The clock’s ticking…

A lot has been said about the ‘currency’ of NHS primary dental care. We have tried direct reimbursements, grants, incentives, continuing care linked to registration, capitation and weighted capitation (including one-off payments at the point of entry into capitation, weighted in various ways). There have been activity measures of many kinds – items of service, prescribing profiles and UDAs being prominent among them.

The NHS is already 63 years old and there is no sign of it being pensioned off any time soon. But, if after 63 years of tinkering and re-tinkering no obvious ‘best solution’ has been stumbled upon, it is a bit of a clue that only the most irredeemable of optimists would be confident that the proposed new NHS dental contract in England and Wales will prove to be the answer to every practitioner’s prayers.

It is more likely, I would contend, that it will prove to be the answer to the prayers of some practitioners, but quite the reverse for others – just like all the other previous incarnations of NHS dental contract over the years.

Holy grail
In each of the previous episodes of navel gazing from Tattersall in the 1960s to the Dental Strategy Review Group, to Bloomfield in the 1990s and latterly Steele, the mantra has been subtly different to reflect the politics and priorities of the day.

But the holy grail that has eluded all of these well-intentioned exercises is that of how to give practitioners enough time and space in which to care for their patients without undue pressure, interference or perverse incentives. The state has always wanted to get more done at the lowest cost and the penny has not yet dropped that the half life of each successive contract has been getting progressively shorter.

Time is a precious and grossly undervalued commodity in healthcare and no NHS/GDS contract is sustainable unless this is factored into the equation.

Is it not, then, all the more extraordinary that this consideration has mostly been both silent and invisible despite the considerable brainpower that has been deployed over the years to cure the chronic condition that is NHS dentistry?

It is well recognised that the treatment of children, the elderly and the medically compromised and/or special needs patients requires much more time than the treatment of other patients. Many patients are fearful of dental treatment and they, too, need a lot more time if they are to be properly cared for.

Communicating with patients whose first language is not English also requires a lot more time and there can be few practices in the country for whom the treatment of one or more of the above groups has not become an ever-greater part of their life in recent years.

Providing ‘whole patient’ care and health promotion activity (such as smoking cessation advice and dietary counselling) takes time, as well as skill and effort. For some patients it takes a lot of time and a lot of repetition and follow-up over an extended period.

Delivering high quality dentistry in a technical sense also takes time, as does training and developing other members of the dental team to make their contribution to the delivery of quality care and treatment. Quality assurance, clinical governance, clinical audit, peer review and regulatory compliance cannot be achieved without the commitment of significant amounts of time.

Attending to contemporary standards of decontamination and infection control takes much longer than in the past and reduces the number of patients that can be seen in a given amount of time.

Enhancing what the jargonistas like to describe as the ‘patient journey’ – or, in plain language, the overall experience of a patient in relation to care and treatment they are receiving – takes a lot more time than simply carrying out the technical clinical procedures involved. So also does the effective management of patient dissatisfaction and complaints and learning any lessons from them.

Lost time
Maximising public access to primary dental care in terms of reaching those patients who seek and receive dental care less often than their actual dental needs might otherwise justify, takes time. It takes a lot longer to get to know and treat a new patient, or a patient who has not attended for many years, than a patient who attends regularly and is well known to the clinician.

And, despite our best efforts, many of these irregularly attending patients will fall by the wayside again, failing to attend appointments and failing to complete courses of treatment that have been arranged for them.

This squanders an extraordinary amount of time that could otherwise be used for patient care – and yet successive governments have, as a matter of policy, actively encouraged the severance of the umbilical cord of the regular check up that helped to reinforce a patient’s sense of responsibility for their own oral health and dental care.

Time needs to be set aside for continuing professional development, not just for the dentist but for other team members. Keeping up to date with the literature, the ever-changing legislation and current guidance documents is almost a full-time task in itself.

It is a recognised fact that one of the greatest sources of workplace stress and human error is time pressure. Rob a practitioner of time and ultimately you make adverse outcomes more likely and you compromise the standard of care that can be achieved.

Communicating effectively with patients, listening to their concerns, understanding their expectations, providing them with information and choice, inviting and answering their questions and delivering the human qualities and professionalism that contribute so much to the effective provision of health care, requires time – and plenty of it.

Patient satisfaction has been shown to be directly related to the patient’s perception of how much time the clinician is prepared to give them.  Similarly, any perception of being rushed has precisely the reverse effect.

But wherever you look in modern dentistry, a practitioner is expected to conjure up time for this, that and the other – but nobody ever asks where this time is going to come from.

I appreciate that many of you may not have had time to read all of the above – in which case I have made my point without using up too much of your time.  But as the pilots for the new NHS dental contract get off the ground, the general practitioners who are looking on (in hope rather than expectation, I fear) might well be saying something along the lines of: ‘We agree with the underlying principles of what is being proposed – but everything you want us to do takes time. If you want us to invest that time and take the financial risk on your behalf, then you need to be prepared to pay for it.’

What would the new NHS dental contract look like, I wonder, if we turned 63 years of history on its head and started with the money that the DH wanted to spend, agreed how many hours of time that bought, and then sat down to discuss what the profession could realistically be expected to provide within those constraints. It might be an interesting debate.

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