GDPUK.com opinions:: Roger Matthews: Seven Billion Reasons
Roger Matthews uses his years of experience working in and owning a practice as well as other dental related work calculates the real cost of general dental services in the UK.
Roger laments the fact that Options for Change was seen across the profession as a step towards the right direction, and this vision has now been lost.
Roger spent 20 years in general dental practice and in 1990 joined the Medical Defence Union as a Dental Secretary. In 1994 he gained a Masters in Health Care Quality Assurance at the Nuffield Institute. His textbook on Dental Risk Management was the first in its field. He joined Denplan in 1995 as Head of Complaints Handling and Risk Management, and became Chief Dental Officer in 1999.
Seven billion reasons
I feel especially privileged to be asked to contribute to this Forum, and acknowledge that I have been fortunate enough to have an unusual career. Spending half of my working life as a practising (and practice-owning) dentist and then going on to work for a Defence Organisation and then Denplan, I have had the opportunity to meet hundreds, if not thousands, of fellow professionals each year, to hear their views and problems and to visit many practices.
But the most singular thing is that I have the chance to present those views and issues to an organisation which takes note of them and where possible, acts on them. This is the very reversal of having to implement policy, it is the chance to shape it, at least within one sector of dentistry.
It’s often assumed that the views I put forward are merely a re-statement of corporate strategy – nothing is further from the truth. And this opinion piece is similarly an individual expression of personal ideas.
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From 1968, when the first UK Adult Dental Health Survey was carried out, to 1998, there was an astonishing improvement in the measurable health of the population. A significant proportion of this was, as most would agree, a consequence of the introduction of fluoride toothpaste to the UK in 1971, but much surely is ascribed to the work of the dental profession in all its branches.
For most of that 30 year span, dental practice in the UK was largely of the “mixed” model. It now seems that this scenario is in the early stages of change. Evidence on dentists’ earnings, published by the NHS Information Centre in September 2007 – and similar data in 2006 – suggests that practices with a more or less even spread of NHS and private earnings are declining in number, whilst those with more than 80% NHS income, or more than 80% private income, are increasing.
A recent survey conducted by a leading dental software manufacturer, covering over 700 practices, demonstrated the same effect, with a “saddle-shaped” distribution of practice activity across the NHS/private spectrum. Whilst this may be due in part to dentists’ own pursuit of their individual practice goals, there is to me little doubt that current Government policy is a significant driver of this change.
When the first draft of the NHS “new contract” appeared in late 2004 – whether a “leak” or a deliberate attempt to test the water – it was unequivocally divisive in that contractors would be required to see all presenting patients under NHS arrangements without fear or favour. This proposal was modified in mid 2005 to permit “limited” contracts at the discretion of each Primary Care Trust.
PCTs in the south of England were on the whole more sympathetic to this approach, since many dentists there had already opted out of NHS work for “paying adult” patients, but further north, PCTs were less likely from the outset to permit child-only or child and exempt-only contracts. This latter policy now appears to be receiving more support from the Health Departments in their recent publications.
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It worries me that such a ‘divide and conquer’ policy is being advocated as a necessary component of the current reforms. Mixed practice delivered much that was good for both patients and professional teams. The concept of differential payment (“from each according to his means”) had existed in many professions for some time, and although unfashionable in today’s egalitarian society, it achieved pragmatic success.
Public spending on health will amount to £111bn in the current year, up from £104bn in 2007. This, incidentally, exceeds income from National Insurance by some £6bn, whilst Health and Social Care in its entirety comfortably exceeds income from NI and Income Tax combined. So the concept of “paying ones stamp” in return for comprehensive NHS care is well outdated.
Dentistry is a political embarrassment. For the most part patients do not die from lack of dental care and its principal diseases are almost entirely preventable. As the incoming BDA President said recently: “Dental disease is voluntary”. Alternatively, one could say that dental diseases are social or cultural. However, whilst dentistry occupies about 2% of the public healthcare budget, around 500,000 citizens visit an NHS dentist every week, making our minority specialism something of a bellwether for the health of the NHS as a whole.
It is difficult to dispute that public dental healthcare provision is a necessity. Quite apart from secondary and referral care, and public health initiatives, there are a significant number of individuals for whom private dentistry is not a financial possibility. My position is that neither the public sector, nor the private sector, can provide comprehensively for the population.
Each day since the early 1990s, members of the Denplan team have visited dental practices and using financial spreadsheets (which have become increasingly sophisticated) have analysed the hourly rate appropriate to that practice (or surgery) which is necessary to support and invest in the facilities, services and profit element required. Currently that figure – which will vary for each undertaking – averages about £175.
If I work upwards from that figure and crudely estimate that, say 60% of the UK population would wish to attend for dental care (the remainder being either unconvinced of its relevance or too fearful to attend) then we would have a potential combined patient base of about 40 million. Reasonable?
Bear with me whilst I calculate roughly one hour of dental attendance for each person – of course some will need far more, some far less. Remember that we are including all primary dental care and publicly funded referral care, so this is still (to my way of thinking), a conservative figure, even given also that it excludes cosmetic and elective procedures. We can argue the detail and the precision, but allow this as a ball-park estimate.
The seven billion (pounds) of my headline is therefore not too far away. Somewhere around three times the current public spend in England or at least a doubling of spend in the UK. I recall that a call for tripling of NHS dentistry investment was a BDA Scotland headline. In a number of Western countries, a one third/two thirds split is not too removed from the actuality of public/private dental spend, either.
Each sector needs the other if we are to provide a full and caring service. Six years ago (Options for Change) it looked as though we might explore ways in which a system of dental symbiosis might occur. We seem to have moved away from that position, which is, to me, a great and lasting shame.
Well done for your sensible analysis.
Their is sadly NO overall Dental UK Strategy, just a poor excuse for an NHS one.
Without doubt it is in the public interest to have Private and NHS services working in synergy for the good of everyone.
This seems to be moving that way for Medicine, but for Dentistry Government policy is the opposite and definately divisive and thus bad for UK dental patients ultimately :(
Until there is a centrally-emerged paradigm shift politically, UK Dentistry will continue to polarise and worsen at a national level.
Thus true public interest will be sacrificed for political motives and PCTs will continue to exibit local discrimination in such a culture !
Dentists will still have to try to do their best for patients within this DoH culture that Dentally, views Private and NHS as enemies rather than helpful neigbours.
Cheers for now,
Tony.
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