In order to achieve a realistic ideal within the future of NHS dentistry, is a fundamental change in the basic concepts and practices of dental care needed? To answer this question, Practice Plan caught up with Judith Husband and Nairn Wilson about the differences a new contract might make to NHS dentistry, as well as what changes dental teams may need to implement to remain successful in the years to come.
PP: At the beginning of the year, prototypes began to be rolled out. In your view, what do the two blends require from the team in clinical terms?
Judith: What we have seen is that wider team working seems to be the approach to take, with DCPs taking on greater responsibility in delivering preventive care − as opposed to reactive treatment, which is what the 2006 Contract is all about. I think what is most important to bear in mind in all of this is that the prototype practices are generally large. It will be more difficult for smaller practices to bring in the DCPs that are perhaps necessary to move forward.
Nairn: I think that both blends require a change of attitude and behaviour from members of the team and their approach to the delivery of care, moving away from NHS treatment to NHS care. I don’t think either blend delivers the truly preventive approach that the new Chief Dental Officer has indicated she would like to see implemented.
“I think that both blends require a change of attitude and behaviour from members of the team and their approach to the delivery of care.” – Nairn Wilson
PP: Is either likely to be more successful than the other, in your opinion?
Judith: It depends on your definition of success. Certainly the British Dental Association has indicated a preference for a significant capitation element, removing the widely discredited UDA and instead having a real focus on prevention. The prototypes are still nowhere near as far as they should be going. It’s very early days on these and there are still significant problems being ironed out.
Nairn: I think there are advantages and disadvantages in both; that’s why two systems are being trialed. If it was absolutely clear-cut, we would be down to one plan. We have yet to find a perfect system for NHS dentistry!
PP: To achieve a realistic ideal within NHS dentistry in the future, do you think a philosophical shift will be needed to embrace the proposed preventive approach?
Judith: I think we do need to change the dynamic of the team, especially extending the role of the dental nurse. We can see by the numbers of nurses taking on enhanced duties like radiography and oral health promotion that they want to work as part of a wider team. I think it will benefit the profession as a whole if we are all able to use all our skills to the benefit of patients and ourselves.
Nairn: I think the necessary philosophical shift is towards promoting and maintaining oral health, rather than the traditional approach of treating disease. I’m very much of the opinion that we do need to move away from focusing on the treatment of disease to motivating patients to adopt a preventive approach to oral health. Therefore, the biggest shift that’s needed is to get people looking after their own health – we dental professionals should be occasional visitors in patients’ mouths, assessing risk and providing support, rather than in continual control!
PP: How can practice owners and dental team members prepare themselves for a potential shift in skill mix?
Judith: That’s very difficult without having a definitive contract or any timelines for changes. But I do think that principals can start to explore giving all team members opportunities to broaden their experience and take on new skills. It’s very important to take a holistic view of what’s going on in dentistry, not just focusing on the NHS reforms but also to consider where we’re going with regulation and CPD.
Nairn: I think a practice owner has to seek out good, quality-assured CPD. Not surprisingly, as immediate Past-President of the BDA, I would suggest that we need to work together as a profession, as there is always greater strength in numbers. It’s about engagement and being stronger together, so that we can voice the need for guidance and support before any change happens.
“I do think that principals can start to explore giving all team members opportunities to broaden their experience and take on new skills.” – Judith Husband
PP: Which team member do you think is likely to benefit the most and which the least from a change?
Judith: I think there’s a risk for associates in terms of their employment status. A lot of work has gone into building an associate contract that fulfils the requirements of self-employment, so I think as a profession we may need to be alert to those risks. We need to ensure both parties negotiate meaningfully and respect each other as equal professionals. On the flip side, I do think there is a real potential for dental nurses and therapists to become a truly integral part of the NHS team.
Nairn: We’re all in it together and the whole team should win. If there are winners and losers in the team, then, in my opinion, any revised contract has failed.
PP: If either of these blends – or a combination of the two – did form the basis of a reformed NHS contract, what does it mean in real terms for the dental team?
