An admittedly cynical observer recently remarked of the United Kingdom’s (UK’s) National Health Service (NHS) that it has been universally admired but never copied. It is an aphorism that, to date, has been as applicable to NHS dentistry as to other fields of medical care. However, that may not be the case in the future, following recent changes to the way in which dentists contract to provide services under the NHS. Although the system is proving to be somewhat less than popular with dentists—and, indeed, with patients, who have found their access to NHS dentistry becoming more difficult—the exception is the paymaster, the British government’s treasury.
Before April 2006, dentists who agreed to work within the NHS general dental services examined patients and provided treatment to make them "dentally fit." For this, the dentist was entitled to remuneration under a predetermined fee scale, negotiated nationally between an autonomous committee of the British Dental Association and the government. The system was essentially a piecework arrangement whereby dentists who provided more treatment earned more money. The government attempted to estimate from one year’s statistics the amount of treatment that would be provided in the next year and devise a fee scale that suitably reflected this approximation by dividing the total sum set aside by the number and complexity of the items of treatment. Inevitably, the math did not quite work out, and the government was left with a larger bill than anticipated.
Since last April, however, the existing nationally agreed-on system was scrapped and locally negotiated arrangements were enforced, without negotiation with the dental profession. Now, each dentist wishing to provide NHS dentistry has to negotiate with a local health agency and bid to provide an amount of treatment activity per year, termed "units of dental activity" (UDA), at a pre-agreed fee per unit, which varies from locality to locality. Although this still is a target-driven structure, it means that, however hard a dentist works, he or she can earn no more. It also means that the government’s financial commitment is effectively capped, which it finds very acceptable.
An additional factor is that, although the money devolved from central government to the local health agencies carries a "protection" that it must be used only for dentistry, that ring-fencing lasts only until March 31, 2009. After that date, the agencies can chose to use some, or arguably all, of the funds in other fields of health care.
The outcome has been that dentists have been forced to review their practice arrangements and their business plans, with many deciding to opt out of providing dentistry under the NHS or of planning to do so beyond 2009.
From outside the UK, it may not be easy to understand why it has taken a development like this to prompt British dentists to make such decisions in relation to their livelihoods. The reasons may well be rooted in the ethos of the NHS itself and the welfare-state philosophy that provides the reassuring security, actual or perceived, that someone else will take care of matters for you and that everything will somehow be OK without its being necessary for you to do anything about it. Civilized in one context, stultifying in another. Consequently, dentists are awakening as never before to the realization that they can be in charge of their own professional destinies without the need of a third party and to a much greater extent than they had dreamed of hitherto.
That is not to say that NHS dentistry has ceased, or is likely to cease, to exist. The budget is the equivalent of approximately $3 billion per annum, which is not a sum to be sneezed at. Nevertheless, figures released earlier this year reveal that for the first time since the inception of the NHS, dentists are now earning more than one-half their income from non-NHS practice (which essentially means private practice) rather than from NHS fees. This is a significant change in the balance and, doubtless, both a real and metaphorical tipping point.
What we also are witnessing in the business of UK dentistry is a wider recognition by practitioners that, however benevolent or malevolent or apparently neutral a third party may be, the resultant triangular complexity is a potential drain on time, money, energy and resources that might otherwise be better focused to superior personal and professional effect. It is proving for many to be a salutary, initially difficult, often seemingly brave but invariably unsatisfactory decision-making process.
An old adage has it that "the proof of the pudding is in the eating," and in this context, the fact remains that for all the fine words and well-meaning values, I know of not one dentist who has left the NHS system—even before this most recent change—and tried the alternative but then decided to return.
So, the much-admired and never-copied system may well be less generally popular with dentists and patients, but since it tilts so effectively in favor of rigorously defining and limiting the third party’s financial commitment, it may well spawn imitations elsewhere. If so, many UK dentists would urge their colleagues worldwide to remember that "two’s company and three’s a crowd."
