Title: The Impact of the new NHS Dental Contract
1The Impact of the new NHS Dental Contract
- D. Bonetti, J. Clarkson, M. Chalkley, C.Tilley
and L. Young
2Overview
- NHS dentistry before and after the New Contract
- Economics of the New Contract
- Some initial estimates of the impact of the New
Contract - Summary Policy implications
3NHS Dentistry before and after the New Contract
- Focus on high street dentistry
- NHS is (still) the major funder/purchaser
- Contracts with independent contractors
Self-Employed General Dental Practitioners
(GDPs)? - England and Wales GDS Contract, PDS Contract
- Scotland GDS Contract some salaried dentists
4NHS Dentistry before and after the New Contract
- The public perception
- Disappearing
- Being replaced by expensive private care
- Abandoning people to their own fate
Man pulls out own teeth with pliers Oct 19,
2007 A man has described how he pulled out seven
of his own teeth because he was told to wait for
an appointment to see an NHS dentist. Taxi driver
Arthur Haupt used pliers and a technique he had
learned in the army to carry out the DIY
dentistry. He said he was forced in agony into
taking the drastic action because he was given a
three-week wait by staff at his local NHS dental
surgery and couldn't afford the 75-a-tooth
treatment he was quoted by a private practice.
5NHS Dentistry before and after the New Contract
- The context
- In both Scotland and England Wales about 50 of
adults and 70 of children have been seen by an
NHS dentist in the last 18 months. The former has
fallen a little since 1995, the latter has risen. - Private sector provision is rising
6NHS Dentistry before and after the New Contract
- The New Contract
- Comes into effect in 2006 in England Wales
- Replaces both GDS (Fee-for-Service) and PDS
(quasi salary)? - Specifies payment in terms of per completed
treatment (in 4 bands)? - Introduces a new contract currency UDA with
each banded treatment given a UDA score. - Complex transitional arrangements but in essence
it is /UDA - Contract specifies volume and price. If under
volume dentist refunds if over volume . ?
7NHS Dentistry before and after the New Contract
Bands of treatment under the New Contract
8Economics of the New ContractComparative Statics
- Consider the intensity of treatment of a patient
t - New Contract replaces Fee-for-Service ( a smooth
continuous function in t) and quasi-salary (a
smooth zero sloped payment function) with stepped
payment function. - How will this impact on treatment decisions
given - Variation in dentists
- Variation in patients?
9Economics of the New ContractComparative Statics
Quasi salaried Fee for service
(self-employed)? New Contract (self-employed
England)?
10Economics of the New ContractComparative Statics
11Economics of the New ContractComparative Statics
12Economics of the New ContractComparative Statics
13Economics of the New ContractComparative Statics
14Economics of the New ContractComparative Statics
15Economics of the New ContractDynamics
- In practice dentists may not adjust
instantaneously - Adjustment costs
- Learning regarding new arrangements
- Changes in administrative arrangements for new
contract (monitoring) are still on-going
16Economics of the New ContractDynamics
- New contract was announced in principle in April
2005 - Initial 3 years of new contract is 'transitional'
- Initial price set in relation to work done in the
year prior to introduction of new contract - Dentists may thus have been adjusting treatment
in anticipation
17Economics of the New ContractSummary
- Static Model
- Treatment intensity determined by
- contract,
- case mix,
- dentists preferences and costs -- b(.) and c(.)?
- Number of treatments determined by
- treatment intensities
- Expect bunching of treatment at thresholds
- Impact of New Contract is ambiguous
- Expect adjustment Anticipatory effects
18Estimating the Impact of the New Contract
- Dentist behaviour (numbers treated and treatment
intensities) before and after contract
introduction confounded by changes in case mix,
dentists costs, practice style etc. - Use individual level data and a
differences-in-differences design (use Scottish
GDS dentists as control).
19Estimating the Impact of the New Contract
- Data
- Administrative records for a sample of 98 (62
England and 36 Scotland) newly qualified dentists
for the period October 2005 to November 2006. - Observe number of courses of treatment and for
each treatment (about 170,000) which UDA band its
falls - (for Scotland we have the full items of treatment
but these are no longer recorded in England)? - We have the dentists ID and characteristics and
some characteristics of the patient undergoing
the treatment.
20Estimating the Impact of the New Contract
- Mean number of courses of treatment per dentist
per month
21Estimating the Impact of the New Contract
- Proportion of courses of treatment in Band 1 (low
treatment intensity)?
22Estimating the Impact of the New Contract
- Proportion of courses of treatment in Band 2
(high treatment intensity)?
23Estimating the Impact of the New Contract
- Econometric specification (courses of treatment)?
24Estimating the Impact of the New Contract
- Results Courses of Treatment (CoT) estimate of
- Fixed effects regressions
- Negative coefficient gt positive impact of new
contract
- Mean number of CoT is 125
- R Square approx. 0.62, mainly due to FE
25Estimating the Impact of the New Contract
- New Contract has had little impact on previous
Fee-for-Service dentists - But has increased number of courses of treatment
by more than 15 for previously PDS dentists
26Estimating the Impact of the New Contract
- Distribution of Treatments across Bands
27Estimating the Impact of the New Contract
- Econometric specification (treatment intensity -
band)?
28Estimating the Impact of the New Contract
- Results Bands
- Fixed effects linear probability regressions
- Negative coefficient gt positive impact of new
contract - Bands 1u and 2 combined (due to classification
issues)?
- Results here are not affected by previous
contract - Results qualitatively similar in MNL and Mixed
MNL specifications
29Estimating the Impact of the New Contract
- New Contract has substantially reduced
(increased) the probability of low (high)
intensity treatments. - Effect is similar across both previous FFS and
PDS dentists
30Estimating the Impact of the New Contract
- Reconciling CoT and Banding Evidence
- CoT seems to suggest treatment intensity
decreasing (for PDS) and constant for GDS
following contract change. - Band Evidence (up-banding) suggests intensity
increasing - Therefore some evidence that previous
intra-marginal patients are being treated less
intensively, whereas patients close to the next
band are having more intense treatment. - The stepped payment function is resulting in
treatment intensity bunching.
31Summary Policy
- New Contract a response to lack of availability
- Theory of incentives embodied in new contract is
not clear - Contract seems to have incentivised more
treatments - But limited to the PDS (the previous experiment
to solve the NHSs problems!)? - Unanticipated consequences Up-Banding of
patients