What are the risks of choosing not to implement complex care pathways?

Ian Gordon explains the clinical rationale, operational reality and practical risk underpinning the decision to use or not implement clinical care pathways.

Complex care pathways (CCPs) are clinically logical. They are designed to support patients aged 16 and over with significant caries and/or unstable or more severe periodontitis, using prevention, risk factor management, self-care support and staged stabilisation rather than repeated disconnected courses of treatment.

The clinical concepts are underpinned by well-established principles of prevention and stabilisation, aligned with evidence-based dental practice. The main criticism is that implementation, reporting and payment systems must be good enough to support the clinical model.

A blanket non-use position is less safe after the July guidance. Clinicians should make patient-specific decisions, in partnership with the patient, about whether a care pathway or a banded course is more appropriate.

For patients with active disease and give or more carious teeth, NHS England says phased courses should no longer be needed, with recording of phased courses for this cohort expected to end by 31 December 2026.

Patient charging is a central complaint risk. A pathway normally gives cost certainty through a single Band 2 charge unless qualifying Band 3 treatment is required. Repeated banded or phased charges for an eligible patient will be harder to defend unless the record explains the clinical and charging rationale.

The right position is controlled case-by-case use, not blind implementation and not blanket refusal. Practices need a readiness plan, patient information, a live pathway register, monthly reconciliation and a clear remuneration policy before encouraging routine use.

What complex care pathways are trying to achieve

The pathways are designed for patients whose disease and risk profile do not fit comfortably into a short, episodic model of care. In these cases, the clinical task is not simply to repair or extract individual teeth. It is to diagnose the disease process, stabilise it, manage the patient’s risk factors, provide appropriate restorative or periodontal care, and then reassess before setting a risk-based recall.

That is a positive clinical direction. Many clinicians have long argued that the NHS contract has not adequately supported planned stabilisation for high-need patients. The July guidance gives that clinical intention a clearer structure. It also explicitly supports use of the full dental team, provided team members are qualified and competent for the care they provide.

The table is deliberately simplified. Clinicians still need to check the full eligibility rules and exceptions, particularly for periodontal staging and grading, and must record the diagnostic basis for pathway entry.

Deciding between a pathway and a banded course of treatment

The July guidance is clear that the decision should be made by the clinician in partnership with the patient. That creates an important practical discipline: the question is no longer simply whether a practice has switched CCPs ‘on’ or ‘off’. The question is whether the individual patient was assessed, whether the pathway was clinically suitable, whether the patient was willing and able to engage, and whether the chosen route was explained and recorded.

This is the key medico-legal update. A practice can still take a cautious implementation stance, but it should not prevent clinicians from making patient-specific decisions. Where a patient appears eligible and a CCP is not used, the record should explain why the alternative is clinically appropriate and what charging consequences were discussed.

4. Phased treatment: the most material update

NHS England now says that care pathways integrate the clinical concept of stepped or phased care for patients with active disease and 5 or more carious teeth, and that recording of phased courses of treatment for this cohort is expected to end by 31 December 2026.

That does not mean banded care disappears. Nor does it mean every high-need patient must automatically enter a pathway. It does mean that for the eligible high-caries cohort, phased treatment should not be presented as a durable long-term workaround if the practice is uncomfortable with CCP administration.

Administration and declarations: the operational risk remains high

A CCP is not just an extended appointment plan. It is a structured course of treatment with monthly declarations, ordering rules, possible suspension, incomplete pathway rules and final declarations. These processes matter because missing, late or rejected declarations can affect crediting, payment and the credibility of the record.

Patient charging and complaint risk

Patient cost certainty is not an incidental feature of the reform; it is part of the stated rationale. Most charge-paying patients will pay a single Band 2 charge for the pathway, unless qualifying Band 3 treatment is needed, in which case the total patient charge is Band 3.

That means repeated banded or phased charges for an eligible high-need patient may become a foreseeable complaint theme. The issue is not that every eligible patient must be placed on a CCP. The issue is whether the patient was told enough to understand the options and whether the chosen route was recorded as clinically and contractually appropriate.

What practices should do now

The practical response is not to stop using CCPs, and not to roll them out without controls. The safer position is controlled, documented, case-by-case use supported by a clear operating process.

