NHS Dental Contract: Proposals for Pilots
December 2010
Inequalities in health and oral health occupy the list of the greatest challenges remaining in health improvement (Chestnutt, 2013). Even though oral ill-health patients in England have decreased in a considerable percentage disparities are still present (PHE, 2017a). Indeed like poor nutrition and obesity, oral health is seen as a marker of wider health and social care issues. The latest oral health surveys in adults and children have shown that one-third of the British population continue to suffer oral ill-health (PHE, 2015a; PHE, 2015b; Steele and O’ Sullivan 2011), especially affected those living in deprivation. Doctor Evans (2002) states that as one goes down the socioeconomic spectrum, high-risk characteristics increases and class status in health appears. Poor dental health impacts not just on the individual’s health but also their family wellbeing. Transforming lifestyles and life circumstances are key to decrease the social gradient in health (Chestnutt, 2013; PHE, 2017).
The main objective of this paper is to critically analyse the health policies related to the oral health system of England, where the principal entity involved is the government through the National Health Service (NHS). These policies’ aim is to change the public oral health contract, in order to provide a proper service suitable for this generation. The principal focus of this analysis will be on the policy NHS Dental Contract: Proposals for pilots (Department of Health (DH), 2010), which was proposed on December 2010, after the creation of the white paper Healthy Life, Healthy people: Our Strategy for Public Health in England (HM Government, 2010).
Across the UK discrepancies in oral health are found. There is also difference between the populations of the public dental services primary care trusts (PCTs), ones with the best dental health and those with the worst in England (BDA, 2009). According to Graham (2004), the meaning of health inequalities has shifted between health disadvantage, meaning that some social classes are worse off than others, to a health gapbetween higher and lower social groups and a gradient where health is related to a position in the social hierarchy. Given this rationale, there can be said that for those in the lowest socio-economic places oral health is
Thinking more critically about poor oral health as an issue there are some other factors that might help explain the nature of the problem. According to Dahlgren and Whitehead (1993), the health status is strongly related to the individual’s environment and other social aspects. Some factors cannot be changed such as genetics, age and sex, but the ways individuals behave are modifiable and have an impact that can improve or damage their oral health, such as oral cleanliness and smoking (Watt and Sheiham 1999). In a second place the well-being can be affected by the social support network, family, and friends. Thirdly, structural factors with the living and working conditions, such as the socio-economic gradient in access to dental care and the inverse dental care law (BDA, 2009) and finally broader factors such as socioeconomic, cultural and environmental (Aveyard et al. 2015). Tooth decay is strongly connected with deprivation (BDA, 2009)
NHS Dental Contract: Proposals for pilots is a policy that was created with the intention to overcome the problems related to dentistry and the management of the NHS. The aim was to create a contract whose priority is the achievement of good oral health and the access to the service, a new arrangement that focuses on: routine reports and registration, the same level of remuneration for doctors and the offer of a good quality service for patients. This approach sets out a proposal to be tested first in contract pilots, selected from among the dental practices that apply.
Dental professionals have a crucial part in maintaining the general and oral health of the nation (BDA, 2009), therefore reforming the NHS dentistry impacts the providers and the recipients of the service. The development of this policy relied on a group of experts, formed by members of the British Dental Association (BDA). It was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government. As announced by Simon Burns (Minister of State for Health – Quality). This NHS Dental Contract strategy reflects the government targets to provide a quality service, not tackling oral health inequalities per se, but permitting dentistry to be more incorporated in health services and therefore allowing holistic patient care (DH, 2010).
The NHS Dental Contract: Proposals for pilots has been selected because carrying out what it proposed has a direct impact on the oral health of England’s population, as well as the general perception of wellbeing. While producing a change in the dental public service, oral health promotion could be accessible to the community, specifically to lower social groups, addressing health for those who continue to suffer oral ill-health and thereby trying to close the gap in oral burden.
