Introduction

The aim of this report is to understand stakeholder perceptions of the new patient premium (NPP) scheme by reporting on a series of focus groups held in November 2024.

Methodology

NHS England held 6 clinical focus group events between 4 and 18 November 2024, in which stakeholders were invited to express their opinions about the NPP scheme. Stakeholders invited to participate were contractors, associates, therapists, hygienists and practice managers. In response to a request from the British Dental Association (BDA), a BDA representative was also invited to and attended each of these focus groups.

2 separate focus groups, 1 for NHS finance colleagues (including dental finance leads from NHS England regions and ICBs) and 1 for NHS commissioner colleagues from across England, were also held during November 2024.

To ensure the clinical focus groups were representative of the NHS dentistry community, potential participants were asked to provide their age, sex, ethnicity, role in the practice, location of practice/work and whether they work as part of a corporate or independent practice. When the invitations to the focus groups were prepared, individuals were purposefully selected based on the characteristics listed to ensure a diverse representation of participants. For more detail on the methodology used to set up the focus groups, see Annex A, which includes the topic guides of suggested focus group questions.

Throughout the focus groups, NHS England assured participants their views would be reported anonymously and their comments would not be associated with the organisations they represented. In this report, some of the words used in the focus groups are repeated verbatim. NHS England is confident it would not be possible for any reader to identify any individual from the comment(s) they made.

The transcripts of all the meetings were read, considered and analysed thematically. Where points were unclear or there appeared to be a case of mistranscription, the recordings of the meetings were watched, selectively, to bring clarity.

During the focus groups some participants were keen to quantify some of the statements they made (for example, in terms of the numbers of new patients seen, or the percentage reduction in complaints). However, such statements were not fact checked at the time or subsequently. Rather, the participants’ views and thoughts about the NPP scheme were distilled and are discussed in this report.

Results

More than 160 people completed the expression of interest to participate in the clinical focus groups. Of those, 83 were invited to take part and 54 individuals participated in the clinical focus groups (see Annex B for a more detailed breakdown of the participants).

5 participants attended the finance focus group and 10 participants attended the commissioner focus group.

While the feedback from participants in the groups was diverse and nuanced, it has been separated into 3 broad themes, and according to whether it was positive or negative in nature:

• reception to the scheme
• views on implementation of the scheme
• views on the impact of the scheme

Participants mentioned several wider issues they felt needed to be addressed in NHS dentistry. While there was an acknowledgement the NPP scheme was not intended to address these issues, participants noted if they were addressed, it may directly or indirectly allow more new patients to be seen. A summary of the areas reported is in Annex C.

Unless otherwise stated, findings presented below relate to the clinical focus group participants.

1) Feedback relating to reception to the NPP scheme

Positive responses

When asked to summarise their views at the end of the session, most people that spoke about the NPP did so in positive terms. The positivity was borne out of several factors. Participants said in their opinion the NPP scheme:

is a positive signal about relevant bodies willingness to invest in NHS dentistry. This in turn had led to a perceived increase in staff morale, loyalty and awareness of NHS dentistry

acknowledges it can be more expensive to treat new patients than existing ones

provides increased job satisfaction for professionals in delivering care to patients who had not been to a dentist for a long time

Negative responses

A small cohort of participants stated they viewed the introduction of NPP with scepticism and pessimism, stating the scheme was more of a “political thing”, in view of the upcoming general election.

Some participants told NHS England the quantum on offer, the actual value of the NPP itself, in their opinion is insufficient to cover the costs of the necessary treatment for a given patient. As such, while the NPP may inspire loyalty among NHS dentists, this is not universally the case. Additionally, some participants felt that, even with the NPP incentive in place, the remuneration on offer is not sufficiently attractive compared to private provision.

Some participants were of the view that the NPP does not compensate for the fact new patients may be more likely to fail to attend an appointment and the NPP does not apply to urgent care treatments.

The commissioner group in general felt the NPP “seemed like a good idea in principle”. However, the group felt the level of remuneration for the scheme meant it may be insufficient to motivate practices and therefore may not lead to patients not known to the practice being seen. There were specific concerns the NPP may lead to existing patients who had not been seen in 2 years being “recycled” rather than specifically targeting patients not known to the practice.

Finance leads were generally less positive about the NPP than the other groups. Furthermore, some participants expressed a view that the NPP had not been well-received by the Local Dental Networks (LDNs) they engaged with.

2) Views on the implementation of the NPP scheme

Positive responses

Some contractors’ positive opinion about the NPP had been enhanced because stakeholders had found the NPP easy to implement technically. In terms of integration into the Compass system (the current dental contract management, payments and superannuation system), for example, the implementation was “seamless”.

