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Coal face dentistry: the three-tiered system
15th Oct 2005
A cherry on top, with mushrooms on the bottom and sandwiched between are the chocolate fillings you just don’t know whats in them until you’ve tasted them, says Richard Pilkington, talking about NHS dentistry: NHS dentistry is a three-tiered system just like NHS medicine. I can make such a statement as I’ve worked in both systems. During my time as a medical houseman, the house officers used to call ourselves mushrooms. Why? Because we were always kept in the dark and always in the manure. As a general dental practitioner working in NHS dentistry, times are not a changin’ (sorry Bob Dylan) but appear to be full of hidden agendas and at present making us feel a bit of a mushroom. Three-tiered system The DoH/Government is the cherry on the top tier. What any Government will not admit is that they are unable to afford to provide such a system. Although Tony has pledged that everyone will receive it. But regardless of the spin, people now vote with their feet and any Government cannot be seen to be axing a part of a service that makes up part of the backbone of the UK. So what do the educated civil servants do, you go back in history and reinvent the wheel. It appears that they must have gained inspiration from: Caius Petronius 66 AD ‘We trained hard, but it seemed that every time we were beginning to form up into teams, we would be reorganised. I was to learn later in life that we tend to meet any new situation by reorganising, and a wonderful method it can be for creating the illusion of progress, while producing confusion, inefficiency and demoralisation.’ So it appears that the DoH has now created a middle tier (TPCT) to reorganise NHS dentistry and let them sort it out at regional level. Trojan horses and organ grinders The TPCT are now the middle tier, now with the huge task of trying to deliver NHS dentistry on a regional level. They have the tug of war relationship between the Government /DoH on one side and the dentist/performer on the other. So what’s happening on their agenda? They have a limited pot of money, so once the quota is filled, no more GDPs are allowed to sign up to PDS. The GDS contract is being squeezed and looking even more unattractive, so more heavy weight leaning to push the GDP into private practice. So what about the GDPs staying committed to NHS dentistry? Well as we’ve become a country of league tables, will your TPCT be the Vauxhall Conference one star or the five star Macdonalds ‘employee’ of the month performer. But on a serious point, the DoH has given the TPCT a limited pot of cash and now the TPCT has got to try and deliver a service with it. The TPCT agenda which the public eye and DoH will be looking at are the amount of registrations, patient access and money in (patient charges) to keep the TPCT afloat. Treadmill = productivity of UDA’S = What are you worth? As mentioned in a previous article, they’ll be subjecting the GDP’S to the Hawthorne effect. The so called treadmill will reinvent itself with the GDP delivering UDAs (units of dental activity) which justifies the practice value. It was only last week on the BBC news that the TPCT in one remote Scottish area was already complaining of paying a general medical practitioner a six figure sum. Although the medical practitioner was delivering a service of out of hours and in a large remote area one of the local TPCT managers thought this was public money wastage! Will the general dental practitioner become the next expensive commodity? If we are the next ones for the chop will the therapist be up for it at a reduced rate? Debt collector The TPCT needs their pot of money to be sustained otherwise local TPCT’s will be folding and will have to amalgamate with other trusts that are still financially viable. So the dentist on the coal face will be responsible for patient charges. Unlike any other health care professional in the NHS, I can’t remember seeing debt collector as being a clause of the BDS qualification. As a health care professional I was always under the naive illusion of thinking that one is paid to do the job of treating patients and are on a salary scale which reflects experience and qualifications. It appears that you’re only as worth of the UDA’s and patient charges collection that you do. But GDPs are hard working, productive contractors. It’s interesting that when the audit commissioning body when looking at NHS dentistry pre ‘options for change’ made public some of its recommendations. The likes of NICE guidelines were to be implemented so that less recalled attendances and a reduction of ‘inappropriate’ scaling could save something in the region of £150 million. Isn’t that a catch 22, seeing that GDPs have dramatically improved peoples oral health over the last 50 years. But the fact that those core patients which your practice has educated and won over will be turning them away to be seen less frequently. I think that these patients who pay their patient charges might have to be coaxed back once the TPCT realises that patient charges have dropped off. Squeaky wheel gets all the grease NHS dentistry has been subjected like most health care to the inverse care law. Those that need it the most are deprived of it and the ones who get it probably need it the least. This has led various auditory bodies to make recommendations and statements about unnecessary costs, what constitutes cosmetic treatment and orthodontic need. Quality control of endodontics, over zealous extractions of wisdom teeth, bonded crowns and longevity of fillings. The managers of the TPCT have the headache of access to NHS care, inequalities in health in regional areas and public money wastage. The dentist has the frustration of making it happen (still too many chiefs but we’re the Indians of which there’s still not enough). They’ve got to educate the public and develop a trust and relationship with them to improve their oral health. The health care in this country is provided by a professional, dedicated body of staff. However, if the system gives in and is centred to the body of individuals who can’t take some responsibility in their lives then NHS dentistry will fold. What has to be done is to make the common ground of that part of the Venn diagram workable where the DoH/TPCT/dentist all share this common ground. The PDS contract on the delivery of NHS dentistry seems to have addressed this by changing the system to one placed in this common ground. It has opened up access to occasional patients by giving them access to a dentist for the fire fighting dentistry they want – the quick fix. More emphasis is placed on prevention and spending time with patients so one can give them more choice on types of treatment. My first impression of PDS has been quite encouraging. Although cracks have started to appear. Firstly, dentists are still being monitored and there appears to be a discrepancy between some items of work dentists do but aren’t being accounted for. If you want us to do prevention at least let us record it! If the organ grinders turn up the heat and open up their Trojan horses and rename the treadmill, I feel it may be the final nail in the coffin. Maybe all this stalling is for this. OK, the dentist may be the ones who look bad in the media focus, isn’t that what they want to happen. At least it saves face for the Government, but it may actually allow the profession to blossom and deliver the type of quality work one was trained to do by the ivory tower academics. I hope it doesn’t come to this but if the TPCT lends an ear and is guided what the GDP can do to work the system so that all parties involved get the best deal I might be able to feel the light on us mushrooms because its been a long time since I’ve felt it.
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