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  1. 1. Dentists’ Commitment Payment Scheme Report January 2004 Prepared for: The Office of Manpower Economics, on behalf of the Review Body on Doctors and Dentists’ Remuneration. Prepared by: Lucy Joyce and Vanessa Stone BMRB Social Research Telephone: 020 8433 4457 Email: Part of BMRB International Limited BMRB/LJ/101803 BMRB International is ISO9001 accredited, and is certified as working to the requirements of MRQSA/BS7911 market research quality standards
  2. 2. Table of Contents Executive Summary 1 Introduction..............................................................................................................4 1.1 Research Objectives.....................................................................................................4 1.2 The Sample..................................................................................................................5 1.3 Methodology................................................................................................................6 1.4 Background to respondents.........................................................................................8 1.4.1 Work history.....................................................................................................................................8 1.4.2 Dental Practices...............................................................................................................................8 1.4.3 Current work circumstances...........................................................................................................10 1.5 Report outline.............................................................................................................10 2 Commitment to NHS dentistry.............................................................................12 2.1 Positive views..............................................................................................................13 2.2 Negative views...........................................................................................................16 2.2.1 Item-of-service fee scale system.....................................................................................................16 2.2.2 Administration and regulation.......................................................................................................20 2.2.3 Patients...........................................................................................................................................21 2.2.4 Future uncertainty.........................................................................................................................23 2.3 Reasons for remaining in or moving away from NHS dentistry..............................23 3 Awareness and experience of the Commitment Payment Scheme.................25 3.1 Awareness of the Commitment Payment Scheme....................................................25 3.2 Knowledge of the Commitment Payment Scheme...................................................26 3.3 Experience of the Commitment Payment Scheme...................................................27 4 Views on the Commitment Payment Scheme.....................................................30 4.1 Views on the design of the scheme............................................................................30
  3. 3. 4.1.1 Eligibility criteria............................................................................................................................30 4.1.2 Payment bands...............................................................................................................................32 4.1.3 Additional payments......................................................................................................................35 4.2 Views on the impact of the scheme...........................................................................35 4.2.1 Personal impact..............................................................................................................................35 4.2.2 Impact on others............................................................................................................................38 5 Summary and conclusions...................................................................................40 5.1 Summary of findings..................................................................................................40 5.2 Suggestions for improvements...................................................................................41 5.3 Increasing motivation, retention and commitment..................................................42 5.4 Conclusions................................................................................................................42
  4. 4. Executive Summary The Commitment Payment Scheme (CPS) was introduced in 2000 following a recommendation from the Review Body on Doctors’ and Dentists’ Remuneration (DDRB). The Scheme operates on a tiered system and is based on gross annual income in respect of NHS work carried out, as well as on the length of dentists’ service within the GDS. The 31st annual report produced by the DDRB, called for the British Dental Association (BDA) and the Department of Health (DoH) to carry out research which explored the effectiveness of the scheme. However, as the research was unable to look at General Dental Service (GDS) commitment in relation to the CPS in isolation, it was felt to have limitations. Consequentially, the DDRB felt further research into the CPS was required. To meet this end, BMRB Social Research was commissioned by OME, on behalf of the DDRB, to carry out a qualitative study that explored dentists’ views of the CPS. The main drivers - both positive and negative, affecting commitment to the GDS Commitment to working within the GDS varied among respondents, with some seeing themselves as committed and others not. Commitment was not generally thought to be related to the level of CP received, nor to the percentage of NHS work being carried out. Rather, commitment to the NHS and dentists’ views of it were thought to be affected by other factors, such as by age, the type of area they worked in, the responsibility they felt to patients, and their ideological attachment to the NHS. Respondents highlighted a range of positive aspects of working within the GDS. For example, they liked the principle of offering affordable treatment to all; they felt it offered a good salary; a secure lifestyle; a ready-made list of patients; a range of different patients; and some also felt NHS patients were less demanding and more appreciative than some private ones. Despite this, a number of more negative issues were mentioned by dentists from across the sample. The main problems highlighted by respondents related to: the item-of-service feescale system - which they perceived as inadequate to cover the cost of treatments; increasing patient demands; the level of administration and regulations associated with performing their role; and the uncertainty surrounding the future of NHS dentistry. A number of factors were thought to influence dentists’ decisions regarding either remaining in or moving away from the NHS. These included: the age of the dentist; the type of practice or area they worked in; their moral or ethical attachment to the GDS; and the contract changes expected to occur with Options for Change or Routes to Reform. Dentists’ Commitment Payment Scheme 1
  5. 5. Views on the Commitment Payment Scheme and suggested improvements Although some dentists’ held the opinion that it would be ‘misguided’ to re-design the Commitment Payment Scheme, unless it was to be completely overhauled, as they believed it failed to respond to the problems experienced by dentists. Others highlighted a number of ways in which they believed the CPS could be improved. Although respondents had generally heard of the Commitment Payment Scheme as a result of seeing it in their schedule, knowledge regarding the details of the scheme was minimal. For the most part, it was felt that a general increase in awareness and knowledge of the scheme would be useful. Mixed views were expressed regarding the eligibility criteria. While respondents tended to accept the calculation based on gross income as ‘fair’, some issues were raised regarding the five year rule which some felt was too long and would discriminate against younger dentists and women who had taken career breaks. Some respondents thought the five year eligibility criteria should be reduced to include either all dentists or those who had been contracted to the NHS for two or three years. Some issues were also raised regarding the payment banding system. Aside from the levels being seen as too low overall, some dentists highlighted other issues, including: • The disparity between the payment received in band 1 compared to other bands; • The fact that top-ups were not made available to those in band 1; and also • The level of gross income required to reach the higher bands was seen as too high. Some respondents thought this could negatively impact on the quality of dentistry carried out, as well as on the health of the dentist. Moreover, some felt this was encouraging a ‘drill and fill’ culture, rather than preventative dentistry. Views on how effective Commitment Payments are at retaining GDPs in the GDS Dentists did not feel that the payment had any real impact on either their views or behaviour regarding commitment to the GDS. They did not believe it would retain them in the GDS as the perceived advantages of working in private dentistry (in terms of income, quality of working life and the quality of service that could be offered to patients) were not matched by the payments offered under the Commitment Payment Scheme. Not only were payment levels seen as being too low, but some also felt the scheme ‘missed the point’, as it focused on income rather than on other issues, such as time pressure, quality of dentistry and workload. 2 Dentists’ Commitment Payment Scheme
  6. 6. The effect Commitment Payments had on GDPs’ motivation to practice in the GDS Although respondents tended not to believe the scheme would have any impact on their retention or commitment to the NHS, receiving an additional cash sum was welcomed by all respondents - particularly by some Associates and those in the higher bands. The payment was seen as a ‘reward’ and some felt this payment motivated them in their role. Some suggestions for increasing motivation among GDPs were made by dentists. Within the existing structure, it was felt that a significant increase in the fee-scale (at least 10%) would positively impact on motivation, as would the re-introduction of specific treatments, such as gold crowns. It was also thought that motivation could be increased by introducing an alternative remuneration system, such as a core service, salaried dentistry, or a system akin to General Medical Practice. It should also be noted, that although the views expressed by the respondents regarding the impact of the CPS did not differ according to the sample characteristics, such as age, gender or the level of the Commitment Payment received. Some respondents felt the system could be more effectively aimed at certain types of dentists, namely those who were older (especially those nearing retirement), younger newly qualified dentists, those working in more deprived areas, and also those with a strong ethical and moral attachment to the NHS. Dentists’ Commitment Payment Scheme 3
