It has taken a while, but the penny has finally dropped. I will apologise for the pun in advance (the clue is in the title) but it may only become obvious if you have the energy to read on, as I hope you will.
I have finally come to realise that there are three kinds of money in healthcare (as in life). Clean money, tainted money and positively dirty money. The fact that we wear gloves is a metaphor for our approach to money.
Clean money is to be found in the public sector – in hospitals and clinics operated by NHS Trusts of various kinds, and similar entities. All the motives in the clean world are good ones; decent, noble and honourable.
Corners are never cut to save money and any decision not to make a particular investment can always be traced back to an authoritative, reliable and evidence-based source. The fact that the source will often share the same ultimate employer (i.e. the secretary of state for health) should simply be seen as an example of serendipity at work.
In the clean world, everything and everybody is clean, and there is never any conflict of interest between what’s right for the patient and what it costs to provide it.
Tainted money is to be found in the hurly-burly of the ‘high street’, i.e. in general (and specialist) practice. All the motives in the tainted world are inherently dishonourable and should be viewed with great suspicion because everyone in the tainted world is in business to make a profit. The fact that many of them don’t do so, despite their best efforts, is immaterial. When corners are cut in the tainted world, it will always be for the purpose of making more money and there is an ever-present conflict between what’s best for the patient and what’s best for the business. People working in the tainted world can be relied upon to put their own interests above those of their patients.
Finally, we reach the dirty world of corporate dentistry, where nobody does anything for the right reasons and everything is done for the wrong reasons.
This is actually quite difficult to achieve when you think about it, but everything is possible in the dirty world if there is money to be made. Corners will be cut at every opportunity and life in the dirty world is a never-ending conflict of interest where the patient will always come second.
In reality, of course, preconceptions such as those outlined above are convenient stereotypes. In many cases they will be wholly without foundation, while in others they may contain a grain or two of truth here and there. The salaried services consider themselves to be inherently ‘pure’ and ‘clean’ because they have no profit motive to concern them. They certainly feel cleaner than those tainted people in NHS general practice, who in turn feel much cleaner than their heavily tainted counterparts in private practice.
And all of the above feel a lot cleaner than the corporates. Yet corporates will often make the investments that nobody else is prepared to make (or able to make) and I know many practices who are so tainted that at any moment in time they will be treating many ‘pro bono’ patients who are charged little or nothing for the treatment they are receiving. Doesn’t quite fit the popular stereotype, of course, but life in the real world can be inconvenient sometimes.
In these difficult economic times, one could argue that there is nothing wrong with the NHS trying to get more bangs for its buck. As a taxpayer this suits me fine. As a patient it might not do.
A PCT may elect to deny a patient a particular drug or procedure, and the patient may then end up choosing to obtain them from the private sector instead, committing a significant sum of money along the way.
In this example, one could argue that the PCT’s motives are purely financial and therefore questionable, and that the patient is being much better served in the private sector. The counter argument will be that the PCT’s decision was responsible and wholly justified, and it is the motives of the private sector that need to be questioned.
Dentistry does not become good simply because it is free, nor bad because it is not – nor unforgiveably bad because it is expensive. Dentists who charge a little are deeply suspicious of dentists who charge a lot – and vice versa.
But every individual or entity providing healthcare needs to live and operate within its means. For the NHS this means staying within its budget and making smart decisions about infrastructure, staff, materials, and managing demand and supply.
In general practice, it means making a profit and this, in turn, means either earning more, or spending less, or a delicate combination of the two. In corporate dentistry it means delivering and maximising shareholder value. Here again, dentistry does not become bad and decisions do not become wrong simply because someone makes a profit along the way. Nor do dentistry and/or decisions become good simply because nobody is making a profit out of them, or perhaps because a shedload of money is being lost as a result of the treatment being provided at all.
It is a lot easier to put the patient first when the gloves are on if one first ensures that the sums add up when they are off.
And isn’t there a designed-in tension and irreconcilable contrast in perspective between a salaried PCT commissioning manager, and a self-employed provider/practice owner whose livelihood depends on the financial outcome of the financial negotiations? Perhaps this is why so many PCT managers have expected practice owners to carry all the business risks of the free market, while behaving in other respects like PCT employees. It is an unsustainable dichotomy.
Isn’t it about time that we realised that we are all greenhouse-dwellers in one form or another? None of us has the monopoly of all things good and admirable. Of the three models, it could be said that the owner-operator practitioner has the greatest personal stake in maintaining patient goodwill. But the corporate also has its brand to protect.
Just as those working in salaried positions within the NHS, especially in management, will often have to make difficult decisions on financial grounds, those in private practice and corporate dentistry may make loss-making decisions in order to keep the patient happy. We all think that we understand what is going on in other areas of dentistry, and why, but I am far from convinced that we do.
Many of those in private practice are surveying the prevailing economic landscape with a fair degree of concern. But are NHS practices not also doing so, even if for slightly different reasons? And does anyone seriously believe that there are no clouds on the corporate horizon?
Perversely, the end result is that the same patient might be offered less treatment in one, and more treatment in another, and who is to say which is correct? And who can say with any degree of confidence whether the decisions are being taken in good faith, or with improper motives?
Is under-treatment in a capitation scheme or block payment scheme (eg nGDS and nPDS in England and Wales) better or worse than over-treatment in a fee-per-item system or private practice? Will the treatment provided in all NHS trusts and hospitals be ‘just right’? Is poor treatment at high cost inherently worse than poor treatment at low cost? And is excellent treatment any better if it delivered at low fees rather than high fees?
It is time to clean up our thinking about the relationship between dentistry and money. The greater shame lies in denying its role and importance, not in embracing it.