It is nearly three-and-a-half years since the NHS pilots began, and nearly five years since Jimmy Steele published his proposals in 2009. Just to remind you, that was in response to the Health Select Committee’s critical review of the UDA contract (now nearly six years ago).
A second report on ‘learning and outcomes’ from the pilots to date, published in early February, makes for mixed reading. There is overall enthusiasm from dentists and their teams, but what is not to like about a system which is financially protected from the real world, and most of all, free of the dreaded UDA and all its attendant woes? Patients are also reported to be welcoming of the reformed world of preventive care, but there is no update of the figure, reported in 2012, which showed that 60 per cent failed to return for their ‘preventive’ appointments.
It is disconcerting, to say the least, that accurate and valid data is only available for patient appointments up until March 2013 – over a year ago. Moreover, the same cannot be said for clinical data even up to that point. The report is, in part, a minority report, since access data for 46 of the original 70 pilot practices (the so-called ‘block payment’ group) is not analysed in detail. Why? Could it be that the decline in registrations in this larger group was even worse than that in the capitation groups (where 19 of the 24 practices who were actually analysed showed a reduction in patients attending)?
It has been common knowledge that the initial richness (meaning complexity) of data was a problem, both for dentists (time taken to assess patients) and the NHS (time taken to make sense of it all). But it seems that variation between the pilot dentists themselves was also an issue. Dentists behaving idiosyncratically… who would have believed it?
The signs emerging are that we are nowhere near the end of piloting. Does the profession – and the administration – have the stomach and the money for a further two years or more of trials?
If, as is hinted in the report, prevention is actually hugely more expensive than cure, then the temptation may be to go for a simpler, blended approach, with a cut-down assessment process. Only 16 per cent of the patients who had attended the pilot practices in the two years prior to the start of the pilot programme had actually had an oral health assessment and a subsequent review during the first two years, which says much about the organisational and cultural issues involved.
Less than one in five patients coded red at assessment had made it to green at review, and nearly one in five green patients had deteriorated. Four out of five amber patients were stuck in the middle, possibly due to underlying conditions that they couldn’t, or wouldn’t, change. Is all that worth the candle?
The Warburton contract – PDS Plus - was brought in as an attempt to ‘blend’ the UDA model. It’s not been an outstanding success, or we would have heard more about it. Along the same lines, perhaps a future ‘blend’ might see 50 per cent of a contract related to UDAs and 50 per cent to some more onerous performance indicators, such as access numbers and RAG status improvement.
You may think that’s less of a blend and more of a dog’s dinner, but then no-one saw UDAs coming way back in 2005. One way or another, some major changes will have to be made to create a reformed contract that looks even vaguely acceptable to the profession, the Treasury and the Department of Health.