  7. 7. 1 Introduction The Commitment Payment Scheme (CPS) was introduced in 2000 following a recommendation from the Review Body on Doctors’ and Dentists’ Remuneration (DDRB). This involved £20 million being made available to help improve retention and motivation within the General Dental Service (GDS). The form of the Commitment Payment Scheme resulted from negotiations between the Department of Health and the British Dental Association (BDA). The Commitment Payment Scheme operates on a tiered system and is based on gross annual income in respect of NHS work carried out, as well as on the length of dentists’ service within the GDS. The original £20 million was extended in subsequent years, with the most notable changes being an extension of the scheme in 2002-03 to include: younger dentists (estimated cost £5 million); Assistant dentists; those contracted for five years; and those working part-time. Payments were also increased by a third in 2003-04 (estimated cost £9million). For more information on the design of the Commitment Payment Scheme see the ‘statement of dental remuneration’ appendix i. The 31st report produced by the DDRB called for the Department of Health (DoH) and the BDA to carry out research assessing the effectiveness of the CPS. An examination of administrative data by the BDA suggested that the CPS had benefits in terms of commitment to NHS dentistry when comparing those who had received the payment with those who had not. However, the data available had limitations, in that the analysis could not look at GDS commitment in relation to the CPS in isolation and consequently other factors may have influenced the findings. In contrast, the DoH suggested that the downward trend in commitment had been not been affected by the CPS. The DDRB felt that further research was needed on the CPS to directly explore the views of the General Dental Practitioners (GDPs) themselves. To this end, BMRB Social Research was commissioned by OME, on behalf of the DDRB, to carry out qualitative research among GDPs. This report is concerned with describing the responses of GDPs to the Commitment Payment. 1.1 Research Objectives The research aimed to explore and assess the impact of Commitment Payments paid in respect of NHS work on GDPs. More specifically the research aimed to explore: • The main drivers (both positive and negative) affecting commitment to the GDS; • Views on how effective Commitment Payments are at retaining GDPs in the GDS; 4 Dentists’ Commitment Payment Scheme
  8. 8. • The effect Commitment Payments have had on GDPs’ motivation to practice in the GDS; and • GDPs’ views on what improvements could be made to the scheme to increase its effectiveness in achieving retention of GDPs in the GDS. 1.2 The Sample The sample comprised a total of 30 interviews with GDPs across four areas – London, Leeds, Cardiff and Edinburgh. This included: • 12 depth interviews with Practice Owners, including four single handed dentists; • 12 depth interviews with Associate dentists, including two who worked for a chain; and • 6 telephone interviews with Assistants. Practice Owners and Associate dentists were also recruited to include those who received payments from different Commitment Payment bands. The Commitment Payment levels are divided into ten bands according to the gross incomes of dentists and these were grouped into four levels for the purposes of this study: Band 1 became level A; bands 2, 3 and 4 went into level B; bands 5, 6, 7 were grouped into level C and finally bands 8, 9, and 10 went into level D. The payment bands are outlined below: Dentists’ Commitment Payment Scheme 5
  9. 9. Payment Bands Gross Earnings (£s) Quarterly Payment (£s) CPS Band Level for research 2002-2003 purposes 27,000- 41,499.99 27 1 A 41,500-53,999.99 235 2 54,000-64,999.99 305 3 B 65,000-74,999.99 366 4 75,000-85,999.99 427 5 86,000-96,999.99 487 6 C 97,000-107,499.99 549 7 107,500-118,499.99 610 8 118,500-128,999.99 671 9 D 129,000 or more 731 10 Respondents were also recruited to include a mix of the following variables: • Age; • Gender; • Number of years they have had a contract with the NHS; • Dentists operating in rural and urban areas (the dentists taking part in the research decided whether their area was predominantly rural or urban); and • Dentists operating in areas with differing levels of deprivation (the dentists identified how deprived their area was). Respondents were purposively selected by our in-house team of specialist field recruiters, using the sample criteria above, as agreed with OME. Respondents were all recruited from sample provided by the Dental Practice Board (DPB), which included a list of dentists in receipt of the CPS. The sample profile table is included with this report as appendix ii. 1.3 Methodology This research adopted a qualitative methodology: Qualitative methods aim to define and describe the range of emergent issues, rather than measure their extent and produce statistics. In other words, qualitative researchers are seeking to understand ‘why’ and ‘how’, rather than ‘how often’ and ‘how many’. 6 Dentists’ Commitment Payment Scheme
  10. 10. Data was gathered using in-depth face to face and telephone interviews, as this enabled us to explore issues in depth, as well as isolating views depending on key variables, such as Commitment Payment level, type of area or age. All the interviews with Assistants were carried out via the telephone, as it was felt these interviewees were likely to be unfamiliar with the CPS. Interviews with Practice Owners and Associates were generally carried out face to face, however in some instances telephone depths were undertaken. Telephone depths with Practice Owners and Associates occurred for two main reasons: Firstly, some dentists requested telephone depth interviews because they were more convenient for them. Secondly, although willing, some dentists were simply unable to make the fieldwork dates organised in their area as their diaries were full. It should be noted, that BMRB were flexible regarding the dates and times of interviews in order to accommodate dentists. For example, BMRB organised second and third trips into some areas for those who were unable to make the original fieldwork dates. Alternative respondents (with the same sample characteristics) were sought in cases where a face to face interview could not be arranged, however, low numbers of dentists with certain characteristics on the sample provided by the DPB (such as those receiving a high Commitment Payment band) meant the option of using telephone depths allowed BMRB to produce a robust sample in line with the sample specification. Moreover, the study needed to be completed in a relatively short time frame that was made achievable via the use of telephone depth interviews. All the issues and topics were discussed and explored fully during the telephone depth interviews. Interviews were carried out either at the respondent’s dental practice or at their home, depending on the wishes of the dentist. Interviews lasted 1 to 1½ hours, although a few dentists were unable to spare a whole hour due to workload; even so, all the main issues were covered in the shorter interviews. All the interviews were undertaken by experienced qualitative researchers, using non- directive interviewing techniques. Interviews were guided by a topic guide or aide memoir which was agreed with OME before starting the fieldwork. The interviews were carried out between November and December 2003. All the interviews were recorded and subsequently transcribed verbatim. The verbatim transcripts were then analysed using an in-house inductive technique known as ‘Matrix-mapping’. For a more detailed description of ‘Matrix-Mapping’, please see the methodological appendix at the end of this report (iii). Dentists’ Commitment Payment Scheme 7
  11. 11. 1.4 Background to respondents This section seeks to provide an overview of the respondents’ backgrounds and current circumstances. As a result of the sampling criteria adopted for this study, it is to be expected that the sample would include respondents with a range of characteristics. For instance, respondents with differing levels of commitment to NHS dentistry; those from different types of areas; and those from different age ranges. 1.4.1 Work history A few of the dentists, particularly those working in family-run businesses, had worked in the same practice throughout their career. However, on the whole, respondents had worked in a number of different practices. Often they moved practice to progress their careers as they moved from Vocational Trainee (VT) to Associate, or Associate to Practice Owner. Some respondents had previously worked outside of General Practice in hospital dentistry. Such respondents mentioned working in army, community or psychiatric hospitals. These people had either moved into General Practice on a full time basis or in some cases split their work time between the GDS and hospital work. A few respondents had worked in dentistry in another country, either for short periods or in some cases throughout their entire career. Interestingly a number of the Assistants in the sample had qualified abroad and were only working as Assistants because their qualifications were not recognised in the UK. Respondents had predominately worked within the NHS throughout their careers, including those dentists who currently only carried out a small percentage of NHS work. Interestingly, some dentists in the sample suggested they had moved away from the GDS in the past, but had reverted back to a NHS practice as they either needed the quantity of patients this brought, or because they felt a moral obligation to the NHS and their patients. 1.4.2 Dental Practices The percentage of NHS dentistry being carried out at practices varied, as would be expected from the sampling criteria, with some respondents suggesting they carried out as much as 99% NHS work and others as little as 10%. Some practices with a high percentage of NHS patients were sometimes carrying out as little as 60% NHS work, as a consequence of the optional private treatments carried out that were not available on the NHS, such as white fillings. 8 Dentists’ Commitment Payment Scheme
