The Incisal Edge

I have a client who has been qualified as a dentist for 30 years. He is skilled, dedicated, talented and knowledgeable. I would happily be his patient if the need arose.

He accepts referrals from other practitioners for endodontics, implants and tricky restorative cases. He has recently completed an M.Sc. in Endodontics and is currently 2/3rds of the way through an M.Sc. in Implantology, He is doing these higher qualifications not necessarily to improve his clinical skills but to ensure that he is up to date with contemporary teaching and thinking on the subjects.

He is practising dentistry that is way above the average.

Here are his Indemnity charges for the past five years and the current year. There has been no change in his circumstances or prescribing patterns and no claims for at least six years and none that relate to his provision of high value dentistry.

• 2010  £2,940 58%
• 2011  £4,656 13%
• 2012  £5,276.52 26%
• 2013  £6,628.48 5%
• 2014  £6,995.56 51%
• 2015  £10,570.00
  Over the six years the fees have increased 3 and half fold.

He is canny enough to know that he will have to load the figures into his budgets, adjust his fees accordingly, ensure his marketing engine is oiled and efficient and get on with life. He also acknowledges that were he in plastics, neurosurgery or obs & gynae the cover would be far higher.

What has prompted me to write this are two questions:

How has this state of affairs in UK dentistry come about?
Where are we on the road to permanent change?

My thoughts, for what they are worth, conclude that there may well be a perfect storm in dentistry (and possibly the rest of healthcare). The contributors being:

Politicians. This is not an anti-politician rant but it is quite apparent that repeated dabbling in health, education etc have not led to marked improvements. The interference with health started with the Thatcher government in 1979 with reforms and attacks on the professions an example of one small but significant move was the removal of consultants’ dining rooms. In 1990 after a decade of small changes came the internal market giving rise to competition in health care, still hated 25 years on. The mantra that “the market will decide” somehow can’t work with the NHS.

NHS. A football to be kicked about. A pig in lipstick, the colours vary according to which party is in power. A religion (according to one of Mrs Thatcher’s chancellors Nigel Lawson) which must not be criticised. Certainly a source of misinformation and fudging especially with regards to dentistry. Two new contracts in 1990 and 2006 with a third on the way have done nothing to improve things.

Dental education seems to have been taken over by the NHS. The preparation for general practice appears to lag a generation behind the reality.

Open borders have resulted in an influx of dentists from other countries in Europe where the situation for dentists is worse – more pressure on the labour market means that associate fees are forced down (see Thatcher & the market).

The TLAs (3 letter acronyms). The GDC has proved itself to be out of touch and overbearing. A generation ago it was viewed with respect and there was a confidence in its abilities.  Now it acts like a cane wielding headmaster whose default position is to flog first, second and third and never to listen. Advertising for business has meant that it has sunk to the level of ambulance chasers and placed itself in the role of an adversary to the people who pay through the nose to keep it in existence. The BDA has done little to truly integrate with its constituents and hides behind committees the decisions of which bear little relevance to the day-to-day existence, challenges and fears of its membership. For too long it seems to have been afraid of its own shadow and has lost years through the distractions of its legal status and constitution. The DoH does things in its own sweet or not so sweet way (see politicians and NHS). Also CQC etc etc. The DPS, DDU & MDDUS are having to play catch up with the numbers of cases that are arriving at their doors, their subscribers fees (remember this started about their fees) having to be hiked to cover spiralling costs. IDH and other corporates have had a significant influence on provision of dentistry, mainly but not exclusively NHS.

Lawyers. It is said that in the 60s large numbers of politicians were economists and the economy went down the pan. Since the Blair government came to power in 1997 there have been lawyers in government by the score and the legal system often appears to have been built for the legal profession rather than its users – or victims. This might not really be new, Jarndyce and Jarndyce was based on a case from 1853.

Health and Disease. The patterns of disease have changed. The flood of rampant caries of the 50s, 60s and 70s seems to have abated. Perio is still not “sexy” either in education or practice. The heavy metal generation of baby boomers who were born and then indulged by parents as sugar came off rationing are able to do something that their parents could not and that is to keep their teeth for life. But like the “full mouth rehabs” of the past their care is costly and limited numbers of dentists are able to perform it with sufficient skill. Without the next generations having the drilled and filled mouths that need to be maintained what will dentists of the future do? Add to this mix the use of higher trained ancillaries hygienists and therapists and stir the pot.

Fashion or fads. From wall to wall veneers, through the cosmetic boom including botox & fillers and on to another TLA, STO or short term orthodontics. Now, it seems that after a weekend course you can become an orthodontist. The practitioners are usually well meaning or sometimes desperate to keep their businesses afloat and are promised much by the purveyors of systems. The suppliers have something to sell and have no responsibility for what is done with “their” appliances when fitted. It is totally understandable that people will make mistakes either through ignorance, enthusiasm or a combination of both. The rise and rise of STO cases resulting in complaints plus those of the far more intrusive techniques of implantology (the last, but continuing, big fad – and I mean no disrespect to those skilled clinicians who place and restore implants, rather the way that the subject is hyped as a “cure-all” for both patients dental needs and practice finances) are threatening to derail completely the indemnity market.

So there you have it. I have no solutions except some that may be unpalatable but are, I gather, being considered within the NHS. This means that there will be tiers of dentists who are limited in what level of dentistry they can provide. It is being done by the NHS for financial reasons without a doubt. But what difference might such an approach mean in private practice? Well perhaps a decent career structure and path rather than the ad-hoc system that now exists would make sense. That of course brings further questions. Who will decide who should join the path? What power will they have? How will proper mentoring happen?

A very big question. Where does the money fit? At the moment an associate 12 months after qualification in the NHS or straight away in private practice is “valued” at the same amount as someone who has 30 years of experience and an armful of qualifications – that does not happen in any other profession. When I raise this subject the responses vary, of course, depending on the circumstances, age, experience and whether the person is a practice owner.

One thing is clear, dentistry needs to get its house in order and by that I mean behaving like a profession that takes responsibility for its actions across the board. However, the attacks from the organisations that I have listed above mean that dentists are disunited, poorly represented, often run their businesses like school tuck shops and persistently act like ostriches with their heads buried in the sand.

Perhaps the market will decide, there may well be widespread unemployment, dentistry will become devalued and will cease to be a career of choice. Whatever happens it will be painful for some. It could be that these indemnity fees are not really large compared with how they will be and that they will continue to rise and be seen as just another cost of doing business that must be passed to the customer.