At the end of a recent seminar about the proposed changes to NHS dentistry, one of the delegates noted on the feedback form that the new dental contract would “take the fun out of dentistry” because it would be all about “painting by numbers”. It was an interesting remark clearly referring to the part of the presentation that focused on the impact of clinical pathways and guidelines.
The smiley face emoticon at the end of the sentence was a little playful, mischievous even. Was the delegate suggesting that that ‘fun’ in healthcare can only be found in an abstract form and that any attempt to standardise clinical practice can only detract from the experience of being a primary care dentist? This view is not an uncommon impression though it is often expressed differently, sometimes as “loss of clinical freedom”. Couched in this way, it somehow lends more validity to the opinion perhaps even taking it to the borders of ‘fact’. To understand the clinical rationale of a pathway-led approach, we must first understand what we mean by guidelines and protocols.
Guidelines are systematically developed statements to help the decision making process. They are a recommended way of working which implies what can be done. A clinical protocol (sometimes described as a pathway) is a detailed description of the steps taken to deliver care; a roadmap which shows how something should be done. Clinical guidelines are written for the ‘average patient’ and are designed to improve health outcomes for patients; their limitation is that they cannot necessarily be applied to a unique patient – this is where clinical freedom applies.
Back to the future
The future of NHS dentistry was written in the past. Options for Change, published in August 2002, introduced the idea of clinical pathways to dentistry with the statement “Treatment should be offered which is clinically appropriate, according to agreed protocols” and that “a clinical pathway approach should be developed, based on best practice and the available evidence base”. The statement in chapter one was very clear: “Clinical pathways, as are now adopted across much of medical practice, should be developed and applied in dentistry.”
As Marty McFly put it (in response to a stunned audience after his rendition of Chuck Berry’s
Johnny B Goode - in the 1985 film Back to the Future) “I guess you guys aren’t ready for that yet... But your kids are gonna love it.” The 2006 contract wasn’t ready for it, but the next generation contract is.
The National Pathway Association defines a care pathway as “a locally agreed, multidisciplinary practice based guidelines and evidence where available, for a specific patient/user group. It forms all or part of the clinical record, documents the care given and facilitates the evaluation of outcomes for continuous improvement.”
First introduced in the early 1980s and developed at the New England Medical Center by Karen Zander and Kathleen Bower, the features of care pathways are:
- The pathway is evidence-based.
- It takes into account resource constraints and budgetary limitations.
- It is dynamic entity which evolves to reflect the findings of clinical research.
- It is part of a continuous quality improvement process.
A good example where these features are demonstrated is the ‘Improving Customer Focus Using Critical Pathways’ project in Australia (funded by the Australian government) as part of a wider best practice initiative – a particularly good example because it emphasises that the ‘customer’ is at the heart of the initiative.
The purpose of the pathway approach is to:
- Standardise processes to reduce variability in outcomes.
- Reduce cost through increased efficiency.
- Improve patient care by delivering better clinical outcomes.
The successful implementation of the pathway approach will depend on a number of factors:
- There must be grassroots involvement in the development of the pathway – one would hope that the pilot site experience is providing this opportunity.
- The pathway should take into account published, peer-reviewed literature and the prescribing experiences of dentists.
- Experience in other countries suggests that implementation from the top down approach is less effective than a bottom up strategy.
- The pathway needs to be clear and concise.
- There needs to be a point of- delivery prompt to increase adherence to processes and policy – the software algorithms facilitate this aspect.
- Measurement is the key – there must be objective measures for outcomes. The Dental Quality and Outcomes Framework (DQOF) is a step in the right direction in this respect.
- Pathways must allow clinical flexibility – autonomy in clinical decision making is essential for the occasional case which doesn’t quite fit the pathway – hence the need for an over-ride facility.
Going forward, the implications of a pathway approach will be far reaching. It will be difficult to justify interventions that breach the clinical protocol unless there is good reason. There is no opt-out other than the particular patient scenario.
In the past, the opt-out for those uncomfortable with the reforms has been to leave the NHS and find sanctuary in the private sector. The challenge this time round will be different; an evidence based pathway is not just aligned to the NHS; some system pathways may be, but those related to the appropriateness of clinical interventions are stand-alone and, where the evidence base is strong, would apply equally to the private sector.
There are medico-legal implications here which have yet to be fully understood. Adherence to evidence based protocols (for a given diagnosis) will support clinicians where there is vulnerability to litigation and a deviation would prompt a plaintiff to argue that the clinician failed to follow a recognised, evidence-based approach, particularly in the event of an adverse outcome. This has the potential to change the medicolegal landscape and some risk management work will need to be done once the pathway details are finalised and the implications understood.
Search for truth
The pathway approach is to be welcomed and is long overdue. The evidence base that supports it is the search for truth and the truth need not detract from our clinical judgement or autonomy; it should enhance it. It does not detract from the ‘fun’ of dentistry; it merely defines the pitch where the ‘fun’ is available (fig 1).
As for ‘painting by numbers’ diminishing our art, it is perhaps worth reflecting on John F Kennedy’s eloquent statement: “We must never forget that art is not a form of propaganda; it is a form of truth.”