On ‘crucial lessons’
I have always said this was a two-stage process. It was going from a national contract to a local contract which was managed by PCTs – and that’s what happened in 2006. It was quite difficult for a number of reasons – dentists felt it was being done to them rather than being done with them and also the atmosphere was very tense. There are people who have a vested interest in the NHS not being a robust service and it was a very difficult time. I have always said that the second stage – moving from local contracting to local commissioning – is the area where the biggest benefits are likely to be for dentists, patients and the NHS.
Jimmy has given some really good pointers in things to do and there are examples in the report of some PCTS already doing this. The second stage needs great and more specific support from the centre. Jimmy’s report brings in an external view and pushes in absolutely the right direction. The whole service needs to be focused on prevention. We did some really rudimentary piloting before 2006 There was not a lot of time for them to run and be evaluated but we did learn some pretty crucial lessons.
• First of all that dentists, on the whole, did not know what
evidence-based prevention was and that’s why we produced Delivering better oral health: An
evidence-based toolkit for prevention which we’re just sending out again.
• And the second thing is that it reinforced that you do need
quantitative indicators because if you don’t, some people will mess around with the system. Any
system can be gamed, but you have to work on the principle that a vast majority won’t do that.
You need a system of quantitative and qualitative indicators.
Quantitative indicators are easy – you just decide what you’re going to count and you count it. Qualitative indicators are much more difficult as the impact is over a period of much longer time, and Jimmy’s report makes the point that the thing about the pilots this time around is that they will not – and must not – be short term. We must let them run for long enough to learn the lessons. Less is better, as long as it’s appropriate.
We’ve seen a drop in complex treatments and in many situations, that’s absolutely spot on. In some cases it’s better treatment, but in other cases it might not be. The point Jimmy made is that pilots – if they’re going to be really effective and robust – need to go for quite a long period and we didn’t have the luxury of that time in 2006.
First of all, we’ve got the expanding access team, which is working with the NHS to procure new practices over the second half of this year. Some of these procurements will start in July. There are 150 of those practices and Jimmy has been working jointly with that team so that they’re informed of the quality stuff. We have the Clinical Effective Outcomes Group, headed up by Serbjit Kaur, developing indicators for some time, so what we’re trying to do is embed quality indicators and quantity indicators into these procurements for new practices.
That’s like a clean sheet of paper. There’s no history and it gives us an opportunity. We are also looking for existing practices to factor in quality indicators and, in my last CDO newsletter, I wrote asking for PCTs and providers to volunteer. Therefore, it’s going to be a mix of new providers and current providers.
On the 3-band system
Jimmy’s view is that the 3-band system is not sensitive enough. On the whole, patients like the
simplicity of patients’ charges but it may be too simplistic for practices. When you change
anything it has intended benefits and unintended benefits and you have to pilot it to work it out. Jimmy makes a recommendation around guaranteeing work and not being paid if you have to replace it. The contra argument is that a dentist might look at something and think ‘that looks a bit tricky’ and not bother doing it. You may introduce an unexpected perverse incentive. You can’t always predict.
On media matters
One of the things Jimmy points out is that in some areas there is good access to dentistry but the patients – because they’ve read the national press – don’t think there is. Part of it is improving the
quality of messaging to patients. We, in fact, have a dental service that provides dentistry to a larger proportion of the population than most countries. It’s like the NHS in general; people like to knock but I wouldn’t go and get dental care anywhere else in the world.
On attracting private dentists
With the extra investment and the PCT commissioning, most PCTs have got letters from either
existing people with a large NHS contract, small or none at all who want to grow it. The recession is one thing that people may want to think about but there are lots of other issues – for example,
pensions. I made a huge point around 2005-6, warning people who were thinking of leaving the NHS that it was important to retain their NHS contract and therefore retain their NHS
pension. And, of course, what’s happened to private pensions
hasn’t been helpful.
We’re making lots of investment now and the PCTs are making investments in improving premises and we’re also developing a system which is based more on prevention and that’s quite rewarding.
On a national approach to primary care
We have a national framework so dentists have to do certain things but it allows the NHS local freedom. There are 152 PCTs and we can do some of the development work with them. It’s then down to them to interpret locally. Jimmy says local commissioning gives us the tools to do the job but what he points out is that there are specific areas that need greater support.
On continuing care
We must ensure that patients get appropriate treatment and measure the outcome without impinging on a dentist’s clinical freedom. There are also always going to be those patients who only attend for emergencies and we need to provide for them. Then maybe we can try to convert them.
On computerising all practices
Only 70% have computerised systems and that’s not good enough. If it’s mentioned in the review, then we have to respond to it. We have to get there.
On the chance of change
It’s a very positive report – I’m delighted. Jimmy is a very independent person, and if I’d tried to lean on him, I don’t think it would have been to anybody’s benefit. I stood back quite a lot. One thing he did fantastically was get clinical engagement. He went around the country and had a blog. The difference with this report is that there is a will to make it happen and there’s a commitment from Andy Burnham to this. We have to make sure we do it with the profession rather than to it. I think the profession is ready for change. I think they now have a leadership that is up for change. Change is always challenging and now is the time to go forward.