Stainless Steele

‘Providers are getting more money for doing less, or perhaps for doing something different. In other words, despite the protestations of the profession, dentists are doing rather well overall.’
These are not my words, let me make clear at the outset, but an extract from An Independent Review of NHS Dental Services in England, commissioned by the Department of Health, carried out by a team of four led by Professor Jimmy Steele and published in late June.

The Review is very much a mixed bag – rather like Options for Change, Bloomfield, the
1993 Commons Health Select Committee report and even the Dental Strategy Review Group report in the 1980s. And when I say ‘rather like’ these previous reports, I should probably say ‘uncannily like’ them – or at least, a hybrid of them. Every one of these earlier reports made perfect sense at the high level, but ran aground on the rocks of their detailed implementation. And on this occasion you don’t need a lighthouse to see where the rocks are located.

The fact that Dentistry magazine moves briefly from fortnightly to monthly publication during the months of July and August, has granted me the luxury of being able to see how others have responded to the Steele review before reaching my own considered assessment. I agree with most other observers that many of the acute problems of the present arrangements, and that many of the key themes for resolving them, have been successfully identified. But that, of course, was always going to be the easy and populist bit. We were always likely to be left with the wider, and perhaps irreconcilable, gulf between what the public wants, what the government finds politically acceptable and is prepared to pay for, and what needs to happen in order to make any alternative system attractive to dentists who have a business to run – whether the purists can face this reality or not.

A number of people have commented to me that the whole thrust of this independent report is so overwhelmingly ‘on message’ and laden with ‘NHS –speak’ that it could almost have been written by a civil servant. Harsher critics than I have pointed to the composition of the review team itself – four salaried NHS employees for whom this will be everyday language – but I sense the fingerprints of the Department in much of the strategic direction, not least in the fact that the UDA system, that sits at the heart of the problems, emerges with little more than a flesh wound. The review is not universally supportive of the government, nor the DoH by any means, but it certainly leans that way. There is much more criticism of practitioners and of PCTs than there is of the decision to abandon fee-per-item in favour of local commissioning, which is described as having been the right thing to do at the time. Unlike most observers, the review stops short of saying that the government got it wrong in 2006.

On message
The endless references to what is happening in medicine, and the unquestioning acceptance of the wisdom of anything that emerges from NICE from the lips of the (now departing) Lord Darzi, from ‘World Class Commissioning’ or any other oracle that has been commissioned by or germinated in the DoH, does impede the digestion of this otherwise nicely structured and well-presented 88-page report. It gets in the way because a truly independent report needs to look further than that – and, when faced with a crisis of trust, acceptance and service delivery, it needs to look a lot further. For reasons that are never made clear, the stated aspiration is to a vision of the NHS as set out in documents that never saw fit to mention dentistry at all when they were published.

And there are other pointers. The Steele review has been widely applauded for the emphasis that it has placed upon quality. But quality is defined here not as you or I might understand it, nor as patients might describe it – despite the best catchphrase in the entire document: ‘The profession knows what quality looks like.’

Accepted business gurus in the world of ‘quality’ would die a thousand deaths were they ever to read a statement like that. No, the proposed definition and measures of quality are just about the most selective parameters one could possibly imagine – mostly focusing upon what the NHS is known to want. High quality means (apparently) patients attending less often, fewer out-of-hours emergencies (that PCTs have to fund) or other emergencies (that attract an enhanced UDA value), and fewer repeat restorations (triggering new courses of treatment and additional UDAs). An ingenious fix for the latter is suggested – effectively, any further attention to a restoration placed in the NHS would attract no further UDAs for a three-year period. But is this really designed to address quality, or simply to address one aspect of ‘band gaming’ that upsets the UDA – patient charge revenue calculations? If the latter, then the innocent will be subsidising the guilty under the guise of something else that is easier to sell to a professional, public and political audience. It was ever thus. And why three years? I do hope that this is evidence based and not simply plucked out of the air because it sends out all the right signals.

There is much here about the respective responsibilities of dentists and ‘the NHS’, but not very much other than platitudes about the responsibilities of patients in the bright new world of the new new new contract. Again – this time with reference to the NHS constitution, which I am sure will be regular bedtime reading for most GDPs – it is mentioned that patients should ‘look after their health, keep appointments and stick to agreed courses of treatment’ in order to make appropriate use of public resources. Dental patients don’t actually need to do any of the above, of course, and there are no sanctions if they don’t. The report doesn’t address that. It even seems to have gone unnoticed that under current arrangements, missed appointments in the GDS, waste the dentists’ money not NHS resources. You can only achieve UDAs when patients turn up and a significant part of many clawbacks has been the cost of having had an empty surgery.

