June 2012

The Health and Social Care Act (2012), until recently wending its weary way through Parliament as the Health and Social Care Bill, will abolish local Primary Care Trusts (PCTs) and revert to commissioning primary dental care through a central National Commissioning Board. It is generally accepted that the performance of PCTs in commissioning dental services was patchy, that to develop and maintain the appropriate skills a more centralised approach was needed (Department of Health 2009) and that good progress is being made. The Minister with special responsibility for oral health, Earl Howe, presented his vision for dental services at the 2011 Spring meeting of BASCD at Sheffield. He seemed well briefed, genuinely committed to improving the quality of and access to dental care, and very willing to engage in open debate at a high level. His presentation was one of the highlights of an outstanding conference. In its previous incarnation the centrally driven dental contract treated with a laissez-faire approach the long standing and grossly inequitable distribution of general dental services (Jones, 2001; Lennon, 1976) Commissioning through local PCTs offered a potential antidote to this problem and, in the future, consultants in dental public heath will need to strive to keep these local issues alive on the national agenda. However it must be appreciated that expenditure on primary dental care accounts for less than 5% of total NHS spend and that there are wider determinants of health. It is perfectly legitimate for BASCD to focus on these wider determinants and in particular to express concern in an open letter to the Secretary of State (BASCD, 2012) that the legislation will reinforce rather than ameliorate inequalities in health. BASCD are not alone in expressing these concerns The Faculty of Public Health, the Royal College of Paediatrics and the Royal College of Psychiatrists, all medical specialities with a focus on vulnerable groups, have expressed similar concerns. But the consensus is wider than this. Lord Crisp, former Chief Executive of the NHS and Permanent Secretary at the Department of Health condemned the bill as a mess (BBC News 26 February 2012). He argued that the bill should set out the direction of travel towards more community and prevention-based healthcare and, although with some use of the private sector, a much greater emphasis on integration. Tim Farron, President of the Liberal-Democrat party went further calling for the bill to be dropped or massively changed. One of the Government’s mantras is that they are peeling away layers of bureaucracy and putting commissioning in the hands of local clinicians. However the idea of local general medical practitioners sitting down to negotiate multi-million pound contracts with sharpsuited Directors of Finance at their local Foundation Trust Hospital beggars belief. The reality is that new layers of bureaucracy are emerging but now from the private sector. The application of EU competition law, the provision that up to 49% of NHS income can be derived from private patients, and opaque contracts deemed secret on the grounds of commercial confidentiality will allow the private sector to flourish. David Rose writing in the Mail on Sunday (26 February 2012) suggested that real power will be exerted by insurers such as Axa and Bupa, by the US private healthcare giants United Health and McKesson, and the consultants KPMG and McKinsey. Certainly in the United States such companies exert huge influence and through their lobbying activities seek to influence, in their own interests, healthcare reform (McColl,2012). Once in the driving seat these companies are difficult to dislodge. Professor Julian Le Grand (Guardian Letters, 27 February 2012), another in the list of distinguished speakers at past BASCD conferences, argues that “a good way to achieve the best possible healthcare for all NHS patients is through the challenge to public hospitals by competition between them. This is not” he continues “based on intuition but on an increasing amount of evidence.” However this evidence probably relates to rather limited and managed excursions into the private market. My intuition is that by the time we have accumulated the evidence on the outcome of the present bill it will be too late to do anything about it. References BASCD (2012): Open letter to the Secretary of State for Health. British Dental Journal 212, 205. BBC News (2012): www.bbc.co.uk/news/uk-politics-17169519 Department of Health. (2009): NHS dental services in England. An independent review led by Professor Jimmy Steele. London: Department of Health. Jones, C.M. (2001): Capitation registration and social deprivation in England. An inverse ‘dental’ care law. British Dental Journal 190, 203-206. Lennon, M.A. (1976): An evaluation of the adequacy of the General Dental Service. British Dental Journal 141, 223-228. McColl, K. (2012): Wendell Potter: Pulling the curtains back on spin. BMJ 344, e833. 130