L
ast month marked the anniversary of the publication of the controversial final report of the Office of Fair Trading into the ‘market’ of dentistry. Whilst the conclusions did not result in a referral to the competition commission, much of the content of the report was critically received by the profession. Satisfaction with dentists was shown by the OFT to be high and a further survey undertaken by the British Dental Trade Association during the same period indicated that trust of dentists was higher than trust in doctors.
One of the fundamental issues that arose was the way in which the report treated dentistry as though the provision of dental services was the purchase of a commodity. The report was triggered by the number of complaints received by Consumer Direct (a body most of us had not heard of prior to the report). In fact Consumer Direct receives more complaints about handbags than dentists but there is no sign of them wanting to investigate the handbag market.
One of the key recommendations in the report was around the provision and display of pricelists for both NHS and private treatment within dental practices and this is a particular point where the profession could consider revising the way it views itself.
From the inception of the health service until the new contract in 2006 dentists were paid on a piecework basis with a complex list of some 1,400 ‘items of service’. This may have been a sensible approach in 1948 when there was a huge backlog of work to be undertaken, but as oral health improved in the 1970s (following the introduction of fluoride into toothpaste) the system became increasingly irrelevant and was widely criticized by the profession as a basis for their remuneration. Payment for the treatment of disease rather than its prevention seemed no longer relevant as we moved into the 21st century.
Whilst the new contract in 2006 went some way towards simplifying the system into a series of bands, dentists were still concerned with what they perceived as their ability to deliver optimum treatment within each of these bands rather than looking at the overall value of their contracts and translating this into an hourly rate of pay.
Similarly, many of the dentists most vociferously critical of the ‘fee per item’ system when they left the NHS to provide dentistry under private contract during the gradual drift away from the health service in the 1990s simply replaced NHS fee per item with their own scale and price list of private charges. This gave the OFT the opportunity to complain that these charging systems should be more transparent with prices clearly on display within the practice at reception.
The new NHS contract (going on the models currently being piloted) will fundamentally shift the way that dentists are remunerated to a combination of registration, capitation and global practice improvements in oral health. If dentists operating under private contract continue to charge on a fee per item basis they will then stand alone in pricing their services as a commodity.
When we visit our accountant or solicitor we do not expect to pay charges based on a pricelist of services offered but rather to pay a fee based on the time taken to perform the service plus disbursements and the only pricelist available will be a list of hourly charge rates for varying degrees of expertise amongst the professional team.
Surely the time is now right for the dental team to move from the commodity based fee per item system to recognising their professionalism, setting an hourly rate and basing their charges on this hourly rate. This rate could vary according to profession, seniority, expertise and additional training. It would be quite justified for example to be charging a higher hourly rate for services requiring greater skill and investment in training such as implants than routine conservative treatment. We all know certain patients take significantly longer to deal with for the same items of treatment than others, either through technical difficulty or individual patient demands and it would seem to be entirely reasonable for this to be reflected in their fees.
Transparency in charging as demanded by the OFT would then be a simple matter of having a price list of hourly rates and the price paid by the patient would depend on the time taken for their appointments. Those working in capitation may not realise that the monthly charges paid are carefully calibrated on a combination of oral health condition and the average time that will be taken to deliver services to any particular group of patients (effectively a carefully averaged hourly rate). We should not be worried by a patient who takes significantly longer to treat in any one year and appears to be a loss making proposition as this will be balanced by the patients whose need for or uptake of treatment in that year is less than anticipated and they are paying for.
I question how many dentists actually know the hourly rate they would currently like to receive to cover their income and the necessary rate to cover their practice expenses. If the business of running a dental practice is to be effective these are essential calculations that every practitioner should make in order to have true control over their business.
The origin of the dental profession was from the barber surgeons, tradespeople who were indeed selling a commodity. Hundreds of years from this origin surely the time is right for us to operate our practices on a professional basis, recognise that patients are paying us for our time and professional expertise and join our fellow professionals in pricing our services on an hourly basis. An OFT report based on this system would have looked significantly different and indeed the need for investigation in the first place would have been much less.