Over the last few years there has been a growing focus on primary care dentistry. There has also been a subtle focus on secondary care but not to the same extent. The oral health system in the UK requires a balance between dentistry provided in primary care and that provided in the secondary setting. Some of the challenges that we face are trying to unravel the complexity of these two different systems and then managing the interface between private practice and publically funded services.
One of the aspirations of the NHS Commissioning Board is to bring most of the publically funded dental budget under one organisation. You may be fooled into thinking this is the case at the moment and to an extent you would be right. The problem arises because the budget holders for primary and secondary care are often two different managers within a primary care organisation. It is envisaged that in the future the two budgets will come under the control of one team.
What is more confusing is where do different services actually belong? Some services have lost their identity as they seem to be a hybrid of both primary and secondary care. For example, the community dental service is often contracted like a primary care service but is managed like a secondary care service.
The rising cost of dentistry has been baffling policy makers for decades. Whilst commissioners and policy makers try to control costs they usually make reimbursement cuts or try and decommission services that cost more. Sometimes this involves moving services from secondary to primary care, sometimes seen as an easy target. Secondary care providers themselves do not measure their costs correctly; they assign them to patients based on what they charge, not on the actual costs of resources, risks and opportunities. The result is that attempts to cut costs fail, and total health care costs just keep rising.
Because secondary care charges and reimbursements have become disconnected from actual costs, some procedures are reimbursed generously, whilst others are priced below their actual cost or sometimes not reimbursed at all. This leads many providers to expand into well-reimbursed procedures, like implant replacements or high-end imaging, producing huge excess capacity. At the same time shortages persist in poorly reimbursed but essential services like primary and preventive care.
The lack of cost and outcome information also prevents the forces of competition from working; hospitals are reimbursed for performing lots of procedures and tests regardless of whether they are necessary to improve patient outcomes. Providers who excel and achieve better outcomes with fewer visits, procedures and complications are penalised as they are ultimately paid less.
Most health care providers have hundreds of opportunities to use time, equipment and facilities more effectively. These opportunities have been obscured by existing costing systems that have little connection to the processes actually performed.
With accurate information on outcomes and costs, providers can improve care and save money by eliminating things that don't help the patient, like multiple medical histories, radiographs that provide little new information and long waiting times. Many routine tasks are performed today by highly trained dentists; these tasks could be shifted to others, freeing the most skilled clinicians for far more productive work.
Health care providers with expensive and poorly utilised equipment, space and staff can see the benefits of consolidating services to improve utilisation. They can also perform routine services in lower cost locations, such as primary care; allowing secondary care settings to be used for the most complex procedures.
These opportunities could allow the oral health needs of an ageing population to be met with little need to increase spending. Understanding costs could be the single most powerful driver to transform the value of health care. This would give commissioners and providers the data they need to improve patient care, and to stop arbitrary Government cuts and counterproductive cost shifting.
However to realise such opportunities, policy makers, budget holders and regulators need to have a grown-up conversation as to what services are core to the NHS and specifically which setting will be best to deliver these services. Then only will it be possible to unravel the mystery of the dental budget.