Discussion Paper Series: No. 0807

Discussion Paper Series: No. 0807 October 2008 Initial Estimates of the Impact of the New NHS Dental Contract on England and Wales Linda Young (NHS E...
Author: Gervase Powell
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Discussion Paper Series: No. 0807 October 2008

Initial Estimates of the Impact of the New NHS Dental Contract on England and Wales Linda Young (NHS Education for Scotland), Colin Tilley (NHS Education for Scotland), Debbie Bonetti (Dental Health Services and Research Service Unit), Martin Chalkley (University of Dundee) and Jan Clarkson (Dental Health Services and Research Service Unit)

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Initial Estimates of the Impact of the New NHS Dental Contract on England and Wales Abstract Introduction: UK NHS dental services face a number of well documented difficulties and there are concerns that a key reason is the level and structure of the ‘traditional’ fee-for-service General Dental Service (GDS) dental contract. In response to these concerns a new NHS dental contract was introduced in England and Wales on 1 April 2006. In Scotland changes to the structure of the ‘traditional’ GDS dental contract are currently under consideration.

Objective: To examine the impact of the new contract on the number of courses of treatment and the probability of each course of treatment being in a particular Band.

Methods: A natural experiment using routinely collected, individual level, administrative data to compare pre-contract with post-contract treatment delivery in England and Wales using treatment delivery in Scotland as control.

Results: After analysing 171,224 courses of treatment provided by 98 recently qualified dentists we find that the new contract had a significant impact. In particular, the number of courses of treatment per month changed in England and Wales after the introduction of the new contract: dentists who were previously on a GDS contract provided significantly fewer courses of treatment while dentists who were previously on a Personal Dental Service (PDS) contract provided significantly more courses of treatment. In addition, the new contract significantly changed the probability that each course of treatment was in a particular Band.

Conclusion: The new dental contract in England and Wales has had a significant impact on treatment delivery. This paper has demonstrated the feasibility and utility of using routinely collected data from different jurisdictions to analyse the impact of policy initiatives concerning the NHS dental contract.

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1.

Introduction

A new NHS dental contract was introduced in England and Wales on 1 April 2006 in response to a number of concerns: significant access problems were emerging when dentists moved from the NHS; there were over 400 patient charges for different treatments, which was thought to be confusing for patients; and the ‘traditional’ General Dental Service (GDS) fee for service remuneration contract created incentives to provide more intensive treatment than necessary.1

In the UK public sector, and more so in England as opposed to other countries of the UK, performance measurement has been implemented in a particularly top-down manner (Sanderson, 2001). Performance regimes, applied to education, health care, local government services and others, have been clearly associated with the setting of standards and targets, and their linkage to the public reporting of performance where rewards and punishments are given to endorse or admonish ‘good’ or ‘poor’ performance respectively (Bevan and Hood, 2006a).

Here, the measurement of

performance is tied to a set of incentives with resulting processes such as ‘earned autonomy’ for those performing well and ‘naming and shaming’ for those performing poorly, with resulting powers to impose sanctions (Huber, 1999; Guardian, 2001). The mechanics of these regimes, in England at least, are driven by central government and are intended to regulate and monitor the behaviour of local agencies such as NHS Trusts and local authorities.

Under the new contract Primary Care Trusts (PCTs) contract with dentists to deliver a fixed amount of weighted courses of treatment, called Units of Dental Activity (UDAs), each year for an agreed annual income.2 For example, a course of treatment which only includes an examination, scaling, or simple diagnostic treatment is worth 1 UDA. In contrast, treatment requiring laboratory work, such as the provision of dentures, is worth 12 UDAs. Each course of treatment is grouped into one of four Bands and each Band has an associated UDA3 (Table 1). In Scotland, dentists work under the ‘traditional’ GDS contract and this remuneration system has remained unchanged over the sample period.

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A key issue for policy makers is the impact of different contracts on the quantity and quality of service provision. Although there is a large theoretical literature which addresses this question, there is a dearth of empirical studies, in part due to a lack of suitable and accessible micro-level data.4,5 In this study, we exploit the natural experiment that arose from the change in the dental contract in England and Wales to examine the relationship between remuneration and a number of dental outcomes. Specifically, the aim of this study is to use routinely collected, individual level, administrative data to examine the impact of the contract on the number of courses of treatment and the probability of each course of treatment being in a particular Band.

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Methods

The details of all NHS GDS treatment are collected by administrative databases primarily used for paying dentists. These databases differ slightly across jurisdictions but each contains information on the dentist, patient, and course of treatment provided. Information was provided by the NHS Business Services Authority and the Dental Services Division (NHSBSA) in England and Wales.

