On 12th June, the Chief Dental Officer (CDO) for England, Sara Hurley, brought together key stakeholders in dentistry to be transparent about the department’s work, to open the lines of communication, and to support efforts to improve oral health on a national basis.
The CDO and her team were at pains to emphasise the importance of everyone working together effectively and, to help demonstrate how this might work, the hierarchical structure of their position was explained. This showed how the CDO receives information and to what extent she can influence change. A somewhat challenging system, it engenders sympathy for the CDO but also does cause one to ponder how realistic change is…
As the CDO said on the day, ‘Things do take time. I’ve certainly found the wading through treacle attitude a bit of a test of my patience during the first two years of this post. I’m now coming to understand that the bureaucracy will actually end up producing a good result.’
Among the attendees was Nigel Jones, Sales and Marketing Director at Practice Plan, following the successful activity surrounding Practice Plan’s NHS Confidence Monitor*, which shone an important light on the dental profession’s status quo in these challenging times. Like many in the room, he was keen to learn more about the progress of the NHS dental contract.
Sara and her team shared with everyone that it was important for the NHS contract currently being prototyped to be patient-focused, with the aim of increasing access and supporting proactive prevention.
“We’ve been living with contract reform for quite some time. There is clearly an evaluation and evolutionary process. I know there is a frustration with the timescale, but we do not want to rush to the wrong solution when we could have, within our reach, the right thing for our patients.” Sara Hurley
She said: ‘We need to create a contract that meets the needs of a 24/7 growing population whilst still working within the economy we have. We also need a contract that is going to support proactive prevention and learning intervention. This, perhaps, means thinking outside the traditional clinical environment. Along with this, regulation and policies need to keep us doing the right thing at the right time in the right way for our patients. The contract also needs to be one that enables learning and critically supports quality improvement.’
She went on to say: ‘We’ve been living with contract reform for quite some time. There is clearly an evaluation and evolutionary process. I know there is a frustration with the timescale, but we do not want to rush to the wrong solution when we could have, within our reach, the right thing for our patients. This reform is about having a contract that meets the health needs of patients. I’ve heard it so many times referred to as a new contract for dentists. It isn’t; it’s a new contract for patients.’
To this, Helen Campbell, representing the Department of Dental Health, added that there would be no roll-out in April 2018, as some were expecting: ‘It’s a given that this contract has to be better for patients, for commissioners, and for dentists, before we would go for a roll-out. And that’s why it’s taken a long time, to be completely honest.’
She continued: ‘There will be substantial evaluation in the autumn and, on the basis of that evaluation, the Department of Health/NHS England will be taking a decision on how the contract should be rolled out – in the case of any roll-out.’
A practical perspective
Speaking after the event, Nigel said he felt that the briefing had served as a good exercise to get all of the stakeholders to the same level of understanding as to the current situation.
“If, as they said today, they’re not going to impose a contract that doesn’t work for all three parties, then some might argue that’s tantamount to saying there isn’t going to be any contract. Trying to find something that works and is affordable is a real challenge.” Nigel Jones
‘It seems that the timings for any contract are up in the air, especially given they’re trying to create something that works for patients, for the profession, and for NHS England. If, as they said today, they’re not going to impose a contract that doesn’t work for all three parties, then some might argue that’s tantamount to saying there isn’t going to be any contract. Trying to find something that works and is affordable is a real challenge,’ he said.
Nigel continued: ‘But then you only have to look at the context in which they’re trying to influence change, and I don’t think that had really come across to me quite so substantially before today, so it was a really helpful insight. I hadn’t properly appreciated the separation between the office of the CDO and the linked departments, such as those responsible for the operational aspects of the dental contract.’
Nigel also expressed disappointment in the lack of a timeline for rolling out a reformed contract, remarking that the concept of a roll-out in April 2018 is certainly off the board now.
Considering this in practical terms, he went on to reflect that many in the profession will feel they have to stop waiting for somebody else to sort out the challenges they face when practising NHS dentistry, ‘…because it’s not going to happen any time soon. I don’t doubt the intentions of the CDO and her team, and clearly there have been some very positive steps forward in respect of the pathway and the overall experience for patients. However, for many practices that has come at the cost of access, the importance of which was again emphasised today so there’s a practical reality, which is the combination of a lack of money and a bureaucratic nightmare hampering real progress. Of course, I’ve obviously got my own undeniable interests in all of this but I genuinely think many dentists will be forgiven for thinking that this reformed contract idea has been developing for too long and that, actually, they need to take control of their own destiny.’
“I genuinely think many dentists will be forgiven for thinking that this reformed contract idea has been developing for too long and that, actually, they need to take control of their own destiny.” Nigel Jones
Record-keeping in the real world
In addition, as someone who works closely with dental teams striving to deliver the very best care whilst running a successful business, Nigel wanted to touch, here, upon Jonathan Green’s response in the Q&A section of the briefing in respect of the challenge of trying to balance the provision of high standards in patient care with the need for an efficient delivery model. (Jonathan Green is Executive Director overseeing Fitness to Practise at the General Dental Council (GDC).)
In exchanges with the GDC in 2015, the Federation of London Local Dental Committees (LDC) raised the question of how one delivers ‘gold standards with a tin-plated budget’, and in reply the GDC said that taking steps to understand the combined pressures under which the profession operates was not currently seen as part of its role.
However, responding to an issue raised during the Q&A session that followed the CDO’s update, Jonathan Green mentioned that regulation needed to address the driver of behaviour of which the NHS contract is one.
He went on to say, ‘When I sit in and observe Fitness to Practise hearings, very often part of a registrant’s defence is that their record-keeping struggled because they were up against it in terms of time. We and our panels are sympathetic to that, but obviously it’s something that needs to be addressed as part of the regulatory picture.’
On this, Nigel commented that it is very reassuring to hear that the GDC is alive to the pressures and feel it is something that should be considered, but was keen to explore what was meant by the panels being ‘sympathetic’ to a dentist being too up against it to keep records to the standards the GDC requires.
“When I sit in and observe Fitness to Practise hearings, very often part of a registrant’s defence is that their record-keeping struggled because they were up against it in terms of time. We and our panels are sympathetic to that, but obviously it’s something that needs to be addressed as part of the regulatory picture.” Jonathan Green
He said: ‘Does that mean a panel will look with understanding that a registered dental professional can’t always reach the desired standards because they’re working so hard under the NHS? To me, that hints at an admission that the Federation of London LDCs maybe had a point and there are circumstances when you can’t deliver the standards the GDC think you should do on the NHS. That sounds very pragmatic and realistic but also potentially significant in terms of what it says about the behaviours driven by the pressure arising from the current NHS contract.’
On a final note, Nigel added, ‘If the objective of the day was to help stakeholders understand the difficulties of the environment in which the CDO is operating, then it worked. Now the profession needs to react proactively and take control of their future in light of the uncertainty, albeit tempered by good intentions by the CDO.’
Other key issues discussed at this briefing were:
- The political and fiscal landscape within which the dental profession has to work, and the need for a business model that can optimise technology use and utilise the dental team to best effect