Following the Dahlgren and Whitehead (1993) model, access to health services have been demonstrated as a crucial part for the improvement of an individual’s wellbeing. Nowadays the principal problem with the dental care service in England remains in the existing system (PHE, 2017a). Back in 2006 the NHS released a dentistry contract aimed to overcome the problem with old dentistry that used to be focused just on treatment (NHS, 2006), and it is worth to mention Watt and Sheiham(1999) words ‘…treatment services will never underlying tackle the fundamental cause of oral diseases’. This contract remained with the same essence, concentrated on the action of healing and repairing damage, also affecting the doctors-patients’ relationship, still leaving a gap in prevention and access (especially to lower income families). When the generation’s needs started changing into prevention and maintenance, there were no incentives for doctors to practice preventative dentistry. In fact, the NHS has never recognised the importance of preventative care in dentistry until now, nor the value people place on achieving and maintaining good oral health (DH, 2010). Therefore, there is a call for dental care services that fit the present population’s needs.
Prevention is the act to impede the course of an action or to stop someone from doing something Reference; it requires an effort that is not countable for the dentist’s reward and it has been reflected in the system. The quality in the service provided is an important determinant to improve the Oral health. Dentists are required to do almost identical numbers of Units of Dental Activity (UDAs), when the majority of people with poor oral health are in need of extensive treatment. In contrast, prosperous population barely need any treatment (Rossi, 2016). It reflects a weak system that has allowed dental services’ inequalities. The existing system does not reward quality: if professionals receive payment for the fee per item, it creates an amount of unnecessary treatments and affects directly the population’s oral health.
Barcach (2012) defines policy analysis as more art than science, encourage the policy makers to realise about the impact of the strategy and approaches and makes one feel participant of the proposal and changes. For the purpose of this policy analysis, the eightfold path proposed by him will be used. The Bardach policy analysis Eightfold Path is a suitable way to systematically approach and to understand the factors surrounding policy making, not necessarily taken in particular order. It is a structured approach that reminds one of important tasks and helps relate the critique and recommendations with reasonable efficiency.
The first step of the Eightfold Path is defining the problem and estimating its importance. Clear evidence has been provided above. However it is crucial to understand the nature of the problem, Bardach also recommends diagnosing the conditions that has caused the problem (Bardach, 2012). In this particular case unbalance is the major issue, affecting access, remuneration and the percentage of ill-health. The contract has failed in solving problems of access for patients, doctors’ rewards and the poor quality of Primary Care Trust’s (PCT) commissions.
Moving forward once the problem has been defined; assembling some evidence is the second step to follow. In the past the population dental needs were impacted by a poor oral health; decayed teeth and the absence of teeth were the main issues presented. Patients used to look for help and attend to the dentist when they already had the problem. Once the NHS was instituted in 1948 oral health needs have changed strongly influenced by the use of fluoride toothpaste and people awareness, moving from a focus on treatment to an emphasis on prevention and maintenance (Ham, 2009).
The established contract is described as a ‘flawed, target-driven arrangements’, in consequence by 2008 there were 900,000 fewer patients seeing an NHS dentist and 300,000 patients losing their NHS dentist in a single month. Some dentists were uncomfortable and insecure about the new arrangements and chose to convert to private care, exacerbating the access problems that had been growing since the early 1990s. In contrast, the NHS Dental contract to combat this problematic has proposed a new way of capitation, in order to provide a fair salary to the doctors and accordance to the patients’ budget. However, one standard system allocated to all the social gradients is a challenge.
The NHS spends approximately £2.25 billion on dentistry each year and NHS patients will fund a further £550 million of services through their charges. In 10 years over £20 Billion has been spent in this system.
Although caries is largely preventable yet it remains a serious problem. Tooth decay is the number one reason of Children’s hospitalisation (PHE, 2015a). The Global Burden of Disease study (2010) found that most disability amongst 5 to 9 year olds in the UK was caused by poor oral health. Findings from the last national dental epidemiology survey of 5 year old children showed that in 2015 in England, a quarter (25%) of 5 year olds had experienced tooth decay (Public Health England 2017c). It reflects the need in access and preventable approaches. Esping-Andersen argues that a social policy should be concerned with social rights. This policy stands for individuals’ protection by proposing a .
Poor dental health influences in people’s ability to sleep, eat, speak and socialise with others.
