
  1. The Executive had proposed that NHS England increase the tolerance for under-delivery by one per cent to recognise the impact that the severe winter weather had had on practices close to the year end. For many practices, the required closure time accounted for more than one per cent of the time they had to do dentistry within the year. However, NHS England had rejected this proposal and would only consider applications for force majeure on a case-by-case basis. The GDPC proposal would have meant that activity would have been delivered in 2018-19, but instead NHS England would now clawback the money and risk losing it from dentistry. It is regrettable that NHS England has adopted this approach as allowing some flexibility would have shown goodwill towards the profession. Some health boards in Wales have allowed an additional one per cent of under-delivery. Lots of variation in UDA target underperformance was allowed with some down 23% without clawback.

Practices in England should contact their Area Team if they have had specific problems in relation to weather as ATs have the flexibility to use Force Majeure on a case by case basis.

  1. NHS England has now acknowledged the recruitment problems practices are facing in many areas and have agreed to work with the Executive to identify solutions to support practices to recruit.
  1. After the Executive had sought clarity from NHS England on the matter, a letter had been circulated to providers setting out the position for charging for referrals to secondary care for an OPG. However, a degree of uncertainty remained about some of the wording in the letter and further clarity was now being sought on these areas.
  1. A note for the avoidance of doubt had been circulated by the CDO on phasing treatments for high needs patients, which appeared to adopt a reasonable approach. However, there were issues for those patients who required more courses of treatment than the note permitted. It was suggested that it should state that it should ‘normally’ be no more than three in 12 months. The BDA had not been consulted on the note prior to its publication.

Amalgam

  1. The Committee had received a consultation on SDCEP guidance on the phase down of amalgam use in deciduous teeth, children under the age of 15, pregnant women and nursing mothers. It was felt that it would be preferable for dentists to be allowed to exercise their clinical judgement in deciding when amalgam can be used in the specified groups. The CQC and defence unions would require good clinical justification for the use of amalgam and clear patient consent and for this information to be included in the patient records.
  1. The BDA had called for the for the communication to the public explaining these restrictions to be led by the four CDOs, not the profession, but there appeared to be a reluctance from the CDOs to do this.
  1. The Executive had also raised with NHS England the need to acknowledge the additional costs practices will incur as a result of implementing the phase down and there was ongoing work by the BDA to establish an estimate of the impact.
  1. In Scotland the SDR would be amended to allow for composite fillings and the SDPC was negotiating the level of remuneration.

Scottish Oral Health Improvement Plan

  1. The Scottish Government’s Oral Health Improvement Plan had been published earlier in the year and was focused on prevention but was felt to be light on detail. The Plan sets out a number of changes to dentistry in Scotland including a potential phase-out of scale and polishing, the practice allowance being reallocated to provide additional funding for practices in deprived areas, and Childsmile would also be extended to cover over six-year olds. There was an intention that in future patients with good oral health would be covered by capitation payments and those with poor oral health would be treated on the item of service. Dentists would also be able to access occupational health. There were also plans to introduce dentists with enhanced skills for oral surgery, IV sedation, complex restoration and domiciliary care. There would be a director of dentistry in each health board and there were some concerns that these posts might not be filled by GDPs. Dentists and their teams would also have protected time for learning.

Patient charges

  1. We also considered our view on patient charges and agreed that, ideally, patient charges would not exist as they deter patients from seeking necessary dental care, that as long as patient charges exist, dentists should not be required to collect them and that any increases in patient charges should be no more than inflation.

