From dental contract to system reform: why an incremental approach is needed

Dental contracts are required to simultaneously satisfy three seemingly unreconcilable requirements: access based on need and not ability to pay (equity); minimisation of costs per unit output (efficiency); and paying for it all without breaking the bank (cost). In dentistry, further tensions exist, such as how to incentivise prevention while maintaining optimal efficiency and minimising opportunism, even though the dividing line between what is too much or too little treatment is often blurred. This is a classic type of policy problem which can be understood in terms of the properties of wicked (or stubborn) problems where stakeholders see the problem differently. There is no obvious solution and every attempt at a solution leaves a mark. This means that it is inappropriate to be talking about a new dental contract as the one perfect resolution to a problem which has eluded us since the 1990s, but rather we need to seek a 'better' arrangement achieving an acceptable equilibrium balancing various tensions. These types of policy problems also tend to be a 'cluster of interlocked problems with interdependent solutions'. We need to recognise that while dental contracts can shape system outputs, outputs are also determined by a range of wider system factors, such as culture and team-working, which determine how the system works, what is produced and for whom. Thus, we should be talking about the dental system, rather than dental contract reform. Further lessons from health policy are that the process of reform can be as complex as the content of reforms. Success in reform is dictated more by how the process is applied rather than purely on what contents are formulated, so implementation is key and a staged or incremental approach to reform is advised. This paper outlines the approach to dental system reform taken by NHS England since March 2021.