The recent news story about the York GP practice which, having received notice from its primary care trust that certain non-urgent treatments would no longer be routinely funded by the National Health Service, wrote to a small number of waiting-list patients to offer them private alternatives, exposes a number of fundamental fault lines in healthcare funding.
You'll recall that a furore was created when one of these private treatment options turned out to be provided by a company wholly owned by the GP partners themselves. The PCT immediately issued a statement that while it did not intend to: '...routinely commission these services' (such as in-growing toenails and wart removal), it 'recognised there may be exceptions'.
This brought to mind past official statements that while dental implants may not be available routinely, there may be patients for whom such treatment could exceptionally be provided at specialist centres and therefore it was not possible for dentists to state that they were not available on the NHS.
The GP story reminded me that in some ways, NHS dentists, even in these nGDS contractual times, still enjoy some privileges that are denied to their medical colleagues, who are unfortunate enough to have to inform their PCT in advance, I understand, of any suggestion to patients that private alternatives might be available.
However, this might be a path down which dentists might have to trail their GP friends (unlike CQC where the traffic was the other way).
The president of the Royal College of GPs has become a leading campaigner against the current trend towards clinical commissioning groups (aka GP consortia) towards which the Health and Social Care Bill is moving.
She rightly points to the conflicts of interest that will soon affect all medical practitioners who will be directly in the front line of health care rationing, distasteful in itself, and will also, if they are legally a part of a 'willing independent provider' find themselves obliged to put forward alternatives to patients, like the York practice, which potentially could add to their earnings. That patients might benefit from such choices is immaterial.
In dentistry, the current pilots suggest that dentists might be spared such raw rationing decisions, saved in this instance, by the chairside computer. No longer will dentists say (usually around the beginning of March each year) 'I'm sorry, but I have no UDAs left to carry out your treatment on the NHS'. Instead, their practice software will dictate what treatments are, or are not available to a patient with a particular oral health risk profile.
Some pilot practices are experimenting with a 'pot' of funding for advanced care (which in this context means metal-based dentures, endodontics, advanced periodontal treatment and indirect restorations). If this particular aspect of the pilots makes it through to the new contract, one can expect that such a pot will be invariably used up within its allocated year, when further such treatment will not be possible on the NHS.
But here the lessons of York may be salutary, for whoever is (by then) actually commissioning dentistry may be able to say, 'Well it's not routinely available, but if we say so then it is', and yet another (dental) practitioner will find themselves in the dock in the court of summary media justice and social outcasting.
The blunt fact is, although no-one wants to say so, that healthcare rationing is a fact. It may be disguised as waiting lists, commissioning decisions, NICE rulings or simple contractual exclusions, but it is a necessity of any public health funding that does not eventually go on to bankrupt its population.
We laugh now when we look back at the 1940s concept, as espoused by Nye Bevan – that when good health care was made available free to the entire population, widespread sickness would drop and the NHS budget could therefore be reduced in the coming decades. But that was the view.
For many years, funding has allowed clinicians to be remote from rationing decisions. Faceless NHS managers have most recently been in the firing line when such activity takes place and suffering patients are championed in the headlines. Little wonder that while clinicians are mostly praised, managers come in for public criticism.
Maybe they've had enough. Or maybe this Government just wants to encourage frank exchanges between practitioners and their patients. Either way – and even with a computer system to cleverly make the decisions for us – telling it straight to patients is going to become a whole lot harder to manage. Even without Dispatches!