Dentists are generally good at being efficient, the current market of dentistry and the way in which small businesses operate often results in an environment which optimises efficiency. In small practices where principals often deliver services as well as run the business there is seldom room for wastage. NHS England as a commissioner is faced with the challenge of trying to make savings and is under considerable pressure to reduce the amount it spends on services. The difficulty here is the disconnect between trying to make savings at a country level and realising that there is very little wastage in individual practices from which to squeeze savings.
Having met with lots of colleagues in different parts of the country working in different environments, there does seem to be a realisation that commissioners are generally looking for more but paying less, whether this is lower UDA rates for additional services or by tendering services at very low contract values. The NHS as a commissioner claims to want high quality services but the way in which commissioning decisions are made in some parts of the country this does not seem to be the case.
In dentistry, much has changed over the last 10 years which has been driven by changes in workforce, regulation, government policy as well as professional and patient expectations. The rate of change seems to be greater than it ever was before. In 2005, when the NHS was still preparing for handing over dental commissioning to PCTs, the amount of time required to deliver a unit of dental activity (UDA) and its value was based on activity in a different system, in a very different practising environment. The current practising environment has seen changes ranging from specific requirements around the use of endodontic files all the way through to changes employed staff leave requirements. The cost of CQC regulation, implementation of additional decontamination processes as well as regulation of dental care professionals have all had resource implications for dental practices, yet uplift in contract values have not reflected these changes.
The proposed changes in the contracting of NHS dentistry in England still remain unclear and I am not sure that anyone has been provided with a vision of how the reformed contract is intended to work and whether it can really be delivered in the current practising environment. The rumours seem to suggest it will include elements of quality, registration and activity but what I am struggling to understand is how any of these promote prevention. It also seems that there will not be any additional funding so the reformed contract will be delivered within the existing envelope. Unless commissioners and the Government are of the view that there are high levels of wastage in dental practices, it remains to be seen how the additional components will be resourced from an already ‘squeezed’ industry.
Only recently I heard that dentists may have to pay for some of their occupational health costs when they join an NHS performers list. The arguments put forward are about consistency with other performers in general medical practice and that hospital and community providers have to absorb their own costs. The issue with such comparisons is that they fail to recognise the surgical nature of dental practice or the way in which dental contract values were determined. Hospitals and community providers were funded for their occupational health costs through the way in which their operating costs were assessed in the past, however as dental contract values were not defined in this way the occupational health costs were never part of dental contracts. Therefore these suggestions that dental providers should simply absorb the additional costs are unrealistic and perhaps borne from a view that does not fully understand the differences in operating model.
In my view, the NHS and Government need to understand that there is nothing left to squeeze from NHS dental providers. If NHS dentistry was inefficient and highly profitable then the private equity firms would be knocking all our doors down and not just the big corporate providers.