A year in the life

The publication of ‘NHS Dental Reforms – one year on’ prompted thoughts about how little has changed in half a century of NHS dentistry, writes Dentistry columnist Dr Roger Matthews.

There were, in the 1970s, a good number of practising colleagues who could clearly recall the days before the introduction of NHS dentistry in July 1948. Sometimes the waiting room would be empty for days on end (apart from the odd acute pain case) as patients waited for the ‘free service’ they had been promised.

And what a promise was delivered! Pent-up demand suddenly leveraged what the Spens report had said was previously – in general – a low-paid and poorly regarded profession into one which could scarcely cope with the level of business flooding in.

It’s revealing to see (courtesy of the National Archive) the Cabinet Secretary’s notes for May 1949. Aneurin Bevan was fighting Treasury demands to cut the burgeoning new NHS budget. He said: ‘Meanwhile, I had begun a series of options to reduce fees for eye-men, chemists and dentists. The dentists soured public opinion by their behaviour. Couldn’t get their co-operation at lower fees. Allowed them to misbehave to get “atmosphere” for the cut. Now cutting fees by 40% net…’

Later in the meeting he said that as Statute forbade him from making a charge to patients (of which he did not approve, anyway), the only alternative was to reduce the service.

So the latest in a series of political moves to bring the dental profession into line with government policy should not come as any surprise. Fifty-nine years ago, the direction was set which was to continue with the introduction of patient charges, the independent pay review body, the 1990 New Contract (and subsequent fee-cut), and most recently, the 2006 reforms.

As a profession, and as independent business-owners by and large, dentists have always had more to lose – and to gain – from the vagaries of the ‘system’ in place for their nationalised remuneration. Whilst hospital doctors, pharmacists and even GPs have always had some compensatory or balancing safeguards, NHS dentists were and are more exposed.

Bluntly, a dentist earns whatever is left when the costs of the business are paid – and sometimes that is a negative figure. It is hardly surprising that to some degree, the ability to ‘play the system’ has become ingrained. And that phrase is not necessarily derogatory. I can recall, in a fee-for-service system of the 1970s, finding legal but imaginative ways to deliver preventive care to patients in greater need of that provision than any number of restorations.

Emerging factors
The reforms of 2006, however, introduced two totally new factors: the limiting of dental budgets and the empowerment (in England and Wales at least, so far) of local health economies to administer those budgets. It is not just that the global sum for dentistry is capped, but it is capped within 170-odd, quite small, pots.

The clear indication, in the August 2007 Department of Health review of dentistry, mentioned at the outset that these dental budgets would not be protected from 2009, and that contractual UDA values should be harmonised and related to both the quality and level of individual performance, comes as a further signal of future intent.

It would be naïve to believe that this means all PCT dental budgets will be shrunk, but equally so to believe that payment will continue to be made either at a significantly higher rate for any dentist, or at any form of guaranteed rate for even the best and most diligent.

The projected increase in UK dental graduates, the opening of international health markets (whether patients seeking treatment abroad, or the influx of overseas graduates with lower economic expectations), and the de-regulation of dental business in relation to hygienists, therapists and clinical dental technicians is likely to feature more widely – all these factors point in one direction, and that direction is pretty clear to me.

The polarisation of dental practice was foreseeable early in the process of reform, which followed (but only selectively acknowledged) the work of ‘Options for Change’. That polarisation is now happening and will accelerate. The removal of the ‘child-only contract’ option is happening increasingly across PCTs. A move towards more centralised provision of primary health care is becoming slowly apparent, and post-graduation/vocational training polyclinics will undoubtedly proliferate.

Equally, the growth of corporate practice in this area has been underlined by a statement from the new owners of one of the largest chains, to the effect that the demise of NHS dentistry has been over-stated (Private Healthcare News August 2007). Dentists with significant private practice, or whose performance does not attain a green light on the new Balanced Scorecard, may be marginalised – though such scores, like UDAs, are of course indicators and not targets!

Views and transparency
Since 1948, I think that the government has felt that dentists enjoy, in their eyes, an unhealthy monopoly. We seem unable to convey the true costs of running an efficient, high quality, compliant and health-promoting practice, with all the investment in technology, personal development and skills that entails. Yes, we are good at bemoaning our fate, but there is no shortage of applicants to soak up surplus UDAs at prices that make me go pale.

Equally, we need to engender true transparency and good old-fashioned communication to our patients. We have become, in many ways and for many (not all) practices, an institutionalised profession.

I heard recently of a dentist who had taken on a new associate who qualified in India. The principal said: ‘He’s an excellent dentist, but he just can’t get his head around UDAs. He thinks they are totally illogical. I will have to spend more time explaining to him.’

Perhaps he would do better to have this associate explain his views to the rest of the practice. We have spent over half a century arguing over the minutiae of the latest system, the most recent tweaks of bureaucracy.

Dentistry is, of course, a political embarrassment; patient charges, independent ownership of facilities, multiple solutions for many clinical problems. We constitute less than 2% of the NHS budget, but three quarters of a million patients (voters) visit an NHS dentist every week, according to government sources.

There is a dilemma, a growing strain which for some is becoming unbearable – and a new, untested and illogical system is not helping – except to keep the global budget in line and local health managers in the driving seat. But there are answers too, are there not?

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