Dear Editor,
As I prepare to demit office at the end of this week, I was reflecting back on the past six years since I was first honoured with the confidence of the profession to lead the General Dental Practice Committee (GDPC).
What a turbulent and unsettling few years it has been; the most difficult in the history of dentistry since the inception of the NHS some 60 years ago. Even the legendary 1992 fee cut pales into insignificance by comparison with the recent chaotic rollercoaster years.
Firstly, there was the proffered three-year pay deal that was roundly dismissed by the committee. Then there was the stop/start introduction of the new contract that changed shape with great
regularity. We had the concepts of adopting a PDS-style block contract, but this was rejected at the 11th hour by the government. This meant that the modified document arrived at 8.30pm the night before it was to be discussed by the GDPC, and was rejected by the committee as unsound.
There followed a meeting with the Minister when it became obvious that we had very different understandings of the proposals, as they thought we were rejecting the PDS-type approach that was so popular with those already working under it. We explained that the PDS model was what we wanted and the officials were instructed by the Minister to work with us to achieve this.
When we returned to the discussions with the DoH, it became obvious that the new team, now on the other side of the table, had no intention of changing anything, but were focused on pressing ahead with the contract we now have.
We spent a lot of time explaining the shortcomings of their proposals, but they either could not – or would not – listen. The eventual changeover took place in 2006, but was so last-minute and chaotic that it created confusion for all concerned, including the PCTs who had inherited the task of supervising the contract but who were, themselves, embroiled in major structural reorganisation.
When the history of the NHS is written, that particular episode should be used to demonstrate the perfect way not to effect a major change which has profound effects on the whole population of England and Wales.
The net result has been a discontented profession and a population partially deprived of easy access to NHS dental care when it wanted it. Coupled with this has been the pressure on MPs who eventually launched an investigation into the causes and effects. Their report was quite damning and ought eventually to result in considerable changes to the present contract in order to make it work effectively.
Care
But what of the long-term care of the dental health of the people of England and Wales? The current terms of the contract encourage short-term thinking and planning for patient care. There are some patients for whom this is ideal as their priority is merely to alleviate a present difficulty. But there are many others who desire more long-term solutions to their own problems as they wish to retain their dentition into old age. And there are the dentate elderly who wish to maintain their status quo until they shuffle off this mortal coil.
Their care, especially as they become infirm, is ill-catered for in the present arrangements. As I progress along the path towards this position, I worry that I, too, might be left in a state of poor dental health and unable to enjoy the food I am served.
Perhaps the most condemnatory comments come from Northern Ireland who, having watched the effects of the new contract in England, stated it would reform the dental service in the province but would definitely not adopt the system presently in England and Wales. The range of health services being constructed and offered in the separate countries of the UK is creating confusion amongst the population. Further uncertainty is perceptible as the various subdivisions, such as PCTs and Health Boards, exert their own autonomy that allows them to pursue their individual paths that may not align with neighbouring authorities.
This is likely to worsen as the countries progress down the self-governing route and areas become more territorial. Some evidence for this is already being seen as contracts are being offered with postcode restrictions. I am concerned, too, that in a few years time the results of the regional variations will become apparent, and the minimalist approach – as encouraged in England and Wales – will prove to have been disadvantageous to the population, leaving patients less well-cared for than their neighbours. Who will bear the brunt of the criticism if this proves true? Should governments be deemed responsible for ignoring the advice of the profession?
The way forward
Despite the difficult birth of the new contract there has to be progress. Between the profession and DoH, there must be some sort of accommodation so that the public can benefit from a decent basic dental service. It is my firm belief there should be a NHS dental provision for those who need – or want – to use such service. At this point, I am often asked why I practise largely – but not exclusively – outside the NHS? The answer is simple: after more than 30 years of working almost wholly in NHS practice, I wished to extend my interest in cosmetic dentistry which lies largely outside the scope of NHS dentistry.
This leads us nicely into thinking again about what treatment should be provided under the NHS? I have been asking since our talks began for this to be defined to assist both practitioners and patients to avoid the confusion of the ill-specified description of ‘clinically necessary’.
What should be provided is a matter for politicians to decide as they are responsible for how public funds are spent. But some responsible dental advice must inform that debate.
There has to come a time when the DoH actually listens to what the practitioners say and acts accordingly to rectify the faults in the current system.
I believe that time is near. They must create an atmosphere of trust that has not been re-established since it was undermined by the infamous fee cut last century. At the same time, the profession must attempt to decide what the majority of those who wish to work in the NHS actually want. No single scheme will wholly gratify everyone’s desires but there will be a discernable majority opinion. We may not get the Utopia we hope for, but we may be able to satisfy the more practical desires, creating a period of harmony when the DoH can work with us and our patients can reap the benefits.
