For a long time I have struggled to answer the question of what the difference between NHS and private dental practice is. I have met many dentists who have wondered the same, most opinions resting on the spectrum ranging from some thinking that the difference is only one of nomenclature, others feeling the difference being that patients become ‘customers’ or ‘clients’.
I lead a double life, half the week practising as an NHS practitioner in a deprived area and the other half working privately, treating patients who either are part of a Denplan plan or pay fee-per-item. I suppose I should make it clear that I don’t think I have a definitive answer to the question of what the difference between the two is, but I like to think that my dichotomous existence gives me perspective of the two in contrast.
In the dental press it is often implied that the aspiration for all practitioners should be to become private dentists at some stage of their career, treating patients who pay the full cost of their treatment where targets are purely those that are self-imposed. I once read an article which spoke of the transition from NHS to private as being like, “casting off shackles”. Other articles I have come across suggest that the “quality” of patients is different between private and NHS with private patients being somehow nicer to treat. I completely disagree with this sentiment.
In my view, patients are patients. Whether they pay privately, NHS or don’t pay anything at all is insignificant when one considers that they all attend to be cared for and they all have a relationship with their treating clinician that is fiduciary in nature; one built on mutual trust and respect, not how much they can pay. This is why the belief that private patients are customers leaves such a bad taste in my mouth. Of course they want value for their money and time, but that is no different to those who might attend the dentists paying NHS charges or as exempt patients giving up their time to attend appointments. All patients have a treatment need, whether it is a dentally fit patient looking for reassurance that the status quo remains, an infrequent attender in pain and all those who exist in between.
I used to work in an NHS practice where a colleague was of the opinion that periodontal root surface debridement should be carried out over two appointments of an hour long each. As an associate earning a relatively low UDA rate, I was quick to comment that I felt that was a private treatment option and not achievable on the NHS. I imagine many readers would not disagree with this, but the dentist I was discussing this with took exception to my comment stating there shouldn’t be any difference. Having reflected his perspective I would agree with this analysis, but unfortunately it is not a realistic option for providing periodontal treatment on the NHS.
The NHS exists to offer universal healthcare. Dentistry, whilst not entirely free at the point of service, is still heavily subsidised by the NHS. Patients who actively choose to remove themselves from having state-funded treatment may be able to access care that isn’t restricted by needing to provide a universal service and therefore private treatment isn’t burdened by the same targets. Targets are burdensome, especially for NHS practices that may be in danger of not meeting them, but they are necessary to ensure that a service is able to offer treatment to all who might need it. Where the NHS often runs into problems with dentistry is that these targets might be too high and quality can suffer.
So what does this mean for those treating patients? What is the difference, because the NHS is clear that there is no problem in providing private quality crowns on the NHS, or spending two hours treating a single periodontitis case if that is clinically necessary? One way of this being explained would be to say that with NHS treatment you get what you need, private you get what you want. However, even this is fraught with difficulty, as why shouldn’t an NHS patient get a white composite instead of a metal amalgam filling if they want one and the composite’s use isn’t contraindicated? The decision to offer the white composite privately is justified often as its placement will take more time with more need for stringent moisture control. Is this right or wrong? I think from the view of trying to keep as much access to care open to patients and have the greatest impact upon disease, this can be justified; the NHS exists to promote the universal health of the nation. Therefore if a patient wants to have a procedure that will take longer when another perfectly reasonable choice is available, taking time away from other potential service users, offering that procedure privately is justified. This is especially true when talking about posterior composites that might actually be inferior to amalgams, their only debatable advantage being cosmetic.
Patients
I remember reading an article that stated that NHS patients were unreasonable, demanding and ignorant whilst those paying privately were well mannered, understanding and a pleasure to work with. My experience is that patients exist on a spectrum; some are rude and some walk into the surgery and lift your mood, some patients have very low expectations with others’ expectations being unreasonably high. These different groups of patients are not mutually exclusive to either private or NHS, they exist in both. Anyone who makes universal assumptions about patients and their personalities is setting themselves up for a fall, and also misses out on the opportunity to build rewarding relationships. Generally, if I buy something, I want value for my money. This is the same whether I spend £1 or £1,000. Patients are no different. I wouldn’t provide a treatment that didn’t offer a patient good value for their time or money, that goes for NHS and private patients. Some dentists seem to believe patients are somehow not entitled to expect decent treatment if they are NHS, the worst case of this is with exempt patients who might get treated as second-class patients who have no right to complain if they aren’t happy.
I enjoy both private and NHS dentistry, the patients I see are in the majority, very nice to treat; those who are perhaps less so are usually only that way because they are scared. Another thing to remember is that money is relative; a band 3 charge for a denture for someone with relatively little could be more of an investment than for the richest private patient paying for the most expensive treatments.
The differences are there, to deny them would be blind, but I don’t believe that they should dictate such a huge difference in perspective as many think. One cannot say that those who pay privately are those who care more about their teeth or that NHS patients place oral health as a lower priority. I would hope that all my patients feel their treatment is good value for the time and money they invest in it. I also hope that those who have treatment on the NHS appreciate their care is conditional upon being able to provide equitable care to all, hence why their choice of materials and treatments is restricted to a certain degree, but that the quality and expertise that goes into providing their care is kept as high as possible.