28 Jun 2013  •  Blog, NHS  •  4min read

NHS Contract – In A Perfect World

Former Technical Director at Practice Plan, Graham Penfold takes some time to let us know what he would like to see from the new NHS contract.

NHS dentistry cannot be said to have been graced with a successful policy-making history. When a new contract was introduced in 1990, it was followed within two years by fee cuts, reduced prior approval limits and registration periods, as spending spiralled out of control. There were a number of reports and white and green papers throughout the 1990s and early 2000s and in the end the new, twice delayed, UDA target-based contract was introduced in April 2006. Fatally flawed on many fronts from the outset, in less than three years, Professor Jimmy Steele was asked to undertake a fundamental review of NHS dentistry.

The lack of an overarching rational policy-making process for NHS dentistry has caused these frustrations as well as a lack of political will to confront reality. I am reminded of the phrase of Professor Charles Lindblom and good old ‘disjointed incrementalism’ or as he referred to it, ‘the science of muddling through’. This is where policy is shaped in parts rather than viewed as a whole, resulting in, most of the time, a mess.

When the Steele report was published in June 2009, it marked a refreshing change from previous policy attempts as it did at least try, in a methodical manner, to prioritise what the State should provide, placing public health and urgent treatment as the highest priority, and complex treatment as the least important or affordable.

Whilst admirable for its approach to clinical priorities, where was the social analysis within this? Is this approach to be applied to the whole population or are there to be priority groups such as children, the poor and the elderly, who are deemed to be the most vulnerable?

Also, what about the economic framework for deciding priorities within public spending which is an especially important factor given the state of the public finances, not just now, but going forward?

It’s all very well getting someone to write a review on this or develop a contract for that, but what is needed is for the role of the State as a purchaser of NHS dentistry to be defined clearly. This needs to be structured centrally so that there is a national framework and then implemented locally so that appropriate refinements can be made to meet individual needs. Some might say the creation of the new NHS England Commissioning Board will achieve this but there are more fundamental matters that need to be addressed.

The most important of these is that the NHS dental budget is significantly underfunded for what it aims to achieve. In the current economic climate, it is unthinkable that there will be a huge uplift in funding so the scope of what can be purchased and, importantly, for whom has to be redefined. For me, after public health and urgent treatment, the priorities are a comprehensive care package for children with a very strong focus on prevention, and then a core service for the poor and vulnerable. The critical issue though is that these services would have to be funded to an appropriate level and that would almost certainly mean that there was not much funding for anything else. However, cast an eye across Europe and even wealthy countries such as Norway do not cover dental care as part of their welfare programme. So, perhaps patients who earn over £30,000 p.a. should pay privately for their dental care; why not?

For this to happen, all policy makers will have to come off the fence and recognise, as Steele did, that the State cannot live in a world of self-deception and pretend that it can afford everything for everyone all of the time. Instead, they will have to formulate policy through a comprehensive series of integrated analytical lenses: political, economic, social, clinical, technological, demographic and so on. Until this is done, State policy in this area will remain confused and NHS dentistry will have more ‘disjointed incrementalism’ and more of the same; a mess!

What do you think?

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