Progress
The growth of DCPs with added skills may create possibilities for patient care but the concern is that some PCTs might see it as a way of providing care more cheaply. There could then be a glut of expensively trained dentists so creating dental unemployment with consequent depression of contract values.
With student debt mounting to unprecedented levels, will those who simply want to be entrepreneurs feel the most simple course will be to qualify as a DCP and then undertake a business degree?
What will happen to the GDP who just wants to treat patients? In difficult times this is food for thought and some gazing into the future is worth the effort.
Decontamination guidance
Perhaps the most difficult area to understand from the rationality aspect, at this moment, is the likely variation in the decontamination requirements in Scotland and England. Surely, there must be some universal standard applicable to the whole of the UK? It belies logic to think that a lesser level of decontamination and infection control can be acceptable in one area but be unacceptable in another.
Do we all troop across the border to Scotland to be sure that instruments are properly decontaminated prior to use on patients, or is the proposed standard for dentistry really so far over the top that it is more applicable to brain surgery than simply the provision of a composite restoration?
I am fully aware that we must assess and cover potential risks to our patients but
surely there should be a greater degree of uniformity across our small islands of the UK?
However, the guidance (HTM 01-05) is scheduled to be issued by DH England fairly soon and is predicted to have considerable effect on the way practices operate. There was discussion with DoH about central funding for both the capital aspects and the ongoing costs of validation and maintenance of the systems but this was not forthcoming. The hint was to approach the PCT as they might well make funding available.
Some good things
As well as the difficulties that the profession has experienced in the last few years, there have been quite a number of good things. Perhaps the most important has been the positive improvement in keeping the profession fully informed of what has been going on.
The initiation of my frequent, but irregular, letters has enabled very many practitioners to understand what is happening and how it might affect their lives. One spin-off has been that many PCT personnel read the letters and quite a number have thanked me for the information, as this seems to have been their sole source of knowing what is going on.
I have worked on the basis that if practitioners know what is going on they are in a stronger position in their dealings with their PCT/LHB. This has often manifested itself by practitioners
demonstrating that the PCT staff are unfamiliar with the rules and are likely to fall foul of them inadvertently.
Of course, once there is one source of information, this generates others. Most of these have more freedom to comment on the events of the day than I and often do so. The contents of my letters have to be factual and it is notable that there have been only two errors of fact in the six years of publication both of which have been corrected subsequently.
Of course there is still a minority of the profession who do not bother to read any of the communications and so remain ignorant, but this would seem rather foolish in this fast moving world.
LDCs
By and large, LDCs are now able to access their statutory levy funds that has eased some of their burdens. There are a few PCTs who are proving reluctant to assist but I feel sure that these are the dinosaurs which will gradually fade out.
Given the fact that in England and Wales all control of the provision of dental care will reside with the PCT/LHB it is essential for LDCs to take their role very seriously and to act in a professional manner as they would when treating patients. This will mean that leading members of LDCs may need to undergo some training in various skills outwith those used in normal practice in order to be able to assist their colleagues. Just thinking this through will lead you to the conclusion that some payment scheme is going to have to be put in place to compensate for time out of practice.
Additionally, the consolidation of regional groups of LDCs sharing information is the only way our small profession can achieve any degree of uniformity in our dealings with PCTs. My view is that it is essential that we build strong links with our colleagues.
Economic pressures
Many practices are feeling the effects of the economic downturn as patients hold back from regular attendance. Those of us who have experienced these conditions previously know that eventually it all recovers, but in the current contract you may well suffer the under-achievement of UDA targets and, possibly, penalties as a result.
I strongly advise that you closely monitor both your UDA scores and the financial position so that you can retain maximum efficiency and viability. Some flexibility in your approach to fixed expenses may become a necessity.
New money
The government has announced that there will be an uplift in funding available to PCTs of 8.5% this financial year though this will not be allocated uniformly.
Given the economic climate, this will be widely appreciated, especially if it gets directly into patient care. Don’t forget though, that any increase which may come from the DDRB recommendations will be taken from this 8.5% reducing what is available to be spent on patient care. This puts us in a dilemma; on the one hand we need the money going into patient frontline services but on the other hand, we all need
additional funds coming into our practices to offset dental inflation: a no-win situation.
Judicial review
It is good to know that the judicial review appeal, which I have previously mentioned, has now ended in a victory for Dr Crouch.
The future
I am sure that my successor, John Milne, will be as protective of the interests of GDPs as I have tried to be. I have no doubt too, that there will be full support from the committee members and from the profession at large. And, of course, I wish him every success and enjoyment in this most useful and challenging role. To all of you, I offer best wishes for the future and hope it will prove to be less demanding than the last few years have been. May our profession go from strength to strength.
Kindest regards,
Lester Ellman