Tier two

  1. We do not support the tier two programme and the participation of GDPC representatives throughout this process has been to get the best possible deal for the profession.
  1. Documents concerning tier two paediatric dentistry had been circulated to the Committee for comment ahead of the meeting. It was felt, that unless the criteria were desirable rather than mandatory, there would be few performers and providers that would meet the threshold for tier two accreditation in paediatrics. There were particular concerns about the requirement for recline wheelchairs and microscopes, and this had been acknowledged by NHS England and these specifications had been removed.
  1. In London, procurement of tier two endodontic services had begun and tier two accreditation was being piloted. However, the tier two steering group was not informed of this before it was announced. It was not clear how or if this pilot would be evaluated. There was also a lack of clarity as to where the funding for these services was coming from. Some had been found from existing tier two provision.
  1. There are a number of other groups working on tier two frameworks for the other specialties. However, the orthodontic workstream had paused, in part because of objections from the BOS. It is unlikely that NHS England would look to commission tier two orthodontic services soon given the current specialist-led orthodontic procurement. Much of the existing non-specialist orthodontic services were in GDS contracts and therefore would not be re-procured.

GDC

  1. We discussed the GDC’s consultation on fee setting. The consultation would lead to the policy being set for three years and there would be no further consultation on the level at which the fee was set. There were a number of related issues that the BDA would be responding on such as the GDC’s reserves policy and its intention to fund non-statutory, discretionary areas.
  1. We felt that the GDC should consider introducing reduced registration fees for those working part-time, as the Annual Retention Fee was leading many part-time dentists to leave practice. There was also support for paying the ARF by instalment and for having a register for retired dentists. Dentists who retire mid-year are not reimbursed pro-rata and we felt that this should be the case. The Students Committee had discussed allowing newly-qualified dentists to defer their first payment until after they had been paid for their first month at work.
  1. LDC Conference Report – Nick Stolls

The theme of conference this year was Contract reform and gave those delegates the opportunity to offer their voice to the current progress. It was chaired by Joe Hendron from Wakefield LDC but as a Belfast lad originally he opted to hold the Conference at the Europa hotel in central Belfast - the first time in Northern Ireland and it proved to be highly successful. Despite previous concerns, the numbers attending were only slightly down and certainly from the expenses I presented for my travel to Will Newport, the Conference treasurer, the costs of having a NI Conference will only be slightly more than in other parts of England.

The format of conference was the same as the previous 2 years, that of a Thursday afternoon and Friday morning. Many opted to stay a while longer to explore what delights the north coast of NI had to offer. This year the chair decided to do back to card voting which had its merits. We lost the perverse few who anonymously persistently voted against obvious motions to the frustration of other delegates however it was fair to say that there were many more unanimous votes with those perverse few intimidated into voting the 'right way'. The conference was again filmed for future viewing and I will send the link when the video has been suitably edited. (I will need a considerable amount of airbrushing or CGI-ing before I accept my appearance on screen!)

The format of conference had the usual default slots - nominations for roles and offices from Conference in the first session and elections in the second session, presentations from the charities (Ben Fund, DHST and the Guild) and presentation from the chair of GDPC (Henrik Overgaard-Nielsen - H O'N). The rest of conference was taken up with two question time types of sessions chaired by the conference chair and finally blocks for motion presentation.

The first block of motions included a motion on an interim contract:

This Conference calls for the implementation of an Interim NHS Dental Contract Proposal while GDPC continues to engage with DH in the pursuit of positive Contract Reform - providing a transitional phase aimed at reducing pressures on the NHS dental workforce and improving its morale and improving the quality of patient care - until such time as Contract Reform is ready for national roll-out.

This prompted some robust debate and was finally passed by 5 votes (55 for).

Other motions included demands for greater financial support from NHSE for those receiving dental care in care homes, an urge to address the recruitment crisis, and deploring the increase in claw back money which is lost to dentistry. Many of these motions were passed unanimously.

Conference then turned to a presentation from Prof Stephen Fayle, consultant in paediatric dentistry.

His message was that 'prevention was everybody's responsibility' and it had gained a higher profile since an intensive media campaign nationally. He demonstrated the statistics showing that caries closely mapped areas of deprivation but in those more affluent areas then the level of caries experienced by individuals was on a par with the larger number of children who exhibited decay in the deprived areas. He feels the time of 'quick wins' delivering big improvements in oral health have gone and now it will be incremental improvement from multifactorial initiatives, one of which will be targeted water fluoridation. He supported the initiatives for tackling child oral health taking place in the four countries of the U.K. and he specifically highlighted Childsmile in Scotland as a success story. He went on to voice his hopes for DCBy1 and the results this might bring but making it clear it may take some time for the effect to filter downstream. Finally, he talked of the shortage of paediatric specialists- 170 across the U.K. Which clearly hampers the expansion of the services.

