Written evidence submitted by Dr Eurico Martins (DTY0002)
Thank you for the opportunity to express my views on changes to the NHS dentistry service. I have worked for the past 16 years as an associate general dental practitioner across practices in Dorset and Hampshire providing, in near exclusivity, NHS dentistry. This is a matter which is close to my heart and affects me as a professional and as a provider for my family.
I hope it is, by now, well known to all that the current dental contract is gravely flawed. This has been unrefuted virtually since its inception in 2006. Sadly, it has been allowed to fester all these years, being responsible, in no small part, for the decline of NHS dentistry.
I personally feel that the introduction of a limited number of contracts, varying wildly in their amount and value for the NHS work they commission, to be awarded to a tender-winning ‘provider’ has impeded dentists of setting up their own businesses to provide NHS dentistry. I certainly would not be able to just research an area with need for NHS dentistry, set up my business and just start providing it, even though this has been a dream of mine for a long time, and I have a valid NHS dental services ‘performer’ number. I would need to wait for a tender in my area to become available; enter an onerous and complex process of tender application and hope to win it. This tender would most likely be won by the latest corporate trying to expand their market share, as they have financial power I cannot compete with and would most certainly undercut me. Let us say the contract is for 20000 UDAs and worth £25 per UDA. They would win it by bidding lower UDA value even though it is now well established that it is completely unsustainable financially to do so. Corporates have been allowed to flourish, from an almost non-existent position to a very big market share, simply because they gobble up all contracts and buy out dentists that want out of the system. The ‘provider’ contracts are guaranteed income and the market share of practices make it attractive to private equity funds and investors. Nevertheless, the unsustainable financial nature of the contract is so stark, that even the corporates are struggling to maintain their stock, with workforce retention problems (you can only get away with paying peanuts for hard labour, for so long), rising running costs and bloated, ineffective middle management. I find there are too many people profiting from NHS dentistry without being part of the small team that provides it – the dentists; the dental nurses; the receptionists; the dental technicians and the practice managers.
Instead of trying to feed hedge funds, middle management of all sorts, solicitors, regulators, etc, why not break the subordinate link between ‘providers’ (those that hold the limited number of contracts available) and ‘performers’ (the front-line dentists doing the work)? I am sure this would not be popular with many stakeholders, especially those living off NHS dentistry without actually getting their fingers wet, caring for the patients they are supposedly trying to help. I am sure the Association of Dental Groups (dental corporate lobby) would quickly be wispering in your ear how preposterous this is. Giving power to the dentist? Surely that can’t be good for their modus operandi, can it?
Well, can we please imagine a system where dentists with a valid performer number can directly claim from the NHS Business Service Authority for the work that they do, independently from a ‘contract provider’? If this happened, I would the same day start looking for locations to open my little business. I would employ a few local people, train and cherish them probably more than a big corporate environment ever could. I would create long lasting relationships with my patients and work hard to establish my local reputation, instead of having to jump from corporate to corporate, hoping to find a place that runs smoothly and responsibly. Basically, go back to how it used to be? People now complain they never get to see the same doctor or the same dentists. This is become the small business run by people whose name is at the door is dying, being taken over by anonymous corporates which only purpose is create value (artificial or not) so they can be sold to the next venture capitalist group. Everyone loses, the patients, the staff and the community, except a few people that haven’t even been in the vicinity of that dental practice.
The commissioning of contracts has one very clear objective. Control and limit the amount of money that is spent on NHS dentistry. It is appealing if you are holding the purse strings, I understand. The problem is, as things stand, the contracts available only cover provision for about half of the population (badly). If you don’t allow a system to grow organically – letting however many dentists provide however much dental service to however many patients want to access it – you are the ones limiting it. What government often asks (and probably doing so again with this consultation) is how much more can be done using the resources we are already investing. I am afraid that ship has sailed years ago. Dentistry is the only area of the NHS where investment has decreased substantially in real terms. Average incomes for dental associate performers like me (the bulk of the workforce) have decreased at least 40%. What contracts pay per UDA simply is not enough to be sustainable and provide a reasonably quality service. What government thinks a dentistry act is worth and the real cost of it is absurdly different. Someone needs to be told how much it costs to keep a dental practice open per hour. I don’t think many outside dentistry have the faintest clue. If government thinks they can do better, why doesn’t the NHS open their own primary dental care clinics and see what happens?
Still, on the cost of providing dentistry, we must talk about UDA value. Due to legacy contract values, some providers being paid £50 per unit and others £20. This has been going on for 16 years and makes no sense. If we are going to keep UDA as part of the metrics, less than £30 gross per UDA is probably not financially viable. Even better would be abandoning the UDA altogether, it is the worst aberration and mocked by colleagues across the world. Buy one filling, get however many more you may need for free. Not sure any other business or service works like this.
In my ideal world:
1) There would be a national table of core dental services (only those needed to eliminate disease, maintain reasonable oral function and avoid social embarrassment) with realistic fees that could make a small business sustainable, partially subsidised by the NHS according to whichever scale of need/affordability you can create for the patients. What is not on the list, patients can choose to pay privately.
2) Any dentist wishing to provide NHS dentistry, if they are GDC registered and have an active NHS performer number, can do so. No need for tendering of limited contracts. We already submit a claim in our own performer numbers, this would not be difficult. They can either open their own business or rent a surgery space in existing practices. They will thrive or not depending on their own reputation and number of patients wishing to access their care.
3) More investment in community and secondary dental services. The waiting lists are horrendous. People waiting months for a difficult extraction by a specialist, children waiting over a year with rotten teeth. Another solution would be establishing training pathways and requirements, with appropriate remuneration for dentists wishing to provide more specialised treatment, such as paediatric sedation or complex oral surgery, in their own practices.
4) A little bit more responsibility on the part of to the patient. There could easily be written and audio-visual instructions on how to care for your oral health. You don’t need the dentist, every time, showing someone how to clean. If, once they have the information, they still don’t do it, the range of treatments available would decrease. Also, failed to attend appointments need to incur some sort of penalty.
I firmly believe this would lead to a naturally expanding provision of dental services, improve the moral of the workforce and its users and ultimately improve the health outcomes. If the fees are realistic, there are many dentists, like me, that would welcome the opportunity and happily devote themselves to NHS dentistry. It needs to be set at a level that obviously would pay less than a fully private dentist but enough to make a worthwhile living, in line with the skills and devotion required. If you look at Germany, nobody can question the quality and thoroughness of their dental work and how well the system covers for the population. The government even helps dentists to set up their practices to provide state sponsored dentistry. The percentage of dental corporates is minimal though, there simply is no need for them.
Ultimately, is the government willing to make radical changes and invest more into NHS dentistry? If the answer is no, sadly, the service as you know it, will be extinct soon. It is unsustainable and with the current format and level of investment has already passed the point of no return. You cannot possibly think that just importing more cheap labour to plug gaps in this sinking boat will solve the crisis. It is demeaning to the profession and a race to the bottom in quality and safety. There are enough dentists willing to provide this service in this country, you just don’t think they are worth it or want to pay for it. I would ask those in power, to put yourselves in the shoes of the millions of families living on middle and low incomes and think if they want to live in a country that can keep them free of dental pain and embarrassment or if they are happy to let oral health become a luxury of the few.