In order to ensure data comparability before and after the introduction of the contract, and across jurisdictions, we converted GDS treatment fee codesinto the new contract Bands. In addition, the sample was restricted in the following ways. We excluded all courses of treatment with an associated registration acceptance date of 1 April 2006 to avoid ‘transitional cases’ which spanned the end of March 2006 and which would have resulted in double counting. We only included courses of treatment with associated registration acceptance dates between October 2005 and November 2006 since some of the claims processed when the data were extracted in March 2007 will have been incomplete. We excluded courses of treatment provided to patients less than 18 years of age because the data for children are not comparable before and after the new contract. A fixed effects multiple regression framework6 was used to analyse the data employing an ordinary least squares model when the outcome of interest was the number of courses of treatment per dentist per month and a linear probability model when the outcome of interest was the probability of a course of treatment being in a

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particular Band. The impact of the new contract was identified by a ‘difference-indifferences’ (DID) estimator.7 This estimator compares post-contract outcomes in England and Wales with precontract outcomes using dentists in Scotland as controls to ‘difference out’ unobserved confounding factors. For example, if we only had information from dentists in England and Wales, we would not be able to determine whether any change in the number or composition of courses of treatment was because of the new contract or because of a secular trend in treatment need, such as improving oral health. Similarly, if we only had information after the change on contract, we would not be able to tell whether the difference between England and Wales and the other jurisdictions was because of the contract or because of some unobserved difference, perhaps in oral health, between the jurisdictions.

For this analysis we analysed the impact of the new contract on four different outcomes: the number of courses of treatment (CoTs) per dentist per month, the probability of a Band 1, a Band 1u2 (a combination of Band 1u and Band 2 CoTs), and a Band 3 CoT being provided.

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Results

Anonymised information was provided by the NHSBSA and PSD for 98 recently qualified dentists who had completed their dental vocational training in July 2003, or July 2004. During the sample period these dentists provided 171,224 CoTs. Table 2 shows the number of CoTs provided under different types of contract over the sample period.

The impact of the new contract on the number of courses of treatment per month Figure 1 shows that the average number of CoTs increased in England and Wales at the time of the change in contract, then fell back for a couple of months and continued to trend upwards thereafter. In contrast, the average number of CoTs in Scotland trends upwards.

Table 3 reports the DID estimates for the number of CoTs per month. The results suggest that the new dental contract increased the number of CoTs provided in England and Wales by 12.6 per dentist per month compared to Scotland. Thus, the

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estimated impact of the new contract on the number of CoTs is quantitatively large; the number of CoTs per dentist per month increased by 10%, compared to Scotland but this was not statistically significant.

The impact of the new contract on the Band of treatment After the introduction of the new contract, the detailed information on the type and amount of treatment provided to patients in the GDS in England and Wales was replaced by the Band of each course of treatment. Table 4 categorises all CoTs into the new Bands and shows that the sample approximates the distribution of bands in the population as reported by the Information Centre.3

Figure 2 shows that there was a sharp reduction in the proportion of Band 1 CoTs in England and Wales around the time of the contract change. In contrast, the proportion of Band 1 CoTs has been trending up steadily in Scotland.

Under the old contract Band 1 urgent (1u) and Band 2 CoTs cannot be distinguished therefore in the following analysis these treatment bands have been combined.3 Figure 3 shows the proportion of Band 1u2 CoTs. In England and Wales, Band 1u2 CoTs seem to trend down just before the contract change and then increase sharply to a higher long-run level after April 2006. In contrast, the proportion of Band 1u2 CoTs is trending down very slowly in Scotland. This suggests that the proportion of Band 1u2 CoTs in England and Wales is increasing relative to Scotland.

Figure 4 shows an increase in the proportion of Band 3 CoTs at the time of the change on contract in England and Wales. In contrast, the proportion of Band 3 CoTs has decreased over time in Scotland.

Table 3 reports the DID estimates for Band 1, Band 1u2 and Band 3 CoTs and shows that dentists in England and Wales are: 9.8% less likely to provide a Band 1 course of treatment; 8.3% more likely to provide a Band 1u2 course of treatment; and 2.4% more likely to provide a Band 3 course of treatment. The estimates are conditional upon a number of explanatory variables and dentist-specific fixed effects. Unfortunately, the loss of information under the new contract means that only a

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limited set of explanatory variables are available: patient age, sex and exemption status.

