Bottoms up, top down

As the government unveils its plans for the future of the NHS, are we really any closer to understanding what it will all mean for primary care NHS dentistry? I suspect not, and nor will we be for a little while yet.

The debate rages on as to whether dental services should be (or will be) integrated with the rest of primary health care. Nice enough in theory, and logical at first sight – but deeply problematic once you start scratching the surface and try to implement it. And when it comes to the crunch, dentistry has always come second. Now that the social care agenda has grown wings – and if you need any convincing of that you need look no further than the CQC outcomes and judgement framework – we can safely assume that the rest of dentistry will in future come third behind medicine and social care.

Another recurring question is whether healthcare in general (and dentistry in particular) is best managed close to the point of delivery, at a distance, or something in between. We have tried just about every variation in the last 20 years and the strategy seems to be that every few years a conclusion is reached that the present plan isn’t working and to swing the pendulum back in the opposite direction. I have lost count of how many times in my career I have heard that we need to re-think the priorities, adopt a more preventive approach, re-target the available resources, avoid wasting money on ineffective treatment, focus on quality and put patients and their interests first.

But isn’t all this a no-brainer? It’s like saying that the Royal Mail should concentrate on getting letters and parcels to their destination ASAP, or that prisons should try not to let prisoners escape.

It strikes me that one of the problems at the heart of NHS dentistry’s eternal search for the holy grail is that successive governments have proved themselves unable to resist the temptation to micromanage the interaction between a willing independent contractor, and a willing recipient of that contractor’s services. Isn’t it ridiculous that two parties to a contract which, in many cases, involves an individual patient paying more for the service than the value of the UDAs that are being generated (this happens whenever a provider’s UDA value falls well below the national norm), have their relationship managed by the DH or a PCT acting as the intermediary.

There is a persuasive logic in the concept of what Sir Kenneth Bloomfield described as ‘local sensitivity’ almost 20 years ago. The experiment has failed, mostly because so many of the PCTs have shown themselves to be incapable of applying the powers that they were given, in a way which squeezed the best out of local service provision and availability. Instead for some PCTs it has been a running battle with providers whose problems they didn’t understand and cared about even less.

It has to be said, however, that other PCTs have been a model of how things could (and should) have been. They have engaged with their local providers, tried to understand them, and worked imaginatively and collaboratively to match local service provision to local needs. They did what it said on the tin and dentists in those areas will look back upon this era with the same kind of fondness as those who were in ‘old’ style PDS.

Whether the delivery of primary care dentistry is commissioned and managed close to the action, or from afar, is not really the issue. The quality of the management and the ways in which performance is measured has a much greater impact on what gets done. Fee per item gets more items done that attract fees, and less items done that don’t. Capitation gets more patients into the net to get counted, and block payment based on the number of courses of treatment gets more courses of treatment. National measures take little or no account of local variations in need, demand, supply or the cost of delivering the service locally, and I have yet to be convinced that the proposed block contracting through consortia is the answer. It creates a reassuring illusion that ill-motivated, bean-counting third parties are no longer intervening in the clinician-patient relationship, but if you believe that you will believe anything.

Having a uniform national currency does at least avoid the lunacy that we have seen with the flawed UDA system. It is crazy enough that one RCT of a lower incisor or primary first molar pays the same as 12 difficult molar root canals, and even crazier when one considers the fact that one provider might have a UDA value that is twice that of a practice 50 yards up the road.

Limpid pool
Nor should we lose sight of the fact that the UDA system was spawned not as an activity measure at all, but in the limpid pool of patients’ charges that the government deemed necessary as part of the traditional co-funding of primary dental care. Simplifying the never ending variations of charges into three broad bands did a far better job for patients than it ever did for dentists, because – unlike patients – practice owners were left to swallow the additional costs of delivering bigger courses of treatment within the same band. A wise man or woman would keep one eye on how the same pool of patients’ charges would be collected out of any new remuneration system, because in the current economic climate I cannot see the government being prepared to meet an even greater share of the cost of primary care dentistry than it does at present.

The designed-in demographic problem that is likely to thwart any attempt to reform NHS dentistry again is the time bomb of the growing dentate, heavily restored elderly population. If you had to design a system that was most likely to leave this group high and dry, the present UDA system would take a lot of beating. I am actually quite attracted to Jimmy Steele’s concept of ‘advanced’ dentistry and making its availability within the NHS conditional upon need, evidence base, and appropriateness to the individual patient’s level of commitment – but it is as if the sentence was cut short before the full stop.

The evidence base tells us that most of the mountain of restorative dentistry that adorns the mouths of the baby boomers (mostly, courtesy of the NHS itself) will fail sooner or later and need maintenance along the way whatever happens. This has the potential to consume a massive proportion of the funds currently deployed in primary dental care and one day it will be necessary to grasp the nettle of dealing with this legacy of the old fee-per-item NHS. Any time now we can expect NICE to be commissioned to report on whether implants should be made available on the NHS.

It is lovely to hear all the talk about placing the emphasis on prevention, the oral health of children, detecting oral cancer, smoking cessation, and playing our part in improving the diet, nutrition and social well being of our patients. But the same money can’t be paying for all this and all that restorative maintenance and replacement at the same time. The challenge for our political masters is to create the illusion that it can – and also buying as much time as possible while they work out how they square this circle.

A good place to start would be to turn the problem inside out and think about the realities of need, supply and demand in individual surgeries up and down the country. Proposals made too far from that reality, and without an understanding of the business dynamics underpinning it, are best left on the whiteboards and spreadsheets of health economists and consigned to history. Fee per item lasted over 50 years, and registration, continuing care and capitation lasted about 16 years. Yet the cracks were showing in nGDS and nPDS within two or three years. It’s a clue.

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