Complex care pathways could improve care for patients with high levels of disease, says Ian Gordon, but questions remain over prevention, remuneration, clinical complexity, patient disengagement and the financial risk transferred to NHS dental practices.
In a previous article, I explored the clinical rationale, operational reality and practical risk underpinning the decision to use or not implement clinical care pathways. I’d now like to consider the wider practical limitations of complex care pathways: clinical complexity, financial sustainability, professional judgement and risk transfer to providers.
The concerns about complex care pathways are not limited to Compass reporting, declarations and patient charging. There are wider questions about whether the model properly reflects the clinical complexity, time, cost and risk involved in treating high-need patients in NHS general dental practice.
Prevention must remain central, whatever the payment model
One important risk is that the debate becomes too focused on whether care is delivered through a complex care pathway or a conventional banded course of treatment. Preventive care and risk factor management must remain integral to both.
If a patient is treated through a banded course rather than a pathway, that should not be interpreted as reducing the need to address diet, oral hygiene, fluoride use, smoking, alcohol, plaque control, diabetes control, xerostomia or other relevant modifiable risk factors. Prevention is not optional simply because the payment mechanism changes.
This is clinically and medico-legally important. If a patient later deteriorates, or complains that disease progression was not properly addressed, the question will not only be whether the correct NHS claim was made. It will also be whether the clinician assessed risk, gave appropriate preventive advice, delivered relevant interventions and recorded those discussions.
Prevention should remain central to all NHS courses of treatment, whether or not a CCP is used.
The remuneration may not reflect the service requirements
The service requirements for CCPs are extensive. They require assessment, diagnosis, staging and grading, risk factor identification, personalised care planning, preventive advice, ongoing review, documentation, declarations, and completion or exit management. That is before considering the operative treatment itself.
There is a legitimate concern that the current remuneration does not adequately reflect the level of work required. The pathway tariff may look more substantial than a conventional banded claim, but the clinical and administrative requirements are also much greater. For some practices, particularly where high-need patients require multiple visits, DCP input, extended review and close monitoring, the pathway may be difficult to deliver sustainably.
That matters because an underfunded pathway can create perverse incentives. If the model is not economically viable, practices may be reluctant to use it, clinicians may disengage, or the pathway may be delivered in a way that technically satisfies the claim but does not fully realise the intended clinical benefit.
A reform designed to improve care for high-need patients must be funded at a level that reflects the actual service required.
Very high treatment need is not sufficiently recognised
The pathways are intended for patients with more complex disease, but they do not appear to scale adequately with the extent of disease burden. A patient with five carious teeth may meet the entry threshold for a caries pathway, but so might a patient with seven, ten or more carious teeth. Those patients may require substantially different levels of clinical time, treatment planning, operative care, prevention, stabilisation and review.
The same point applies to periodontal and combined caries/periodontal cases. There is a significant difference between meeting an eligibility threshold and presenting with very extensive disease requiring prolonged, staged intervention.
This creates a practical limitation in the design. A fixed pathway tariff may not adequately recognise the upper end of complexity. The risk is that patients with the greatest need may be the least financially viable to treat under the pathway model, even though they are precisely the cohort the reform is intended to support.
Non-carious treatment need is under-recognised
The guidance necessarily focuses on caries and periodontal disease because these are the main clinical entry routes into the pathways. However, many patients in this cohort also present with significant non-carious treatment needs: fractured teeth, heavily restored teeth, failing restorations, tooth wear, broken cusps, defective margins, compromised occlusion and complex restorative decision-making.
These issues are not incidental. In real practice, stabilising a high-need patient often involves managing both active disease and the consequences of previous restorative history. Broken or heavily restored teeth can be time-consuming, technically challenging and costly to restore, even where they are not simply ‘carious teeth into dentine’ for pathway-entry purposes.
If the pathway design does not properly recognise this broader restorative complexity, it risks underestimating the work required. It may also create disagreement about what is included within the pathway, what should be claimed separately, and what the patient should reasonably expect to receive.
Financial risk is disproportionately transferred to practices
A further concern is that pathways may be clinically front-loaded. In many cases, the assessment, diagnosis, urgent stabilisation, prevention planning and much of the operative intervention will take place early in the pathway. If the patient then disengages, fails to attend or becomes unable to continue, the practice may already have incurred a substantial proportion of the clinical time and cost.
The pathway cannot simply be unwound. If the patient does not complete the pathway, the practice still has to manage the declarations, incomplete pathway rules, patient communication, any complaint risk and the clinical consequences of partially completed care.
This transfers a significant element of risk to providers for factors that may be outside their control. High-need patients may be more likely to have irregular attendance, social barriers, anxiety, competing health problems or difficulty engaging over six or twelve months. These are precisely the patients the model is designed to help, but they are also the patients most likely to create completion and financial risk.
A fair model needs to recognise that risk. Otherwise, practices may reasonably hesitate before commencing pathways for the very patients who could benefit most, particularly where early treatment costs are high and later patient engagement is uncertain.
Prescriptive requirements may affect clinical flexibility
Standardisation can be helpful. It can support consistency, reduce inappropriate variation and give practices a clearer structure for managing complex disease. However, there is a balance to be struck.
If service requirements become too prescriptive, there is a risk that clinicians feel they are delivering a contractual pathway rather than exercising professional judgement for the individual patient. Patients do not always respond predictably. Their attendance, motivation, disease activity, social circumstances and treatment preferences may change over time. A pathway model needs enough flexibility to accommodate that reality.
The concern is not that clinicians should be free from accountability. It is that contractual requirements should support clinical judgement, not replace it. The records should show why decisions were made, how the patient responded, and why care was adapted. That is preferable to a rigid process in which compliance with the pathway becomes the dominant objective.
Summary of additional risks
| Issue | Why it matters | Publication framing |
| Prevention in banded care | Risk that non-pathway care is treated as less prevention-focused. | Prevention and risk-factor management remain essential regardless of claim type. |
| Remuneration | Assessment, documentation and review requirements may exceed what the tariff can sustainably support. | Clinical ambition needs realistic funding. |
| Very high need | Fixed pathway values do not scale for patients with very extensive disease burden. | The model may under-recognise the patients with greatest need. |
| Non-carious complexity | Fractured or heavily restored teeth may drive major treatment time and cost. | Eligibility criteria do not capture the whole restorative problem. |
| Patient disengagement | Work and cost are often incurred early, while completion depends on attendance over months. | Risk is transferred to practices for factors partly outside their control. |
| Clinical flexibility | Rigid requirements may narrow professional judgement. | Standardisation should support, not replace, patient-specific care. |
Overall conclusion
The success of complex care pathways will depend not only on whether the clinical rationale is sound, but on whether the model is practical to deliver in NHS general dental practice.
A workable system must preserve prevention across all courses of treatment, recognise the full range of clinical complexity, fund the time and documentation required, allow appropriate clinical flexibility, and avoid transferring disproportionate financial risk to practices where patients disengage.
It is therefore reasonable for the profession to support the ambition of better care for high-need patients while remaining critical of the current mechanics. The question is not whether prevention, stabilisation and risk management matter. They clearly do. The question is whether the pathway structure, reporting systems and remuneration model are sufficiently robust to deliver those aims safely, fairly and sustainably in real practice.
The clinical idea may be right, but it will only succeed if the pathway is simple enough, flexible enough and funded well enough to work in everyday NHS general practice.
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