Perhaps the old-fashioned dental practice wasn't so bad?

The dental practice of 25 years ago was a 2 to 2.5 dentist practice, because one receptionist could cope with that number: it often had three surgeries, two dentists, one hygienist, with each surgery having a dental nurse: the practice owner was, more than likely, one of the dentists, an associate (perhaps with ambition to become a partner) being the other. The practice was stable, the patients were happy to see the same dentist from one year to the next, some perhaps awaiting their recall invitation cards (some of the patients in my practice used to telephone to complain if their recall didn't arrive at exactly six months!), and some attended the hygienist on a regular basis. There were emergency slots in which regular attenders could be seen. The regular patients were generally well controlled and required little more than maintenance treatment, which may not be considered to be a ‘profitable’ enterprise for the dentists, but sufficient patients recommended the practice to new patients who needed (sometimes extensive) restorative or prosthodontic treatment and the practice remained busy. A Vocational Trainee (now renamed an FD1) might occupy the third surgery and receive excellent advice from the experienced practice principal: from time to time, before the era of UDA Contract Values, the VT was invited to stay on as an associate. Stability was the name of the game and the practitioners purchased the materials which they considered had an evidence base and carried out a wide variety of treatment. Boredom therefore did not set in! There remain practices who follow this model and I would suggest that many such practices are now private, because they could turn away from the NHS because of the quality of care that they provided and their stable patient base.

However, it is apparent that the dental practice of today in much of the UK does not resemble this model. Many practices have been taken over by Corporate dental providers or dental bodies corporate (hitherto called Corporates): by talking to dentists working in some of these, I am aware that the dentists are not in control of the materials that they use for patient care, these being chosen, on the basis of cost, by a non-dental administrator (although this does not apply to all Corporates) and the associates or assistants are directed to ‘sell’ the treatments which generate the highest ‘profit’. Criticisms of Corporates include the notion that they have reduced (or removed) professional autonomy, leading to deskilling, this potentially affecting patient services.¹ In this regard, the Australian Dental Association believes that there is a potential conflict of interest between the responsibilities of a dentist and the corporate owners of dental practices, insofar as the Corporate needs to provide financial returns for its shareholders and the potential risk of shareholders/owners' equity being placed above patient need.² The crux question is – are they correct? As I see it, Corporate practices are there solely as a business to make a profit, whereas the average (old-fashioned) dental practice is there to provide ethical, satisfactory or good treatment for its patients, albeit at a fee which will generate sufficient income for all its staff members.

A recent study of BDA members who work for Corporates (with 15% of respondents holding EU qualifications and 7% graduating from other countries) revealed much of interest,³ although I worry that this has not painted the true picture because Corporates rely on a source of (cheap) labour from Continental Europe, and many of these dentists may not elect to be BDA members because they may only be in the UK in the short term. This leads to an important difference to the ‘old-fashioned’ practice, namely a high turnover of staff (both dentists and nurses), resulting in patients not seeing the same dentist on a regular basis. This, in turn, leads to a lack of patient empathy with the dentist/practice, and a high potential for patients to approach a solicitor if and when things go wrong, similar to what is happening in modern medical practice, where, again, patients may not see the same doctor and build a relationship with the practice. Results from this survey gleaned several other matters of interest. Corporate associates were significantly less likely to report high morale than their non-Corporate counterparts, although both groups were dissatisfied in their present jobs. However, non-Corporate associates reported a greater level of autonomy and greater ability to make workplace decisions. The authors of the study³ explain that the work of dentists in a Corporate practice has a direct effect on profitability and on the income of the business, so it would appear logical to introduce ways of maximizing revenues. Perhaps this is reflected in the Corporate associates being less satisfied with their jobs and feeling that they had fewer opportunities to carry out challenging and interesting work. In addition, dentists working for Corporates reported a lower level of satisfaction with the standard of care that they provided.³ Kevin Lewis, in an excellent editorial,⁴ suggested that this should be ‘enough to prick up the ears of the GDC’, but argued that they might have ‘fallen for the Corporate rhetoric’ and will not take action.

The UK Government opened NHS dentistry to competition in 2006 and, by 2015/16, a quarter of NHS Contracts were held by Corporate providers, who had lower UDA values and higher UDA targets than non-corporate providers.⁵ Indeed, NHS Corporate dentistry in England alone had a contract value of £1.3 billion on October 2015 (and will have increased by now), that then being circa one third of the total.⁵ Also, in 2015, the Corporate dental sector was estimated to be 200 dental groups, with 2,000 practices.¹ It seems that this is the way that things are going. Is this good or bad? The Corporate practices are generally larger, providing a mass, less-personalized service, while the ‘old-fashioned’ dental practice provides a more bespoke service. Perhaps the continuing success of private dental capitation companies, such as Simply Health Professionals (known in the past as Denplan), indicates that some members of the UK dental public are prepared to pay extra for the personalized service that such practices provide. The dentists operating in such schemes own their practices and thereby have a vested interest in their patients' continued attendance and in their patients' oral health. Many are the smaller practices that I have described. In my view, there is nothing wrong with that model. The ‘old-fashioned’ dental practice was not at all bad!

A year ago, as we approached the festive season of 2017, I wrote⁶Sadly, there is now a whole generation of dentists who think that UDAs are the only currency by which dentists are paid for their treatment of NHS Patients, adding ‘Perhaps the new contract will seem clearer a year on?’. Is there therefore now light at the end of the UDA tunnel, with the announcement that dentists in England and Wales may have a new contract by 2020? All UK-based readers will be aware of the seismic political ramifications that Brexit is causing, and, with this, the fact that the Government may still, by 2020, have other matters than a dental contract to worry about. Given that, I wrote ‘The UDA system has always been broken and remains thus. The Government are not in a hurry to change how dentists are being paid: they manufactured a cash-limited system, which is what they wanted’. Perhaps Brexit will be the excuse not to change the system which has served Government so well. We wait on the edge of our seats!

As we approach the end of another year of Dental Update, I wish all readers, everywhere, Season's Greetings and a happy and peaceful 2019. But also, to thank you, the readers of Dental Update, for continuing to subscribe to our journal – I hope that you have enjoyed this year's issues. Also to thank the Editorial Board for their input and wisdom, our superb authors for sifting through the voluminous dental literature and telling us what it means by way of the review articles that they write, our peer reviewers for their advice and, finally, all the excellent team at Guildford, ably led by Angela Stroud, Lisa Dunbar and Stuart Thompson, for producing each super issue.