Blurred Lines: NHS Rules and Regulations in Dentistry

So when I started my foundation year I thought providing NHS dental treatment would be relatively simple. Think again. Once you start practising you'll realise there are lots of little clauses that you need to be aware of - otherwise you might end up in trouble!

Thankfully I had a study day just before Christmas lead by Raj Rattan and Len D'Cruz on NHS rules and regulations. There is a summary of the main points I took away from the day.

Structure of NHS dentistry

The 27 Local Area Teams (LATs) throughout the country get contracted a set number of Units of Dental Activity (UDAs) which are then dished out to providers. Providers are not necessarily the dentists who provide NHS dentistry; they can then contract these units out to individual performers i.e. associate dentists. 

For foundation dentists like me, we are given a target UDA value of 1875, but this is just a target and there is no penalty for not reaching or surpassing it.

Associate dentists usually get 50% of their UDA value, with the other 50% going to the practice owner in order to cover practice costs and the average UDA value is around £20.

UDA values for courses of treatment are as follows:

BAND 1 - examination, scale and polish, prevention, denture alterations. 1 UDA

BAND 2 - everything above plus fillings, extractions, periodontal treatment, endodontics, denture repairs and additions. 3 UDAs

BAND 3 - everything above plus crowns, bridges, dentures, mouthguards. 12 UDAs

URGENT treatment is the same charge as band 1 for the patient, but you receive 1.2 UDAs

Additional NHS services in primary care:

  • Orthodontics
  • Sedation
  • Advanced Mandatory Services 
Therefore unless you have a separate contract with your LAT for one of these services, they cannot be provided under NHS care. 

Courses of Treatment (CoT)

What is a course of Treatment?
An examination of a patient in order to assess oral health, planning of treatment and provision of planned treatment (and any treatment planned at another time to initial exam). Includes all proper and necessary dental care and treatment.
Therefore it is treatment that a patient needs rather than what a patient wants - you can then justify saying to a patient since they do not need tooth whitening in order to obtain oral health, you may charge privately for this treatment. 

When is a CoT finished?
When all treatment recommended at the initial examination has been provided

How long does a CoT last?
A reasonable period of time. Most dentists will probably say that following the initial completion of treatment that you planned as the examination, there is a 2 month window after submitting your claim where if the patient returns for any other treatment, this should be included in the initial CoT. 

So does crowning a tooth following root canal treatment have to be on the same CoT?
Not necessarily. Why? Because although the general opinion in dentistry is that root treated teeth need some sort of cuspal coverage restoration (usually in the form of a crown or onlay) in order to prevent fracture, according to a Cochrane review in 2012 there is no evidence to support this view. 
However, it is down to a clinician's experience to decide whether a tooth needs a crown (personally I have seen a few instances of fractured teeth which were root filled as a result of not have a cuspal coverage restoration) and if there is an active and symptomatic periapical infection, it may be wise to wait to see if the endodontic treatment is successful e.g. resolution of periapical radiolucency or symptoms. 
You need to communicate this very clearly and honestly to the patient for example: 

'After I have completed this root filling I would like to wait a while before reassessing you to measure the success of this treatment. If I think that the treatment has worked, it may then be sensible to have some sort of crown on this tooth as from my clinical experience, there is a higher risk of this tooth breaking than a tooth that has not been root filled.' 

When can I refuse to see a patient?

Any reasons for refusing to see a patient must be reasonable and must not be based on race, gender, age, religion, disability or their medical or dental condition.
Reasonable grounds could be for example:
  1. The patient decides to accept private services
  2. The patient has not paid. The NHS allows you to ask for full payment upfront, although some practices do make exceptions for band 3 treatments
  3. The patient becomes violent
  4. On the reasonable opinion of the contractor there has been a breakdown of the dentist-patient relationship

Urgent treatment

What is urgent treatment?
Treatment necessary to prevent deterioration of oral health or relieve severe pain. This may include:
  • Examination
  • X rays
  • Extirpation
  • Reimplanting a tooth
  • Repair or refixing a crown
  • Extractions
If a patient comes in with a broken filling, this is not urgent and therefore comes under band 2 and if the patient indicates that they want a course of treatment e.g. come back for fillings, then treatment will also come under band 2. 
Urgent treatment can also be split over more than one appointment. 

Guaranteed replacement

Some treatments should be guaranteed under the NHS for 12 months, this includes crowns, fillings, root fillings, veneers, inlays, onlays. However, this does not have to be honoured if:
  • Another person has provided the treatment
  • Their treatment has been placed as a provisional 
  • The treatment was not advised by the dentist
  • The failure is a result of trauma  

Grey areas

What band should fissure sealants come under?
If the fissure sealants are provided as a preventative measure, they will come under band 1; however, if they are provided to seal a composite restoration i.e. a Preventative Resin Restoration (PRR) they will come under band 2.

Do you have to provide a scale and polish for all patients?
No. It it down to your judgement as a clinician whether a patient would benefit from a scale and polish. However, if it is justified and the patient does not want to see the hygienist privately, then you must provide NHS treatment under band 1. 

Can I do molar endo on the NHS?
Yes, if it is a non-complex case. More complex cases e.g. curved canals, re-endos, poor access, can be referred to a practice with an Advanced Mandatory Services contract or to a dental hospital. You can also offer referral to a private specialist or if you have the expertise yourself, you can provide the treatment privately. 

If the patient returns after the initial completion of their CoT needing further treatment, does this come under a new CoT?
No but you can claim more UDAs; however the patient does not have to pay again (as long as it is within 2 months). 

The main thing I took away from the day is you can never say a particular treatment is not available under the NHS. Say this and if the GDC gets wind of it, they'll crucify you. Wording treatment options is a minefield in terms of communicating costs, especially when a patient asks you things like why do they have to pay more for a white filling or a chrome denture. 
Have template answers for these questions so that you are prepared and not caught off guard! Sorry to end things on a bit of a downer, but the threat of litigation or a GDC fitness to practice hearing are things that you really want to avoid!

For more information see Raj Rattan and Len D'Cruz's book, 'Understanding NHS Dentistry'.


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