One participant mentioned they had previously been part of a local scheme which was linked to mandatory targets and felt there was a risk they would not be able to deliver mandatory targets in addition to their UDA contract. Therefore, they preferred the NPP scheme because it had no targets.

Negative responses

Participants indicated they felt the timing of the introduction of the NPP was unhelpful (“at the 11th hour and to some confusion”), meaning organisations had to change financial arrangements and other plans late in the financial year. They felt this issue was exacerbated because they were not initially clear whether the introduction of the NPP scheme represented a new investment in NHS dentistry, or merely a different way of accessing the same funding. This, in turn, meant these participants felt there was limited time at the beginning to make an informed decision about whether to opt-out of an existing local scheme and engage in the NPP scheme, or even whether to change behaviours to actively deliver the NPP scheme or not.

Participants reported it was not made clear how long the NPP would continue to be in place beyond March 2025 and supported by NHS England. Finance participants also reflected on the need to understand how and indeed whether any such incentive would operate next year. Taken together, there was clearly a concern for the long-term plans for the scheme, and this was the reason participants felt it was difficult for them to make plans that took the NPP into account, whether those plans were purely financial or, for example, around the means and frequency with which they recall existing patients.

Associates and therapists said it was not clear how the NPP credits would “filter down” to them from the outset and they needed more information on how the premium could be distributed within a practice.

Some administrators referred to “operational challenges” including initial issues with NPP credits not being shown correctly on dental practice management software systems and updating NHS.uk practices’ website pages.

Commissioners and finance leads both described situations in which different parts of the country had experienced differences in the response to the NPP. Participants assigned much of this to the difference in concentration of corporate practices over independent practices and the rurality of different regions. They also highlighted the interaction between local schemes and the national NPP, emphasising the need for better alignment and understanding of local needs.

The clinical and commissioner groups reflected on how details of the scheme had been communicated. The commissioner group spoke more than other groups about patients’ understanding of the scheme. Commissioner participants commented that patients often misunderstood the initiative, leading to frustration and difficult conversations with practice staff – and clinical participants shared that those difficult conversations (see example below) sometimes resulted in practices reconsidering their participation in the scheme.

“[we have been] bombarded with … patients saying it says you’re accepting new patients. Well, it does, but unfortunately, we do have a waiting list”

3) Views on the impact of the NPP scheme

Positive responses

One of the strongest, repeated messages from the clinical focus groups was participants’ preference for the scheme to continue. When expanding on the reasons why they thought this, participants indicated:

the NPP gave people in the NHS dental community a sense of loyalty towards NHS dentistry – and believed those who were actively considering moving exclusively to the private sector may have been persuaded to continue to provide NHS services

“Not because the new patient premium is so fantastic in its own right, but because it shows the momentum towards making an improvement overall … and that’s something that’s hard to measure”

some practices altered their ways of working in response to the NPP. For example, associates stated it encouraged colleagues to start working late evenings and on Saturdays; to open kids’ clubs on Saturdays; and in some of their practices where there were part-time associates and mentors, they engaged with the scheme by taking on more overseas mentees to deliver care. They felt it would be disruptive to change back if the NPP was withdrawn

some participants felt that withdrawing the NPP would be likely to lead to fewer new patients being seen, and the incentive to hold extra evening and Saturday clinics would also cease

there was a perception the NPP had directly led to NHS dentists seeing more new patients and to NHS dentists receiving fewer complaints

In expressing keenness for the NPP to continue, some clinical participants (though not all) used emotive language, indicating a strength of feeling. They stated the consequences of removing the premium would be negative: “absolutely tragic”; “it would be felt as a kick to those dentists who are using this scheme” “[it has helped with a workforce that is] demoralised”.

Rather than focusing on how practices would respond to the withdrawal of the scheme, some articulated the impact on patient numbers, with one participant noting:

“The following year, data [would be] …very grim in terms of the number of new patients that practices have taken on”

The commissioner group’s view remained positive about the impact of the scheme; some commissioners believed it had had a significant impact on the numbers of new patients being seen.

Negative responses

Participants described their concerns about the impact of the NPP scheme on practices that usually deliver their annual contracted UDA value. They said the payment mechanism can lead to practices fulfilling all their contracted UDAs more quickly than desirable, a phenomenon repeatedly described as “burning through” UDAs. As a knock-on effect of this, participants stated they felt the NPP created difficulties and mentioned receiving negative responses when seeking extra funding from ICBs.

