The tail wagging the dog

It sometimes seems to me that here in the UK we are in real danger of losing the plot. Or, if I am honest, it regularly seems to me that we lost the plot some time ago – and are in real danger of not being able to remember what it looked like when we last had it.

How and why, for example, did we ever come to be the most heavily scrutinised, the most overbearingly regulated and (almost) the most frequently sued dental professionals in the world? Are we really so awful that these excesses are necessary, appropriate and desirable? Of course not, so other factors are clearly at work here that have little or nothing to do with the quality of the care and treatment being provided. But whatever the sub-plot, these shackles are progressively squeezing the breath out of the profession and out of British dentistry. 

Another source of irritation is the fact that dentistry is so often swept up in regulatory and legislative changes that were introduced (and arguably, needed) for other healthcare professions. When applied to dentistry, they look awkward, illogical and out of place, but someone somewhere has decreed that if in doubt, include more people rather than less. The agenda seems to be that dentistry should look and feel like medicine. The only flaw in this otherwise impeccable rationale is that primary care dentistry isn’t remotely like primary medical care. Indeed, the many differences are infinitely more striking than any occasional similarities. At a time when the delivery of primary care dentistry has become a postcode lottery from one corner of the UK to another, who on earth thought it was a good idea to lump a load of different healthcare professions together and pretend they were all the same?

The Pareto Principle (or the 80/20 rule as it has latterly come to be called) is a powerful tool when considering priorities. Vilfredo Pareto (a social economist), George Zipf (an engineer) and many others following in their wake, have described the value of recognising the fact that 80% of the problems we experience, come from just 20% of what we do. Likewise, 80% of the potential benefits and opportunities are to be found in just 20% of what we do – or could be doing. If you focus on the wrong 20% you miss 80% of the opportunity, and if you manage to focus on the right 20% you are poised to reap 80% of the opportunities on offer.

The fatally wounded UDA system provides a stunning example of this very principle in action – not least because, very conveniently, NHS patients charges represent 20% of the total cost of NHS dentistry. Unfortunately, the well-intentioned attempt to simplify the calculation of these charges three years or so ago, ended up with the now discredited three-band system that has inflicted massive systemic damage upon the ‘other’ 80%, to an extent that a flawed-but-just-about-workable system, was replaced with a flawed-and-largely-unworkable system. Neither system is fair, and neither is sustainable – so at least they have that in common.

For years, the GDS was built on the ‘independent contractor’ status of the general dental practitioner. How earnestly we cherished this status, and how valuable it was. But I wonder how many GDPs today – at least, amongst those with a meaningful NHS commitment – still feel like independent contractors. Contractors they may be, but independent they are not. Incrementally, the PCTs in England and Wales have tightened their grip on primary care dentistry and most worrying of all perhaps – and the most short-sighted, too – is the latest penchant for locking and bolting the side door to the private sector. One hears of dark clouds gathering over children-only lists, impending assaults on those with ‘insufficient’ NHS commitment, and on the ‘mixing’ of NHS and private treatment.

Also in the Government’s sights, one gathers, are the presently ‘fluffy’ boundaries that determine firstly what is and isn’t available on the NHS, and secondly, what is and isn’t necessary to secure the patient’s oral health. The same ‘oral health’, I might add, that had a specific definition under the ‘old’ NHS regulations, but doesn’t anymore.

In the heyday of quality assurance and systems and process management, there must have been a world shortage of paper and lever arch files, such was the volume of documentation associated with it all. The quality of a process was determined by the number of lever arch files needed to document it. Now the rainforests can start to relax because the world has turned its attention to creating electronic data vaults and online portfolios. The quality and robustness of today’s processes is measured by the time it takes to enter all the information. The fact that the information exists, is captured, stored, backed-up and available matters so much more than whether it actually means anything.

In many areas of professional development and contemporary governance, one sees training (and proof of training) being confused with competence. Is this simply because training is easier to demonstrate than competence? Or is it because we are focusing upon the process (i.e. the training itself) rather than the outcome (the achievement of competence). An extension of this is the fact that we demonstrate our continued fitness to practise by recording training. And provided that we can verify that the training really did take place (and how long it took), we then impose no requirement whatsoever in relation to the quality of the training itself, or its outcome in terms of any tangible benefit derived. Where did we lose our way, and when and why did we stop noticing?

Chit chat
My growing concern is that the more we deflect time and attention towards climbing the mountains of compliance, the less time we have left for that most endangered of species – the consultation. There is a growing body of evidence to support the view that patients measure the quality of care and their overall experience of healthcare, in part at least, by how much time the dental team spends talking with them. And not only in discussing the treatment itself, but also in discussing the little things – the human things – that show that you care for the patient at a human level. We will sacrifice this precious time at our peril, but that is precisely where we seem to be going in the headlong rush to achieve more UDAs, and/or fitting more and more treatment into the shrinking time available after all the compliance has been attended to.

World-class exit
Inconsistency and local variation was always an intentional, designed-in feature of local commissioning. How bizarre, therefore, that the cry is now for greater consistency. Following the mantra of the day, NHS bodies are commissioning services they can measure, and turning a blind eye to the consequences that they can’t (or won’t) measure. And almost unnoticed, Mark Britnell, architect and supremo of ‘World Class Commissioning’ has slipped away to offer his consultancy services to KPMG and perhaps anyone else in the private sector who wishes to commission them. And why wouldn’t he? And why wouldn’t they? His capture by KPMG is a huge coup for them, and a huge loss for the DoH. I doubt very much he will prove to be quite as willing as his erstwhile healthcare subjects to allow these private companies to commission his own services at half his asking rate? He had always been in favour of using the best of what the private sector could offer, to enrich the NHS, but I guess the wind is now blowing in an altogether different direction. We should wish him well firstly for a spot of gardening leave I suspect, then in his new role. He at least seems to have a very clear idea of where he is going.

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