  12. 12. ‘It is a National Health Service practice, we see National Health Service patients, we are not fussed about whether they’re contracted in or out, they come in as National Health Service patients. There are so many items you can’t [use on] patients like white fillings, you cannot do them on the Health Service, therefore we’re between 40% and 50% private, but that is just things like a gold crown or a porcelain crown on a back tooth that you can’t get on the Health Service, it adds up ... I think it was actually 39% last year, the previous year it was 42.’ (Associate, London, CP Level B) Practice Owners generally had a higher percentage of private patients than the Associates who worked for them. This was said to be a consequence of either having an insufficient number of private patients to fill the Associate’s list, or because the Practice Owner wanted to reduce their workload and increase their income. In some cases, Associates suggested they wanted to work with private patients, but felt the Practice Owners kept the private patients for themselves. Although Practice Owners tended to suggest they were making a conscious choice about what percentage of NHS work to carry out, it was clear that in some ways the percentage was guided by external factors, such as the area in which they worked and patient demand. For example, some Practice Owners felt their patients demanded private treatment, and others felt they would be unable to sustain a private practice in their local area as a result of the level of deprivation. For the most part, practices performing a high percentage of NHS work tended to be located in the most deprived areas (the respondent identified whether their area was deprived or not). However, some practices in Scotland were carrying out a high percentage of NHS work and described their area as ‘affluent’. A number of the practices visited during this study, suggested they had closed their books to new NHS patients. This was either because they were full to capacity or because they planned to convert to a completely private practice and would only treat existing patients under the NHS. In some cases, where the practice only treated a small percentage of NHS patients, they felt their private patients were subsidising those being treated under the NHS. Many respondents described their practices as being situated in areas that drew a range of different people, including people of different ages, ethnic backgrounds and socio- economic groups. Practices were also said to have a number of exempt patients on their lists, however, in a number of practices the exempt patients were the elderly or children, rather than those on welfare benefits1. By contrast, a few practices were situated in very 1 It should be noted, that the elderly are not on the whole exempt from charges, rather they are means tested. Dentists’ Commitment Payment Scheme 9
  13. 13. deprived areas that drew a large number of exempt or low income patients. In these cases, dentistry was felt to focus on treating immediate dental problems and disease, rather than prevention. The size of the practices taking part in the study varied and ranged from small single handed practices, where the dentist was often moving towards retirement and running the practice down; to large dental practices that had multiple surgeries and a range of staff including: Practice Owners, Associates, dental nurses, hygienists, reception staff and practice managers. ‘I don’t take new patients on now., I haven’t taken any new patients on for a number of years. If people telephone or call at the door, we don’t take new patients on, but obviously patients who come here and get married and ask if my wife or my husband or children, they expect to bring their children, so I would see those, but I wouldn’t see complete outsiders. So in that way the numbers are falling because obviously people move away, die. I would say that the hours fall in relation to the number of patients’. (Practice Owner, Cardiff, CP Level A) 1.4.3 Current work circumstances The sample included dentists working in General Practice both full and part time. Part time workers tended to be either older, female, or those who were also working part time outside of General Practice, for instance in hospitals or prisons. Dentists tended to work from one practice, however, some did work part time in other practices on an on-going basis, or peripatetically to cover absences. Furthermore, some dentists had additional responsibilities associated with dentistry, such as teaching under- graduate and post-graduate courses at Universities; training VTs; assisting with peer reviews; as well as sitting on health related boards or committees. It was found that Practice Owners tended to take approximately 50% of the Associates income. However, it varied as to whether they also took 50% of everything included in the schedule, or whether they only took 50% of the fees received. For example, some Practice Owners did not take a percentage of any additional payments, which included the Commitment Payment. 1.5 Report outline This report is divided into four main sections following this introductory chapter. Chapter two looks at the dentists’ commitment to NHS dentistry and reasons for this. Chapter three explores respondents’ awareness and knowledge of the Commitment Payment Scheme, as well as providing a description of their experiences of the Scheme. The fourth 10 Dentists’ Commitment Payment Scheme
  14. 14. chapter focuses on the dentists’ views of the Commitment Payment Scheme, initially focusing on dentists’ views on the design of the scheme and then looking at the impact of the scheme on them. This chapter also explores the perceived impact on others. Finally, chapter five concludes with a summary of the findings, suggestions for improvements and possible solutions to dentist retention and motivation. Dentists’ Commitment Payment Scheme 11
  15. 15. 2 Commitment to NHS dentistry As part of the study we explored dentists’ commitment to NHS dentistry. This chapter of the report outlines the views held by respondents, the reasons given for these views, and finally it outlines the reasons why dentists chose to remain in or move away from the GDS. Across the sample views regarding commitment to NHS dentistry varied, with some respondents describing themselves as being ‘committed’ to the NHS, and others suggesting they were not. ‘At this present moment in time, I’m not committed at all. To be quite honest with you, the way things are going at the moment, and all the uncertainty, I would seriously consider for the first time in my life, shutting my list of NHS patients and actually going private, because I know I could do it’. (Practice Owner, Cardiff, CP Level D) For the most part, respondents were able to mention both positive and negative aspects of working within the GDS. However, even those who described themselves as ‘committed’ highlighted problems, and some respondents were unable to identify any positive aspects of working in the GDS. ‘I’m committed, that’s what I would say…My reasons for saying I’m committed is, I enjoy doing my work, I enjoy doing the work I’m doing. I’m just answering the question you asked, if you asked me for my reservations or what I have against it, I can go further’. (Assistant, Leeds, CP Level A) Interestingly, it was not necessarily those with a high percentage of NHS patients who expressed the most positive views. In fact this group were often disenchanted with the system but remained for a range of reasons, such as the demography of the local area, or responsibility to their patients. Reasons for remaining within the GDS are outlined in more detail in section 2.3 of this report. However, certain respondent characteristics were found to have impacted on the views and behaviour of dentists regarding commitment. In particular, type of dentist; age; gender; and the type of area in which they worked, appeared to influence their views. Associates were in some cases more positive than Practice Owners about working in the GDS, as they felt they were able to learn their trade by working in a NHS practice. It was also felt that Associates experienced fewer problems with the system, as they did not have the responsibility of running a practice. However, a number of Associates expressed negative views and some expected they would move to private dentistry in the future. 12 Dentists’ Commitment Payment Scheme
  16. 16. 2.1 Positive views There were a number of positive aspects of working within the GDS mentioned by respondents, for example, it was said to provide: • Affordable dentistry; • A good salary; • A secure lifestyle; • A ready-made list of patients; • An appreciative clientele, compared to private patients; and • A wide range of different patients. These positive aspects of the service are discussed below. Ideologically a number of dentists liked the idea of working with NHS patients rather than private patients, as they felt it was morally and ethically correct. From their perspective, the NHS had performed an important role in improving dental health and they believed in the ideal of providing affordable dentistry to all. ‘There’s a sense of fulfilment, there’s a definite need there and you’ve got the ability to make people’s mouths more comfortable and keep them in good dental health and it’s a very fulfilling profession really’. (Assistant, London, CP Level A) For example, one respondent was extremely proud that they had patients over 30 years old without fillings which they saw as a consequence of the service they were able to offer under the NHS. ‘NHS dentistry has improved the health of people’s teeth, even in the 34 years that I’ve been working I’ve seen a big improvement in people’s teeth in that time, and that’s what, one generation? Most of the children that I see now and the children who come here are brought here by their parents when they are very small and they take the advice that I give them and they come along on a regular basis, and now there are young people coming here, well they’re probably in their 30s and they’ve got no fillings at all. If they’ve got as far as that the chances are that they are not going to have any fillings the whole of their lives’. (Practice Owner, Cardiff, CP Level A) Dentists’ Commitment Payment Scheme 13