Under the proposed model, patients can please themselves whether they want to access dental services or not (and are, in many ways, actively encouraged to stay away for as long as possible), but they have a right to expect that the full range of NHS dentistry will be ready and waiting if and when they ever change their mind at some point in the future.

A simple table d’hôte menu will be available to all, but ‘advanced treatment’ will be confined to a new à la carte menu that will be kept locked away in the kitchen until the diner has washed their hands, can use a knife and fork nicely and has promised not to wipe their hands on the tablecloth. Referrals of ‘advanced treatment’ to a virtual specialist NHS workforce somewhere out there in the ether will in future be encouraged, not frowned upon. What a pity that such a workforce doesn’t exist and is never likely to. Unfortunately, as ever, we will still be recycling and redistributing the same money and in order to restore a per capita ‘registration’ fee (to encourage acceptance of patients with access in mind), and be paid more for delivering ‘advanced treatment’ (including molar endo, the report recommends), dentists must accept the inevitability of being paid less for delivering the table d’hote menu. Alongside this, the great unanswered questions are what will happen to the bands, and will patients charges and UDAs both be linked to them as they are at present? The review sees this linkage as illogical, and it is mooted that up to 10 patients charge bands would be acceptable (to whom?). But a way would then need to be found to recover the requisite patient charge revenue from the ‘advanced treatment’ and/or registration elements or the patients charge would quickly outstrip what dentists actually got paid for treatment in these bands.

Many of my comments will seem one-sided and negative, but there are some excellent and very sensible proposals in this Review, too. Unfortunately, most of them have been suggested many times before and there has never been the political will to implement them. Barry Cockcroft assures us that such a will now exists – and let us hope that he is right – but let us not forget that we may well have a change of government before any of the proposed ‘rigorous pilots’ have been reported, and the Conservative vision for NHS dentistry does not sound very much like this one. Few will want to argue about creating a fairer system, a better targeted system, a more preventive-based service, a focus on delivering oral health rather than generating UDAs and a threshold for the provision for ‘advanced treatment’.

Plus, safeguards to ensure that complex, expensive treatment is only provided in appropriate circumstance and more data in order to measure what’s actually happening (and to facilitate this, a PC in every NHS practice whether they want one or not). All this, and a renewed commitment to quality, access and choice – it’s all great, but it’s not new.

Critics have pointed to the fact that the Review team did not include any GDPs. I never had a problem with this because a token GDP would have run the risk of that single perspective carrying too much weight – but it is difficult to resist the conclusion that some of the recommendations do strongly reflect the composition of the review team itself (not least, the more central roles repeatedly advocated for consultants in Dental Public Health and NICE in any new arrangements). The voice of the coal-face GDP and the business realities of owning and operating a dental practice are significant by their omission even though the anecdotal views of some practitioners are quoted in passing. None of them, interestingly enough, have anything nasty to say about anything that is proposed in the Steele Review. So it’s unanimous, then.

Practitioners will be encouraged to hear the acknowledgement – at last – that everything in the GDS garden is not rosy, and that ‘rigorous’ pilots will be undertaken before any major change is considered. But I think I have heard that somewhere before – Professor Phil Holloway’s capitation pilots were still running and unfinished when capitation was introduced in 1990, and I need not mention the 50 or so Options for Change pilots that preceded the 2006 introduction of a system that had not been piloted at all. But what the Review does achieve is that

it gets the government past the next election – whatever happens next summer – it buys the PCTs some time in which to learn how to spell ‘dentistry’, and it gets the select committee off Barry’s back long enough to allow some ‘smoke and mirrors’ non-surgical cosmetic treatment to be carried out on the access figures.

The Department had been trailing for some months the view that access had suddenly turned the corner, and either Jimmy Steele and his team got the message, or it was thoughtfully added to the report en route to the printers.

One way or the other, we are now given to understand that the access problem is no more than an unfortunate illusion, and when patients can’t find an NHS dentist it is simply because they are looking in all the wrong places. Like England, perhaps?

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