Cutting it out

There has long been an inherent flaw in most of the ways in which dentists are remunerated for their services. Many of them are barking mad in terms of the perceptions, incentives and rewards they create, and despite countless attempts over many years, we still haven’t found a way of paying dentists fairly and in proportion to the level of oral health in their patients.
It has been recognised that school league tables need to take into account the ‘value added’ element of education (i.e. not just measuring the final outcome in isolation, but also the difference between the level of knowledge and achievement before and after the educational experience).

Similarly, there may be less justification for bouquets and a carpet of rose petals if a patient is orally healthy on the way in, as well as on the way out

Similarly, there may be less justification for bouquets and a carpet of rose petals if a patient is orally healthy on the way in, as well as on the way out. If, on the other hand, we manage a diseased patient in a way that halts or slows the progress of their caries and periodontal disease (for example), then the value of our intervention is much easier to demonstrate. Keeping edentulous patients caries free, or patients in a fluoridated area, is hardly the most impressive of achievements. If we are honest, some patients remain orally healthy because of what we do, and other patients do so despite what we do. And the reverse is equally true of course.

Paying dentists in proportion to how much tooth tissue they remove has always been a pretty wacky approach – popularised by the NHS fee-per-item system and only latterly reversed (in England and Wales) by the UDA system by default, so to speak, and as an accidental if welcome consequence of a system that was primarily designed to achieve something entirely different.
Fee-per-item private dentistry suffers the same problem of course, but it is made worse because the rewards for intervention are so much greater. In the case of wholly elective, cosmetic interventions, the biological cost is not infrequently of even greater significance than the financial cost. And if and when it all goes pear-shaped, you can always give the money back, but the tooth structure is gone for ever.

Paying dentists whether they do treatment or not is the dental
version of the ‘set aside’ principle in agriculture, whereby farmers are paid money for not growing crops (the aim being to avoid creating an oversupply). The knock-on benefit for those still growing the crops is that avoiding an oversupply also avoids the consequent downward pressure on prices and profitability – and there the similarity with dentistry grinds to a halt. Clearly an outbreak of masterly inactivity would be the greatest potential risk in any capitation system, the risk being greatest in an under-funded capitation system.

But in an unintended way this is also precisely what the UDA system achieves – at least, once the threshold for Band 2 and/or Band 3 has been crossed, because all that is awaiting you if you carry out more treatment within that same band, is additional expenditure and the risk of missed appointments and hence, non-productive time. This in turn increases what you need to achieve in the remaining hours in order to avoid a clawback. If you went out of your way to design a system with the maximum number of quality disincentives and downsides, this must surely be it.
In order to make it more likely that over-treatment will be avoided in fee-per-item, and that under-treatment will be avoided in a block payment or capitation system, adequate checks and balances need to be in place. In the case of fee-per-item, the sluice gate needs to be positioned at the diagnosis and treatment planning stage, before reaching for the air rotor. In the case of block payment and capitation, it needs to be positioned downstream, to ensure that necessary treatment has been provided and supervised neglect is not occurring. In both cases, these controls are administratively unwieldy, unpopular and relatively expensive.

In England and Wales, the NHS has all but given up on the screening process and the days of ‘prior approval’, ‘prior approval by volume’, ‘prior approval by targeting’ and wide scale DRO inspections of selected patients (or at least, the 30% of them who ever turned up) have become a distant memory. The Dental Reference Service, as it was best known south of the border, is but a pale shadow of its former muscle-flexing glory. Someone, somewhere decided that eyeballing a small handful of patients each year was less cost-effective and less indicative of overall quality and standards, than ‘big picture’ trawls of clinical governance and high-level triaging. It costs a lot less to review a significant number of record cards and clinical governance documentation, than to put DRO’s into their cars and persuade patients all over the country to take time off work to allow a DRO to check that they really did have a sealant restoration placed in that buccal pit in their lower left six. In the face of the recent debacle regarding MPs expenses, it would all be hilarious if it wasn’t so serious.

Déjà vu
The government’s appetite for funding genuine and meaningful quality assurance is less obvious than its enthusiasm for talking about it. The recent Steele Report speaks of quality and pathways for achieving it. But would it be too indelicate to point out that this was the stated aim of the 1990, 1998 (PDS) and 2006 reforms of primary care dentistry? It was also central to Bloomfield, the 1993 Select Committee recommendations, the NHS Plan, Modernising Dentistry, and Options for Change. And we are still waiting.

Over the past quarter of a century, we have seen great improvements in some key areas of oral health in the UK. Many of today’s young parents have grown up with much less caries and restorative intervention than previous generations. In the 1940s and 1950s we were removing teeth, in the 1960s and 1970s we were removing tooth tissue as means of treating disease, and in the 1980s and 1990s we were removing tooth tissue as a means of restoring the effects of disease, and the provision of crowns and bridges in the NHS peaked. In each case, the NHS was entirely supportive and benignly encouraged us in our endeavours. But in recent years we are removing tooth tissue electively, in the absence of disease, and some would say we are destroying more tissue, more quickly than caries ever did.

The nation’s teeth are crying out for a way of paying dentists that might give the teeth a fighting chance of staying in one piece. But perhaps we are searching for the impossible because lawyers earn more when cases last longer, opticians earn more when people need glasses or contact lenses, and taxi drivers earn more when they take the longest route. You get what you pay for.
Perhaps the answer is to incentivise patients as well as dentists, so that both parties receive benefits and rewards when the patient achieves and maintains oral health. While NHS patients can save money by staying away for longer, and by ignoring sound advice and treatment recommendations, we will always be on a hiding to nothing. The fact that this has become official government policy probably tells us all we need to know.
Right now, most of the ‘cutting’ of teeth is occurring in the private sector, and the only wholesale cutting left in the NHS in England and Wales is the relentless cutting of patient responsibility.

Meanwhile, future generations of endodontists and periodontists will no doubt look back fondly on the last 10-15 years, and thank us for getting it so wrong. Twice.

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