2017 the year questions finally get answered

Nigel Jones’ reflections on the unanswered questions from 2016

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Within dentistry, 2016 felt to me like the year of the unanswered questions – the most important one arguably being, ‘how long can the profession’s status quo be maintained’? This question, amongst others, needs answering if the profession’s worryingly low levels of morale and insecurity about the future are to be addressed before the end of 2017.

I say that the above question is the most important of all that needs answering for several reasons. Not least due to the pressure pot of tighter contract management, increasing regulation, an ever-escalating risk of patient complaints or litigation and a drop in average dentist income of over 15% over the past five years.  It seems inevitable that something has to give as some, though admittedly not all, dental practitioners reach their limits in terms of propping up an NHS by sacrificing their health and their wealth.

One influence on the profession’s mental health that emerged more strongly than ever during 2016 is the tension between professionalism and working within the NHS, particularly in respect of the current English NHS dental contract. Concerns about this issue were brought into sharp focus by the exchanges between the London Federation of LDCs and the GDC about the disconnection between the “apparent gold standard expectations of the regulator, compared to the tin-plated budget the NHS expects practitioners to work with”.

“Practitioners are also tackling increasingly vocal personal demons as they wrestle with the rights and wrongs of providing the best care they can.”

The fear of a GDC investigation is enough of a pressure on its own, but more and more practitioners are also tackling increasingly vocal personal demons as they wrestle with the rights and wrongs of providing the best care they can, versus providing the best care they can “under the circumstances”.  The question of how to remain professional and work within the constraints of a cash-limited NHS looks certain to be increasingly explored in the months ahead.

Of course, for dentists in England, it might have been hoped that 2016 would have provided some light at the end of the tunnel in the form of greater certainty as to the future shape of the NHS dental contract.  NHS England would no doubt argue that the testing of the prototype contracts gives a clear sense of direction in that regard.  The prevention-orientated care pathway, complete with oral health assessment and the assigning of a Red, Amber, Green (RAG) status to patients, the inclusion of a blend of capitation and activity payments and the implementation of the dental quality outcomes framework all look to have been accepted as features of a new contract, even if the fine detail has yet to be agreed.

“Of course, for dentists in England, it might have been hoped that 2016 would have provided some light at the end of the tunnel.”

However, for all the positives conceptually about such a contractual framework, doubts remain about how successful any national rollout would be given NHS England’s priorities to maintain or improve access within the current budget.  While some practices have both the scale and the wherewithal to reconfigure practice teams to enable patient number targets to be achieved, others may find it more difficult.  Indeed, after the significant falls in patient numbers experienced by most pilot practices, the challenge of restoring patient list sizes to their pre-pilot stage is making some practices fearful of clawback.

Therefore, another key question that needs answering during 2017 is, how does NHS England, within the existing budget, create a contract that squares the circle of imbedding the new preventive care pathway, while providing appropriate incentives for both access and activity in a way that is scalable for a national rollout?

However, some observers would argue that there is an even more fundamental question to be posed to do with the legitimacy of the current reform programme and the likelihood of any contract seeing the light of day.  It certainly seems unclear whether the political benefit of moving to a more preventive dental contract will outweigh the political pain that seems certain to accompany its implementation, given the likely resistance of many within the dental profession.

Such deliberations are obviously being undertaken against a backdrop of the wider NHS which was described to me by a group of GPs as being in meltdown.  Financial pressures have beset the NHS for as long as I can remember, but appears to have reached an unprecedented level of intensity in the past year.  You know things are becoming unsustainable when even Chris Hopson, the Chief Executive of NHS Providers, the trade association for acute, ambulance, community and mental health trusts, talks on the Andrew Marr Show about the need for rationing and sacrificing services.

“Financial pressures have beset the NHS for as long as I can remember, but appears to have reached an unprecedented level of intensity in the past year.”

So an age-old question that seems to have more relevance in 2017 than ever before is, against that context of rising demand for health services and social care, where does dentistry sit on the priority list for an ever-stretched NHS budget?

Of course, there are other important issues related to the NHS such as the future for the self-employed status of associates within any new look contract and the spectre of the introduction of time-limited contracts, described as a matter of when, not if, by senior figures within both the NHS and the BDA.

Yet, with NHS funding increases set to drop from 3.8% in 2016 to 1.4% in 2017 while total NHS demand and costs are expected to rise by at least 4% a year, there is a much bigger picture to be debated. Primarily, about the future of the entire NHS and the potential necessity to depart from the principle of care being available to all on the basis of clinical need not ability to pay.

In the absence of an increase in funding, an option conspicuous by its absence in the autumn statement, as Chris Hopson has noted, unpalatable choices need to be contemplated such as controlling the size of the NHS workforce, extending or increasing patient charges and cutting the number of priorities the NHS is trying to deliver.

Whether the Government, as it deliberates such choices, considers the public to be ready for NHS dentistry to be reprioritised to a core service remains to be seen.  What is certain, is that 2017 should see an open and honest debate about the future priorities of the wider NHS that both informs and involves the public, and the role of dentistry within the NHS should not be immune from such scrutiny.



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