21 Oct 2015  •  Blog, NHS  •  4min read

Rubik’s NHS Blog– No.4

The subject of this latest blog continues the theme of solutions to problems with the English NHS dental contract having unintended consequences that create yet more problems. Hence the title of the blog!

This time around, I want to focus on the vexed issue of value for money for the tax payer, a phrase trotted out at regular intervals by anyone in Government, or politics for that matter. For the purposes of this exercise, I’m going to think of it in terms of what I consider to be the true definition such that cost is one component and benefit is the other.

In doing so, I fully accept that this seemingly ignores what some people would argue, with some justification, is the reality that the term ‘value for money’ is often Government code for ‘cheap’ or ‘low cost.’

I have a lot of sympathy for this view based on first-hand experience from earlier in my career. However, I also think it’s worth remembering there are instances, e.g. private finance initiatives or NHS software development, where it might have been intended to mean low cost and resulted in anything but.

In that context, it is unarguably important to ensure the taxpayer gets value for money from the English NHS dental contract, whereby the benefits justify the costs, but how do you then go on to define ‘benefits’ in respect of dentistry?

I have two Rubik’s concerns about this issue with what I understand to be on the cards with the new English dental contract. These concerns revolve around the old mantra about ‘what gets measured gets done,’ which is entirely appropriate in many scenarios, but less so in others.

That’s mainly because ‘what gets measured is what’s easiest to measure’ which can be very different to what’s right to measure.

In the proposed contract, value for money for the taxpayer will be in large part assessed by the performance of contract holders against a range of largely quantitative measures, including patient numbers, activity and the elements that go to make up the dental quality outcomes framework. This is a significant step up in terms of complexity when compared to simply counting UDAs, which is where the first of my Rubik’s concerns arises.

Unlike the pilots in which contract value was guaranteed, the financial risks in either of the two contract blends that form the prototypes will be transferred to the contract holders, with the potential for earning significantly less if eyes are taken off the measurement ball.

The fear is that mitigating this risk will divert practice time and resources away from patient care such that the efforts to ensure value for money for the taxpayer could actually reduce value for money for the taxpayer.

But it’s the bigger picture that really bothers me, which is that while all those measures are valid to build a picture of value for money, it will be an incomplete measure because the benefits that patients derive from their relationship with their dentists do not always come in easy-to-measure ways.

And that’s really the second Rubik’s concern; that all the focus on the easy-to-measure ways of assessing value for money for the taxpayer deflects attention from what I believe really matters to patients, which are more intangible things like the creation of trust or confidence in the clinician; like the removal of the damage to quality of life caused by dental pain or discomfort; like radically improving someone’s ability to get a job or a partner; like allowing someone to attend a wedding and smile for the photographer.

Yes, there are patient satisfaction surveys to carry out which give an indication but I’ve yet to see the output of a survey that adequately conveys just how transformational the dental care provided up and down the land can be to the lives of taxpayers. The danger is that the opportunity to provide such transformational care and give real value for money to taxpayers gets harder and harder within the financial and bureaucratic constraints of NHS dentistry imposed to ensure artificial value for money for taxpayers.

Of course, I’m sure someone at NHS England might argue that NHS dentistry is not there to provide transformational care. I would welcome such an argument because that would hint at an acknowledgement that the NHS cannot be all things to all people.

It’s once we can have an open and honest debate along those lines that taxpayers will truly be able to assess the value for money from NHS dentistry.

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