Sensitivity analysis The analysis above has been repeated excluding all dentists who at any time during the sample period worked under either a Personal Dental Service (PDS),8 or Trust Dental Service (TDS) contract in England and Wales. PDS dentists are typically paid a fixed annual contract value in return for a level of service. TDS dentists are employed by PCTs.

The results are reported in Table 5. While the results for the Band of each CoT are qualitatively similar in magnitude and level of statistical significance to the results reported in Table 3, the DID estimates for the number of CoTs per month for Scotland has changed sign from negative to positive. This suggests that dentists in England and Wales who have never worked under a PDS or TDS contract are providing 14 CoTs per month less than dentists in Scotland. The corollary of this is that dentists on PDS and TDS contracts increased the number of CoTs significantly as reported in Table 6.

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Conclusion

After analysing 171,224 CoTs provided by 98 dentists we find that the new contract had a significant impact. In particular, the number of CoTs per month changed in England and Wales after the introduction of the new contract. Although there was little change in the number of CoTs provided by dentists who were previously on a GDS contract, dentists who were previously on a PDS contract provided significantly more CoTs. In addition, the new contract significantly changed the probability that each course of treatment was in a particular Band.

In summary, this short paper has used routinely collected administrative data from England and Wales and Scotland to provide initial estimates of the impact of the new NHS dental contract in England and Wales.

While the composition of CoTs analysed in this paper is almost identical to the population statistics reported in Table 4, the data reflect the activity of only a small

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sample of dentists. Nevertheless the results suggest a number of tentative conclusions and highlight avenues of future research. •

The impact of the new contract on the number of CoTs per month depends upon the dentist’s old contract. There was no significant difference in the number of CoTs per month for dentists in England & Wales who were previously on a GDS contract. However, dentists in England & Wales who were previously on a PDS contract provided significantly more CoTs per month.



The new contract significantly reduced the likelihood of dentists in England and Wales providing a Band 1 course of treatment. Dentists in England and Wales are 9.8% less likely to provide a Band 1 course of treatment after 1st April 2006 compared to Scotland.



The new contract significantly increased the likelihood of dentists in England and Wales providing a Band 1u2 course of treatment. Dentists in England and Wales are 8.3% more likely to provide a Band 1u2 course of treatment after 1st April 2006 compared to Scotland.



The new contract significantly increased the likelihood of dentists in England and Wales providing a Band 3 course of treatment. Dentists in England and Wales are 2.4% more likely to provide a Band 3 course of treatment after 1st April 2006 compared to Scotland.

This paper is also novel in the sense that it is the first to compare individual level, routinely collected dental data from different jurisdictions. The paper has demonstrated that this approach is feasible and therefore provides the foundation for future policy relevant, research in this area.

This paper was unable to analyse the impact of the contract on the amount of treatment per patient. However, the NHS Information Centre has recently reported the results of analysing a sample of CoTs processed between April and July 20078. Compared to activity in 2003/04, there has been a significant reduction in all reported items of treatment per 100 CoTs apart from extractions (which increased but not significantly). One of the limitations of that analysis is its inability to control for secular changes that might be driving changes in treatment trends such as oral health.

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One way to overcome that limitation is to compare the sample of CoTs in England with a sample from Scotland using the DID approach adopted in this paper.

Finally, the sample period for this paper was necessarily short. Therefore an important question to be addressed in future work is to estimate the long run impact of the contract using a longer sample period.

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Authors’ Contributions Linda Young, contributed to the scientific development, administration, conduct, analysis and interpretation of the study; authored drafts, critically revised and approved the final version of the paper; Colin Tilley contributed to the scientific development, conduct, analysis and interpretation of the study; authored drafts, critically revised and approved the final version of the paper; Debbie Bonetti and Martin Chalkley contributed to the scientific development, analysis and interpretation of the study, critically revised and approved the final version of the paper; Jan Clarkson contributed to the scientific development, conduct, analysis, interpretation of the study, critically revised and approved the final version of the paper. Conflicts of Interest None Acknowledgements The authors are extremely grateful and wish to acknowledge the contribution of Steve Lucarotti from the NHSBSA Dental Services Division in England and Wales and Alan Collins from Practitioner Services Division in Scotland. We are particularly grateful to Steve Lucarotti for his detailed comments on previous drafts of this paper. The original version of this paper included information from dentists in Northern Ireland and the authors are extremely grateful and also wish to acknowledge the contribution of Sandy Fitzpatrick and Brian Stanfield of the Central Services Agency in Northern Ireland. Due to the small number of dentists these data were omitted from this version. The results including the Northern Ireland dentists are available from the authors on request. Funding Economic and Social Research Council, Public Services Programme (Res-153-250049). Ethical Approval Tayside Committee on Medical Research Ethics A, REC Reference Number 05/S1401/85

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References 1. Audit Commission National Health Report. Dentistry: Primary dental care services in England and Wales. London. Audit Commission for local authorities and the National Health Service in England and Wales, 2002.

