Riding through the glen

It is very much a matter of opinion whether you view Robin Hood as an outlaw and villain or as a folk hero. The good people of Nottinghamshire and Lincolnshire may have been wasting away under King John’s rule, but one gathers that Little John and Friar Tuck were not. But it is difficult to separate any grains of truth from the acres of popular myth and – as a rule – fairytales make better stories anyway.

Since the days when Robin et al were in their prime, the principle of taking from the rich in order to give to the poor has become not only legal, but well established.  These days we call it taxation – which is a little ironic, given that the ‘reverse taxation’ prevalent at the time of King John led to many of the problems in the first place.

The ‘swings and roundabouts’ principle operates on much the same basis. You have good days and you have bad days but it all evens out in the end. The dodgems are arguably more exciting for a while, but you know that it’s only a matter of time before the ‘big hit’ arrives.

The fee-per-item NHS was clearly designed with all this in mind, but it was never fair (excuse the pun). Many of the fees were always frankly insulting for a professional person, and in some cases they were non-existent.

But for some, it was possible to work within the system so that it added up to a reasonable business, and a reasonable living derived from it. Others will argue that the real price was always paid in terms of quality and standards, ethics and professionalism, and human wear and tear.
The block payment system that has replaced it for the past three years – in England and Wales, at least – arguably trades even more on the ‘swings and roundabouts’ principle, with the occasional ‘big dipper’.

The popular myth is that all the rides on the big dipper consist of a sharp downward plunge – and there are plenty of these in the new contract, particularly in some areas. What never makes the headlines, of course, is that the big dipper also has to go up at some stage and there are plenty of very decent paydays to offset at least some of the bad days at the office.


Under fee-per-item, the dodgems consisted of the endless jousting between practitioners and the authorities whose job it was to oversee the system. The weapons of war included the NHS Regulations, the fee scale and narrative, the provisos and time limits, the conditions of payment, prescribing patterns, prior approval restrictions and so on – but it kept an army of people busy and got a lot of mortgages paid.

In a roundabout way (the puns are really flying today), this imperfect system was responsible for what sits in the mouths of the UK population today. This fact is often overlooked, but the State’s
fingerprints are all over all those restorations that were placed in the last 50 years – sometimes with the express permission of the State or its appointed agents, sometimes with their silent acquiescence.

The problem that this has created, in the context of the block payment system that replaced fee-per-item – and which may soon do so in Northern Ireland, even if in a somewhat modified form – is that this is a wretched system for achieving the long-term maintenance of millions of existing restorations. Did nobody see this coming?

As time passes, these restorations will reach their sell-by date. Practitioners are already coming under fire for their unwillingness to embark upon larger, more complex courses of treatment, or to provide preventive care. Meanwhile, secondary care providers resent being referred work that they believe could and should be done in general practice.

The Department of Health would defend itself by arguing that the money is already there, because the baseline calculations at the time of transition from fee-per-item relied upon the ‘test year’ gross income, uplifted for inflation. It would probably also argue that practitioners have since enjoyed a windfall profit, because of the sharp drop in Band 3 treatments, and the fact that laboratory and other costs related to them are no longer being incurred.

But it’s always easy to focus upon the dodgems alone. Unfortunately, the exit from the dodgems is also the entry to the big dipper in the form of financial clawbacks for those who under-deliver on their UDA targets.

And as soon as you start making significant claw-backs, and as soon as you start commissioning UDAs at anything less than the £24 or so that was the national average at the time the new contract was introduced, you begin the systematic dismantling of the swings and roundabouts. Once you take away the swings, in no time at all it becomes all roundabouts.

Even the ‘Robin Hood’ technique of subsidising an increasingly unprofitable NHS component of one’s practice by growing the private component is frowned upon and discouraged. In some PCT areas it is actively penalised.

Three years down the track, it is too harsh to say that the whole of the new contract sucks, and nor would it be true to say that it is impossible for anyone to make it work.
Those who are making it work – and in some cases, spectacularly well – are by and large not the ones doing all the shouting. There is no doubt that the system has shown itself to be much kinder to certain types of practice, in certain types of area, treating certain types of patient. Other practices get a kicking whichever way they turn.

It has manifestly not succeeded in eliminating geographical inequalities in access (and nor was it ever likely to) and this is certainly not the fault of the dentists working in those areas, however much they are demonised.

The demise of what used to be the DPB and the Dental Reference Service in England and Wales, is not only an inevitable consequence of the move away from fee-per-item, it is also a pointer to the changing values of the new healthcare system.

I wonder if at the heart of these present difficulties is the fact that the new dental contract was
always designed first and foremost for the benefit of the State, and secondarily for the benefit of the newly empowered PCTs and LHBs.

Yet the point of it all would always boil down to the relationship between the patients and their dentists. For the patients who are actually receiving the treatment that their taxes and National Insurance contributions have paid for (just before many of them pay for it again at the point of delivery), the people who matter most are not the Government, nor the PCT, but their dentists and dental team.

Fortunately, I believe that patients are smart enough to realise that these people are doing their best to help, and are really not the outlaws they are portrayed as being. Now where have I heard that before?

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