Genetically modified

Before Facebook and the internet, there was Radar. I should explain, perhaps, that I am referring here not to the electronic wizardry that gave the allied war effort a crucial edge in the 1940s, but to the bespectacled and omniscient marvel on two legs that formed part of the MASH team (the 4077th Mobile Army Surgical Hospital of TV and movie fame). Corporal ‘Radar’ O’Reilly was always one step ahead of the game and whatever was happening Radar knew about it, and whatever anyone was doing, or thinking of doing, Radar had generally got it sorted already.

So, while everyone was naively sitting back and waiting for the government’s public response to the Steele Report, we have instead witnessed the unveiling of the government’s ‘Blue Peter’ response to the Steele Report – that is, the one they made earlier. A lot earlier.

It is a close run thing whether either the internet, or Radar, can ever match the quickest way ever devised to spread the word. That is, of course, the ‘Can you keep a secret? What I am about to tell you is in the strictest confidence’ technique. And it never fails.

So it was, via this time-honoured but ever-reliable route, that the first glimpses of the possible shape of the new, new, new contract (NNNC) came to be revealed to the world. This was doubly unfortunate for the chief dental officer for England because (it being the Parliamentary summer recess when the story broke) it was left to Barry – not for the first time – to do all the explaining, back-tracking and cartwheel-turning that was necessary to reassure a stunned
profession that this NNNC wasn’t actually the NNNC at all, but simply a work in progress. Or one of many works-in-progress in fact, because in the words of our NHS masters, you asked for rigorous piloting so they thought they should make an early start. But even Biggles was a better looking pilot than this, and he at least seemed to know where he was going before he took off, and where he planned to land.

Wrong footed
The big story, though, was nowhere near as exciting as it appeared to be at first sight. The reality was simply a clumsy mismanagement of key communications, not the discovery of the Turin Shroud. In fact, most of the story was to be found in the ‘history’ section of the BDA library, not on the ‘current affairs’ shelves. The Department’s Dental Access Programme (DAP) team had been working quite openly for some time on designing different service procurement models that looked further than UDAs alone, at wider measures of performance – the long-trailed ‘basket of indicators’ that is so sorely needed to restore some balance to the ill-targeted melee that is the current nGDS/nPDS. Obviously, given the government’s stated priority, the key to this is access.

In the July/August issue of the Access@dental newsletter, aimed at SHA dental leads and PCT dental commissioning teams, the DAP team made no secret of the fact that it was already working with 10 ‘front runner’ PCTs on a new DAP template contract, and developing the Key Performance Indicators (KPIs) that would be central to it.

The government is clearly losing its patience with seeing such a large proportion of the profession’s UDA targets being achieved on maintaining the same group of patients, attending almost as regularly as they were before NICE sought to rewrite the rules of engagement. In mid-July, PCTs received a new toolkit aimed at reversing this and, be under no illusions, the government is serious about this. Mike Warburton, the national programme director for dental and GP access at DoH, could not have made the point clearer when (at a meeting at the end of June) he spoke in the following terms:
‘47% of providers delivered less than 96% of contracted activity, but many PCTs have written off
under-performance or not clawed back the full amounts.’
‘Re-basing contracts and transferring funding to reliable providers would provide services for extra people.’
‘The biggest cohort of patients is seen at six-to-eight month intervals (contrary to NICE guidelines). A 10% reduction in frequency of attendance for this cohort would provide
additional access for 800,000 people nationally. Reducing unnecessary
re-attendance will realise capacity within existing contracts.’
‘There is scope to use delivered activity more effectively by reducing the number of patients unnecessarily re-attending within nine months through good contract management.’
‘The new procurement framework will ensure that additional, new patients are seen, and that quality and extended working hours are achieved.’

So, against this background, what came to light two-to-three months later should hardly have come as a big surprise to anyone. What had started to surface was simply a new shape for individual contracts being created by PCTs when commissioning fresh services de novo, and it came complete with some challenging new KPIs.   

Tablets of stone
The BDA has made known its view that, if these early clues really are the shape of things to come, then the Department needs to think again because this incarnation is ‘not fit for purpose’. So far, the DoH has just about been able to argue that nothing is set in tablets of stone – without yet being forced to concede publicly not only that the stonework itself came from the Department in the first place, but also that the early carvings were made long before Steele was invented.
And this, of course, was the real story behind the story – although it should not have surprised anybody because we have seen it all so often before. Genetically modified crops and animals remove unwelcome surprises, and make it more likely that you will get precisely what you want, need and expect. Thus, it has become with government-commissioned reports. When were you last really surprised by one?

In my August column, I highlighted the fact that the measures of ‘quality’ suggested by the Steele Report bore all the fingerprints of the DoH, re-hashing all the flagship targets expounded by the NHS as being ‘desirable’ and ignoring many of the quality measures that dentists themselves might recognise. Now we know that these very measures were being proposed by the DoH many months earlier, it is now clear that the government’s plans for NHS dentistry and the basis for future local commissioning of dental services all pre-dated even the selection of the Steele review committee, let alone the publication of the Report itself. And, because these plans have not moved a whisker since the Report’s publication, this has (just like the NICE report on recall intervals before it) been revealed as a disappointingly cynical device to legitimise and support already-established government policy. In the case of the Steele Report, it did serve another valuable purpose in taking the steam out of the Health Select Committee’s criticisms of the 2006 dental contract and, in doing so, bought some valuable time.

But I do think NHS dentists, and the future of their practices and, not least, their significant investment in these practices and indirectly in the NHS, deserved to be taken more seriously than that. Unless we get a radical U-turn, it seems increasingly likely that once the small print of the definitive NNNC really does see the light of day, PCT commissioning leads may be left to ‘engage’ with each other because the profession may, at last, be able to read the hieroglyphics on the wall of the cave.

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