Once that it has been provided a few facts related to the main issue, it is time to see the solutions in the third step of the Bardach guidance. Reviewing the alternatives constructed to the problem, the main objectives of the New Dental Contract proposal are registration, capitation and quality (DH, 2010). This new approach aims to place patient first and incentive doctors’ autonomy and their own criteria, therefore they could be able to choose the most suitable treatment for individual patient. According to Hudson et al. (2015) access to healthcare services is vital for our general well-being.
Through the registration the goal is to provide the patient a guarantee that they can access to a dentist who knows about their oral health history, and at the same time ensure a stronger continuing relationship.Capitation force a standardise payment, according to the quantity of patients the dentists service to. However not all the patients are the same, needs are different by age, gender and social status, including deprivation. These are factors that should be taken into consideration before applying a standard approach to different social gradients. In relation to the quality, this contract approach aims to account the quality of the service provided, using a tool named the Dental Quality and Outcomes Framework (DQOF) (DH, 2011), which is a guide created after the policy proposal to assess the performance of the practice while measuring three principal stages: the clinical effectiveness, patient safety and experience.
It is important to set the criteria that help to connect the analytic and the evaluative part of the process. The fourth step is to select this criterion, introducing values and philosophy to the policy analysis (Bardach, 2012). In respect to the registration proposed by the NHS Dental Contract: Proposals for pilots, it needs to be doing with formality. It is also important to highlight that this process requires a practice staff more qualify and trained. Indeed it represents a higher expense for the practice budget, the patients should be the first priority and with innovations is precious to not lose the focus.
Equity and Fairness are pillars for the capitation, because there is a thin line between what is seen as fair and what is seen as unfair related to remuneration. One of the issues of the existing contract is that the doctors’ payment is unfair, and it is related directly to the work done. One consultation in a dentist practice is totally different from one another; therefore the proposal of capitation is a great idea under the spectrum of heterogeneity. However diversity is how the world can be defined as, the system also needs flexibility in order to adapt to the different manifestations of oral diseases and needs. A minimum contribution should be given to the doctor with the alternative to increase if necessary, in cases where the harder work is required.
Quality is a delicate part and it is the essence of a service, whereas efficiency is a key value for this stage. The most important evaluative criterion is whether or not the projected outcome will solve the policy problem to an acceptable degree.
As the fifth step to do, for each of the alternatives on the current list, the outcomes resulting from this approach will be projected, but before moving getting deeper into the topic it is necessary to explain how these strategies would be asses. The model will be test in pilots first, to ensure it works. They will extract from this testing, a capitation formula and put into running DQOF, as the measure of the outcomes. Hudson et al.(2015) have suggested that a healthcare policy apart from the medical services delivered by the healthcare professionals might include the delivery of measures that aim to tackle particular health-related problems through health promotion programmes. The measure of dental outcomes has been setting out as part of this proposal. Therefore it could encompass attempts to tackle healthcare inequalities as well.
The Dental Quality Outcome Framework is a tool for accounting dentists’ work and the outcomes achieved. Every year a new one has been released. Thanks to the pilots, because it is tested and any correction needed is made. In relation to safety, the New Contract desire is to emphasise the professional’s commitment. Nevertheless patients’ safety is part of the duty, and it should be by passion. The ultimate clinical outcome is to achieve good oral health. In addition to this, the first principles are: patients free from pain, with functionality and aesthetic, and the maintenance of them. Assess good oral health now and will continue into the future.
The outcomes will be measured by: the numbers of patients that had passed from high risk to a lower risk; percentage of new patients undertaking a full primary care; existing patients with follow-up appointments; new active carious lesions in review; adults improving BPE score at review; and percentage of patients with an oral health and treatment plan. The aim is to collect data about dental caries, periodontal health, soft tissue and tooth surface loss, therefore it could show the quality of the oral health. It is good to highlight that dentist cannot control social but clinical outcomes.
The step six is to confront the tradeoffs. The most common trade-off is between money and a good service received by some proportion of the citizenry. As the New Dental Contract: Proposal for Pilots has been implemented, for the purpose of this analysis, the resulted outcomes will be evaluated.
After the dental practices were piloted, in 2014 was time enough to see the results. 100 practices were testing the new system: 70 in 2011 and 20 in 2013. After carrying on the proposal, there were patients with less engagement. Also a part of the population no interested in improving their oral Health, even though the access were provided, therefore not prevention and follow-up actions applied. Regarding the new registration system, some problems emerged, as lack understanding due to the structure of the new sophisticated software and long questionnaires. Also the practice investment increased. Overall, the system kept focused on treatment (UDA’s).