Judith: One disadvantage is that we would still have an activity-based contract. Also, social deprivation and inequalities in health are not being addressed in the prototypes; nor is the potential impact of our aging population. It’s all well and good having a capitation-based contract, but if patients can’t physically get to the practice there have to be different ways of delivering care. On the other hand, the advantage is that it will be good for patients who can make it to the practice, because the blends are more prevention-based than the current contract.
Nairn: Anything that moves on from the existing UDA system will be seen as a blessed relief. However, personally, I don’t think either of the blends offers a long-term solution, as they will not realise the vision of truly preventive, minimal-intervention, patient-centred oral healthcare, capable of giving people teeth for life.
PP: What steps can dental professionals take to ensure patient welfare remains top of the agenda within the parameters of a potentially amended NHS contract?
Judith: We have dental committees within which both dentists and DCPs should play a key part. On a local level in England we have health and wellbeing boards that currently hold the budgets for preventive health, so we should be engaging with them in our localities.
Nairn: I think dentists should be working together to get the powers that be to understand there is so much more dentistry can contribute to healthcare, such as being part of vaccination programmes. Over and above arrangements to improve oral health, dentists could be giving flu jabs and helping to reduce waiting times to see GPs. We could have a significant effect on patient welfare if the NHS truly embraced and funded integrative healthcare.
“I think dentists should be working together to get the powers that be to understand there is so much more dentistry can contribute to healthcare.” – Nairn Wilson
PP: Do you think that the new prototype contracts will have unintended consequences?
Judith: I’m sure there will be; there always are. But it’s too early to comment decisively. We should permit them to run their course and then very carefully review the evidence.
Nairn: Yes – resulting in frustration, again! Dentists still won’t be able to deliver the holistic dental care they were taught in dental school.
PP: So, to summarise, do you think that either of the blends realistically provide a solution to the NHS’ challenges?
Judith: I think there could be an improvement on what we’ve got, and certainly both prototypes offer such potential. My concern now is whether there will be an imperative for change, because having a capped budget in the NHS is top of the agenda for the Department of Health. And I think we’ve seen already how the timelines have all slipped and are still slipping. It’s important that the profession is alert and knows what’s going on. By the profession, I mean DCPs as well as dentists.
Nairn: Neither offers the right solution, in my opinion. We need fully integrated, preventive-orientated, minimum-intervention, patient-centred care focused on supporting people keeping their teeth for life. That is going to involve some retraining of the existing workforce and changes in dental schools. So I think we should be looking at evolution rather than revolution.
PP: And finally, if you could offer dentists and their teams one piece of positive advice given the potential for change, what would it be?
Judith: My advice would be that we offer something tangibly important and vital to our patients, so I think it’s essential that we are positive in our outlook. Also, although it is often mentioned, it remains true that with change there’s always opportunity. That’s why it’s so important to be alert, to know what’s going on and be informed. Don’t just consider the impact on your own practice but on the wider profession; that’s how you can make informed, positive changes.
Nairn: We’ve got a Chief Dental Officer who, I think, sees the bigger picture, and who’s willing to work with the profession to move on from where we are. That’s a really positive position for us to be in, and a platform from which we can press for further change in terms of not just integrated healthcare but also fair remuneration.
About Judith Husband and Nairn Wilson
Judith Husband is a clinical dentist working in secure setting dental care. She also sits on the BDA’s Principal Executive Committee and is a member of the Wesleyan Advisory Board, as well as Chair of The Oxfordshire Local Dental Committee. Judith is a key member of Practice Plan’s NHS Insights panel, which meets to explore the results of the NHS Confidence Monitor in greater depth.
Professor Nairn Wilson CBE FDS, FFGDP, FFD, FKC, is an Honorary Professor of Dentistry at King’s College London Dental Institute. He is also the immediate Past-President of the British Dental Association. Nairn’s expertise encompasses the regulation of dentistry, international trends in dental education, tooth-coloured filling materials and related systems, and minimally invasive approaches to conservative dentistry. Nairn has received numerous awards for his contributions to dentistry.