Brave new world?

By the time you read this column, the new-look GDC will have sat for its first session. This is quite unlike the GDC of old; for starters, there are fewer registered dentists than ever before (eight), and only four of them have any previous GDC experience. They are joined by four DCPs and eight lay members. Hew Mathewson will continue for a brief transitionary period (to the end of the year) before being replaced not by a president, but by a chairman.

And, if you can’t remember receiving any voting papers for the elected members, there is a very good reason for this. You weren’t sent any, because there are no longer any elected members. This is a strange kind of self-regulation, I hear you say – and I can only agree with you because your Annual Retention Fee has not reduced in proportion to the diminishing share of dentists on the Council. In fairness, it has recently been frozen for the third year in succession, but there would have been some pretty vocal comment had this not been the case, given the Council’s significant additional income from DCP registration over the same period.

This is, of course, not just a strange kind of self-regulation, but no kind of self-regulation at all. And nor is it intended to be (in anything but name).

NHS plc
Similarly, the Key Performance Indicators (KPIs) that are starting to appear in new provider contracts in England and Wales, and which underpin the ‘PDS Plus’ option, sever the last tenuous strands of the ‘independent contractor’ status of NHS practitioners – that other prized bastion of our former professional existence. There is nothing inherently wrong with some of these new KPIs, let me add, and some of them are actually welcome conceptually. But there are no prizes for guessing who will be expected to capture all the additional information and gather all the additional ‘evidence’ of performance, and whether or not you happen to agree with the chosen KPIs and Service Requirements, they do still fundamentally change the landscape of NHS dental practice.

While you are still investing your own capital, and doing so at entirely your own risk, you are actually signing up to delivering the clearly specified objectives of an entirely different organisation – NHS plc – and these objectives will not necessarily coincide with your own business plans. Some will be signing up precisely because they don’t have any.

Indeed, like any other company, the priorities of NHS plc can – and will – change over time and at the whim of our political masters. So, in order to succeed, and for its face to fit, an NHS practice needs to be willing to change, too. And to be ready to change again before paying off any investment they made in delivering the previous round of changes.

When the NHS was born in 1948, it was all about treating rampant disease by delivering as much treatment as possible for as many people as possible, as quickly as possible. It was the era of forceps and vulcanite (and later, acrylic). And it worked. By the 1970s, the wind had changed and it was all about restoring teeth rather than extracting them and the (then) Dental Estimates Board started to produce glossy annual reports, proclaiming how many more fillings, root fillings, crowns and bridges were being provided, while extractions were falling. And how the politicians loved it and those endless graphs pointing north.

In 1990, it was all about registration, continuing care and list sizes. Some 14 years later, it was all about quality, access and choice. Another five years on, it is really all about access, especially now that quality and choice have been hastily re-defined. And, by an astonishing stroke of serendipity, the Steele Report came up with exactly the same definitions of ‘quality’ as the Department was already factoring into the new commissioning model a couple of months earlier. Wow! How lucky was that?

No, whichever version of the ‘balanced scorecard’ of ‘weighted’ measures you happen to be looking at and, however one dresses it up, most roads lead to access. The best news of the new contracting model that is currently being trialled is the reduced dependence upon UDAs as the sole source of oxygen in the system. Let us be thankful for that at least, but let us also be patient and see what the finished article looks like. After the ‘Options for Change’ experience, this could all be an elaborate hoax and the real, real new, new, new contract (RRNNNC) will be plucked like a rabbit out of the Department’s hat when we are least expecting it.

The current access agenda may be all-pervasive, but it is nothing new – the State has always incentivised the profession to deliver what the State wanted and needed at the time. Right now, it wants and needs access – and it wants it quick and big. Only yesterday, it seems, ‘choice’ meant that patients should be free to drop in as and when they wanted to, free from the shackles of registration and regular checkups. As a result, instead of dropping in, huge numbers of patients ended up dropping out, and as soon as this attracted the attention of the media all of a
sudden it became unfashionable for all these patients to have no dentist to call their known.
We may well see the reappearance of registration (as recently recommended by Steele) – and Scotland is moving even further, of course, with lifelong registration – but, south of the border, the government will first want to be quite sure that the profession really is taking on and treating ‘new’ patients from the ranks of ‘the great unwashed’ (i.e. those patients who have not attended for some time) before putting itself in the position of having to report progress on this contentious front.

So with this in mind, PCTs are being actively encouraged to adopt robust ‘contract management’
techniques in order to persuade dentists to re-open their doors to these recalcitrant patients,
recognising the likelihood that many of them will require a fair bit of treatment to welcome them back.

Those practices who have become tired of jumping through endlessly-changing hoops may already have taken their decision to look increasingly to the private sector, investing their time, money and energy in developing their own businesses rather than somebody else’s. But these have hardly been the easiest of times to take such decisions.

Whether the PCTs and LHBs will reach for the big stick or the carrot remains to be seen (they have both in the tool cupboard this time around), and if history is anything to go by the mix will vary widely from one PCT to another. Many practices, I am sure, will feel that the re-stated priorities of the NHS are still within touching distance of their own business direction and they may even feel in some cases that they could end up being rewarded for doing what they would probably have been doing anyway. In which case, good luck to them. Which brings me to one final lesson from history. Every time since 1948, that NHS practitioners have enjoyed a brief moment in the sun, the government of the day has always seen fit to pull down the shades smartly and firmly. Dentists doing (too) well was never the plan, even in times of economic plenty.

Reward and punishment
So before anyone gets too excited about any apparent ‘rewards’ on offer to providers, we should also remember that in this brave new world of nGDS (and nPDS) (and PDS Plus) – apart, that is, from the small detail of the continuing underspend of the ‘ring-fenced’ overall primary dental care budget – PCTs and LHBs must now literally rob Peter to pay Paul. This is the harsh reality of local commissioning from a finite budget, and it’s a world apart from the world we knew so well for so long.

And in case you are confused, Peter is the noisy, angry one who didn’t see this coming and for whom it has all come as a terrible shock. And Paul is the quiet, smiley one with a whacking great blue NHS logo over the front door of the practice. No, it certainly wasn’t like this in the old days.

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