The recent publication of the Steele Implementation Programme documentation takes forward Prof Steele's recommendation that any planned or proposed changes to contract for the provision of dental services should be piloted extensively.
The review recommended the development of quality measures that would allow for more effective performance management of the dental contract. Much has been said (some of it behind closed doors) about the use and abuse of the UDA system of payment; the department of health calls it gaming and in a world of heroes and villains, it is the dentists who are cast as villains. Statistical analyses help to identify the so-called outliers and the providers become the subjects of further inquiry. Nothing wrong with any of that many would argue because of the public monies involved, except that there is some risk to reputation if inferences are drawn from raw data alone.
But there is another side of performance management that is less well publicized. It is the competence, capability and commissioning strategy of the primary care trusts. Many are failing in all three areas. Consider, for example, getting a patient seen for a molar re-treatment where the complexity of the procedure necessitates a higher level of skill, experience or expertise. The contract clearly states that treatments that require this higher level is an advanced mandatory service. In other words, it is a treatment that falls outwith the requirements of a mandatory services contract. It remains the PCT's responsibility to provide such services. How many do? Not many, and when the service is available, it is limited and waiting lists are often long and unacceptably so for the treatment that is required.
The PCT has a duty of care to contract for such services, but there is little performance management in place by strategic health authorities to ensure that there is the necessary level of service to ensure that patients are well cared for – yes, it is about patients at the end of the day.
If there is to be a strategic rethink about the way services are delivered in the future, then any implementation group or pilot site must ensure that there is accountability for PCT performance in such matters.
The intention of the pilot sites in wave two is to look at whole system pilots. Let's hope that whole system analysis identifies the advanced mandatory services commissioning gap.