The Office of Fair Trading (OFT) released its second report on UK dentistry last month. It has previously looked at the private dental market in 2003 and concluded with three sets of recommendations:
1. Improving consumer information
2. Resolving problems and improving complaints procedures; and
3. Reducing unnecessary restrictions on the business of dentistry.
It’s fascinating to note that in its scoping document, the OFT acknowledged the UK dental market to be a large and important market, providing an essential service to 60% of UK adults. It comments that demand for dentistry has been growing consistently since the early 1960s, when less than 40% of the population attended the dentist regularly.
It observed that in 2010, the primary care dental market in the UK was valued at £7.16 billion, and spending on NHS was less than half – in fact only 40% of the spending. We know that the 1990 reforms sparked off the growth of the private sector, as colleagues noticed that government had their own agenda, which didn’t include looking after the interests of the dentists.
So, as dentists reduced their commitment to the NHS and patients asked for dentistry outside of it, the private market grew from negligible levels to a healthy 60% of all monies earned in dentistry now.
However, the OFT final report saw it declare a smaller sized market (£5.73 billion) and a juxtaposition of the relative size of the NHS: PP markets – see table below.
The explanation can be found on page 22 of the OFT report which says: Dentistry UK Market Report 2011, Laing and Buisson: The estimate that the dentistry market is valued at an estimated £5.73 billion a year is for 2009-10 and does not include cosmetic dentistry. The value of the dentistry market including cosmetic dentistry was estimated as £7.2 billion in 2010 according to 'The UK Dentistry Market Development' Market and Business Development (2010).
What is less clear, is why the OFT chose to represent the size of the market in a way that enhances the relative importance of the NHS although a cynic could conclude that politics may have played a part.
Other comparisons between the cost of NHS treatments to the private ones also struggled to provide the complete picture, as there was no consideration given to the difference in times allocated to treatments, equipment used or why the costs in a defunct UDA system should become a benchmark for comparison: ‘In England, a root canal treatment will typically cost from around £360 to £475 per tooth when provided by a dentist privately, but only £48 when provided by a dentist on the NHS. Furthermore, around half of NHS patients are exempt from NHS charges and so, for these patients, the difference in cost between NHS and private dental treatment will be greater still’.
However, the OFT had a job to do and they concluded with 5 recommendations, which shouldn’t be ignored:
1. Provision of clear, accurate and timely information for patients – the OFT is calling on NHS commissioning bodies, the General Dental Council and the Care Quality Commission to be proactive in enforcing existing rules which require dentists and dental practices to provide timely, clear and accurate information to patients about prices and available dental treatments.
Surveys indicate concerns around patients' ability to access clear and transparent information on prices and treatment, especially around mixed treatments, i.e. both NHS and private. It’s difficult not to empathise with patients on this issue. After all, how many of us would walk into a supermarket and buy products in the absence of price details? Well two points emerge:
1. If we wouldn’t like it, we shouldn’t be doing it
2. This fault is not restricted to the dental profession, e.g. do doctors clearly display their private fees for signing passports, etc? When did you last visit a lawyer and know accurately and upfront what their fixed price would be? Perhaps this is a ‘professions’ problem. That does not excuse it, but whilst dentistry is having its second investigation, where is the first one in any of the peer professions?
2. Direct patient access to dental care professionals – the OFT urges the General Dental Council to remove restrictions preventing patients from making appointments to see dental hygienists, dental therapists and clinical dental technicians directly, as soon as possible.
In its scoping document, the OFT noted that, ‘Over the next few years, the UK dental market is likely to face challenges, including constraints on government spending on NHS services, and tighter budgets as consumers' incomes become squeezed. It will be important therefore to ensure consumers of dental services receive improved quality services at lower prices and that the competitive process is supporting these objectives’.
As tax payers we would expect the Department of Health insisting on getting more for less, but is it only me that finds it strange that the Office of Fair Trading began with that expectation? Every survey has shown that the costs of compliance and the poor economy has hit dental practices’ profits adversely and yet we witness this independent body looking to substantiate an inequitable premise. However, closer scrutiny of the conclusions shows us how it intends to drop the price, by increasing the skill mix, no less.
3.Reform of the NHS dental contract in England – the OFT is urging the Department of Health to redesign the NHS dental contract to facilitate easier entry into the market by new dental practices and allow successful practices to expand. The OFT is not convinced that indefinite contracts to supply NHS dentistry are in the best interests of patients.
This came to the OFT’s attention when IDH and ADP merged in 2011. The OFT research revealed that ‘In some local areas where there are high levels of concentration in NHS dental services, the market by itself may not lead to greater competition due to existing NHS rules’. Here facts are treated to a positive spin instead of seeing PCTs being blamed for not encouraging/creating a competitive market. What seems to be conveniently overlooked is the loss of goodwill to the practice owner(s). Does anyone care that the £3 billion worth of goodwill has just been liberalised to the Government’s control?
4. Simplification of the complaints process – the OFT considers that the current system should be reformed to make it simpler, easier and less time consuming for patients and dentists to resolve complaints.
Anything that resolves complaints with a quicker and simpler system has to be welcomed by all. However, in this section the OFT states ‘That dentists must, with limited exceptions, remedy at no extra cost to the patient, any dental treatment, including private dental treatment, which they have provided and which fails within one year. This must be in addition to patients' existing statutory rights’.
First impressions could have one thinking, well that sounds fair and indeed many dentists already operate such a policy. However, where one would have been tempted to bond composites as part of a minimally invasive process, will colleagues want to continually take the risk on the patient who shows signs of wear but denies bruxing? A real fear is that this just might push some dentists to thoroughly deal with or over treat problems as a matter of routine and it becomes another law of unintended consequences, just as the 2006 contract decimated our dental labs industry.
5. Sale of dental plans – following discussion with the OFT, the British Dental Association has agreed to develop a robust and effective code of practice covering the sale of dental payment plans.
The request for the BDA to create a short ‘Code of Practice’ advising on the sale of dental plans is not likely to have a major effect. Most, if not all, of the elements of the Code suggested by the OFT are already in place, at least with the three main plan providers, whose team training and guidance ensure dental plans are promoted appropriately already.
So, for the dental profession, the message is clear, your future in the NHS will be about delivering more for less. In fact the OFT states: ‘Over the next few years, the provision of NHS dental treatment may face increased pressure from cuts in public spending’. Additionally, you may even have to compete with DCP colleagues you once employed.
All of us need to ensure that our patients know what they’re buying, especially in terms of price. In short, nothing horrific but very little worth reaching out for a bottle of champagne! The usual rule of success still applies, look after your patients well and you’ll succeed. Don’t and there are likely to be more rules to trip you up!