Synapse-free dentistry

Once upon a time, long before evidence-based dentistry, there was synapse-based dentistry. Some of you may remember it. A few of you may even have fond memories of it. The fundamental principle was that you needed to think about dentistry and make clinical judgements taking into account all the circumstances of the case, using your skills and experience. If you also had a good knowledge of the patient and their oral health history, you threw this into the mix – this being one of the great advantages that a general practitioner has over most of their secondary care colleagues, especially if they stay in the same practice for long enough.

But it soon became apparent that the engagement of neurones was fraught with risk for the GDP. Several dentists ended up in jail or in other versions of the deepest doo-doo, simply because they started thinking too much. This was an annual phenomenon, generally manifesting itself around the time when the new NHS (fee per item) fee scale was published. Whenever a fundamental change in the fee-per-item arrangements occurred, the sound of crackling synapses in the dental practices of the nation was as deafening as the finale of Riverdance. Little boys go scrumping for apples or (to their shame) for untended birds’ nests. Birds can be seen scrumping for worms after a brisk shower. NHS dentists went scrumping for loopholes.

The cynic might say this is the price of recruiting a bunch of academic over-achievers and locking them up in a university for five years with other bright people. But I couldn’t possibly comment.

Dispatches

Fee per item is alive and well in Scotland and (for now anyway) in Northern Ireland, but in England and Wales the modern equivalent is, of course, scrumping for UDAs. Channel 4’s Dispatches programme will stick the boot into NHS dentistry in UDA-land either just before, or just after this column sees the light of day. I am penning it prior to Easter so a lot of water may have flowed under the bridge (although that seems as unlikely as any other extensive Band Three treatment) before the programme is aired. But the word on the street is that this exposé features yet another investigative journalist doing the rounds of different dental practitioners and comparing what is recommended or, more pertinently in this instance, offered.

The traditional version of these media ‘rentagob’ outings would reveal that 10 dentists can come up with 11 treatment plans for the same patient. Then the mixing of NHS and private treatment became possible and 10 dentists could suddenly come up with 22 treatment plans. The former was evidence of one form of synapse-based dentistry (natural variations in clinical opinion), while the latter is evidence of an entirely different version of the genre. History tells us that you get more variation in clinical decision making if any kind of reward gets mixed up in the thinking process.

This may take the form of real money, or virtual money (such as UDAs), or performance ‘targets’ of the kind that robbed hospital managers of any semblance of rational behaviour as they tried to manipulate their results in relation to waiting list targets.

The timing of the Dispatches programme, due to be screened just a few weeks after the extraordinarily confused, one-sided and emotive anti-dentist piece by John Naish in the Daily Mail (22 April) suggests that there may have been an extensive briefing of the media by Department sources, over and above the 24 March ‘Dear Colleague’ letter from the CDO, linking the results of the Adult Dental Health Survey to the 2004 NICE guidelines on dental recall intervals.

Perhaps this was timed to coincide with (and add weight to) the government comment picked up in the national media in mid-April advising patients to disregard any advice from dentists to attend for six monthly check-ups. It does all have the fragrance of a bit of orchestration.

Pathways

The NHS pilots for the proposed new contract in England are starting to take shape, and we need to keep a close eye on the direction they seem to be taking. The concept of clinical pathways is not new, but it is less familiar in dentistry than it is for our medical colleagues – it is an attempt to take the guesswork, judgement and operator variation out of clinical decision-making. If the patient presents with f, g and h, then they should get x. If, on the other hand, they present with f, g and j, then they should get y. At its core, it is incredibly prescriptive and restricting, but there is the capacity to override the decision-making framework in certain situations and with appropriate justification.

But to what extent – and for how long – might we see a scenario unfolding where you get paid more if you stay on the prescribed pathway than if you depart from it?

Another real issue and threat for the profession is that clinical pathways and the evidence base should never be allowed to run roughshod over patient autonomy and a proper consent process.

Many passionate devotees of the evidence base have discovered to their pain that they can be sued for not having offered the patient treatment options that were not top of the evidence-based leader board. Nobody mentioned this in the EBD publications and seminars, where everything had seemed so straightforward and pre-ordained.

It is argued that clinical pathways work because they take full advantage of the evidence base, and support greater professional standards. I am not so sure about that, either.  Not at this stage, anyway. It depends on what we mean by ‘professional’, because governments and government agencies produce guidelines which (quite rightly) take account of the public finances and value for taxpayers’ money. The National Institute for Cost Effectiveness is a good example of that process at work. But professionalism must have, at its heart, doing what is best for the patient and this may well conflict with what is best for the coffers of the nation.

Brain time

It takes five years to carry a school leaver through their undergraduate dental training to the point where they can become a registered dentist. For graduate entrants, this has already been reduced to four and some would have us believe that there is scope to reduce this still further.

The government would love to reduce the time and cost of creating a dentist, but clinical pathways have a secondary and more far-reaching function when linked to skillmix because they have the potential to drive more dentistry down channels where the clinical knowledge and judgement that currently takes five (or four) expensive years to ferment, becomes progressively surplus to requirements.

So instead of thinking too much, the GDP may soon be at risk of thinking too little and instead managing a widget factory that has been designed by others.

Yet another possible outcome of clinical pathways is to breathe some life into that somewhat stalled brainchild of the previous government, dentists with special interests (DwSI). Will we see a time when clinical pathways will dictate that at various thresholds of complexity, the mere GDP must bow out and refer to a DwSI in the relevant area(s) of dentistry, and similarly a higher threshold at which the DwSI must defer to the expertise of a registered specialist? This is more in the realms of the probable than the possible, and while the prospect will seem quite threatening for the average GDP, it will bring a smile to the faces of the DwSI and specialist ranks.

Pathways are much more than a way of guiding clinical decision making. They could become a very powerful way of guiding clinical behaviour in a much wider sense. Guidance has an insidious way of becoming accepted wisdom, and eventually, a dictat. Today’s NHS pilots may be looked back upon as the first step on the silent road to synapse-free dentistry. So, if you have any unused brain cells in the months ahead, this is one development that is well worth thinking about – and keeping a very close eye on.

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