All change

By now most of you who have been practising under the NHS will have either signed the new contract or decided to opt out. Either way, the contract will have a huge impact on dentistry in the UK.

The changes that are about to happen are the biggest thing to hit dentistry since the NHS. While Sir Kenneth Bloomfield told us in his Government review in the early 1990s that ‘no change is not an option’, for many practices not much has actually changed.

For some, there has been a change in the mix of dental activity; for others, PDS contracts have replaced the old GDS arrangement. But for most the cataclysm that is about to unfold will represent an unprecedented change in the way of working.

Any sort of change usually hurts and also usually generates fear and anxiety, but that is not to say change is a bad thing. Few would argue that the old system was creaking, cumbersome, difficult to manage and very bureaucratic. For patients it generated great uncertainty over how much they were going to be asked to pay. For practice teams it meant a lot of form-filling and record-keeping that consumed vast amounts of time.

But the one thing about the old system was that we were all familiar with it. We had been warned that change was coming but few were anticipating the scale of the change about to unfold.

This month sees the arrival of two new sets of regulations that will at once replace the old-style GDS and the PDS. The NHS (General Dental Service Contracts) Regulations 2006 and the NHS (Personal Dental Service Agreements) Regulations 2006 will come into force, and will directly change the way dentists work in the NHS.

Both sets of regulations look and read remarkably similarly to each other. The reason two sets were necessary is that the GDSC regulations introduce the GDS and the PDSA regulations ratify the existing PDS schemes into something that looks more or less the same.

The biggest difference with these new regulations is perhaps the intended recipients. In the old world, the regulations bore largely on dentists themselves, with the PCTs and the DPB acting only as enforcers of the terms of service for dentists and the Statement of Dental Remuneration. The new regulations, control the responsibilities and powers of the local bodies and dictate what they must provide by way of services, and what contractual terms they can, cannot and must include when contracting with dentists and dental practices.

As you are probably aware the contract is initially for three years, which can be regarded as a ‘protected

period’. After this, the PCTs in England and LHBs in Wales will be better versed in the art of negotiation and will have a clearer view of what they want and where they want it. They are therefore likely to be far more prescriptive, and pick and choose the practices they want to deal with and those they don’t. They may also find themselves with areas of surfeit and areas of need.

This will put them in a far better position to drive down contract values in areas where there are too many practices bidding for a smaller number of contracts. Correspondingly, they will be able to divert ‘incentive’ money to encourage new practices to open in areas of scarcity.

The future beyond this three-year period is very uncertain, although I believe that dental practice in the future will fall into two distinct forms. At one end, we will see utility, low-cost, low-investment, necessity-driven dentistry under the residual auspices of the NHS. This type of dentistry will be tightly controlled by the increasingly empowered local commissioning bodies.

It will be highly cost-conscious and recurring contract rounds will be price-driven. Practices in this market will have to bid against each other and, in line with other public-sector commissioning, the local commissioners will buy solely on price. As a result, the investment potential and expenditure on materials and staff will be driven ever and ever downwards. This will be welfare-type dentistry that will focus on need and basic treatments only.

Alternatively, there will be private practices that derive their fees from paying patients, either on a fee-per-item basis or as part of private capitation plans. These practices will need to deliver on many fronts. They will need to demonstrate investment in the infrastructure, in both the clinical and public areas. They will also need to invest in their skill bases, both from the perspectives of customer service and clinical standards.

Having made that investment they will also have put in place realistic pricing structures that reflect it. If these businesses are to survive they will need to spend time understanding their financial needs and acting in a correspondingly business-like way. This will be private dentistry where the options to spend time and explore modern techniques are standard expectations.

I believe that ‘mixed’ practices will become increasingly difficult to sustain. While there may be opportunities under the NHS contract for ‘private upgrades’ this will not really be in the same category as private treatment itself.

There will still be utility dentistry and it will need to be modestly priced to reflect consumers’ expectations and the available levels of investment in skills, equipment and materials in the practice. But it is very difficult to work in two different ways or to two different standards, and the idea of being able to complete low-grade NHS dentistry one minute and start high-quality, time-intensive private treatment the next is counter-intuitive.

I believe these will be the two forms of business model in dentistry after the new contract. I cannot say which model will succeed for you, as it is a matter of personal choice after evaluating all the pros and cons of each one.

At the end of the day, however, there will be winners in both segments. These are the dentists who will master the art of analysing their practice’s performance, in financial as well as non-financial terms. That is because they will be better informed and more commercially astute when negotiating with PCTs or LHBs and other stakeholders, and in devising their organisational strategy regarding future activities – whether it be in private dentistry or NHS dentistry under the new contract.

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