Following news in the CDO update of the health department's plans to further delay the promised review of HTM 01-05 until 2012-2013, I thought I would revisit this topic from a different perspective.
When HTM 01-05 was devised and gifted to the profession the first reaction seemed to be of utter outrage. I was worried that dentists would down drills and form picket lines with buckets, mops and their trusty portable suction units. Although I may be joking, it certainly got the profession thinking about value for money.
It's no joke; decontamination is a very expensive business. The implementation of this memorandum coincided with Care Quality Commission registration and then more recently with new contract pilots. If that wasn't enough the new residents at number 10 decided to go a bit further and throw a new health bill in for good measure. Whilst most of the health bill will leave dentistry untouched, our colleagues in dental public health seem like innocent victims this time. So dentists could be forgiven for thinking that they were receiving electro convulsive shock therapy on an intermittent basis and are left wondering, what next?
Once upon a time when dentists in the NHS were faced with increasing or spiralling costs resulting from central policy, they may have
received a grant or may have worked harder and treated more patients to help generate income to pay for essential quality improvement. Such notions have long since died a death, the grants have dried up and extra funding is a dream.
What does value for money mean in the NHS and what would happen if dentists demanded it? If for a moment the NHS had to decide it was going to fund decontamination measures in dental practice, the health department would turn to their friends at NICE and ask them for an economic evaluation. Despite concerns about NICE, they do seem to do a fair job when the civil servants and politicians avoid meddling.
NICE would assess the risks and benefits of the new decontamination regime and compare it to the old regime. They would calculate how much it would cost to gain one QALY (Quality-adjusted life years measurement) using each system. If it costs more than £20 - £30k to generate one additional QALY then the new regime would be deemed not to be cost effective. Now generating this QALY is no easy business and the clever economists at NICE work very hard to get this right. Whilst this all seems very long winded it's one of the few reliable ways of identifying whether a new technology or process can provide value for money. Most of us are concerned about the evidence base around the new decontamination regime and we are right to be concerned, however the likelihood is that the evidence base will show that these measures provide some benefits relative to the old regime. The bigger question is whether these benefits outweigh all the risks and does this regime offer value for money?
The suspicion is that if a health economist was to dismantle HTM 01-05 and start applying some clever calculations then it may be possible to demonstrate that the cost of this technology exceeds the Government's own threshold. If that were the case, it is unlikely the Government would be able to support the implementation knowing this as it would be seen as double standards.
There is some irony in all this of course. When GPs were required to move away from local sterilisation and move towards disposable single use equipment or central sterilisation, the NHS supported them and provided them with funding to make this happen.
It seems very unfair that the NHS wants its NHS dentists to provide more activity or more new patients, without really thinking about the increasing costs in raising quality. So should dentists demand that independent health economists are appointed by the Government before HTM 01-05 is fully implemented and then all sides can really have a fully informed transparent debate and let the evidence speak for itself?