Kevin Lewis column

Kevin Lewis ponders what effect the gloomy UK economic forecasts will have on the dental industry.


Fair trade


In a recent column I made passing reference to what I saw as the progressive unravelling of the whole infrastructure of dentistry, in terms of the relationships that have traditionally existed within the broader dental industry – the profession (both dentists and DCPs), the labs, the trade, the corporates, external bodies in both the NHS and private sectors, and so on.

Faithful readers of this column (both of them) will remember that I likened it to a fragile ecosystem, each component delicately dependent upon the next for its survival.

Starting from the charitable premise that no one ever intended it to be this way (not a word at this stage, please), the combined effect of the amendments to the Dentists Act, the new NHS contract and various other developments has been to throw almost every relationship in dentistry up in the air – principal (provider)/associate (performer): dentists/DCPs: dentists/laboratories: dentists/patients: dentists/dental trade: laboratories/dental trade: dentists/PCTs: corporates/PCTs: hygienists, therapists and dental nurses/PCTs. It is truly remarkable when you come to think about it. Richard Branson probably had a better idea of where he would land midway through one of his ill-starred ballooning exploits.

There seems to be a variable level of awareness of the possible implications of the recent proposals to extend into the general dental services, the same NHS logistics/NHS supplies approach that enables NHS hospitals and clinics to purchase equipment and consumables at prices which have been beaten down to a level which is much lower than in the open market. In the world of purchasing, size matters. It is certainly all about ‘clout’; but is it ‘clout’ as in ‘influence’, or ‘clout’ as in John Prescott?

It isn’t difficult to see why the Department might consider this to be a stunning wheeze, nor why many practices might be attracted by the prospect of saving some money. But what, in the longer term, do we think will happen if dental suppliers find their profit margins squeezed until the pips squeak? Their turnover has already been very badly dented by the NHS reforms, one gathers, with less dentistry being done overall. Less dentistry requires, in most cases, less materials. And reduced volume, delivered at a significantly lower price, is a recipe for real problems, and real pain.

In such a climate, not every supplier could survive. In any market, traders must buy before they can sell, and they are at the mercy of high interest rates already. Low prices can only be sustained while high volume is also sustained. The burgeoning private sector might have come to the rescue, but can you think of a way in which one could prevent an NHS practice sourcing cheap materials and equipment through NHS supplies, and using it on their private patients? Because I can’t.

The dental trade throws a lot back into the profession in many other ways – how many major conferences and local meetings would take place if not supported and sponsored by one or more members of the dental trade? They can’t be expected to maintain present levels of sponsorship out of fresh air, and any rejoicing in the ranks at the prospect of a short-lived and relatively modest saving on practice expenses would betray short-termism of alarming proportions. Something, sadly, that we have always been good at.

The alternative – brace yourself for a revolutionary thought here – is that we should actually pay our own way instead of expecting the trade to bankroll us every step of the way.

Double whammy
I have only recently mentioned, in a previous column, the plight of many dental laboratories in the aftermath of the new NHS contract, and this creates a double whammy for the dental trade, because dental laboratories will also be ordering less materials, and perhaps shopping around for the keenest prices at the same time.

None of this bodes well for any part of the dental industry, and certainly not for the profession itself. This is a problem for us all, not just for one sector of the dental industry. The possibility that something rather fundamental has been happening to our fragile little ecosystem is strengthened by the recent reports of employment problems amongst dentists and young dentists this year, as NHS providers have been re-assessing their options.

The worst of these problems appears to have been in the South East, but it should be of some concern that these problems have occurred at all, given that two new dental schools opened only last month (in Plymouth and Central Lancashire) to address the UK’s perceived shortage of dentists. It seems like only yesterday that we closed three dental schools because we had too many dentists – and with the expanded EU and overseas recruitment, we no longer rely on home-grown graduates to swell the Dentists Register.

Some may take the view that a little pressure on the dental workforce is no bad thing, because it helps to move the workforce from parts of the country where additional dentists are not required to those parts with an obvious shortfall. This geographical mal-distribution has been a problem for decades. But there is nothing in all the recruitment material encouraging young people to consider a career in dentistry, to warn them that they may not be able to live and work in the part of the country that they might choose to. Funding and local commissioning/contracting is at the heart of this, of course, and this was always part of the game plan. But it is still one more pressure on young dentists, on top of many others, and it is they who bear the brunt of these developments.

The pendulum of power is swinging through a wider arc between practice owners and associates. Practice owners (especially corporates) need a plentiful supply of good associates, and associates a decent supply of jobs to choose from. The same wide arc is being traced in the shift of power between the purchasers and vendors of dental practices. Practices are suddenly worth whatever a willing purchaser is prepared to pay – neither more, nor less (but weren’t they always, despite the historical formulae for calculating goodwill value?). If the Regulatory Impact Assessment which preceded the legislation leading up to the implementation of the NHS reforms were to be revisited today, with the benefit of hindsight, it would all look very different.

So if you are travelling to the BDTA exhibition at the NEC in Birmingham this week, bear in mind that the whole dental industry – every part of it – is precariously balanced upon itself. And ultimately, it is the patients who fund every last bit of it either directly, or through their taxes. That may not be a wholly encouraging thought as the economic forecasts are of a sharp slowdown of economic growth in the UK in 2008 and 2009. The newspapers are full of tales of a sharp credit squeeze, and a prolonged period of high interest rates starts to bite in the high street. What price dentistry? How many more changes can dentistry absorb before the dominoes start to tumble?

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