  17. 17. Some respondents felt they were able to make an acceptable, and in some cases good wage by working in the GDS. In particular this tended to be young Associates, or Practice Owners who by their own admission ran ‘low cost’ practices with few overheads. Some dentists suggested they were able to run low cost practices as a result of either being located in rural areas, or because they had been in practice for a number of years and owned the building. The cost of premises was often seen as the main overhead, especially in inner city areas. ‘I think most things on the NHS are reasonably well paid, but I can say that because it’s a low cost practice, this, you know, we don’t have high overheads like you might have in a town centre or something… Well this is a private house, but basically yes, wages, overheads are lower here than perhaps they would be in town or in Sheffield or somewhere like that’. (Practice Owner, Leeds, CP Level D) Moreover, the capitation / registration payments received were seen as a real incentive to remain in the GDS, as it was thought this payment really boosted their salary. ‘Benefits, obviously at the moment with the registration payment, you know you’ve got some sort of guaranteed income every month and also you can basically set your limits for how many patients you think you can cope with having registered on your books’. (Practice Owner, Cardiff, CP Level D) Furthermore, some Practice Owners highlighted the importance of these payments in providing a guaranteed income. Other financial perks were also mentioned by respondents, for example receiving a council tax rebate and also being eligible for a pension scheme. Some older dentists suggested they were ‘thankful’ to the NHS for providing them - and in some cases, their family before them, with a secure lifestyle throughout their career. However, some said that despite this gratitude, if they were younger and at the start of their career, they may be more apprehensive about remaining in the system as a consequence of increasing overheads, the current system of remuneration and uncertainty about the future of NHS dentistry. ‘Well I am completely committed to the NHS. Three generations of my family have worked here and had a very comfortable and a very secure lifestyle because of the patients who come here. Most of that then has been because of the NHS. You know, I know there are a lot of things wrong in the NHS but I think that as far as I am concerned I’m quite comfortable with it’. (Practice Owner, Cardiff, CP Level A) 14 Dentists’ Commitment Payment Scheme
  18. 18. Working with NHS patients was also thought to be beneficial as it provided a ready-made list of patients. This was thought to be essential for those working in deprived areas where they felt they would otherwise have an insufficient number of private patients to draw on. Similarly, it was seen as important for those dentists either starting a new practice where they needed to build-up a list, or for those trying to expand their business. ‘I know one of my colleagues he bought a practice which is purely private and he had a lot of nightmares at the beginning when he first established. You know that patients sometimes they follow the dentist and if you have like 400 patients you might end up with 200 patients. But with the National Health patients you always, you never run short of patients’. (Associate, London, CP Level D) Some of the Practice Owners, who initially took on NHS patients in order to fill their lists, said that despite now being in a position to convert to a private practice, they continued to provide an NHS service as they felt they had a responsibility to their patients to continue. It was clear that for a number of dentists the relationship with patients, coupled with a sense of responsibility to them, impacted on the decision to remain within the NHS. This was especially true for older dentists, who felt they had built up good relationships with their patients over the course of their career. Furthermore, private patients were sometimes seen as being less desirable, as they were thought to be more demanding than NHS patients. For instance, some respondents thought private patients acted as though they had a right to preferential treatment - such as not having to wait for an appointment, and they were thought to expect a ‘plusher’ environment. These views were primarily held by dentists who felt they simply wanted to perform dentistry, rather than focusing on customer care or the aesthetics of their practice. For some dentists, remaining within the NHS also meant they were able to see a wide range of patient types, including those from a range of social groups and those with differing needs. Having a variety of patient types was something they enjoyed. ‘I always prefer to have a wide range of patients. I don't want to commit myself to just a narrow range, just those that can afford private dentistry to come and see me. I like to be on the National Health, so that I can see more people, can help more people’. (Associate, London, CP Level D) ‘The location of the area, you know I’ve worked in this practice I enjoy the sorts of patients that we deal with they’re an interesting cross section of the population, we do have people who come from the better areas around here but also we get them from some of the rougher areas and I like the variation in that’. Dentists’ Commitment Payment Scheme 15
  19. 19. (Practice Owner, Cardiff, CP Level D) 2.2 Negative views On the whole, the negative views expressed by respondents tended not to relate directly to their salary – although this was an issue for some, rather dentists were generally more concerned with the quality of service they were able to provide to patients, as well as the quality of their working life. This said, Associates were generally more focused on their salary than Practice Owners. However, the issues raised in this section were echoed across all types of respondents. 2.2.1 Item-of-service fee scale system Overall, the feescale was seen as being outdated and generally too low to cover the ‘real’ cost of dental treatments, especially when compared to fees for private dentistry. ‘It doesn’t pay, you know … you can do root canal treatment, the National Health Service, they’ll pay you £60, now from start to finish to do that treatment. In an ideal world, to make sure you do it as ideally and deal with complications, and do it perfectly, it could at least take three to four hours to do. So if you’re making £60 in three to four hours work, that wouldn’t even pay if you turned the lights on. Whereas privately that’s going to cost £300 to £400 at least, so you’re actually providing the correct treatment with no restrictions, and that’s what I want to do at the end of the day’. (Practice Owner, London, CP Level A) However, the feescale was also described as having ‘swings and roundabouts’, as although some fees were seen to be more fitting, others were regarded as insufficient. For example, the fees for such treatments as dentures, root fillings, crowns and scaling and polishing were said by some to be insufficient. ‘There are some items of treatment that are much more profitable than others, so there are others that you do that are less profitable’. (Practice Owner, Cardiff, CP Level A) The problems created by the feescale were thought to have been exacerbated by increasing overhead costs, such as the cost of property, staff and laboratories. Which meant dentists felt they needed to work even faster in order to make a profit and cover the costs of running a practice. Furthermore, the feescale was not thought to adequately reward experience, as all dentists, no matter how experienced, received the same fee for treatments. For example, one dentist thought it wrong that they were still earning the same hourly rate as ten years before. 16 Dentists’ Commitment Payment Scheme
  20. 20. ‘Economics is the straight answer. If you were to go and see a solicitor who has been qualified for 30 years, what would you expect his hourly rate to be? We are still working at the same hourly rate as we were 10 years ago’. (Practice Owner, Leeds, CP Level A) The fees paid for emergency call-out were also viewed as inadequate by some. For example, one respondent explained how they were called out in the middle of the night to a patient who they treated for one hour and yet only received £16 from the NHS. Respondents drew a number of analogies between the fees earned by dentists and other professional workers, such as solicitors, General Medical Practitioners (GPs) and plumbers, who they believed earned a higher wage. They did not believe these types of professionals would work for a similar hourly rate to dentists and felt there should be greater parity between their incomes. In particular, they drew attention to the emergency call-out rates commanded by other professionals, compared with that of dentists. Time According to respondents, the feescale was not thought to balance with the time required to complete treatments and this was thought to result in treatments being carried out more quickly in order to earn sufficient money to cover costs. ‘You know that you’ve got X amount to do a filling, so if you want to make any money on it you've got to do it rapidly, which isn’t good for the patient, and it’s not good if you want to work well either, that you know you’ve got to be rushed’. (Associate, London, CP Level C) Additionally, increasing patient demand in NHS practices created by the reduction of NHS dentists was thought to have increased list sizes and further impinged on dentists’ time. Constraints on time were said to result in poorer quality work being carried out. According to some, working under pressure meant that mistakes were inevitably made, examples included: not packing a filling properly, taking the wrong tooth out or making an inaccurate clinical judgement. ‘I would say that the quality of work that I do, if I’m working where time is no object, the quality of work I would do would be higher. Now whether the patients would perceive any difference, whether the work would last any longer, that isn’t something I know. There are certain occasions where I’m sure you do something, you’ve been in a bit of a hurry, and occasionally the patient comes back and a couple of weeks later something’s broken or whatever, but you replace that, you do it free, and that happens probably in any job. Some days you do something a bit better than another’. Dentists’ Commitment Payment Scheme 17
