You know how it is, one sunny day you're walking along a beach watching the waves lapping and feeling the sun on your shoulders then suddenly there's a clap of thunder and glancing round you see an enormous cloud is nearly upon you. The wind suddenly gets up, you shiver as the sky darkens and a sheet of hail hits you, the waves are crashing at your feet...
Did it feel like that with the CQC? One minute we were minding our own business (or possibly trying to get to grips with HTM 01-05), when, all of a sudden, we were thrust into an inexplicable, even more complex and potentially frightening - and frighteningly expensive - process called 'regulatory reform'.
Although barricades were hastily constructed and protests were raised, it was, we were told, the law. Reluctantly most began to get involved.
In October 2009, a full year before the new regulations were passed, the last Government had thoughtfully considered what the prospects for this new regime might be in an impact statement which sought to predict and assess its methodology, costs and benefits. How do those predictions stand up in the light of the past 18 months?
Methodology
The impact statement clearly envisaged a much more straightforward and integrated path to registration of both dentists and GPs. It anticipated, for instance, that CQC would work with NHS Dental Services, which already had a great deal of data on NHS dentists. The NHS DS's role could be expanded to include the provision of advice, guidance, and indeed, undertaking routine inspections of practices.
It's a shame that whichever branch of the health department drew up this guidance was clearly not talking to the branch which approved the redundancy of almost all dental reference officers. That collaboration would at least have ensured that inspectors and those assessing applications had some knowledge of the profession.
The anticipated process for regulation went something like:
- All dentists would carry out a self-assessment and then declare their compliance status.
- The CQC would check this data against other information, from bodies like the GDC, PCTs and NHS DS.
- There would then be risk-based assessments where necessary and a random sample of practices (say 10 per cent) would be inspected.
Simple – so you may ask what went wrong? By 2011 it was anticipated that all NHS contracted dentists would be completing an annual self-assessment for NHS DS, so it was cheerfully assumed that no additional regulatory burden would fall on them. However private practices, about which next to nothing was known, would have to shoulder this task individually.
Costs
The assessment goes into much detail about the costs to the CQC of bringing in regulation across primary care. What of the costs to providers? The NHS dentists would have little or no costs in applying for registration – since they would already be self-assessing for dental services. The cost for a wholly private dentist was estimated at £3,600, based on earlier research among private medical clinics.
The cost to the dentist of an inspection was put at £370 – again based on interviews with doctors, and hardly an insightful approach to the particular workings of dental practice. It was assumed that about 10 per cent of NHS practices, but all private practices, would be inspected in the first year following registration. That would be about 1,800 practices, or seven per day.
Benefits
The benefits perceived as flowing from registration of dentists were listed as:
- A level playing field across the public and private sector
- Increased patient reassurance and confidence
- Patient choice
- Better decontamination standards and lowered transmission of vCJD
- Benefits to patients in secondary care.
While it was admitted that quantifying these benefits was 'difficult', the last one suggested that fewer patients would have been treated in hospital for vCJD as a result of dentistry, resulting in a national saving of between £1,200 and £860k. Quite a spread of risk there.
In a surprisingly candid admission, the health department said: 'There is relatively little information as compared with primary medical care, about what is happening in NHS dentistry and whether the services patients receive are contributing to oral health'. This statement is referenced in the Steele Report.
The paper then goes on to describe how studies in Turkey had shown that patient trust in their dentist was related to 'better health outcomes, quality of treatment and increased attendance'. All mind-blowing stuff, but presumably NICE wasn't consulted about the last bit...