2. Department of Health. Primary care dental services: Implementation of local commissioning. Gateway reference 5641, www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid ance/DH_4121058.

3. The Information Centre. Dental Treatment Band Analysis England 2007 Preliminary Results. London: The Information Centre, 2007.

4. McGuire T G. Physician Agency. In Culyer A J, Newhouse J P (eds) Handbook of health economics. Volume 1A. pp 461-536. Amsterdam: Elsevier Science B. V, 2000.

5. Chalkley M, Malcomson J M. Government purchasing of health services. In Culyer A J, Newhouse J P (eds) Handbook of health economics. Volume 1A. pp 843-890. Amsterdam: Elsevier Science B. V, 2000. 6. Baltagi B H. Econometric analysis of panel data. 3rd edition: Wiley, 2005.

7. Blundell R, Dias M C. Alternative approaches to evaluation in empirical microeconomics. Portuguese Economic Journal 2002; 1: 91-115.

8. Department of Health. Personal Dental Services – a step-by-step guide. London: Department of Health, 2004.

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Tables Table 1: Treatment, Bands and UDAs3 Feeband

Description

UDA

Band 1

Routine examination, scaling and diagnostic procedures

1.0 1.2

Band 1 urgent

One of a specified set of possible treatments provided to a patient in circumstances where: 1. prompt care and treatment is provided because, in the opinion of the dental practitioner, that person’s oral health is likely to deteriorate significantly or the person is in severe pain by reason of their oral condition; or 2. care and treatment is only provided to the extent that it is necessary to prevent that significant deterioration or address that severe pain

Band 2

Fillings and extractions

3.0

Band 3

Treatment requiring laboratory work

12.0

Table 2: Courses of Treatment by Contract October 2005 - March 2006 527

April 2006 - November 2006 629

Total 1,156

Non-salaried General Dental Service (Scotland)

22,259

34,475

56,734

General Dental Service (England & Wales)

25,183

32,866

58,049

Personal Dental Service (England & Wales)

19,314

35,231

54,545

Trust led Dental Services (England & Wales)

0

740

740

67,283

103,941

171,224

Salaried General Dental Service (Scotland)

Total

Table 3: Courses of Treatment by Contract Coefficient

SE

t

P>t

Dentists

Observations

CoTs per month

Delta S

-12.585

9.245

-1.360

0.177

98

1216

Band 1

Delta S

0.098

0.018

5.590

0.000

98

171224

Band 1u2

Delta S

-0.083

0.015

-5.410

0.000

98

171224

band 3

Delta S

-0.024

0.005

-4.420

0.000

98

171224

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Table 4: Percentage of courses of treatment by Band and time period

Band na

October 2005 - March 2006 England & Wales Scotland 0.95 1.23

April 2006 - November 2006 England & Wales Scotland 0 1.12

April 2006-March 2007 England & Wales3

1u

2.58

2.75

9.51

2.56

10.3

1

56.86

45.45

51.64

51.4

51.3

2

34.17

41.39

32.6

37.66

32.2

3

5.45

9.18

6.25

7.27

6.1

55

33

58

37

44497

22786

68837

35104

Dentists Observations

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Table 5: D-in-D estimates comparing GDS dentists in England and Wales with dentists in Scotland Coefficient

SE

t

P>t

Dentists

Observations

CoTs per month

Delta S

13.792

11.468

1.200

0.234

55

706

Band 1

Delta S

0.102

0.025

4.120

0.000

55

91879

Band 1u2

Delta S

-0.090

0.024

-3.760

0.000

55

91879

Band 3

Delta S

-0.020

0.008

-2.570

0.013

55

91879

Table 6: D-in-D estimates comparing PDS dentists in England and Wales with dentists in Scotland Coefficient

SE

t

P>t

Dentists

Observations

CoTs per month

Delta S

-33.777

9.697

-3.480

0.001

47

599

Band 1

Delta S

0.105

0.020

5.140

0.000

47

77153

Band 1u2

Delta S

-0.082

0.018

-4.650

0.000

47

77153

Band 3

Delta S

-0.033

0.007

-4.720

0.000

47

77153

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