Dentists who worked in the NHS prior to 2006 will be familiar with the idea of treadmill. Sadly this wasn’t a euphemism for a specially discounted gym membership for NHS dentists, it was a common reference to the way that dentists worked in an activity based system. It’s hard to explain to a lay audience what has really changed. We used to fill out lots of forms and get paid based on how much treatment we carried out, we still have to fill out lots of forms and still get paid based on the amount of treatment we carry out. A few things have changed, for example we no longer have patient registration and don’t have responsibility for our own out-of-hours services. Patients are presented with a simpler charging system and unlike the old system they now only pay one of three charges.
Have we gone from treadmill to merry-go-round? NHS reforms are never ending and as politics become more sophisticated and as the health system creaks towards capacity the rate of reform seems to be increasing. It can sometimes feel like a never ending cycle which we should probably expect but it’s the rate at which we reach the change point which is becoming quicker. The current set of reforms are being marketed as ‘dental reforms’ as opposed to the creation of a new contract, this is really just semantics as a contract which is different to its predecessor is new. This set of reforms appears to be aiming to improve oral health and increase access. There seems to be an emphasis on improving the oral health of children, which always go down well politically. The technical aims seem much more definitive as the reforms intend to introduce some capitation, quality and registration.
I find myself meeting lots of dentists and speaking to lots of dental opinion leaders from week to week and even though I am immersed in the world of NHS dentistry, even I sometimes struggle to understand what all this means in reality. From what little I have picked up, there appears to be no more money for investment in the system or for implementation, and politically it still seems the output measure of access is to remain. The pilots seem to be very mixed in their success, although I appreciate that these are pilots and it is very hard to judge their success with such a short time horizon. A common myth that needs to be addressed is that the reforms are not going to pick one of the pilots and implement the model; the reforms will most probably pick elements from different pilots and bring these together in the form of a contract.
The bedrock of these reforms appears to be the care pathways approach, which ideologically are a good thing, designed with the profession and supported by the evidence. This in itself is a good thing for patients as the chance of receiving a consistent response between NHS practitioners increases. Of course, dentists as independent health professionals will still treat the patient in accordance with their wishes and where necessary will veer away from the clinical decision support tool but overall the range of decisions is likely to be narrower.
What will be much harder will be setting the capitation fee, designing the quality monitoring framework and establishing the tangible benefits of registration. GP registration has some obvious benefits in relation to out-ofhours care and home visiting; it would be hard for dentists to provide similar benefits within the same cost envelope and this could come at odds with lack of available resource. If these reforms are to deliver value for money and efficiency then it would have been hoped that they were aligned to other policy agendas such as big data and data linkage, and other initiatives such as summary care records.
In my view, the Government has an opportunity to design a system that addresses patient needs however the policy makers and senior leaders need to work harder to be heard by the profession at the cold face of clinical practice – otherwise this could end up being yet another merry-go-round.