NHS contract reform began with an enormous burst of optimism that a new system might be designed that actually improved health and gave dentists the time to care for their patients over the long term. Professor Steele’s report was hailed as a new way of thinking about how dentistry should be delivered. Care was the aim; care that enabled treatment to be delivered when necessary and to a standard that would last. The care centred around sharing with patients the risks of future disease, and enabling them to have time spent with them reducing risks, giving preventive advice and treatment. If the disease risks weren’t controlled then treatment was limited. There was talk of guarantees,
but the spectre of the sticky toffee undoing good clinical work was never far away.
The government changed, but the goal remained - a reformed system based on registration, capitation and quality. The BDA was enthusiastic, it would have “welcomed” the process if the word police had allowed, instead it was “positive”, engaging in steering groups and constructively working for change. Pathways were developed, prevention was enshrined in the system to be piloted, RAG indicators for patient education and contract monitoring were developed; 90 brave practices began piloting “elements” of the reformed system. Everyone was keen to say that the pilots were just testing things out.
As time (a lot of it) flew by the results came in. Patients liked the time and care they were given; dentists liked the preventive pathway approach. The data began to show signs that the oral health of patients in the pilots was actually
improving but some dark clouds were gathering over the horizon.
The first wave of pilots didn’t know that they needed to retain their patient numbers. As they spent time on oral health assessments, treatment waiting times increased and patient numbers fell. So too did patient charge revenue. The second wave of pilots were able to use less clumsy software and the fall in patient numbers was reduced. Without a live capitation payment there was no incentive for practices to maintain their numbers. Clawback began to be whispered, and when it was applied it was no wonder those who had given time, energy and commitment were resentful. The dead hand of financial control began to squeeze and grip the process and the minister announced that prototypes would now be developed carrying live models of working, and introduced activity targets in a so called “blended” model.
The BDA found this a tough one to swallow. The original aims of designing a system that rewarded good clinical care and prevention without the perverse incentives of activity seemed to be being lost. The GDPC, I was informed, feared that we might lose the gains and end up with the worst of both worlds, although one of the prototype models restricts activity payments to band three treatments, which is perhaps closer to the original vision. The “dreaded UDA” as the minister dubbed it will remain in place in the prototypes. Any pilot practice moving to a prototype might feel they are sliding back to an unwelcome past.
The Department of Health documents that give details of the prototypes lament that there is no neutral way of assessing population treatment need, and this is why activity models are being used. The risk now is that treatment volume will once again be placed ahead of delivering care and improving health.
It is still possible to design a system that meets what was described as “the big challenge” and minimise perverse incentives. It will take courage, will and intelligence. I hope there is some of that out there. Those who take up the prototypes will need to think carefully about how the elements of the blend affect not just their business, but whether health will be improved or not. Let’s wish them luck.