Tsars meet to discuss commissioning
By: Stephen Tidman
Last month saw the gathering in London of those PCTs responsible for commissioning, financing and providing public dental advice on primary care dentistry. Organised by the Department of Health, the aims of the day were to:
- Set out the direction for NHS dentistry moving through the
second year of developing local commissioning. - Provide an opportunity to influence emerging thinking about
Department of Health guidance for future commissioning and delivering for patients. - Help develop their long term vision for NHS dentistry.
If these aims were met, then I continue to be deeply concerned about the direction NHS dentistry is heading.
The day began with Ann Keen, Parliamentary Under Secretary for Health Services with responsibility for dentistry, who was the day's ‘keynote speaker’. But nothing much here, a thank you to her predecessor and to the audience for delivering what many thought impossible – change, after sixty years, with the transition to local commissioning of dental services. She made reference to the improvements in dental health over the last 30 years before returning to the Department’s familiar mantra of recent months: prevention, prevention, prevention.
She talked about an evidence based ‘tool kit’ in primary dental care and ‘rolling out’ of an NHS identity scheme for dental practices. Dentists had for too long, she warned, not behaved as full partners of the NHS. The complexity of data had been reduced but PCTs needed, and would receive by April 2008, ‘enhanced clinical data’. She concluded by saying that 2009, when the ring fencing of dental budgets is removed, would not be similar to 2006. It was to be an incremental process that all parties should begin thinking about now.
Next up was the Chief Dental Officer, Barry Cockcroft, speaking on working with the profession. It wasn’t long before we were
into needs assessments with an interesting reference to therapists and a greater use of the skill mix in dentistry. He also raised the question about the type of service to be provided by the salaried services – whom I think should be the providers of a targeted, public health service. Barry then went onto to say that primary dental care services needed to move from access to the next phase in their development, improving the quality of services to patients, before concluding with the observation that we had moved from a provider to a commissioner driven service.
John McIvor, Chief Executive of Lincolnshire PCT, then gave a presentation on why dentistry mattered to PCTs and how his PCT had tackled the problems in his area by targeting areas of greatest need.
Liz Phelps, Social Policy Officer for the Citizens Advice Bureau, spoke on delivering for patients. While welcoming the reforms, CAB were ‘very disappointed’ that the first year figures showed no overall increase in patient access and this remained the big issue with its clients. Many patients still couldn’t find a dentist and key to this was much greater publicity. Also, additional funding should be targeted at PCTs with the worst access problems, and that ring fencing should continue until targets were met.
The need to change
Then came Tony Jenner, Deputy Chief Dental Officer and Head of Oral Health Policy. He began by saying that 80 per cent of what
was currently being commissioned, using the words of Elizabeth Blackwell a 19th century dentist, was merely ‘patching and mending what was broken... we must be watchmen, guardians of life and health of our generation, so that stronger and more able generations may come after’. This was the result of commissioning contracts being based on GDP courses of treatment under item of service. But commissioning, he continued and using his emphasis, was a process by which the health needs of a population are assessed; responsibility is taken for ensuring that appropriate services are available which meet these needs; and the accountability for the associated health outcomes is established.
Tony then went onto highlight the improvements in the oral health of children, due primarily to fluoride toothpaste, which ‘had little to do with dentists despite their hard work’. These improvements meant that what was commissioned had to change, a theme repeated by Barry Cockcroft throughout the recent media focus on dentistry. However, this must not be at the expense of the post war baby boomers. It was this cohort of the population, at risk of developing caries, who benefited from the provision of NHS dentistry with its techniques of extension for prevention. The consequence of this was that they entered the restorative cycle and will place the greatest demands on dentistry over the next twenty to thirty years – accounting for the majority of the 80 per cent of what is currently being commissioned and derived from the demand led GDS.
From demand to need
But with the introduction of a cash limited service, which coincided with commissioning, we saw the end of a demand led service. This has always been a sacred cow of primary care services – imagine the outcry if a patient could not be seen by a doctor because his/her budget had run out? So now some other measure than demand has to allocate resources and decide priorities in dentistry, hence the emphasis on needs assessment. But this is very dangerous territory and goes against the trend throughout the world of abandoning attempts at planned economies.
I took issue with part of Tony’s presentation, which, at best, was misleading.He used Birmingham as an example where fluoridation had contributed to it having one of the lowest DMFT rates amongst 11-year-olds and yet it had some of the highest valued UDAs in the country - and no Tony, it did not need an oral health assessment to resolve, the two are entirely unrelated. Fluoridation was introduced to address the poor state of dental health in Birmingham, hence the continuing improvement in the oral health of children. But, as you know, it does not reverse caries nor repair the damaged teeth of the population who did not enjoy the benefits of fluoridation. My concern was that the commissioners left the meeting eager to progress the purchasing of prevention at the expense of those locked into the restorative cycle.
The final speaker was Colette Bridgman, Consultant in Public Dental Health, Oldham, speaking on delivering a commissioning strategy. All very earnest and well meaning but I really could not see what was meant by ‘understanding the needs of populations and individuals’ through the onslaught of jargon and clichés. These included: strategic steps, care pathways, prioritisation matrices, applied needs assessment, risk assessment, treatment locks, prevention tool kits, impact assessments and, of course, the old classics of joined up and rolling out!
The afternoon was an interactive session, lead by Elaine Maggs, PCC Dental Support Advisor, the purpose of which was to test emerging Department of Health guidance. This included considering ‘key messages’ from dentistry ‘focus groups’ held around the country and consisting of PCT representatives:
- PCTs did not want to have to review all contracts for 2009 but they did want the ability to ‘tackle’ poor performers.
- PCTs should start to develop and implement their review processes and not wait until 2009 but they wanted clear support from the Department for commissioning decisions taken
- Clear and timely communication to contractors and other ‘stakeholders’ about the nature and scope of the review process was essential
Following ‘group work’ at tables with feedback and questions, Barry Cockcroft brought the day’s proceedings to a close.
A footnote
I close with an example of perceived need rather than demand driving the allocation of dentistry. After three years in the offering and extensive publicity, not least because of delays in opening due to health and safety issues, a purpose built NHS practice was finally opened near me in Cobham, Surrey. The River Mole Dental Practice was opened by the local MP, amid much celebration and festivities. Unfortunately, and despite the principal dentist's expectations that the places would be ‘filled quickly’, six weeks later almost three-quarters of the register remained empty. Chairman of Cobham’s League of Friends, which donated £70,000 to the practice, said ‘it's disappointing as far as I am concerned. I thought people would be jumping at it’.