• Update clinical templates to include a CCP eligibility screen, disease and risk profile, diagnostic statement, personalised care plan, SMART goals, patient consent and charging explanation
• Create a controlled implementation policy that allows CCP use where criteria are met and the practice can manage declarations, appointments, charges and remuneration
• Review phased treatment templates and identify patients with active disease and 5 or more carious teeth, given the expected end of phased recording for that cohort by 31 December 2026
• Prepare clear patient information explaining the pathway, expected duration, Band 2/Band 3 charges, attendance commitment, missed appointment consequences and what happens after completion
• Maintain a live pathway register showing pathway type, start date, responsible clinician, monthly declarations, suspension/incomplete status, final declaration, patient charge and payment reconciliation
• Keep pressing for reliable, exportable, performer-level and pathway-level reporting, with clear separation between core UDA delivery, unscheduled care delivery and converted UDA credits.

Conclusion

The July guidance is a welcome and important clarification. It makes the clinical case for complex care pathways much easier to understand and places the pathways firmly within prevention, stabilisation, periodontal care, minimally invasive dentistry and skill mix. The clinical direction is difficult to criticise: for the right patient, a longer structured pathway may provide more coherent care and clearer charging than repeated disconnected courses of treatment.

However, welcoming the clinical rationale is not the same as accepting that the implementation is ready. There is widespread criticism across the profession of the mechanics of these reforms: the complexity of the pathway rules, the monthly declaration process, the interaction with patient charges, the reporting requirements, the ability of Compass and Eden to show activity clearly, and the difficulty of reconciling pathway activity with contract performance and associate remuneration.

Those concerns have been raised by providers large and small, professional bodies, LDC voices software suppliers and on dental social media sites. They should not be dismissed as resistance to clinical reform; they are legitimate concerns about whether the system can safely support the care model it is asking practices to deliver.

Clinical governance risk

There is also a further clinical governance risk. The assessments described in the guidance reflect current best practice, including structured diagnosis, caries staging and activity assessment, periodontal staging and grading, risk profiling, SMART goals and documented prevention. That is clinically sound, but it may feel unfamiliar or administratively burdensome to many practitioners who have worked for years within a simpler banded-course framework. If practices do not adapt their records, this could create another route for complaints or regulatory criticism.

CQC inspections already look at whether practices can evidence compliance with recognised guidance, including periodontal guidance. A pathway model that depends on detailed risk assessment and documentation will expose weak records more quickly.

The central patient-facing risk is therefore straightforward. If a patient appears eligible for a pathway, the practice should be able to show that the option was considered, the alternatives and charges were explained, and the chosen route was clinically appropriate. This will become particularly important as phased treatment recording is expected to end for patients with active disease and five or more carious teeth. Repeated banded or phased charges for an eligible high-need patient may be difficult to defend if the record does not show why a pathway was not used or why the patient declined it.

Controlled, documented, patient-specific use

The safest position is not blanket refusal and not uncontrolled implementation. It is controlled, documented, patient-specific use. Practices need practical systems before CCPs can be used confidently: an eligibility screen, clear patient information, a pathway register, declaration tracking, charge reconciliation, record templates and a remuneration policy for cases involving multiple clinicians or skill mix.

It is entirely reasonable to be critical of the current process. The profession can support the ambition of better care for high-need patients while still saying that the administrative and reporting architecture is too complex and not yet sufficiently transparent. A reform with sound clinical intent still needs an operating system that works in real practice. Until that is fixed, the best protection against complaints is to make the patient-facing decision clear: assess eligibility, explain the options, record the charging implications, document the clinical reasoning, and make sure the care actually delivered can be justified from the notes.

Source basis and limitations

This publication should be read alongside the NHS dentistry quality and payment reforms contractual guidance, the relevant SFE/payment provisions, and any further NHS England, BSA or BDA updates.

This is a practical commentary article rather than legal advice. Guidance and reporting arrangements may continue to evolve, including further phased-treatment guidance and changes to Compass/Eden reporting. Practices should keep their approach under review as national systems and guidance develop.

Got questions or need advice?

If you have any questions, or would like further advice on how to mitigate risk around Complex Care Pathways in your practice, contact your indemnity provider. Densura policy holders can contact their dento-legal advisor by emailing notifications@densura.com, or calling 020 3859 8765.

This article is sponsored by Densura.