Pricing In Dentistry
Following a "super-complaint" lodged by the Consumers Association (CA) with the Office of Fair Trading, and the subsequent announcement of an OFT investigation over private dental charges, the Press is again having a field day. The dentist has often proved a good target for covert investigations and sensational headlines involving money. The present furore centres upon the lack of pricing transparency in the private sector and the apparent refusal of 20% of those dentists that the CA investigated to discuss their private fees. Some history is an important starting point in an attempt to have a truly objective picture of how dental fees are calculated both in the NHS and the private sector.
In the Beginning
Dentists proved to be a difficult group of people to negotiate with in the run up to the introduction of the NHS in 1948. Not surprisingly a disparate group of single minded and very independent professionals running their own practices did not want any interference from the Government. Whilst Nationalisation accompanied the medical model, dentistry was left in private ownership and carefully laid plans introduced by Aneurin Bevan guaranteed a successful introduction of the General Dental Services (GDS) that recognised this fundamental difference. Bevan had predicted with brilliant political foresight that a generous fee structure would guarantee a queue of dentists eager to sign up for the new NHS Dental Contracts. The problem was the fees were so generous that dentists’ earnings quickly became the focus of a major debate in the House of Commons and headline news (nothing much has changed). Indeed the new Treasury budget for dentistry had been overspent by more than 100% within the first year! There were two factors that were not foreseen, firstly the release of unprecedented demand for the free service and secondly the business skills of dentists who started to work exceptionally long hours in order to fulfil the demand. The Government acted quickly on both counts and introduced direct charges to stem the demand and the dental fees paid to dentists were cut by 50% without warning.
The Basis for Dental Earnings
It was Lord Spens and his Commission that were tasked with the duty of deciding upon the level of professional earnings for those who were to work for the new NHS. Lord Spens and his colleagues had to take into account the earnings of long established and successful private practitioners and the needs of the not so successful - an unenviable task. He accomplished this difficult brief with considerable skill and set a level of professional earnings for doctors and dentists that were to underpin their new NHS Contracts. His job however was only part of the dental picture as the most difficult part of the puzzle centred upon the fact that dentists made it abundantly clear that a salaried service was off the agenda. How could NHS Contractors be paid when their business consisted of an item of service model?
The GDS Fee Scale
Sir William Penman was given the other part of the contract puzzle and he and a group of experienced people set about evaluating the average chair side timings that dentists took to complete the various dental tasks in practice. He then translated these timings into a fee scale that recognised the number of hours that were spent at the chair side and those also spent on administration. This fee scale recognised that the dental earnings equated to a set number of hours per week with the Spens formula and required a calculated output of dental items of service to reach target earnings from the NHS.
Hours of Work and Productivity
Having launched the service and created unlimited demand and a GDS fee scale that reflected conditions in private practice the trouble started. The world and his wife queued at dental practice doors and dentists burned the midnight oil. Dental companies invested heavily in developing new technology and kept their focus on better and quicker ways of "drilling and filling". Soon patients were to benefit from one of the most significant technology breakthroughs that heralded a new era in dentistry-the end of the treadle and the entry of the Airotor or Airturbine. This virtually vibration free drill was a real winner - it increased patient comfort and at the same time productivity increased dramatically. The tungsten carbide and diamond cutting burs removed tooth substance in an effortless way that truly revolutionised the back breaking "drilling and filling" of dentistry. However the Treasury again experienced a serious deficit in the GDS budget with the significant increases in productivity. But this was now easy to deal with (for the Government) as they adjusted the GDS fee scale downwards to neutralise the inflationary effect on Government funding. This of course is the foundation of what is well recognised as the "Treadmill Effect" with the GDS Fee Scale that has never been properly addressed. This is directly responsible for the continuing exodus of dental practitioners from the NHS that also reflects the inequality of the "one fee for all" model. There has never been another Sir William Penman Enquiry to keep a regular eye upon chair side times (and also quality control) neither has there been another Lord Spens Commission to ensure that professional earnings are not only fair and reasonable but also equitable. The present model has created a huge divide between the GDS Fee Schedule and the private sector with misunderstanding, politics and emotions running wild. So how are fees set in the private sector?
Private Fees
The way in which the original model was used for setting NHS fees is still used as the basis for the private sector. This essentially begins with the number of clinical hours per week and the target net earnings that the principal practitioner will set. Here it is true that there is a considerable difference in some dentists’ aspirations but so there is in the GDS - the difference will be in the ability of the NHS contractor to complete his tasks in a time set by the Government as opposed to the individual times of the private model. There will of course be numerous other variables such as expenses and overheads, style and location of the practice itself, the staff wages reflecting their experience and qualifications, the standard of equipment, the choice of dental materials, the use of specialists who have invested heavily in post-graduate training,the use of skilled technicians and a host of other factors. Because the patient is very much in control of their destiny in the private sector (he who pays the Piper calls the tune) recommendation and choice will be important factors. Those practices therefore that best fulfil the patient needs (including price) will tend to be the most successful. Their success will then be reflected with higher prices - a business model common in all walks of life in a capitalist economy.
Price Transparency
The biggest problem for a dental patient is judging value and the one thing that must be delivered by the profession (perhaps reinforced by GDC ethical guidelines) is pricing transparency that enables a patient to make an educated choice of practice. Most practices will make their private fees freely available and these practices, as a matter of course will discuss treatment plans in detail in advance of treatment. There is a very simple message here for the patient - do not shop anywhere that fails to display or provide prices on request. The days when the professions (legal, medical, dental etc.) were held in awe are long gone and the age of consumerism is here. This choice is nothing but good and it is to be hoped that the dental model of a mixture of NHS and private will feed and flourish on the best of both worlds with the one learning from the success or failure of the other.
It is interesting to note that on the two occasions since the last War when dental earnings have been questioned by the politicians as being excessive, they have been associated with great patient benefits in higher quality services and product being delivered. Those dental practices that wish to flourish are investing in all the latest and expensive technology and audit systems that identify their practice as being above average (Investor in People, Denplan Excel etc.). They are in addition performing intricate operations previously carried out at great expense in a hospital environment by highly paid consultants (impacted wisdom teeth removal for example). When assessing the incomes of private dentists talent, endeavour, quality and success should be used as a yardstick of measurement rather than the purely statistical measure of the GDS. Like any small businessman in a local community a successful practitioner will expect to be properly remunerated. Those that are successful and enjoy a higher income as a result should attract praise rather than censure and envy.
