The NHS contract: talking points, part 2

Here, Kevin Lewis offers his view

We may not yet have entered the new world, but dentists in England and, to an extent, Wales are a step closer to it. On 1 April, the NHS Commissioning Board for England swung into action, a couple of months after another publication had burst onto the bestsellers list. Securing Excellence in Commissioning NHS Dental Services is all you need to take with you on your next flight. It need not be a longhaul flight, but it will soon start to feel like one – unless, of course, you happen to fall asleep mid-read.
  If you are susceptible to motion sickness, this may be an uneasy experience because it describes a world of perpetual motion. Dentists and patients are (mostly) intended to be travelling along care pathways, and it’s all about the patient journey. There is a fast lane (or a ‘fast track’) to circumvent nonsense requirements like having to carry out a caries risk or perio assessment on a patient with no teeth, and there are more traffic lights than you would expect to encounter while navigating through a major city centre. Right now, only those involved in the ongoing pilots have a real appreciation of what the final incarnation of the latest new contract might be like in real life.  

Path-ology is the mystic science of paths, where they start, where they lead, and all the landmarks and milestones along the way. Care pathways are a relatively new concept for dentistry. Having an established protocol based on the best available evidence, consistently followed, universally understood, and transportable between locations and operators, sits at the heart of aviation safety, emergency response teams in a variety of accident, disaster and crisis settings and any number of other situations. A lot of dentists won’t like it because it is a world apart from individual decision-making autonomy, personal judgement and clinical freedom. A lot of dentists won’t like it because they don’t or won’t accept the rationale or the claimed benefits for patient care, or because they mistrust the government’s motives. And a lot of dentists won’t like it because they just don’t like it. But, just as with every system that has ever been imposed on NHS practitioners, there will be others who will embrace it, understand, support it and love it.

GDS by satnav
While it is glaringly obvious that at a micro ‘street view’ level it will, as ever, create winners and losers out of practitioners and practices in different situations, it is less obvious it will create winners and losers out of individual patients in a variety of different situations, too. The State (or those bits of it in England and anywhere else that elects to adopt this model) will certainly be a winner because it retains all financial control it recovered when local commissioning replaced a national fee-per-item payment system, and much more direct clinical control than it would ever have thought possible in its wildest dreams.
There is a lot of it that I like, and some of it I like a lot. For example, there is a greater emphasis on prevention, although the achievement and maintenance of health is not actively rewarded – at least, not in the same way as it would be in a capitation system if working as intended.
Minimising the squandering of finite and ever-more-precious NHS resources on costly treatment doomed to premature failure, placing a greater onus on the patient to take responsibility for their own oral health, and basing every treatment decision on firm foundations has to make sense. Seeking patient feedback is hardly revolutionary. It engenders more of a partnership with the patient – and I certainly like that, and the proposed return of a sense of ‘relationship’ between patient and clinician.  It makes provision for those patients who prefer just to dip their toes into dental care as and when they fancy it (or need it) but this time does not actively reward them for choosing that kind of ‘as you like it’ approach. That is a step in the right direction.
I have yet to be fully convinced by how the Quality and Outcome Framworks (QOFs) will work in real life (the pilots in Wales have been exploring this, too), and similarly there is an inbuilt tension in the fact that patients do not pay money over the counter for most of the other care pathways in widespread use in medicine – but they do for primary care dentistry. If they are not happy, they will blame the person who is charging the money, not the people safely out of the firing line who decided what patients can and cannot have in return for money. The patients charge details are yet be revealed but, while we are waiting for this, there is much to commend in the courage of trying to change the culture of the delivery of oral and dental healthcare. The rationale for embedding care pathways into the psyche of NHS practitioners is persuasive in that patients do not suddenly get a different treatment approach every time they change dentists. That problem has plagued the GDS for decades. As care pathways become understood and accepted, treatment decisions progressively normalise.  
The ambition is that this new way of approaching the delivery of dental care will permeate way beyond NHS dentistry in England, and quickly become established as the norm in Wales, Scotland and Northern Ireland – and in all corners of the private sector too ‘because it is evidence based’. Not sure I have seen any evidence for that sweeping assumption, however.

Speed cameras
Because the practical operation of the new contract, and the clinical decision making within it, will be heavily dependent upon IT, practitioners need be under no illusion that their every action can be tracked and monitored from afar. Although some marginal deviation from the main highway may be possible, they had better be prepared to account for every such detour. It conjures up images of a Big Brother kind of scenario, where outliers can expect to be challenged and the slightest misdemeanour will be visible from outer space. Meanwhile, as viewed from outer space, the extra terrestrials will be falling over themselves laughing that some of the earth people on such a tiny group of islands have felt the need to create a fourth new system for NHS dentistry in just 23 years. In galactic terms, this fixation upon such a small part of the anatomy of earth people must seem puzzling. They will probably be taking side-bets as to how long it will be before we go back to drawing board yet again and, no doubt, postponing their invasion on the grounds that there is little point in wasting rocket fuel conquering a land which is perfectly capable of conquering itself without external help.


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