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In my most recent blog, I likened the challenge of embedding prevention in a redesigned English NHS contract to the challenge of completing a Rubik’s Cube – solving one issue unintentionally creates others. This analogy can of course be extended to various other aspects of the potential look and feel of any new dental contract.
The most obvious of these is the thorny issue of providing the appropriate mix of financial incentives within the system to keep everyone happy. This has been a conundrum for successive Governments for decades and despite the most recent wave of pilots and the imminent prototype contract tests, it doesn’t seem any closer to being solved.
The current contract clearly isn’t the solution. It may have left Government happy, given it wrestled control of the NHS dental spend out of the hands of the dental profession, but it has left patients baffled and most of the dental profession (though by no means all) deeply unhappy.
The pilots sought to take forward the work of Professor Jimmy Steele and in large part, with the ring fenced contract values, left the owners of pilot practices feeling a lot happier (though maybe not associates) with their lot. In fact, listening to some of these practice owners relate their experience of being a pilot, with the more relaxed way of working and more time available with individual patients, could have left some in the audience wondering if they were listening to the owner of a private practice not one in the NHS. However, even the most positive of those involved in the pilots generally ended their account with huge scepticism about the sustainability of this approach and the likelihood of it ever being rolled out across England.
This scepticism has proven to be well founded because an approach that made practice owners and to a very large extent, patients, very happy has clearly not made Government happy. Access, the main benchmark for a successful contract in the Government’s eyes it seems, was significantly down and was never going to be acceptable.
There were also reduced levels of activity. Although it could be argued that is consistent with a more preventive approach, it does present Government with the problem of how to determine if they are getting value for money for the tax payer. Quantitative indicators such as treatment volumes are reliably measured; qualitative measures less so.
And so we end up with the current prototypes which apparently seek to address both issues by testing different blends of incentives to both register patients and to increase activity. But surely if this is successful, it will be at the expense of those aspects of the pilots that made dentists and patients happy? Of course, that may not always be the case as the structure of the prototype contracts may prompt some innovation in some practices that have the capacity, in terms of both resource and space, to challenge the normal way of doing things. But that seems unlikely to be the case for the majority.
And this is where the analogy with the Rubik’s Cube breaks down. There are people that can solve the Rubik’s Cube. In fact, they have got more and more skilled at solving it such that the world record is currently a mind boggling 5.25 seconds! There is little evidence to suggest that such progress is being made when it comes to solving the conundrum of appropriate incentives in the NHS dental contract.
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