The fragmentation of the health services increases and the winners and the losers seem like an unknown. What seems clear is that dentistry is going to be divorced from its medical counterpart more so than it was before. General medical practitioners are now taking on their new responsibilities with gusto and some clinical commissioning groups are already using their new powers in shadow form and bringing innovation and flexibility to the forefront of primary care. For the time being it seems like the chaos has brought about a real sense of opportunity for our GP colleagues. The health service seems to have recognised that GPs are independently minded and whilst they are still learning about their new train set they do have the qualities to lead clinical commissioning.
It looks like dentistry is moving in a very different direction, a much more centralised approach. It seems unlikely that groups of dental practices will be able to come together and decide how dental budgets are spent. Instead practices will still be told how to operate. A new dental contract looks highly likely but still fails to recognise the complexity of general dental practice. Commissioners and contract managers want the delivery of high quality services and providers want to deliver high quality and responsive services.
Medical colleagues have negotiated much better arrangements for their contracts, such as the reimbursement of rent for their premises, access to grants and funding for IT connectivity. Under the commissioning arrangements, GP commissioners are working hard to drive up quality by opening up access to innovation grants in primary care and making it more attractive for practices to delivery more services locally. Innovative schemes include a form of referral management that is entirely managed and organised by GPs often called 'Clinical Advisory Services', such schemes allow peer review between clinicians for referrals to secondary care.
It seems strange that NHS dentistry is moving further away from the model used by GPs. It also seems like double standards that commissioners are expecting higher quality but have failed to put any of the funding mechanisms in place that will help improve quality in NHS general dental practices. Most if not all of the commissioning of NHS dental services will move from the responsibility of primary care trusts to the NHS Commissioning Board. It does not appear as if this centralised organisation will receive an increase in the dental budget and it looks as if any development within dentistry will have to happen from within the same 'cash' envelope. In reality this means that either the price of dentistry has to be driven down to free up resources for development or to release resources from time limited dental contracts.
If NHS dentistry is going to survive the changes to the NHS, then it needs space to breathe and resources to develop services. NHS dentists do not have the freedom to generate more income from the NHS in order to develop their services, their trade is largely restricted. The only way that NHS dental practices can develop is for the NHS Commissioning Board to recognise that practices are in much need of investment for service development.
Until now any additional funding to practices seems to be linked to activity, however that was probably politically motivated and less about quality but more about statistics. It remains to be proven that increased activity and '24 month access' has improved health outcomes for patients. Quality and value in NHS primary care has a cost which requires adequate funding through which practices can offer high quality services to patients. In my view, NHS dentistry needs prime funding irrespective of any new contracting mechanisms, without this it will become harder for services to remain viable in the future.