  21. 21. (Associate, London, CP Level C) To avoid this, some respondents said they chose to take longer over treatments and chose not think about the cost, and others suggested they subsidised NHS patients with their private patients. ‘Well basically, because I do enough private treatment I can ignore the financial constraints and do the treatment that I see fit, so they get the same amount of treatments, I’m able now to do whatever treatments I need to for them without worrying about the finances of it, so they get exactly the same treatment’. (Associate, Cardiff, CP Level C) The feescale was also thought not to allow sufficient time to be spent on non-clinical tasks, such as time spent making appointments, preparing the surgery for the next patient, talking to the patient, providing them with information, or coaxing them prior to having treatment. ‘For instance you know a child may come in with a swollen face and you’ve got to treat that child and as an acute case its difficult its time consuming. It might take you half an hour to coax that child round to allow you to open the tooth up and allow all the infection out of the tooth. You don’t get paid anything for that do you’. (Practice Owner, Cardiff, CP Level D) ‘It’s very simple – let’s just pick a figure. Let’s just say that to run this practice I've got to gross £60 an hour, the National Health Service expect me to do a full examination of the patient and they need their teeth cleaning – I get paid for that, gross, about £18, so to earn £60 an hour I've got to do over 3 of those in an hour. And it’s not the time in the chair, it’s from when one person walks out of the chair to the next person walking in and out of it, so apart from the clinical time there’s the cleaning time, there’s making the appointments, there’s setting up the surgery for the next patient’. (Practice Owner, Leeds, CP Level A) Some dentists also felt that the inability to remunerate time spent on educating patients on dental health meant that there was a lack of focus on prevention. ‘I just think that you can spend more time with them and spend more time concentrating on preventative areas. I think I’m not too bad at spending time discussing diet with children, and brushing techniques and things like that, but you just don’t get enough time to do it. I usually find I’ve got about four patients waiting all the time, so you really haven’t got time to sit and discuss things’. (Associate, Edinburgh, CP Level D) 18 Dentists’ Commitment Payment Scheme
  22. 22. Some respondents working in deprived areas highlighted the problem of oral hygiene and felt they should receive a higher fee to reflect the additional time it took to treat patients with poor dental health. In one instance, an Assistant had removed some of the more medically demanding patients from their list as they believed they could not afford to treat them. Materials and equipment While the costs of laboratories were said by the respondents to be increasing, conversely, the quality of work produced by laboratories was thought by some to be decreasing. Consequently, some dentists felt they had to use the most expensive laboratories, in order to get a good standard of work. As a result of the high cost of laboratories, dentists suggested they were unable to make a profit on certain items, especially on dentures, which some dentists said they could make a loss on. ‘NHS fees for a lot of things aren’t great, there’s some things where the fee is very nearly as much as the lab bill … Dentures, so you’re almost onto a loss when you do things like that, which doesn’t really inspire you to do NHS dentistry’. (Associates, London, CP Level C) ‘I think with the laboratory you choose, I don’t know if you’re aware how we’re funded, particularly with laboratory works, there’s a fixed fee for an item, so if I choose a very good lab I might be running at a loss, if I choose a cheaper lab then I might break even, or if I use an even cheaper lab I might make a profit’. (Practice Owner, London, CP Level B) In order to overcome this, some respondents had begun charging their patients privately for all laboratory work carried out. ‘I do all my lab work privately because I can’t afford not to, for example the NHS pays £75 for a crown and my lab charges me £70 for a crown, you know, I can’t do a crown for £75, I’m getting paid less than my Assistant, so I don’t do lab work on the NHS and it’s great, because the lab work we do is quality.’ (Assistant, London, CP Level A) In an attempt to cover costs and make a profit, respondents suggested that some dentists used inferior material as it helped to reduce the cost of treatments. Despite identifying the pressure to do this, no Practice Owners interviewed for this study said they currently did this, although some said they had tried. According to them, this was generally thought to be a false economy as it was harder to work with the material and resulted in them carrying out sub-standard treatments which often had to be repeated. Dentists’ Commitment Payment Scheme 19
  23. 23. However, some of the Associates interviewed said they had been told, or else suspected, that their Practice Owner had been purchasing inferior material in order to cut costs. For instance, one respondent thought their Practice Owner had been buying lower quality amalgam, which the Associate found more difficult to work with. ‘I think you cut corners in the quality of the materials you use. When it gets to the stage where you’ve got two levels of practice, when you’ve got cheap amalgam for your cheap amalgam filling, and you’ve got quality amalgam that costs four times as much than the Government pay you for a filling’. (Associate, London, CP Level B) Equipment was also said to be overly expensive, for instance the dentist’s chair was said to cost £7,000. Some respondents felt that it would be possible to reduce the costs of this type of equipment, if it could be bought in bulk centrally by the Government or another organisation, and then sold to dentists at a lower price. Staff costs Practice Owners thought it was also becoming increasingly difficult to manage staff costs under the feescale, particularly with the introduction of new employment law. They felt that in order to employ good staff it was necessary to pay both appropriately and competitively, as well as providing training. As staff become more qualified and experienced then it was thought necessary to increase their wage in order to reward and retain them, which ultimately resulted in it being increasingly difficult to keep good, well trained and experienced staff on the team. 2.2.2 Administration and regulation Views on the level of paperwork varied. Some respondents did not see paperwork as a problem provided the practice was organised, however, others did. In particular, new health and safety regulations were thought to exacerbate the level of paperwork required. One respondent said they spent two days going through paperwork relating to health and safety issues, such as X-ray regulations, disposal regulations, and staff related documentation, such as criminal checks. ‘In order to meet health and safety regulations we have to do, for example, staff inoculations and so on, we have to do staff documentation regarding any previous convictions and so on which we never used to do previously. We have to do testing for electrical equipment and compressor testing and so on. It all takes a fair bit of time’. (Practice Owner, Leeds, CP Level C) 20 Dentists’ Commitment Payment Scheme
  24. 24. The need to request permission for treatments to be carried out was also thought to negatively impact on the level of paperwork required. Moreover, requesting permission was thought by some to demonstrate a general lack of trust regarding their clinical judgement and it was also said to be time consuming and frustrating. ‘There are limitations on the treatments that you can administer to the patients, which I object to wholly. This permission is based on the fact that, I presume it can only be that we’re not trusted, our clinical judgement is not trusted in that, you know, why would a dentist need to apply for permission to somebody, namely people who are working up at the Health Board, some of which have not been in a general dental practice for many, many years and we have to ask them for permission to do the work’. (Associate, Edinburgh, CP Level B) For some the current system was simply seen as being overly regulated. Some drew an analogy to ‘big brother’, as they felt they were being watched over. In contrast, others felt this regulation was good and called for closer checks to be carried out within private dentistry too, as they felt it was under regulated. It should also be noted, that where computerised systems were in place, particularly an Electronic Data Link (EDI), paperwork was generally not thought to be a problem. The EDI link was viewed extremely positively, as it was not only thought to be effective but time saving. ‘The girl I work with, as I say she does invest quite heavily in the practice and she’s just invested in this software of excellence computer program, which really has cut our administrative work dramatically so I don’t think that’s a problem anymore … It sort of has an EDI link right through to the Health Board, when you put in your treatment plans on the computer.’ (Associate, Edinburgh, CP Level D) ‘I've got no problem, we are all e-linked, so our system of payment is quite straight forward, it goes through the computer, so that’s fine, that works brilliantly. We used to have to fill in forms for every item of payment and that was a real pain but as most practices become computerised the actual system of recouping that money is not a problem, that’s easier and easier. Filling in the forms and the bureaucracy that used to go with it was a lot more time consuming in the past but since it’s been computerised it’s brilliant, not a problem.’ (Associate, Edinburgh, CP Level B) 2.2.3 Patients Patients were identified by some as being an increasing source of pressure, primarily as a consequence of having higher expectations regarding the treatments available and the Dentists’ Commitment Payment Scheme 21