The next session was a question time style discussion with Collette Bridgeman (CDO Wales, Stephen Fayle, H O'N, Claudia Peace (a prototype performer) and Eric Rooney (dCDO for England). This was wide ranging with CB stating that any contract has to deliver prevention. When ER was asked when some of the recommendations from the Prototype evaluation report would be introduced he explained some recommendations were easier than others but did acknowledge that the business part of the prototypes weren't working and needed more work. H O'N made it clear that more money was needed as only 50% of the population had the capacity to be seen under the NHS for dentistry. This was rebuffed by ER that many practices weren't hitting their targets as exhibited by claw back and at this point the solids hit the fan predictably! All agreed that UDAs were not helpful and practices shouldn't be simply chasing the UDA activity targets. CB outlined how the prototypes in Wales worked with a flex of 10% to allow for additional patients to be taken on and no penalty if that target wasn't met. Other questions including how to measure prevention and the quality tests within DQOF were outlined but granularity of bands was not seen as helping the situation. CB felt that a needs assessment was essential to identify need whilst H O'N explained that with the introduction of any new contract, weighted entry was required.

A further block of motions was then debated including subjects relating to rolling out Starting Well across England, pressures on dentists working within a system where work load and lack of support resulted in stress and mistakes.

This concluded the first session.

The evening black tie dinner concluded with an impassioned speech from the conference chair which detailed his time working within a pilot and then a prototype and described his initial dream of bench testing a better system of primary dental care but what then turned into a nightmare. He pulled no punches in criticising DH and NHSE officials personally for the delays and obfuscation in contract reform, many who were sitting on the top table.

The Friday morning session began with an update from H O'N, chair of GDPC recounting to conference the progress made on motions passed at last year's conference. He focused on

  • Contract reform and the need to lower the access targets, a gradual roll out, an income guarantee, weighted entry capitation and an increase in bands or Item of Service (IoS) if 100% capitation doesn't make it onto the statute books.
  • Whether to withdraw from negotiations was discussed at length by GDPC and their view was that it was better to be at the party than not.
  • PCSE/Capita. He explained the ongoing problems with performer list applications and particularly highlighted those going through the PLVE process.
  • Work is ongoing to arrive at a fairer way for LDCs to collect their Stat levy reflecting the demands of each LDC.

At this point it was announced that Leah Farrell was to be chair for 2020 conference. She is sec of Northants LDC and the first female chair for many years.

This was followed by the final block of motions which included two lively debates about equalization of UDA values and investigating other forms of industrial action for the profession to bring pressure to bear.

Due to time pressures 10 motions had to be deferred directly to GDPC for consideration with no debate or vote.

The final session was another question time format to discuss 'Does devolution take the N out of the NHS'. Those taking part were the CDOs from Wales, NI and Scotland and the dCDO from England together with the head of Primary Care in Greater Manchester which is testing the devolution model.

NI still operates an IoS model with some capitation although they are testing other models of 100% capitation in those very deprived areas where recruiting dentists has been difficult under the current NI system. They experienced a crash in the economy in 2008 which meant that many patients who had moved to private practice returned in their droves with GDS treatments increasing by 35% over 5 years which was difficult to fund as the dental budget was non-cash limited due to IOS.

Gt Manchester found the focus they experienced because of their new way of working was creating their own pressures. Andy Burnham, the mayor was very supportive of oral health which put the focus back on dentistry. Although devolved they still adhered to the 7 principles enshrined in the NHS constitution and so felt that the N still remained in the NHS.

Each country highlighted how their service operated and the restrictions that each service faced, particularly with oral health initiatives.

The final act of conference was to induct Vijay Sudra as the 2019 conference chair which is to be held in Birmingham on June 6/7th 2019.

  1. Date of Next Meeting

Wednesday, 19th September 2018

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