Do additional services really exist in the NHS? This may seem like a strange question but one which really needs to be resolved. In the current NHS contract there is a specific reference to additional services. These are dental services that are not ordinarily delivered as part of general dental services, for which PCTs have a commissioning responsibility. Services that could fall into this category could include oral surgery, endodontics and orthodontics. There are of course other services that may also fall into this category, for example special care dentistry, specialist restorative dentistry and periodontics to name a few. This issue for patients and their dentists is that the provision, availability and thresholds for referrals vary hugely across the country.
The problem can be the cause of much anxiety for patients and their dentists as the inclusion and exclusion criteria for additional services is not defined in one place. The interpretation in one part of the country could be very different from another part of the country depending on the commissioners’ intentions, availability of dental advice and local demands. However, none of these seem like good reasons for poor availability of services.
Using endodontics as just one example, it seems absurd that a patient that needs a molar root canal treatment can receive treatment under the NHS in some parts of the country but not in others. It seems even more ludicrous that in some parts of the country, commissioners have taken a view that they will only fund treatment for a shortened dental arch. Clearly this sort of inequity is unfair and furthermore it seems unreasonable. There does not seem to be any objective justification as to why the NHS has such variation in services for what is supposedly a national service.
Some PCTs have used a multitude of methods to manage demand for additional services, using levers such referral management and referral criteria as well as very specific referral forms. All of these mechanisms help manage demand and in some cases even deter referrals by creating an artificial barrier. Even waiting lists are used as a form of managing demand; some referral management centres will control the flow and speed of referrals through the system as a way of managing demand. Relatively few patients will complain to their PCT about access to additional services. Most of those that complain are most likely to complain to their own dentist or perhaps even their doctor. It is the general dentist that is left managing a patient’s frustrations.
The current process of commissioner decision making can be haphazard in some parts of the country, even in those areas where they have access to dental advice. This is because of the issues that patients face go beyond clinical dentistry. The example that comes to mind is orthodontics, where some PCTs provide adult orthodontics and others do not. Other than the age of the patient, there seems to be no other reason for the variation in access to services. However, this form of discrimination could breach the Equality Act. Commissioners have a duty to ensure that their providers are delivering services in a way which is consistent with anti-discrimination legislation and this is an area where they do not seem to have recognised age discrimination.
There are probably few people that do not recognise the financial challenges that the entire NHS will face in the future. However, this is still not a valid excuse for the postcode lottery in access to additional services. It is very hard for the NHS to fund everything and there has to be a point at which a line must be drawn, however the system needs to be consistent and transparent. Commissioners need to agree at national level which additional services they are willing to fund and which they are not. These policy decisions must be evidence based and must utilise clinical expertise.
In my view, the NHS needs to use the opportunity from reorganisation to define its core offering to patients and to ensure that service availability is consistent and transparent across the country.