  25. 25. materials used. For instance, patients were said to be more likely to request white fillings and other types of cosmetic dentistry. Similarly, it was felt that patients were more demanding in terms of how long they were prepared to wait for appointments and these changes in expectations were said to have been brought about as a consequence of the rise in private dentistry. ‘Patients are becoming more demanding, even NHS patients, even exempt patients, they want something that you have to spend a lot more time on. Well, you know, quality of crowns for example, or dentures, or even simple fillings, they are asking for highly cosmetic appearing fillings and you have to spend more time doing them. You know, it doesn’t work out feasible, you know. Because you have a certain target you have to meet in an hour, say for example, to cover your out-goings, your expenses for the nurse and the general running of the practice, lighting and whatever. It might not meet it’. (Associate, Cardiff, CP Level C) The patient’s idea of what constitutes an emergency was also thought to have changed, with some patients calling dentists out in situations not deemed to be critical by the dentist, such as for a filling replacement. Moreover, patients were said to be generally less appreciative of this service. ‘When we do emergency rota we have a telephone at home and come out any time up to 10 o’clock at night … Sometimes somebody telephones coming up to 9 o’clock at night, and sometimes you know they are calling from the pub because you can hear all the noise that’s there, and you turn out and you see them and you put a temporary filling in - something which possibly didn’t need to be seen at that time, it could easily have waited until the following morning, and the fee is what £3 or £4, something like that. And you think, what value do those patients put on a service or someone who has turned out at night, has done something for them, and you know it’s really small change. I suppose that’s the only time when I feel perhaps under-valued’. (Practice Owner, Cardiff, CP Level A) In addition to this, some dentists also felt that patients had become more litigious, which required them to keep full and accurate records or any problems of difficulties that occurred. This, they believed further encroached on their day and increased their workload. ‘We live in an increasingly litigious society as well, and you know things that were considered accidents are no longer considered accidents, so you have to be hyper aware of that and everything has to be written down verbatim and our note keeping has to be much more thorough than perhaps it was 10 years ago. That again takes time you know where’s that time going to come from. And you can’t write the notes up at end of the day you have to write them up as it happens, you can’t sort of leave stuff to do that evening because by the time that evening comes round … you’ve replayed in 10 times in your head before you go home, you then re-write what you think happened but not actually what did happen’. 22 Dentists’ Commitment Payment Scheme
  26. 26. (Practice Owner, Cardiff, CP Level D) 2.2.4 Future uncertainty Throughout the fieldwork, it was clear that a number of respondents were concerned about the future of NHS dentistry, in particular they were apprehensive about the imminent changes to be brought about by ‘Options for change’, or ‘Routes to reform’ in Wales. A great deal of speculation was being made regarding what direction NHS dentistry would move towards following these changes, with some thinking there would be a move to a salaried service and others believing a core service would be implemented. ‘There’s a lot of changes coming along. We’ve already had a few changes. But this one next year is obviously affecting a lot of people. I don’t know how it’s going to affect me yet. It would be nice to have a fixed salary, but I don’t think they’ve thought it through properly. If you’re on a fixed salary, what happens, say for example, if you have more patients demanding more work and your income can actually go up, but you know you are on a fixed salary. Do you see what I’m saying?’. (Associate, Cardiff, CP Level C) ‘Well, fundamentally we currently get paid on a scheme where you get paid a fixed price for treatment and patients pay a contribution and you get a certain amount for having patients on your list, and they’re scrapping the whole of this system and nobody knows what they’re putting in yet. This is all going to come in, in 2005, and nobody knows what’s going to happen and how it’s going to work, you know, fundamentally these changes are going to be imposed on us’. (Associate, London, CP Level C) Certainly, a number of dentists said they were waiting to see what changes would be made, in order to make a decision regarding their future in dentistry. 2.3 Reasons for remaining in or moving away from NHS dentistry During the interviews, respondents raised a number of specific points regarding why they believed dentists chose to either remain or move away from the GDS. Respondents suggested they and others remained in the system as a result of: • Feeling morally and ethically bound to provide affordable dentistry to all; • As a result of feelings of responsibility to their patients, some of whom they had treated for a number of years and built a relationship with. Some dentists explained how they were known within the local community and consequentially felt a sense of duty to treat their patients; Dentists’ Commitment Payment Scheme 23
  27. 27. ‘I don’t feel committed to NHS dentistry at all, I’m committed to the patients. We have talked endlessly about coming out of the Health Service, and when it comes down to it, we are a high street practice with a clientele who probably if we said we were [going] private tomorrow, we’d have enough patients … They keep on asking us, they read it in the newspapers and they say “When are going to be private?” “You’re not going to go private are you?”, we say “No, we just give the options”, and it seems to suit them.’ (Associate, London, CP Level B) • The demographics of the local area in which they practised which they felt could not sustain a private practice; ‘Yes, I mean very committed. I mean basically because of the type of the patients that we’ve got in the area, I don’t think there really is the scope here to switch to a completely sort of private practice’. (Practice Owner, Cardiff, CP Level D) • The NHS providing a ready made list of patients, which was thought to be particularly important for new practices and those in more deprived areas; • Being older and moving toward retirement and their pension; and ‘I think I’m too old to change really, sort of filling my twilight years until I retire. I’m not interested in changing really to a private practice. If I’d have done that I’d have done it when I was younger’. (Practice Owner, Leeds, CP Level D) • Younger newly qualified dentists learning the trade in GDS. In contrast, it was felt that dentists were moving away from the GDS because: • Private dentistry was more appealing, as they believed it was possible to work less hard and earn more money; • They would be able to provide a better service to patients, by spending more time with the patient, and by offering a wider service, including a extensive range of treatments and materials; and • They could take greater care and more pride in their work. 24 Dentists’ Commitment Payment Scheme
  28. 28. 3 Awareness and experience of the Commitment Payment Scheme This chapter of the report explores the dentists’ awareness, knowledge and experience of the Commitment Payment Scheme. It looks at the level of awareness of the scheme; how dentists were made aware of it; what they knew about it (for instance who introduced it, who was eligible, and how the payment levels were organised), and finally dentists’ personal experiences of the scheme. 3.1 Awareness of the Commitment Payment Scheme Respondents generally suggested they had heard of the Commitment Payment Scheme, however, some respondents had not. In particular Assistants and some Associates were unfamiliar with the scheme and some confused the Commitment Payment Scheme with other schemes, such as seniority or registration payments. A number of dentists who had heard of the scheme, suggested they first became aware when they received a payment or saw it written in their schedule. Others mentioned hearing about it in a range of ways, including: • Reading about it in the remuneration book, or items-of-service; • Hearing about the scheme ‘word of mouth’ at local dental committees or training events. One respondent said they had called the DPB to gather more information on the scheme after hearing about it at a conference; and others thought they had been sent information directly about the scheme. Although they admitted that they had not necessarily read it. Although some respondents had initially heard about the scheme through ‘word of mouth’, this tended to be via formal sources or during organised events, rather than informally from colleagues or friends. In fact, some respondents said they did not believe the scheme had been widely discussed among their peers, and one respondent described it as a ‘non- issue’. ‘I’ve never heard anybody at the meetings I’ve been to, I’ve never heard anyone discussing Commitment Payments either way. I’ve never heard anybody saying how wonderful they are and I’ve never heard anybody saying that they were a waste of time. I don’t really think they make a difference. The issue is what the fees are, what the items of service are, you know … the money for a scale and polish for example, or an examination’. (Practice Owner, Cardiff, CP Level A) Dentists’ Commitment Payment Scheme 25
  29. 29. Although they were aware of the scheme, some dentists were unable to recall how they had heard of it. Respondents were generally unclear about who had introduced the scheme, although they guessed it to be Government led. However, they were quite clear that it had been introduced to encourage dentists to remain in the GDS, with some describing its purpose as a ‘reward’ or as a ‘sweetener’. Additionally, some felt it had been introduced as an alternative to increasing the feescale. 3.2 Knowledge of the Commitment Payment Scheme In order to ascertain the dentists’ knowledge of the Commitment Payment Scheme, respondents were initially asked to spontaneously describe what they knew about the scheme, and following this they were prompted about particular aspects, such as what they knew about payment levels or the eligibility criteria. Although the dentists exhibited varying degrees of knowledge about the scheme, on the whole their awareness was limited. For the most part, respondents were spontaneously aware that the payment was related to income in some way, some also mentioned it being related to list size and length of time contracted to the GDS. Despite awareness that the scheme was linked to income, the link with annual gross income was not always made. Instead respondents often linked it with quarterly earnings or the number of patients seen each month. ‘Sketchy – I did read about it when it first came out. If you’re very good and you’ve been working for the National Health Service for long enough, they give you an extra couple of shillings for being a good boy – that’s basically what it boils down to – I can’t remember the amount’. (Practice Owner, Leeds, CP Level A) ‘I just know that every now and again I get a few hundred pounds on the schedule, that’s as much as I know about it, I think it’s based on your years of service and also on your income’. (Associate, Edinburgh, CP Level D) In terms of the eligibility criteria, respondents were generally aware of the five year prerequisite and one dentist was aware that this had recently been reduced from ten to five years. However, some thought you were eligible after three years and others thought all dentists were entitled regardless of length of service. The fact that this had to be five years in General Practice, rather than time spent working in hospitals for instance, was also raised. 26 Dentists’ Commitment Payment Scheme
