“I’m going to India for a holiday, and I wanted to know what the local weather was like. So I phoned my bank…”
This minor gem from the stand-up comedy circuit resonates because it is topical, and of course contains more than an element of truth. I’m sure we have all, on occasion, attempted to deal with our finances, insurance or utilities, and ended up having a surreal conversation with an outsourced call centre on the other side of the globe.
Dentistry has not escaped this creeping trend of remoteness, with all the frustrations and sense of powerlessness that it brings; the way in which our work is monitored has changed beyond all recognition. At the time when I qualified the then RDO [Regional Dental Officer] would actually pitch up at your practice, and examine a pre-selected list of patients. His sharp eyes would miss nothing and in addition to commenting on work you had completed, he would sometimes suggest other treatment you might like to undertake.
Clearly one would await these visits with trepidation, but what better way can there be to assess the service a GDP is providing; two professionals standing side by side over a patient. Indeed, as Vocational Training practices we are taught to directly observe procedures and conduct case-based discussions. It is the only valid way in which you can assess how patients are being treated, but of course this is time-consuming and tricky. Clinical records, treatment logs and other portfolio evidence are vital, but are indicators only and should be seen as part of a pattern. The paradox is that the further you get from the dental chair, the easier [and cheaper] it is to quantify things, but the less is known about what has actually been done.
Fast forward to today, and direct examination of sampled patients is a thing of the past. The last time a “Dental Reference Officer” came to my practice was in 2007 as a follow up to the new contract. Several patients were seen, but the clinical work was barely a consideration; our most lively and prolonged discussions centred around aspects of record keeping. I hasten to add that this approach was by no means the fault of the officers involved, it is simply the system they are now required to work to, and it was quite useful in the current climate.
But back to the remoteness mentioned at the beginning. Our patients are now highly unlikely to be looked at unless in response to serious concerns. Our contracts are remotely monitored and a push of a button can provide figures for any metric which has become fashionable, to 2 decimal places, then compare it to local and national averages. Indeed, there are 14 metrics in the new Quality Assurance Framework, and the BSA have just lobbed in an extra one which monitors 28 day re-attendance rates.
There is no doubting the numerical accuracy of these reports, as the numbers are simply crunched from the computerised data we submit. But it is equally true that they are easy to compile, and are far cheaper and less challenging than actually taking a look at a patient. They have their role in identifying claiming patterns and treatment profiles which are causing concern, and it is only right that these should be looked at early, and in an educational and supportive manner.
But these reports should always be a means rather than an end, as they can never fully get under the skin of what is happening. No account can be taken of the local area, the patient mix or simply the practice culture and the quality of treatment provided.
None of this would be too bad if all this remoteness emanated from one source, but of course our fragmented regulatory system has many stakeholders vying for our attention. As well as NHS England there are the CQC, FFT and BSA, and it’s one way traffic. All are quick to send you new directives, but have generic e-mails and can be pretty impenetrable when you want a quick answer to a query. It is the sheer duplication and pointlessness which is so exhausting, the recent Information Governance Toolkit and infection control visits being particular cases in point. This disconnect works both ways, and NHS England commissioning teams have lost extraordinary amounts of knowledge about the practices from which they commission NHS care as their teams have contracted and disappeared into a “regional abyss”.
So, both as a individuals and a collective group of LDCs what can we do?
Firstly, we should invite representatives from NHS England and other agencies to attend our regular meetings; this has always worked particularly well in Croydon, and can be of great benefit to both parties should local problems arise.
Secondly, we must support members who “get a letter” over their contract profiles, and support the view that this is a basis for a discussion, never for immediate or automated punitive measures.
Finally we must continue to press for a “one stop shop” instead of dealing with a myriad of competing regulatory organisations. Also anybody who feels the need to regulate us should be made to provide a dedicated phone line on all communications, exactly as patients should also have access to.
At the very least it would tell us that there is still someone out there…
Chair, Croydon LDC