The seventh step of the Bardach analysis appears to clarify the importance of the policy making and to realise if this is a government problem (Bardach, 2012). As it has been broken down, evidence has been provided to support the importance of this motion.
After almost all the step have been developed, is time of the final product and tell the story this policy analysis brings with. Relevant evidence has been presented to show that New Dental Contract: Proposal for Pilots is all about hitting government targets. Patients should be first priority and focus should be on awareness’ campaigns as well.
There are a number of cost effective interventions to prevent tooth decay that can save money in the long term and reduce the number of children needing time off school because of tooth decay. Targeted community fluoride varnish programmes can, for example, result in an extra 3,049 school days gained per 5,000 children. PHE estimates that the return on investment (ROI) for this intervention is £2.29 for every £1 spent after 5 years, increasing to £2.74 after 10 years (PHE, 2017).
Some Specific dental interventions as provision of toothbrushes and toothpaste have been found to be a feasible strategy. A review undertaken to support the NICE guidance (NICE, 2014) found one economic evaluation with minor limitations suggesting that providing fluoride toothpaste and a toothbrush by post to children aged 0-5 years reduced levels of tooth decay, but did not provide details of saving from treatment costs avoided. This review has identified two further papers conducted in the United States which found that toothbrush provision and fluoride toothpaste (within a multicomponent programme) are cost saving (PHE, 2016).
One Australian study (Koh et al. 2015) looked at the economic impact of home visits by oral health therapists or telephone contacts compared to usual dental care on early childhood caries. Both telephone contacts and home visits were cost saving compared to usual care and so were considered to be dominant strategies.
Also in United States, Samnaliev et al. (2015) undertook an economic analysis of two component disease management programme. The first programme was based in dental surgeries fluoride varnish and setting self-management goals for home care and another programme at home. Parents were given information on how to avoid tooth decay in their children, and also dietary advice. Parents were also given topical fluorides to use in the home, two to three times per day. Both programmes were cost saving over 12 months
NHS England is currently ensuring that the longer term commissioning of dental services fits with NHS England’s Five Year Forward View, proposed in 2014 (NICE, 2017). Access to health services should be based on need rather than on ability to pay. Governments should pursue sound macro-economic policies which aim to reduce poverty.
Investing in health in order to promote economic growth is an available path to take (Beaglehole and Bonita, 2009). When The State involved with the provision of health care, there are two alternative related to state funding, one central funding from taxation and the other one through insurance (Hill, 2006).
Education is a way to ensure the effectiveness of the use of a product. Higher social classes take greater advantage of preventive health services. In strategy of ‘Equality’ the distribution favoured the better off the higher social groups with professionals, employers and managers. This is why a person well prepared is more able to enjoy the benefits of a service. Governments should expand basic schooling, especially for girls, because of their relation to house holding and motherhood, impacts on how the information and financial resources are used for diet, health care and life-style choices, and influence on the health of household members. Focus those supplying health Basic health care and implement strong government regulation (Allsop, 1995). Clinical dental teams have an important role on the population’s health, therefore the UK Government has develop strategies such as the Delivering Better Oral Health to encourage professionals in advising their patients about how they can make healthier choices (PHE, 2017a)
Despite the long delay in its introduction, a new dental contract is a ‘very high government priority’. While there are many things to improve in this policy, it was a much needed step towards the urgency of transforming the dental service. And through the years it has been a tool to make Improvements in the management and delivery of NHS dentistry. It has served to make arrangement in quality provided for patients with oral needs in England through the DQOFs.
The New Dental Contract: Proposal for Pilots policy is the first step in a list of prototypes of a possible new system whose aim is to change the existing NHS Dentistry in beneficial to the population. Even though anticipated outcomes did not were as expected, it has been a helpful document to set out the priorities and the baseline for future guidance. Moreover, in 2015 Dental Contract Reform: Prototypes was proposed as a policy purpose document. In present it is a guidance to refine the pathway approach used in the pilots with the same broad set of quality measures (DQOF).
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