The elephant in the room
Kevin Lewis addresses a situation brought to light at the recent British Dental Conference and Dentistry Show involving purchasing new, essential equipment and NHS funding, or lack thereof.
Over two days in May, the British Dental Conference and Dentistry Show took place at the NEC in Birmingham, attended by an estimated 10,000 people. With more than 400 exhibitors, and multiple CPD sessions taking place, there was certainly a lot going on.
Quite apart from the valuable networking opportunities created by bringing many professional colleagues to the same place at the same time, these occasions provide a regular litmus test of the profession’s health and the wider dental industry – and you can learn a lot from sniffing the air to sample the mood, checking out what’s on display, what you have to pay to own it, and where the crowds are congregating. But in recent years, an intriguing subplot has been playing out that I am yet to rationalise.
Many of the stands are self-evidently promoting hardware or services that are only ever going to be available privately, such as implant dentistry and certain aspects of cosmetic dentistry.
Others display hardware or services associated with procedures, which, in theory at least, can be provided within the NHS.
But practice owners in England and Wales contemplating an investment in the purchase of the latter, will (or should) be aware the NHS will never contribute a single penny towards the capital cost of that equipment. This anomaly arises because no additional UDAs will be generated when the equipment in question is used to provide NHS treatment.
Paradoxically, if you have an NHS contract, once you have bought and installed the equipment, you can’t reserve it for use on private patients only, if it could be used to provide NHS treatment.
In the 70+ year history of NHS dentistry there has never been another remuneration system that so effectively discourages and penalises capital investment in equipment of this kind.
The economic case for buying such equipment relies on the private income it can generate, which can, in turn, subsidise its (free) use on NHS patients.
Surely, it must be time that NHS dental practices can register with the Charity Commission?
It is equally true that the NHS expects (and indeed, contractually requires) dentists to make a lot of other investments without ever putting any money on the table to fund them.
This sometimes results in dentists shopping around for the cheapest (rather than the best) goods and services; so in its stated desire to drive up standards, the NHS ends up doing precisely the opposite.
While claiming to make patients safer, it encourages an environment in which they are actually less safe.
There were several striking examples of this in evidence at the NEC, yet when the finger of blame is pointed, it will not be at the NHS, nor any invisible elephants like the commissioning and procurement processes.
Meanwhile, in Scotland and Northern Ireland, the fee-per-item remuneration system exists at least as part of the overall income package, and each fee includes a notional contribution towards fixed costs, as well as the variable costs associated with each item of treatment.
Here, too, things are not quite as they seem, because those dentists whose gross earnings are lower than average end up not fully recovering their fixed costs.
Those whose gross earnings are higher than average, on the other hand, end up over-recovering these costs, and reach a point where any further treatment they provide becomes perhaps twice as profitable – out of which there is plenty of scope to make further capital investment. Everyone is a winner except the state, which is precisely why it spends so much time and money trying to prevent it.
In fact, the situation in UDA-land is even more nonsensical, because any clawback resulting from under-delivery of contracted UDAs takes back some of the notional contribution to the fixed costs of dental practice, as well the variable costs that have not been incurred because the UDAs were not provided, and the profit the ‘missing’ UDAs would have yielded.
Buying decisions are made for a wide variety of reasons. Sometimes we buy things because we need them, and sometimes because we want them and can see a use for them.
Sometimes we buy things because they will directly generate income (and profit), or sometimes do so indirectly by saving us time, or making life easier.
Sometimes our sole aim is to do something better, or to achieve higher standards more easily or consistently.
And sometimes we buy things simply because they take our fancy or look like they might be fun.
Generations of dentists have walked the corridors of dental trade exhibitions and done all of this, and thousands of wise exhibitors have tapped into one or more of those thought processes to sell their wares.
At this point I throw myself at the mercy of the court and ask for about 300 previous offences to be taken into consideration – including the occasional questionable impulse decision made in car showrooms over the years, to be brutally honest. But whatever our motivation, applying ourselves to decisions such as this means we are at least ‘on the dancefloor’ in terms of professional engagement – never a bad thing.
But what about that elephant? The current state of NHS dentistry helps some exhibitors by giving dentists a glimpse of the kind of dentistry they could be doing outside the NHS, or a reminder of what they trained four or five long years for.
But there was a palpable contrast between the positivity at large at the NEC, and the underlying negativity so obviously prevalent in UK dentistry, as reported from many surveys, and from a variety of sources ranging from the NHS to those involved in the private sector.
In my experience, time spent at CPD events, conferences and exhibitions is always a great antidote to complacency, apathy, negativity and mediocrity.
The trick is to keep that pilot light of enthusiasm burning when you get back to the four walls of your surgery.
I am reliably informed the conference and exhibition organisers contacted the NHS to thank them for having so kindly provided the elephant in the room for this year’s show.
To which an NHS spokesman is reported to have replied: ‘Don’t mention it’.