Others told a different story indicating that in their view there is variation in how ICBs invest in dentistry at a local level:

“Different ICBs have different priorities. Some ICBs are so proactive. They’re willing to uplift UDAs. They’re willing to work with you and other ICBs are saying. ‘Sorry – we’ve got other stuff that’s more important’ [and dentistry is] just way down the list [of priorities]…for them.”

Some participants felt mechanisms such as NPP are unlikely to maintain the oral health for some patients being seen, for example, high need patients. They stated while the NPP will help towards the cost of treating these patients, they recommended other funded oral health programmes (running parallel to this scheme) are required, which may also help to keep these patients motivated, ensuring they do not return in the immediate future with a significant clinical need.

Participants mentioned that because practices are not required to take on a specific number of new patients, some practices and clinicians were less engaged with the scheme. Participants expressed concern that this may not lead to improvement in access to NHS dentistry in the geographical areas where it is needed most (some referred to ‘inequalities’; others to ‘dental deserts’).

Discussion

The NPP was introduced as part of the 2024 Dental Recovery Plan as a time-limited scheme to increase the number of patients able to get an NHS dental appointment and to improve the oral health of those who do not have an existing relationship with a dental practice. The scheme was also intended to recognise the additional time that may be needed for practices to assess, stabilise and manage the oral health needs of patients who have not received NHS dental care for more than 2 years. The launch of the scheme was coupled with the intention to measure the impact of the new payments by assessing the number of new patients accessing NHS dentistry.

The results above demonstrate that the principles of the scheme were welcomed, mainly due to it signalling a willingness to invest in NHS dentistry (it being part of the first additional investment package in the sector since 2006) and because it acknowledged and attempted to address the issue that new patients can be more expensive to treat than existing patients.

Although the qualitative data suggests there was a perception among participants that more new patients have been seen as a result of the scheme and there was support for it to continue, the quantitative data suggests that at ICB and national levels the scheme has not achieved the desired impact of changing practice and clinician behaviour to take on more new patients. This does not exclude the outcome that some contracts may have seen more new patients as a result of the scheme. However, if this is the case, then the data suggests this is offset by lower new patient numbers across other practices.

While the scheme was welcomed as a positive message of intent from NHS England to the sector, a great deal of feedback was shared relating to difficulties with the scheme’s implementation and delivery. These represent valuable learnings for planning initiatives in general, and should local commissioners wish to implement similar schemes in the future. A summary of this feedback is shared below.

Financial incentives should be refined to ensure appropriate remuneration for the time taken to deliver the service and to encourage dentists to deliver NHS services, but also taking into account the responsible spending of taxpayers’ money.

Consideration should be given to the complexities of patients who present to a service, for example, new patients who specifically require urgent care, and how these can be accommodated in the service.

Improved communication (clear and consistent) with providers and the public should be planned ahead of implementation (the NPP was implemented at speed to support the government’s dental recovery plan and communications did not allow for an optimal time for assimilation), including clarity on whether financial commitments are additional and the term of commitment.

Consideration should also be given to the appropriate level and messaging of communications for patients. A balanced approach is needed to ensure practices are not overwhelmed with an influx of new patients but equally that patient expectations are managed to avoid potential conflict with providers.

There is a need to understand and address the reasons for local variations in the level of support that commissioners gave to the scheme.

NHS England addressed some of the issues heard in the focus groups around implementation at the time. For example, NHS England worked with dental practice software suppliers to correct issues and provided alternative solutions in the meantime; and in response to early feedback from contractors changed the options given to practices to report their availability to accept new NHS patients on the NHS.uk website.

Strengths and limitations

It is recognised that different representatives of bodies corporate may represent their organisation’s view in focus groups rather than a personal one. There is a risk that the feedback heard from the focus groups was impacted by this, as it was noted that some participants from the same organisations tended to share very similar points.

Focus groups tend to draw participants who have strong views on a topic, which is likely to be the case here and the feedback should be interpreted with this in mind. Similarly qualitative research can only reflect the views of the people included and relies on this being a representative sample. An open expression of interest process was undertaken with a purposeful selection of participants to try to counter this risk and ensure a range of protected characteristics was represented. A facilitator from outside of the NHS Dental Policy team was used to ensure views could be shared openly and reported in a balanced manner. Nevertheless, some residual risk of bias may remain.

Conclusion

Participants from the focus groups received the intention of the NPP positively, mainly due to the investment in the sector, the recognition of the costs of treating new patients and the associated improvement to job satisfaction and moral. Some also perceived that behaviour change at a practice level had resulted in access to new patients.

