Your flexible friend

Readers of a certain age will remember the above advertising strapline that dates back to a time when the word ‘Access’ could be uttered without making anyone else in the vicinity feel an urgent need to leave the room. Or the NHS. Or the country.

But if anybody thought that Access was flexible in those far-off days, it has certainly become a whole lot more so since it entered the NHS vocabulary.

In its original incarnation, it meant that anyone who wanted an NHS dentist could get to see one. Later, it became sufficient if the patient could see one in the distance, through the business end of an astronomical telescope. After Tony Blair’s impromptu and unscripted ‘promise’ to the nation left civil servants and successive health ministers scuttling around for years trying to explain what he actually meant – which, of course, was something completely different from what he said at the time – we have recently been treated to a strikingly similar ‘promise’. Or something ever so slightly like a promise, anyway. And this time it was delivered not off-the-cuff in a speech at a conference, but in the Government’s latest considered response to the Commons Health Select Committee and its July 2008 report on Dental Services that had pulled no punches in questioning the Government’s assertions that the new dental contract had been an unbridled success.

This time around, the ‘promise’ comes not from the PM, but from 10 English SHAs who have ‘indicated’ to the Department of Health that the plans they ‘intend to develop’ with their PCTs will be ‘aimed at’ providing access to anyone who seeks help in accessing services ‘no later than March 2011’. So it’s all pretty definite and firmed-up, then.

Picture if you will, a provider entering this year’s contract round with a frowning and sceptical PCT, and armed only with a huge deficit of undelivered UDAs. All the provider needs to do to avoid a clawback, it seems, is to ‘indicate’ that he/she ‘intends to develop plans’ with their performers, which will be ‘aimed at’ pulling their finger out and delivering some of the missing UDAs within the next two years or so.

And if you feel yourself being submerged in a wave of cynicism, take heart, because the DoH’s official (and now published) reaction to these long-term good intentions from SHAs was this: ‘We strongly welcome the level of commitment that this demonstrates from the NHS to tackle dental access.’

Wow. How committed and supportive is that?

Access is certainly back up there on the giant scoreboard – literally, since yet another ‘access indicator’ is about to be rolled out, we are told  – and one thing you can be absolutely sure of is that the blame for any lack of access is going to be laid squarely at the feet of NHS providers. Not the Government, not the Department, not the SHAs and not the PCTs. But those naughty, naughty independent contractor dentists who never seem to want to behave like dutiful employees. I wonder why not? Whatever NHS dentists are doing – and however they are using this contract (which they didn’t ask for in the first place) – their actions will be blamed for any access shortfall that transpires.

We have already seen examples of this in recent months when the Department went live on the alleged ‘splitting’ of courses of treatment. The story was not just that dentists were earning UDAs (and hence, money) to which they were not entitled, but more pointedly – through these nefarious tactics – dentists were achieving their UDAs without being forced into treating irregular attenders from the ‘access’ black hole. So the fact that some of these patients cannot find a dentist – despite the fact that many of them have turned dentist avoidance into something of an art form – is all the fault of the dentists. Not the Government, not the Department, not the SHAs and not the PCTs. Not even the patients this time – but those naughty, naughty dentists again.

But the fundamental and insidious defect in the whole ‘access’ debate, is that the Government is trying to get the public excited about finding them ‘a dentist’, when what they really wanted all along was ‘my dentist’. A lot of the problems disappear when the system itself is designed to bring dentists and patients together, and to keep them together. A system like the 1990 NHS ‘continuing care’ arrangements, or like capitation-based systems, for example.

There is a clue in the fact that you don’t get patients ringing their MP to complain that they can’t find a private dentist, or a patient-plan dentist. Many patients have voted with their feet away from the NHS, simply because they valued the relationship they had built up with ‘their’ dentist.

Having meticulously (and deliberately) dismantled every remnant of a long-term ‘continuing care’ relationship, with the help of NICE and its recommendations on recall intervals, why is anyone surprised that the Department is not getting the emphasis on prevention that it wanted in NHS primary dental care?

The Government says one minute that what it really wants is ‘high-quality dental services’, and in
another breath, that it wants to optimise patient experience. While at the same time, to ‘enhance the working lives of dental professionals’. Underpinning all of this, it is seeking ‘rapid improvements in the availability of NHS dental services’.  But I can hear my grandmother‘s words offstage: ‘You can’t have everything’. 

Unfortunately, PCTs are suddenly waking up to the astonishing powers bestowed upon them by the Health and Social Care (Community Health and Standards) Act. And they are using (and abusing) these powers with relish to achieve much, much more than anything that dentists ever realised they were signing up to. PCTs are demanding information from practices that even the Inland Revenue and MI5 would struggle to obtain.

Some of them are actively seeking to dissuade patients from making a free choice as to what treatment they wish to receive, from whom, and on what basis. If the PCT officers were dentists, they would be hauled before the GDC. But healthcare regulation does not extend to the managers and administrators of healthcare. And dentists must look to the courts to protect themselves from these excesses.

Eddie Crouch has fought an admirable lone battle in standing up to the combined forces of the PCTs and the DoH. His judicial review success in relation to the grounds for the termination of a PDS (orthodontic) contract is both encouraging and, at the same time, salutary because of the huge financial cost he has suffered in pursuing this landmark action. The fact that the DoH had felt it necessary and appropriate to fight the case at all, let alone to the Court of Appeal, tells us less about the specifics of the case and more about how determined the Government is to have (and to be seen to have) absolute control over NHS dentists.

When the Government refers to the dental access problem, its definition has much more to do with the political problems that access (or the lack of it) has the potential to create, and much less about what a lot of patients actually want or need on the ground. Dentists have already solved the ‘access problem’ for hundreds of thousands of patients – but because they have done it in the private sector, it doesn’t appear on the scoreboard. Many of the same patients who are part of today’s ‘access problem’ were once regularly attending, ‘registered’ NHS patients. And it was the Government, not the patients, who had a problem with that.

History, it is said, has a habit of repeating itself. And we all know what happened to the Access card.

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