Title: Impact of a change to remuneration on the technical efficiency of dental practices: evaluation of the pilots of a new NHS Dental Contract in Northern Ireland
Funder: Department of Health and Social Care

Abstract: The results of a recent Cochrane review led by the research team for the Effective Practice and Organisation of Care (EPOC) Review Group, found that incentives in remuneration systems changed the patterns of care provided by dentists in primary care. Fee-For-Service (FFS) remuneration led to increased activity levels, whilst per capita payments led to under-treatment. However, the quality of the evidence was poor and further research was recommended, particularly during natural experiments where changes to remuneration systems were planned. In addition, the EPOC review argued that attention should be paid to the impact that provider remuneration had on patient related outcomes. Further evidence from changes to the NHS Dental Contract in England and Wales, showed that FFS payment systems incentivised treatment over preventive care. This has led to growing criticism of the current England & Wales dental contract, which was introduced in 2006. As a result, the Department of Health (DH) in England began piloting a new NHS dental contract in 2010, with an “emphasis on prevention". Similar concerns have been raised in Northern Ireland. Following escalating pressure on the General Dental Service budget, the Health Board has decided to pilot a new model of delivery between July 2014 and December 2015. This will be based on a prospective payment system (per capita basis), rather than a retrospective payment system (FFS) and will focus on containing the costs of NHS care, improve the quality of care and broaden the population coverage to reach marginalised groups. This presents a unique opportunity to undertake a methodologically rigorous and affordable evaluation of a natural experiment using an experimental design to determine the impact of changing a remuneration system. This will enable the research team to examine the impact of this change on the productivity and quality of care delivered, thereby linking this research programme with the existing HS&DR grant (11/1025/04). The outputs will also directly address the gaps in the evidence base identified by the EPOC review and support policy makers across Europe who are grappling with the problems involved in redesigning dental services. The aim of the proposed research is to evaluate the impact of a change in the system of provider remuneration on the productivity, quality of care and health outcomes of dental services. The objectives will be to measure changes in activity and costs over the different phases of the pilots; examining productivity, the service mix of key indicator treatments, time spent by dentists delivering patient care and co-payment income. In addition, the research will assess dentists’ and patients’ views about the extent to which changes in remuneration affect delivery and quality of care, measure patient reported oral health knowledge, attitudes and behaviour and patient rated oral health outcomes and quality of care. The research team will utilise “Realistic Evaluation” to examine the underlying theory about change and will build on the conceptual framework developed as part of the NIHR SDO-funded study and empirical approach to productivity utilized in the HS&DR study (11/1025/04). Three work-streams are proposed (WS1-WS3), based on a randomised controlled trial methodology to compare activity data from test and control practices before and during the change to per capita payments and after the return back to FFS.

Lay abstract: The results of a comprehensive review of the literature, led by the research team, found that dentists are influenced by how they are paid. If dentists are paid for the number of items that they provide (fee-for-service or FFS) e.g. fillings or dentures, they tend to over-treat and do more fillings and dentures. However, if dentists are paid a set amount of money for each patient (known as capitation), which isn’t linked to any clinical activity, they tend to under-treat or see patients less frequently. However, the quality of the studies in the review was poor and further research was recommended, particularly during times when policy makers are changing the way that dentists were paid. The review also recommended that attention should be paid to the impact that paying dentists had on factors that the patient thought were important. This problem of dentists responding to the incentives within a payment system is evident in the National Health Service in England and Wales and the new contract introduced in 2006 has received growing criticism for not delivering appropriate levels of care for patients. As a result, the Department of Health in England has been piloting a new NHS dental contract since 2010, with an “emphasis on prevention while meeting patients’ treatment needs more effectively”. Concurrently, concerns have been raised in Northern Ireland (NI) due to dentists over-claiming for treatment and causing the budget for dentistry to become over-spent. As a result, the Health and Social Care Board decided to pilot a new way of paying dentists, based on capitation i.e. paying for the number of patients registered, rather than paying for individual items of treatment (FFS). Two phases are planned, the first will involve a small number of pilot practices over a six month period, which will be followed by a second phase with 15 practices over a period of 12 months. Practices would then return back to a FFS payment system. This presents a unique opportunity to undertake a rigorous evaluation of this change in NI and so address the recommendations of the comprehensive review. This will also build on an existing research project being undertaken by the research team and enable the methods used in this study to inform the assessment process. The aim of the proposed research is to evaluate the impact of a change in the way that dentists are paid in NI on the productivity of the dental team and the quality of care provided. The objectives will be to measure changes in clinical activity as dentists move from being paid for what they do (FFS), to a capitation system and then back again to FFS. In addition, the research team will use interviews and questionnaires to assess dentists’ and patients’ views about these changes and how they affect the quality of care received. This will help support policy makers across Europe who are grappling with the problems involved in redesigning dental services. It will also contribute valuable information to the health and social care system more broadly. Recent reports argue that patients will need to contribute to health and social care in the future. Co-payments by patients have been a fundamental component of the NHS dental contract since 1950 and studying the impact of changes to the co-payment system is an important part of the proposed programme. It will also explore the unintended consequences of changes to the remuneration system on health inequalities, including access to services.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: ORAL AND GASTROINTESTINAL