GDPUK.com Opinions: John Renshaw - A Fairy Tale
Heart Your Smile, the dental charity with a mission to find innovative ways to promote oral health and regular dental visiting, has devised a Market Index which charts the growth of dental activity and patient uptake across the spectrum of dental care in the UK. This is based on industry figures for sales of dental treatment gloves and dental local anesthetics, providing a proxy for the volume of dental visiting actually taking place.
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John Renshaw
John graduated from Leeds University in 1969. He has been a general dental practitioner in Scarborough for 39 years but has taken a great interest in wider healthcare since the early 80’s. He was a member of Scarborough Health Authority for eight years and a non-executive director of North Yorkshire Health Authority for five years. For ten years he was dental practice adviser (DPA) to North Yorkshire Health Authority and was for a time DPA to Selby and York PCT. John participated in the creation of the NHS Plan in 2000 and was subsequently a member of the NHS Modernisation Board and the NHS Workforce Development Board for five years. John has held many positions in the dental political field and led the British Dental Association for six years between 2000 and 2006. He was Chairman of the Department of Health’s Standing Dental Advisory Committee for two years (the only general dental practitioner ever to hold that post) and has played a part in many DH working groups e.g. sedation in dentistry, general anaesthesia in dentistry and, later, ‘Options for Change’. He has lectured widely on many dental topics including quality assurance, strategic service planning and the broader topic of commissioning of services. |
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Just another fairy tale ….
Let’s just suppose for one insane moment that Barry Cockcroft has decided he wants to put things right with his own chosen profession. He wants to ‘sue for peace’ as they say in all the best diplomatic circles.
Yes, I know we’re in the land of Walt Disney make-believe, now, but indulge me for a moment or two longer.
Let’s imagine for example that he has been told quite firmly by the House of Commons Health Committee that the ridiculous and ruinous stand-off between the Department of Health and the dental profession must end immediately. A pragmatic way forward for NHS dentistry must be found and that has to include him talking to the dentists who work in the NHS and who deliver the goods.
What exactly would we say if we were asked? What would we want brought in to replace the ludicrous mess we have now? Would we be able to present even the basics of some joined up thinking on our side of the argument? How would we choose to begin to build a new funding system for NHS dentistry that meets some of our long term aspirations for our businesses and for our patients?
The profession’s dilemma
This article may not provide you with a guaranteed recipe for success but it does offer some practical suggestions to start the ball rolling. If the article achieves its key objectives I may well emerge somewhat battered and bruised but our thinking as a profession may have taken on a more workable form. If that happens, the bruises will be worthwhile. For too long we have been criticising Government for its failures in NHS dentistry but the time has come for us to resign from that cushy number and take a leap into the future and create some positive plans for an alternative system that we can support.
The first thing to acknowledge is that patients will never be squeezed successfully into three treatment / charging bands so let’s abandon the three bands for a start.
The second thing is to put clawback, based on UDA count alone, where it belongs - in the bin. There is no possible justification for retrospective contract value reductions carried out in the way that the Department of Health recommends.
The third thing to go is PCT responsibility for collecting a specific level of patient charge revenue. They should not be held responsible for something over which they have absolutely no control.
Now, wielding the axe like that was a liberating experience but it was also the easy part. How do we set about the task of building a new system to replace the old one that is now filling the round file under the desk?
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A practice allowance
I believe we must begin with a basic practice allowance payable to every practice that provides any NHS dentistry based on their level of commitment to the NHS. That commitment should be measured in three ways, numbers of patients registered, amount of treatment carried out and the number of hours of NHS work provided. This allowance might account for as much as 50% of the practice’s NHS contract value. This money is to cover the fixed overheads of the practice and is not subject to ‘clawback’.
Registered patients
Once a practice’s list of registered patients has stabilised, the number of patients concerned can be scrutinised for its demographic spread and caries incidence (based on data already held and clinical experience) and a block payment calculated for providing their care. These patients are the genuine ‘swings and roundabout’ cases we know are the backbone of any practice. They are maintained over many years and pose little threat to the financial stability of the practice. This could be seen as the NHS ‘Denplan’ group within the practice. Entry to this group would be under the control of the practice owner.
High needs patients
Patients who present with very high needs can and should be identified separately and paid for differently. Why should we not go back to a system of prior approval with treatment fees calculated on the basis of a detailed paper / computer claim? We have about 60 redundant DROs based in Eastbourne, I am sure they would be much happier looking at difficult cases that deserve greater attention and help with treatment planning than doing their current vacuous hand-holding job, looking at patients that have been carefully pre-selected for them.
A specific fund of cash could be set aside each year for this group and bids could be made against that fund until it runs out. That way it will never become a serious financial embarrassment or be the subject of an overspend. Monitoring would be rigorous and anyone caught flouting the rules should be barred from accessing the fund for the next year.
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Treatment quality
Treatment quality should be enhanced by offering bonuses for improved performance, local commissioners could decide what they want to see happen and create financial incentives to encourage it. Instead of threatening to remove money from practices for poor performance it makes far more sense to make additional funds available for better performance. The difference in the psychology never seems to have dawned on the DoH, but dentists know only too well just how effective the right incentives can be.
Treatment quantity
Treatment quantity will always play a major part in any funding system, it would be foolish to waste time trying to argue otherwise, so what we need is a method of assessing the performance of the practice against professional norms, particularly local norms. My idea would be to group treatments into bands and count up the numbers completed. This is a significant development of the banding system we have at the moment with three major differences, there are no pre-set targets, there are more bands to create more flexibility and the money is not directly linked to the total.
Performance management is an essential tool in the utilisation of public funds and a practice that signally failed to match the performance of other local comparators would be required to explain their problems. If no explanation was forthcoming then contract values would need to be renegotiated on the basis of current performance.
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Creating a hybrid payment system such as this does not plump for capitation, nor does it go for simple item of service. There is no need to choose an absolute pay model; block contracts such as nGDS and nPDS have been shown to be just as bad as any other. There is no pure system that does not carry with it in-built probity problems. Too much treatment is just as bad in its own way as too little treatment. What is required is a compromise approach that builds several strands of funding into an acceptable new scheme that can be modified over time to eliminate the worst anomalies.
It is impossible to remove all perverse incentives from any scheme, no matter how carefully thought out, but a serious attempt to balance out the incentives is possible. If money can create perverse incentives it must surely be possible to use the same money to persuade practitioners to treat patients under NHS rules in return for a fairer remuneration package.
We know how utterly clumsy a simple system can be – just look at the one we have at the moment. The proposed scheme is complicated and it will take a great deal of time to work out but if it survives that early gestation period successfully you would see a new system emerge that is balanced, realistic and controllable. Refinement will be possible and all parties can be seen to benefit.
How patient co-payments are levied within a system like this remains untouched in this paper but if the general approach meets with wider support the question of patient co-payments can be literally stitched on as an afterthought. How Government covers its financial shortfall from its taxpayer users of the service is largely their problem.
Stand by for incoming fire!!
John Renshaw
The other thing that isn't quite clear to me is whether you envisage the contract being commissioned locally, ie the PCT deciding how much they want to spend on registered patients versus new patients, or whether the contract would be administered centrally as it was before. I assume you mean the former, but there would have to be safeguards against PCTs squeezing practices 'until the pips squeaked' in their quest for 'value for money'.
Best wishes
Jane
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