NHS complex care pathways: the clinical logic holds, the fee does not follow
Ian Gordon, dental director at Riverside Healthcare, holds that the clinical logic of the NHS complex care pathways is sound, but that the fixed fee does not recognise the most severe patients, and the cost of treatment falls on the practice at the very start.
A fixed pathway value does not follow the volume of work
Ian Gordon, dental director at Riverside Healthcare, writing for Dentistry.co.uk, supports the clinical logic of complex care pathways (CCP) in the British NHS, but lists the reasons the model could stall in everyday practice.
The first is remuneration. The requirements of the pathway are extensive: assessment, diagnostics, staging and grading, identification of risk factors, a personalised care plan, preventive advice, reviews, documentation and closing the pathway. The value of the pathway, Gordon argues, does not reflect everything that is asked. The second is the range of severity: the threshold for entering the caries pathway can be met by a patient with five carious teeth, but equally by one with seven, ten or more. Those patients require substantially different clinical time, so a fixed fee, Gordon warns, may not recognise the upper end of complexity.
The third problem is non-carious need. Fractured teeth and failing restorations consume a considerable share of clinical time, and the entry criteria do not cover them in full. The fourth is the transfer of financial risk: the practice bears most of the cost at the start of treatment, while completion depends on whether the patient keeps returning for appointments over months. The fifth is the rigid prescription of the process which, instead of supporting clinical judgement, may constrain it.
Gordon also insists that prevention remain at the centre of every NHS treatment, whether or not a CCP is used: the payment mechanism must not decide whether prevention happens at all.
Context
The CCP is an attempt to pay for a patient with a high burden of disease as a complete care pathway rather than as a sum of individual procedures. Gordon's objection is not aimed at that idea but at the question of whether the pathway as set up is simple, flexible and funded enough to survive in general practice.
For the practice
- Transferable to the Croatian context: a flat per-case fee poorly recognises the patient with the greatest burden of disease. When negotiating packages, insist on a threshold above which work is paid separately.
- Transferable: the cost arises at the start, the payment at the end. If you work in stages, arrange the appointment sequence so that the most expensive material does not go in before the patient has shown that they turn up.
- Not transferable: the CCP entry criteria and the level of the fee are tied to the NHS contract and have no direct equivalent in the Croatian system.