  30. 30. The respondents were generally unable to provide exact information regarding payment levels. While there was awareness of the tiered system of payment bands, many were not able to provide specific information about the details of the bands, such as the number of bands, the level of payment received in each band, or the gross income required to reach a certain band. Furthermore, some were also aware that an additional payment was received by those over the age of 45 years. Other ‘top-ups’ such as the additional 50% for those contracted for 20 years or more, or the additional payment for number of hours spent on NHS were not known about it. Although some respondents felt they knew little about the CPS, they generally felt confident that they would be able to locate the information easily in their files, if they needed to. 3.3 Experience of the Commitment Payment Scheme Both Practice Owners and Associates were generally aware that they were in receipt of the Commitment Payment. This said, there were instances where Associates did not think they were in receipt of the payment. Views among Assistants were mixed with some believing they were not in receipt of a payment and others knowing that they were. There were two reasons for not thinking they received a CPS payment: either they regarded themselves as ineligible as they had not been working for five years2, or they had simply not heard of the scheme and so assumed they must not be receiving it. ‘I have only heard of it for the first time when someone rang me [from BMRB], and I said I didn’t know anything about it because I’ve not received it before.’ (Assistant, Leeds, CP Level A) Across the different types of dentists taking part in this study, respondents said they had not been officially notified about receiving a payment. Many felt that awareness came when seeing the CPS information laid out in their payment schedule. In some cases, the dentists said they were anticipating a payment, as they knew they would be entitled once they had been contracted to the NHS for five years. The dentists had been in receipt of a payment for varying amounts of time, with some having been in receipt of a payment from the outset of the scheme, and others having received it more recently. Payments were said to be made automatically to the dentist 2 The sample supplied by the DPB was said to only include those who were in receipt of a payment. In the cases of those who did not believe they were receiving a payment, it is not possible to corroborate or refute their claim for this study. Dentists’ Commitment Payment Scheme 27
  31. 31. alongside the income outlined in his or her schedule. However, one respondent thought they received CPS payment separately in a cheque. For the most part, the payment was said to be paid on a quarterly basis (as is the case), although a few thought they received it bi- annually. The administration of the fund was felt to be efficient, except in one instance where the respondent did not receive their payment at the correct time and instead received back pay of two or three payments at once. ‘I think at the beginning we were chasing it, but that was because we didn’t know the system and they were behind at the beginning, and then they paid two lots or three lots at the same time, it eventually came through, and we checked it back and made sure we had it, but my Principle is very good at making sure’. (Associate, London, CP Level B) Dentists were generally aware of how much Commitment Payment they were receiving and in some cases, they were also aware of what band they were in as a result of seeing this outlined in their payment schedule. Certainly those in the lowest and highest bands tended to be aware of their placing in the banding system. As one respondent explained: ‘I’m on level 10 I think or something, yeah, level 10, eight or nine hundred quid I think’. (Practice Owner, Cardiff, CP Level D) Following the introduction of the scheme, some dentists said they were ‘surprised’ about the level of the payment they received which was lower than they expected. Particularly, some of the older dentists who despite thinking they would benefit as a result of their length of service, were actually receiving a band 1 payment, as they did not gross sufficient income as a result of ‘running-down’ their practice with a view to retire. As a consequence of being in band 1, these dentists were not entitled to the additional 50% top-up for 20 years service, or for being over the age of the 453. ‘Well when I heard about it I thought that it would reward people who had spent a lot of their working time committed to the Health Service. I thought I’m bound to feature very well in that but it hasn’t worked out like that at all … It would have coincided with the time that I was starting to ease off. As soon as my children were through university and I didn’t have to support them I eased off. So that would have coincided with the commitment payments coming in. Because of that, because the amount of work I was doing was below the threshold I just get the basic commitment payment. So from that point of view I feel that having spent the whole of my working life working within the health service, its not a commitment payment in the way I would look at it’. (Practice Owner, Cardiff, CP Level A) 3 Those receiving a band 1 payment are not entitled to additional top-ups. See statement of remuneration in appendix i. 28 Dentists’ Commitment Payment Scheme
  32. 32. In contrast, some dentists receiving the highest payment levels suggested they knew they would be in the top bands, as a result of working in a very busy NHS practice and seeing high volumes of patients on a daily basis. For instance, one respondent said they saw a patient approximately every 15 minutes. The quarterly payment was generally said to remain constant, however others said their payment was more variable and on some occasions they did not receive a payment at all, which they found confusing. Those dentists receiving top-ups as a result of their age or length of service were generally aware of this. Although they were not always able to say exactly how much the additional payments were and what they were for. The arrangement between Practice Owners and Associates regarding the percentage of the Commitment Payment paid to the Practice Owner varied, with some Associates paying half of the payment to their Practice Owner along with the rest of their income; and others being able to keep the entirety of their payment. Dentists’ Commitment Payment Scheme 29
  33. 33. 4 Views on the Commitment Payment Scheme This chapter of the report looks at the respondents’ views of the Commitment Payment Scheme, including their views on the design of the scheme, and its overall impact. Interestingly, dentists’ views regarding both the design and the impact of the scheme were not related to specific characteristics, such as the type of dentist or the level of Commitment Payment band received. 4.1 Views on the design of the scheme This section considers the dentists’ views on the design of the Commitment Payment Scheme. It should be noted that not only were these views based on their spontaneous knowledge and understanding of the design, but the respondents were also provided with information regarding the scheme in order to help them make informed comments. For instance, they were told about the eligibility criteria, the payment bands and the additional payments, or top-ups, and in some cases they also referred to their own copy of the ‘statement of dental remuneration’. It should be noted that when discussing the design we referred to payment bands utilised in 2002-03, but also made the respondent aware of the new payment levels for 2003-04 and this was not thought to impact on the findings. A copy of the payment bands for 2003-04, can be found in appendix iv. 4.1.1 Eligibility criteria Some respondents felt the five year eligibility criteria was ‘fair’ as it meant that only those who had worked in the NHS for a substantial amount of time would be rewarded. Additionally, it was also thought that it could potentially act as an incentive to remain in the NHS. ‘I think that’s fair enough. It’s quite a big outlay for the NHS and you know you do want to make sure that the people you are rewarding or trying to get to stay in the system are committed, so I think that’s fair’. (Practice Owner, Cardiff, CP Level D) However, other respondents took issue with delaying payments as they felt the scheme should be extended to include younger dentists. They believed that all dentists practising in the GDS worked hard and as a consequence felt they should all be rewarded. Furthermore, some thought waiting five years removed the incentive for younger dentists to remain in the NHS as they believed the decision regarding whether or not to work in private dentistry was generally made before the five year point. This was particularly 30 Dentists’ Commitment Payment Scheme
  34. 34. thought to be the case if the dentist had also worked for a year as a VT, which meant they would have to work for six years before they received the payment. ‘I think making you wait five years before saying you’re committed to the health service. I say for younger people that’s five years down the line, five years after finishing a year’s VT - so 6 years post qualifications. That’s quite a long time. I think that’s quite a long time to make people wait for a commitment payment, if its going to be called a commitment payment’. (Practice Owner, Edinburgh, CP Level C) It was also felt to be unfair that only time spent working in General Practice counted towards the five years, rather than time spent in other types of NHS dentistry, such as time spent working in hospitals. As one respondent explained, this meant friends who had qualified at the same time but who worked in hospitals for any period of time, were ineligible for the payment, despite working for the same length of time and being just as committed to the NHS. Women who took a break from dentistry to have children prior to working for five years, were also said to lose out under this scheme. As despite being qualified for over a five year period, they would not be entitled to receive a payment. ‘But if they worked for two years and then they had their children, or didn’t work for four years and either came straight back to work or did a back to work scheme, then there were another 5 years after that so you were doing 10 years down the line before, before they were considered for it. I don’t know whether people should factor in about women coming back to work because dental schools are at least 50% female now [in terms of] intake. So there’s going to be lots of women in the future and you know why shouldn’t you go off and have children and be allowed career breaks and things like that. It’s a long hard career if you’re not having breaks’. (Practice Owner, Cardiff, CP Level D) The preferred length of time respondents felt a dentist should be qualified for before being entitled to a payment varied, with some suggesting the system should be available to all dentists no matter how long they had been qualified, and others thinking it should be reduced to two or three years. ‘I think that is good, I’m not sure about the, you know you have to have worked for five years thing. I think three years would probably be quite, quite a lot’. (Assistant, Cardiff, CP Level B) The idea of relating the payment to gross income was generally accepted as being ‘fair’. However, some issues were raised regarding the level of gross income required in order to Dentists’ Commitment Payment Scheme 31
