I was asked this question by a dentist, and I think it reflects wider concerns among the profession and a feeling they are being asked to perform an increasingly difficult balancing act to achieve conflicting goals.
The desire of dentists to deliver quality care to patients and improve their oral health has been consistent in the 20-plus years I’ve worked with the profession. However, many feel that their hands are often tied in their pursuit of this by targets that do not focus on patient care, but rather measure figures such as patient list size and amount of activity.
To consider this quandary, I asked four industry experts for their views on: How can dentists square a system that feels target orientated with delivering quality patient care?
Tony Kilcoyne: ‘Put simply, you can’t. Everyone in healthcare will tell you that targets are bad for patients, and that has been shown in many studies. It is also not good for professionals, but the message we have to get out there is, it’s not good for patients.
Dentistry is about caring for people, and when an anxious patient comes in and you spend an extra 10 minutes helping them feel relaxed, developing rapport, what does a target system do? Does it say you’re a great dentist, we’re going to reward you and give you the resources to provide more of that care? No. It says, “Oh, you haven’t reached a volume target, you’re going to be punished for it.”
You’re going to be punished for providing more time and more care; how can any target system be good in healthcare?
Of course, there has to be some measures in place, but what’s important to the Department of Health or the politicians? How much patient charges are we going to get and how many people are we going to rush through your surgeries so we can look, in volume terms, like we’re doing something good.
“You’re going to be punished for providing more time and more care; how can any target system be good in healthcare?”
Nobody’s actually measuring the real quality of personal, professional care, which is what adds the highest value to our service and is at the core of the patient-centred care delivery system.’
Paul Worskett: ‘My practice was part of the contract reform pilot scheme and is now a prototype, and there’s a palpable difference between the two in terms of targets.
In the pilots there was no real measure on activity as such. We got paid for the time that we spent with patients which meant we could focus on that. As a prototype we’ve got two targets to aim for now, which are capitation numbers (i.e. our patient list size), and we’ve also got activity, which unfortunately is still measured in UDAs.
“We’re not focusing on the things we should be looking at and what the system is supposed to be achieving, which is improving the quality of patient care and the health of patients.”
So, we have two things to measure, two balls in the air to try and keep going. And for a number of the prototypes, this is the main thing that they’re having to look at and manage, for example cutting down the time they spend with patients so that they can keep their numbers up, and that’s the wrong focus.
We’re not focusing on the things we should be looking at and what the system is supposed to be achieving, which is improving the quality of patient care and the health of patients.’
David Houston: ‘My practice has never been a pilot nor a prototype practice and we are still operating under the existing UDA scheme.
I think that as a profession we’ve become extraordinarily adept at making any system that’s given to us work, and usually very quickly as well. We’ve obviously tried to make any system that we’re given work to best advantage. And because, I would like to think, that we’re still a caring profession full of very moral and ethical people, we always try to do our best by the patients even when sometimes that’s not doing the best by ourselves. Many dentists will be financing socially-deprived parts of the demographic with their private practices or their fee-paying patients, and it worries me when patients’ fee charges on the NHS are such a large a percentage of our income.
“We know what is best for our patients but the Government controls us 100%. I’m realistic enough to understand that we will always be given some form of targets because no government will ever give us a blank cheque and allow us to spend it as we see fit…”
We know what is best for our patients but the Government controls us 100%. I’m realistic enough to understand that we will always be given some form of targets because no government will ever give us a blank cheque and allow us to spend it as we see fit, even though we might be the best people to know what to do with that money.
However, if it could be a measured system where patient care is put first, and it was proven to us that it worked, I think the profession would get behind it, But it would need to be all about quality of patient care, and sadly that’s why so many people are heading into the private sector, to ensure that they can deal with that one-on-one and not be restricted by a system that doesn’t seem to work.’
Eddie Crouch: ‘The introduction of the 2006 contract was supposed to take us off a treadmill but that hasn’t been the case and the real problem going forward with the prototypes is that we haven’t got rid of UDA targets. You only have to look at the situation now with the number of practices that are underdelivering UDAs; I won’t say underperforming because that’s a horrible word used by the NHS. Underperforming is completely different in my opinion to underdelivering a target of UDAs.
A patient can walk in needing a large amount of work and time, which you of course provide, but often the UDA payment does not cover this type of treatment, and therefore you end up subsidising the cost. To further compound this, at the end of the year you have a meeting with the area team and they tell you that you’ve under-delivered on UDAs or underperformed – it’s a real smack in the teeth.
“What we need is to have targets that are actually beneficial to the patient and the practice.”
Any indicator that we have going forward needs to be more about the outcome of the quality of care that you give to a patient. Even in the old system under target annual net income and target annual gross income on item of service, we had a treadmill. What we need is to have targets that are actually beneficial to the patient and the practice.’
There is clearly a consensus, regardless of whether you are working in the NHS, in private practice or have been involved in the contract reform process, that the current set of targets is not aligned with a system that truly prioritises patient health.
There has been some positive feedback from dentists involved in contract reform, in terms of the oral health assessment and the preventative approach. However, as long as measurement involves UDAs, many will continue to feel they are being hampered in delivering the kind of care they would like to.
About Tony Kilcoyne
Dr Tony Kilcoyne works mainly in his own specialist referral practice and teaching centre. His vast knowledge and experiences are now utilised by mainstream media with programmes for ITV, C4 and the BBC and he is currently best known as the ‘resident dentist’ for the popular BBC Radio 2 Jeremy Vine show. He is also a member of the British Dental Association Principal Executive Committee. Any opinions expressed are independent of Tony’s other roles, including being a member of the British Dental Association Principal Executive Committee.
About Paul Worskett
Paul has been the Principal of Amblecote Dental Care in the West Midlands since 1988. Paul has extensive experience of dentistry and has a special interest in cosmetic and implant dental care. He has had two papers published in the BDJ and Dental Update. Amblecote Dental Care is a prototype practice as part of the ongoing NHS contract reform process, having initially been a pilot practice since 2011.
About David Houston
David is the joint practice principal of the Houston Group of dental practices which includes the UK’s largest single-site practice. He has authored over 50 articles for the dental press, spoken at BACD Annual Scientific meeting and World Aesthetic Congress, and is a former clinical governance lead for North Somerset Primary Care Trust.
About Eddie Crouch
Eddie Crouch works in two practices in Birmingham. He is Vice Chair of the Birmingham Local Dental Committee, Vice Chair of the British Dental Association Principal Executive Committee and past President of Central Counties Branch of the British Dental Association.