There is no sense of irony from NHS England commissioners when they state how pleased they are with the results from the implementation of the Dental Assurance Framework (DAF). “It is working”, we are told, “practices are reducing their red flags”. This gives the game away of course: the DAF is about pressuring dentists into certain behaviours, about bringing outlying practices to the average; it is not about providing the NHS with ‘assurance’ in any meaningful sense of the word. But where in the regulations does it say we must be average?
As a patient I wonder, would I feel assured by NHS England’s DAF? On the contrary, if I learned that the NHS uses national and regional average treatments (which, perversely, become targets, of course) to monitor the “performance” of my dentist, I would worry that the quality of my NHS dentistry might be being compromised – what might they do or not do for fear of being flagged in some report?
So where are we practitioners left in this situation? Between a rock and a hard place, of course. If I aspire to the “average” (doing my best to avoid becoming an “outlier”) every time a patient sits in my chair I might not feel able to care for that particular patient in the best possible way. Clearly, this undermines and potentially compromises my clinical independence. If I exercise my clinical freedom however, and follow my training and experience, doing the best I possibly can for that patient and others like them, I might end up an outlier. As such, I would receive a report from NHS England and a letter asking for an explanation of why my indicators vary from the average. So I would be sentenced to a process of Kafkaesque correspondence, form-filling, inspection, interview, interrogation and ongoing scrutiny, often about implied misdemeanours that are only the statistical outputs of my attempts to provide the best care to my patients. (Kafka’s work seems to anticipate brilliantly how NHS England would one day manage dental contracts.)
And what about patient choice? Has it not occurred to anyone that a one size fits all metric for the whole of England just might not be the best way to check that clinicians are providing patients with the best possible care? How can an average indicator for extractions be useful for an area in which some of the wealthiest and the most disadvantaged people in the country live side by side? How is the average number of days between two band three courses of treatment comparable when some practices serve heavily restored populations and others do not?
The answer is it can’t; it’s nonsense, of course. The DAF is simply a tool to scare dentists into behaving in certain ways (to encourage us to aspire to the average) for the purposes of saving money. How demoralising. Sadly, it appears that there is little interest within the NHS about whether or not the DAF itself is actually appropriate, or whether the reports and indicators are actually useful for the practices and the dentists they engage. This does a disservice both to us as professionals and to the patients we care for.
Stick to what you know…
Those at NHS England, the CQC and the General Dental Council (GDC) must all have sore toes at the moment as they have all been trodden on by one another so many times recently.
Despite the Care Quality Commission (CQC) being legally responsible for regulating practices that provide dental care, commissioners seems obsessed by the notion that it is only NHS England that is able to secure the assurance it requires from practices providing NHS services. We have raised our concerns about the duplication of regulation and the potential double (or even triple) jeopardy that practices, providers and individual dentists may be subjected to in the existing regulatory blizzard.
When we complained about the duplication of practice inspection in London, David Geddes, Head of Primary Care for NHS England, told us that he was concerned that “a practice could continue providing NHS services without undergoing a practice inspection by the CQC for over 10 years”. Clearly NHS England’s rationale for behaving as it does is that it cannot trust the judgement of the healthcare regulator. Does this mean that, in order to be fair to patients, private providers should be putting signs on their front doors stating: “NHS England is not assured about this service”? Or perhaps the CQC should be offering NHS providers a discount on their registration with the CQC, on the basis that the work of regulating these practices is already being undertaken by NHS England.
We all know there is a desperate need both for paediatric and restorative dental services across London (to name only two). Could the money being wasted on duplicating the CQC’s role not be spent more wisely on services for patients?
Down in the mouth
This August 2015, the Government produced its own data identifying that dentists who work in the NHS were likely to have a ‘motivation index’ at least 15 per cent lower than the same dentists working privately.
Given this environment we are working in, is it any wonder that morale is so low? What can be done? Surely we must start to recognise that the regulatory environment in which professionals deliver care is intimately linked to the care patients receive. Getting it wrong puts both professionals and patients at risk. Following the inquiry into the tragic failures in care at Mid-Staffs hospital, NHS England’s own work with nurses has highlighted the importance of ensuring that the professional and regulatory environment enables the delivery of compassionate care. They have shown that helping professionals to reconnect with their work can transform the care patients receive.
I worry that overbearing regulation and NHS interference in our practising lives creates in us a disconnection from our clinical dentistry. This anxiety is something I hear other colleagues across London bemoaning frequently. Proportionate regulation is one thing but when regulation is duplicated and when we are relentlessly scrutinised by ill-conceived metrics, our morale and motivation just cannot cope. This is bad for us as people and as professionals, and it is bad for the patients we are trying to care for (not to mention being bad for the taxpayer).
LDCs have a crucial role to play. There is now a gaping chasm between NHS England and dentists who are delivering NHS dentistry. Where once something local existed, there are now national performance management frameworks driving the “computer says no” culture of our age. I fear the professional voice has been lost within these distant and inaccessible national agencies. LDCs can help in ‘caring for the carers’ and providing the much needed pastoral support to our profession, which has so rapidly been lost over the last few years. But commissioners too really must take advantage of the local professional expertise available within LDCs. It is disappointing that input from LDCs into the commissioning process is not sought more frequently and more proactively. When will the NHS really begin to grasp the fact that contracts don’t treat patients, clinicians do?
Whilst I appreciate the importance of regulation, I believe collaboration is a much more effective and efficient tool when it comes to redesigning services and delivering care to patients (I think the current jargon is “co-production”). And it can only be by working together that we will be able to rebuild the morale and motivation of those in our profession. It is dentists, not commissioners or regulators, who are the ones engaged in caring for patients. The regulatory and contractual environments must serve as ‘enablers’ of good patient care.
The agencies involved owe it to us, to the public and to the patients we care for.
Chair, Ealing, Hammersmith and Hounslow LDC