  35. 35. reach the various levels of Commitment Payments, as some felt that these were unrealistic, particularly the higher levels. Some also viewed the additional list size required to qualify for the higher bands as being overly high and this and other issues relating to payment are discussed in the next section, 4.1.2. When asked about the types of dentists they felt should be entitled to the scheme, the respondents agreed that the scheme should be open to all dentists including Practice Owners, Associates and Assistants. ‘I think as far as Principle, Associates, Assistants, I think they should all get it, I don't see why Assistants shouldn’t in the past have got it’. (Associate, London, CP Level C) 4.1.2 Payment bands The problems raised by respondents regarding the payment bands tended to be related to three main points: the level of payment received; the disparity between band 1 and the other bands; and the level of gross income required to obtain the higher payments. According to the respondents, payment levels were thought to be too low overall, especially when the payment was looked at on a monthly, weekly or indeed daily basis - which is how the dentists tended to view it. One respondent in receipt of Commitment Payment level A estimated that they received £1 per week, which would not ‘even buy a pint of beer’. ‘Roughly – they give you that, then they take 40% tax off it, for starters, it’s about £1 a week, you know, it doesn’t buy you a beer, you know, so it’s a milksop basically, they might as well just scrap it. I think they’ve got to realise several long term problems. They’ve got to address the issue of the actual basic National Health Service fees, particularly nowadays when they are so paranoid about things like cross-infection control. I mean, you can’t do it like that to do the job properly, it takes several minutes between each patient. The fees, basically, have gone up over the years by 3% here and 4% there but they haven’t kept pace with the cost’. (Practice Owner, Leeds, CP Level A) Even though it was acknowledged that payments received in the higher bands were more worthwhile, it was still felt that the payment levels were generally too low to compete with the income they felt it was possible to accrue from carrying out private dentistry. Some respondents believed they could earn the equivalent of their Commitment Payment in a couple of hours carrying out private work. 32 Dentists’ Commitment Payment Scheme
  36. 36. ‘If you’re grossing £100,000 a year then you get a quarterly payment of £549 [laughs]. You know, it doesn’t encourage one to stay, because if you did private work you could get that for a few crowns. I’ll go back to my example of if you hire an emergency plumber it’s £70 – 3 or 4 visits and a plumber covers that’. (Practice Owner, Edinburgh, CP Level D) When asked about how much they felt the Commitment Payment would have to be increased by, in order to compete effectively with private work, the responses varied: with some suggesting it would have to be at least doubled and others suggesting it was pointless to consider as it would have to be increased by such a large amount that it would be unrealistic. ‘Basically because a sort of £900 per quarter payment is beneficial, and it’s nice, of course it is. But I don’t think in the greater scheme of things it would be enough to, like I say with the uncertainty of changes coming up now, something like that wouldn’t be anywhere near enough to stop you looking for other venues, other practice schemes such as independent or private really…I don’t think it would work. If they were looking at using it to try and keep people within the NHS, they would have to put it up [by] such an amount that it would become prohibitive to do it anyway’. (Practice Owner, Cardiff, CP Level D) It was also noted that the payment became even lower for those Associates paying their Practice Owner 50% of their Commitment Payment. The disparity between the payment levels of band 1 and band 2 were highlighted by some respondents, particularly those in band 1, as they felt that it was ‘unfair’ that there should be such a gap in amount between these levels 4. Band 1 was described as ‘insulting’ by some, as it appeared to acknowledge the need to provide an additional payment to the dentist, but then provided them with a quarterly payment of £27 (under 2002-03 payment levels), or £36 (under new 2003-04 payment bands). ‘I mean what do you think of these payment bands in terms of the amounts and how much you have to be earning? … There’s a pretty big disparity between level one and those of 2, 3 and 4, there seems to be quite a sort of quantum leap there between someone earning £41,499.99 and someone earning £41,500 a year that just seems a huge, huge difference’. (Practice Owner, Edinburgh, CP Level D) As previously mentioned, respondents also felt it was unfair that those in band 1 were not entitled to any other additional top-ups, such as the extra 50% for 20 years contracted to 4 Band 1: £27, band 2: £235, difference of £208 Dentists’ Commitment Payment Scheme 33
  37. 37. the NHS, or for being over 45 years old. Especially as a number of older dentists were thought to be in this band due to the fact they often worked part time, or more slowly than younger dentists. Some dentists also felt it would be extremely difficult for them to reach the higher bands 8, 9 and 10, as a consequence of the level of gross income required to do this. They felt they were already working very hard and believed it would be impossible for them to achieve these bands unless they were in a larger practice with a higher turnover of patients. Others who were in the higher bands disagreed, as they felt they were easily able to make this level of income without working an overly long week. However, this did tend to be those respondents working in large, busy, NHS practices where, according to some, they carried out a large number of very quick treatments, such as extractions. ‘I don’t know from the middle ranges to the top are better to retain the staff you know on the NHS, but I think to get those levels you’re working really damn hard in the first place anyway. So people may think why should I slog myself off to get this you know, what is a small percentage to what they could be earning 100% private. I don’t think it’s sufficient…I don’t know just to get that big gross I mean I know how hard you have to work to get that initial gross, to be eligible for that. So for me I think it's more trying to get that gross is quite difficult for me to comprehend’. (Assistant, London, CP Level A) In criticism of the design, some dentists felt the focus on maximising gross income, meant the scheme encouraged a ‘drill and fill culture’, rather than a more preventative style of dentistry. ‘Gross earnings, £27 quarterly - £27 quarterly? … It’s difficult really isn’t it because if you’ve got a really good, efficient practice and you’re preventing decay then you’re actually getting less money than people who drill more cavities aren’t you … It’s not based on time either, no, it’s based on what you earn isn’t it. So if you’ve got a really good prevention practice you’re losing out aren’t you because you’re not earning as much [laughs]’. (Practice Owner, Edinburgh, CP Level C) In addition, some also felt it ‘discriminated’ against dentists who worked part time, such as women or some older dentists. ‘I think one of the problems is I had a part time Assistant until recently and because of the nature of the work she wasn’t really able to do much with that scheme and I have a part time worker who doesn’t get any benefit from it because he never reaches the bottom level. [It] seems a bit unfortunate because it’s a huge disadvantage for him to work for me really, because he doesn’t get any benefit from that. So I think it seems to not quite fully value part time work, which seems an unfortunate part of it’. 34 Dentists’ Commitment Payment Scheme
  38. 38. (Assistant, London, CP Level A) Moreover, the drive to encourage dentists to increase their NHS income was viewed negatively by some respondents, who deemed it to be ‘unhealthy’ to encourage dentists to work harder. As they felt working harder may negatively impact on physical and mental health, such as on stress levels. There was also concern that this may also reduce the quality of the work being carried out. ‘We don’t want a dentist to do more than £100,000 year after year after year, and that’s not good for him, not good for the NHS, so why putting this?’. (Practice Owner, London, CP Level A) 4.1.3 Additional payments Overall the top-up payments were viewed positively, particularly the additional 50% for 20 years service or being over the age of 45, as it was felt this was a good way of rewarding experience. Although, as previously mentioned, it was felt this should be extended to include dentists in receipt of band 1. Some felt that top-ups could also be introduced to reward dentists with varying lengths of service, for instance by paying an additional percentage incrementally so that an additional amount was received at say 10, 15 and 20 years, in order to encourage a broader range of dentists. The additional payments made relating to the number of hours worked were found confusing. As respondents felt it was unclear exactly how long and how frequently they were required to work before they received an additional payment. Again, it was noted that dentists working part time, although committed to the NHS, would not benefit from this top-up. 4.2 Views on the impact of the scheme In order to ascertain the impact of the scheme on dentists, we asked the respondents to consider any impacts the scheme had on their views or behaviour; as well as the impact they perceived it to have on others, such as on friends or colleagues. This section of the report outlines these views. 4.2.1 Personal impact Receiving an additional amount of money each quarter from the CPS was viewed positively by respondents. The payment was seen as a ‘reward’, which according to some, made them happier in their work. In particular, it was said to be ‘appreciated’ by those receiving the highest band payments and also by some Associates who saw the payment as a direct Dentists’ Commitment Payment Scheme 35