Quantitative data suggests that this behaviour change has not been widespread and the NPP has not resulted in more new patients being treated than in the period before its implementation.

Annex A: Methodology

Expressions of interest

Excluding the commissioners and finance leads focus groups, participants for the clinical focus groups were purposefully selected to provide a diverse sample in terms of age, sex, ethnicity, whether the individual works in a corporate or independent practice, and the region within which the practice operates. Where there was sufficient interest, 15 participants were invited to each group. For the group involving dental therapists, all those who expressed an interest in attending were invited. For the commissioner and finance leads focus groups, regional leads were asked to put forward 2 volunteers for commissioners and finance leads who would be willing to represent each respective region.

Pre-testing of questions

While the questions that were asked in the groups were not complex, they were discussed in advance with a small number of colleagues, to test whether the questions would be likely to generate conversation around the NPP. The discussions indicated strong support for the simplicity of the questions. Accordingly, the questions that were asked remained unaltered from the original intention. During these discussions, the views colleagues expressed about the NPP were recorded and the feedback they provided has been analysed appropriately and is included within the main part of this report.

Analysis by characteristics to ensure representativeness

We monitored responses to the expressions of interest and drew up invitation lists that represented the characteristics of respondents proportionately.

Topic guide for clinical focus groups

What did you think about the new patient premium when it was first introduced / when you first heard about it? (this is in part an icebreaker but may provide interesting feedback)

What’s been your experience of the scheme?

Specifically, what kind of impact has it had on you and your practice?

(Prompt: thinking in terms of business, and impact on colleagues, have there been any changes in relation to providing care to new patients; what about the level of incentive) (follow on prompt: what kind of mechanism do you think might encourage more practices to see new patients?)

(Prompt: how have you and/or your practice responded to the scheme and approached implementation?)

(Prompt: direct and indirect – what kinds of patients have you been seeing through this scheme? Are you seeing new kinds of cases? Is a greater proportion of patients requiring treatment?)

(Prompt: some of our stakeholders have mentioned they thought the dental needs of new patients would be greater than that of the existing population that currently use NHS dentistry – has this turned out to be the case?

Prompt: have there been any other benefits that you didn’t expect that you think we might need to know about?

There is also the opportunity to ask questions with additional context that focuses the conversation – these usually start:

“Some of our other stakeholders have told us” or “Some of our desktop research appears to show…”

Extra question for associates:

What has been your experience of how the NPP has been shared with associates and other clinicians?

Extra question for contractors:

How did you manage the remuneration attached to this scheme with your associates?

Topic guide for finance and commissioner focus groups

What did you think about the new patient premium when it was first introduced / when you first heard about it? (this is in part icebreaker but may provide interesting feedback)

What are you doing locally to communicate the NPP scheme to practices and patients and to support practice participation?

(Prompt: how have practices in your region / ICBs responded to the scheme and how was implementation of the scheme approached?) – (Follow on prompt: have there been particular practical challenges, or things that have made it easier to implement?)

(Prompt: how have new patients been signposted/matched to practices?) (Follow on prompt: if local schemes are running, how are patients being signposted into practices operating the NPP versus any local scheme?)

(Prompt: Has anything been put in place locally to assure that contractors are implementing the scheme appropriately?)

What’s been your experience of the scheme?

Specifically, what kind of impact has it had on the patients and contractors in your region / ICBs?

(Prompt: thinking in terms of any impact on patients, contractors and interactions with any local initiatives, have there been any changes in relation to providing care to new patients?)

(Prompt: what kind of mechanism do you think might encourage more practices to see new patients?)

(Prompt: has there been any impact on local relationships following the introduction of the NPP or any local new patient scheme?)

(Prompt: has there been any other benefits that you didn’t expect that you think we might need to know about?)

You will have a view on how incentives operate – do you have any views on how the NPP could have been improved?

(Prompt: do you have any views on the level of renumeration? If you have a local scheme how have any financial differences between the schemes played out?)

There’s also the opportunity to ask questions with a bit of context that focuses the conversation – these usually start:

“Some of our other stakeholders have told us” or “Some of our desktop research appears to show…” or perhaps “In our other Focus Groups, participants told us…”

Annex B: Analysis of participation

Breakdown of attendance

Progressing through: responses to expressions of interest, invitations, attendance

Geographic representation

Expressions of interest were received from individuals who work primarily in 41 of 42 ICBs.

The individuals invited to take part work primarily in 32 different ICBs.

The individuals who attended the focus groups work primarily in 27 different ICBs.