Banksy has nothing on the warnings currently emanating from all around us in dentistry. Indeed the metaphorical graffiti seems at times to be 10 feet tall.
Let’s go back a little to the statement by NHS England chief executive Simon Stevens who said, in effect, that if the government could come up with about £8bn of the expected £30bn shortfall anticipated in funding by the year 2020, then the service itself could manage to pull together the mere £22bn remaining.
Observers such as the King’s Fund have commented that this will be an awfully stretching target, requiring year on year efficiencies of the order of 3.5 per cent. When it is considered that this figure is eye-wateringly large when considered in the context of a £110bn plus budget, it has often been noted that the achievements of ‘economy’ to date have largely concentrated on what’s known as the “low-hanging fruit”.
Over the past four years, we have seen pay freezes, tough pay caps and redundancies across the service. The latter have, in turn led to redundancy payments of up to £600m in a year. And further pain is planned, with a reduction in middle management staff and the likely amalgamation of the current 27 sub-regional (formerly area) teams in England into a more concise (and hence less local) configuration.
These have been, none the less, the easy bits, together with some mothballing of wards and selling off of unused land and facilities. Now the cuts must, somehow, bite deeper.
Against this, the dental budget has remained more or less flat, rising only slightly in real terms. In the first two quarters of 2014/15, fewer UDAs were delivered than in the corresponding quarters of the previous year.
Laing and Buisson, the healthcare analysts reported in 2013 that the priority for primary care dentistry was not considered sufficiently high for substantial additional funding to be forthcoming over and above the small annual increments budgeted for the service as a whole. In short, ‘no more money’. The chancellor’s promise of a modest increase – of £2bn – for the NHS in 2015/16 gives whichever party that comes to power a significant headache, according to BBC commentators.
So however – and whenever - the new dental prototype contracts work out it will be a case of spreading the jam as thinly as before.
It’s likely that early proposals for the commissioning of advanced and specialist dental care will be published before you read this, but expect to see more rationalisation (a word which shares its derivation with ‘ration’) and control of the most costly end of dental treatment.
Whilst in recent speeches, representatives of the Department of Health and NHS England have been anxious to point out that this will not mean that experienced GDPs can’t carry out more advanced care, it’s likely that they will not receive any enhanced fees for doing so. And as with any official “pathway” or “guidance” approach, in the current hostile climate, dentists will be wary of taking on anything remotely risky.
“Tell me, Dr X, given that there exists an established referral pathway, why did you decide to undertake root canal treatment yourself on Mr P’s lower left six which had a curved root...?”
That having been said, it’s likely that the difficult decisions on what restorative treatment should actually fall into tiers 1, 2 and 3, will be deferred until later in the year.
Whatever the eventual outcome and the timetable, we can also expect to see much more specific data being collected on each item of treatment being delivered. At least with a fully electronic submission system, there won’t be a problem with making FP17 forms bigger.
In the meantime, much bigger experiments than piloting of a new dental contract are now in the pipeline. The announcement that Manchester will be taking full responsibility for an integrated health and social care budget from April 2016, and that 29 “vanguard sites” will be piloting local versions of integration leaves open for the moment the question of whether primary care dentistry will be folded into these mixes.
Last autumn, many dentists observed that the Five Year Forward View for the NHS did not mention their profession. At the time, the CDO observed that despite this omission, the strategic proposals would have far reaching implications for dentistry. Maybe we will learn in the future that NHS dentist contractors will have different
commissioning pathways? Or maybe once again, dentistry will be left out in the cold.