Back in 1948, when the NHS was established (but by a narrow squeak I was delivered into the world under private contract) it was natural for the ‘new’ dental contract as it then was, to reflect common practice at the time.
Common practice, back then, meant payment, frequently in guineas, for a service rendered, whether that was an extraction, a denture, or some other form of treatment (in order of frequency). If you were born post decimalisation, you may need to look up guineas in the dictionary.
And so the era of fee-per-item dentistry came to pass and lasted, more or less, for 58 years. True, in 1990, there was a flirting with capitation chiefly for children, although it was condemned by many – rightly so, as it proved to
be seriously underfunded. The only answer was to register as many patients as possible (registration was introduced at the same time) which led, as many will recall, to a serious government overspend situation and the first real experience of clawback.
So it is fascinating to see that the new climate (68 years on, and after a disastrous flirtation with the UDA, which will probably go the way of the guinea) is warming towards capitation again.
Even more interesting is the fact that it is not only England and Wales who are considering this major change. In Northern Ireland, there has been much discussion about the relative merits of fee-per-item and capitation in various
blends since 2006. I guess the one thing that dentists here have agreed upon is that looking ‘over the water’ at the appalling fall-out from the UDA, that’s the one thing they definitely don’t want...
However, at the stroke of a pen, more or less, Northern Ireland policymakers have decided that a full capitation contract is the way to go, albeit with a clear 18 month timetable of piloting and with a number of differences from
the English (and probably Welsh) approach.
As with its political ambitions, so with its healthcare system, that leaves Scotland alone, and in the 1948 camp (for now at any rate).
In a day and age when most patients want a continuity of care and are beginning to see the benefits of a preventive approach to oral health, it’s hardly surprising that capitation is seen as an optimal system for funding routine dentistry. An agreement to maintain health (given an informed patient and an ethical dental team) is a more mature framework than paying per diagnosis or per restoration. I guess you’d expect me to say that.
The issue that arises is whether the payment accords with the provision of good quality, patient-centred care. Common sense suggests that if you skimp on the payment, the likelihood is that the quality will suffer. And if quantity as well as quality enters the mix then the old ‘iron triangle’ comes into play.
I’ve always thought that the motorcycle analogy works well here (sorry if you’ve heard this before). The ideal component for a ‘motorbike is one that is light, strong and cheap. The snag is that you can only have two of these three features. If you want something that’s ultra-light and also strong, guess what? It’s expensive.
If you want something that’s strong and economical it will turn out to be heavy. And so on. So if you constrain the cost, you will either have to sacrifice quality or quantity, you can’t have it both ways. And therein lies the rub.
It’s always assumed that in private dentistry, the first consideration is the dentist’s standard of income. Quite apart from the NASDAL accountants’ (and the Inland Revenue’s) figures, there is little evidence of this from where I sit.
What dentists aspire to most is to practise the dentistry they were trained to deliver (and continue throughout life to refine and develop); and the time in which to provide this to their patients.
At the same time, when publicly funded dentistry calls on taxpayers’ money (and incidentally has little to do with National Insurance), there will always be an auditor lurking somewhere who quite rightly wants to ensure bangs per
buck.
So if capitation finally emerges, blinking, into the light of day as the preferred route for public dentistry, we have to stand up for Jimmy Steele’s other proposal: namely that limits should be set on what can be publicly provided.
I urge you to read an interim report: A new settlement for health and social care, published by the King’s Fund earlier this year. It doesn’t have any firm conclusions, but it does make you think.