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Ch-ch-ch-ch-changes...
15th Sep 2009
There are many constants in life, and you will often hear jokes made about those constants, usually relating to death or taxation. In my case it seems to be Bolton Wanderers' yearly struggle to avoid relegation from the premiership.
But the one that has probably caused more discussion, concern, worry or interest from the dental profession over the last few years has been the period of almost constant change which seems to have swirled around the dental world for the past five or six years.
When I first entered general dental practice in 1975, dentists were paid an item of service fee for every item of service provided, could establish their own new practice wherever they wished or could join an existing practice wherever a practice principal wished to expand the services he/she provided.
The only part the NHS played in this process was to administer the list of dentists who provided services in their area, manage disciplinary hearings when problems arose and in the early days, actually make payments.
For the vast majority of practitioners, that situation remained unchanged until the introduction of the new arrangements in April 2006.
My personal situation changed in 1997-98 when my practice became part of a first wave PDS pilot. The impact of this was two-fold, the complete reliance on item of service payments was removed and, by necessity, we developed a positive working relationship with the local NHS (a health authority at the time) which worked well for both parties.
For most dentists, item of service had become a ‘way of thinking' and this, combined with the rigid nature of the transition of contracts from the old to the new arrangements, certainly hampered the ability of both sides of the commissioner/provider relationship to take advantage of the flexibilities and opportunities within the new contractual arrangements.
Some PCTs have worked with innovative providers and already started to take advantage of these flexibilities to develop blended contracts where the indicators within the arrangements are broader than just activity.
Professor Steele's review, which has been so warmly welcomed by the vast majority of the profession, certainly points the way ahead to further developing contracts which focus not only on activity – although when spending taxpayers' money it is important to get value for money – but also the quality of the service provided and the outcomes including improved access to services and an improvement in oral health.
Changing a system of payment is difficult, changing a culture is even more difficult but we now see many more PCTs working with their providers to develop more prevention-focused services.
There was some ‘piloting' carried out before the introduction of the new contractual arrangements in 2006, but it was very ad hoc with little coordination and no robust evaluation. We were, however, able to learn a few things, one of which was that there was no clear or evidence-based guidance on what effective-based prevention in primary care really meant. I am delighted to see the response of the NHS and dentists to the publication of the Evidence-based prevention toolkit and its incorporation into commissioning plans.
The two main diseases of the mouth – dental caries and periodontal disease – are both almost completely preventable, but only if patients are given correct advice on how they should behave, and if they follow that advice.
Prevention and correct treatment provision have to be at the centre of dental services as they develop.
We have already seem massive improvements: when I entered dental school in 1969 nearly 40% of the adult population were edentate and levels of dental decay in our children were horrendously high.
Adult dental health survey
We are currently about to start survey work for the 2009 adult dental health survey and I expect the overall proportion of adults who are now edentulous to be in single figures.
The rates of dental caries in our children have plummeted since the introduction of fluoride toothpaste in the 1960s. Although current levels of oral health in our children are good overall, the inequity between the majority of children with good oral health and those whose oral health is poor is unacceptable and we are now seeing the NHS in many areas using its new commissioning powers to target these inequalities.
Author
Barry Cockcroft
Barry Cockcroft is chief dental officer for England – and an ardent Bolton Wanderers fan.
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