Practice Plan’s Nigel Jones looks at whether the NHS may experience a mass exodus in the next year.
The next few months are decisive
The loyalty of the dental profession to the NHS is stretched like never before. And dentists committed to the NHS for decades are already leaving and handing back contracts.
More are now getting their ducks in a row ready to leave at an appropriate opportunity. While others are hanging on, clinging to the hope that the various administrations will offer hope about the future.
At the same time, the pressure on government to improve access to dentistry continues to grow. Healthwatch reports it as one of the biggest public concerns. Protest groups such as Toothless in Suffolk are springing up around the country. And members of the various parliaments are inundated with frustrated constituents.
Simply requiring the profession to undertake more NHS activity is difficult.
A modification to the IPC may help. But it is far from the complete answer. Especially given that complexities will remain that mean, for months to come, a return to pre-pandemic levels of patient throughput is unlikely.
Workforce challenges
Throwing more clinicians at the problem has two issues, and the first one is the cost.
In the face of so many competing demands from many private industries as well as the public sector, including, of course, the wider NHS, it is tough to secure additional funding for dentistry.
Secondly, the availability of suitable resource. In addition to Brexit and the growing appeal of early retirements, the long-term trend among dentists moving towards part-time work is being accelerated by a pandemic-driven desire to reduce the intensity of life as a dental practitioner.
And even if you could find the dentists, you need the dental nurses in support. It’s hard to criticise the growing numbers of the wider practice team that are attracted to better paid, PPE-free opportunities in other sectors.
Such workforce challenges have resulted in some practices in England handing back contracts as they simply cannot find the associates or nurses needed to deliver the activity targets. And those that have the resource are struggling to retain team loyalty in the face of other practices willing to offer more when it comes to pay and career development.
As NHS activity expectations rise and daily working lives further intensify, fending off the competition from private practices who have the flexibility to pass on additional costs to patients will become increasingly difficult.
The next few months are decisive. Further announcements on activity targets and contract reform will need to demonstrate that the NHS has a level of understanding of these issues. That, to date, has not been readily apparent.
Above all, the announcements will need to offer hope. Or they risk becoming straws on the back of a beleaguered NHS dental workforce.
Private is becoming ever more attractive
The financial support for NHS dentists has been impressive. Some might even say generous. Although others counsel about stings in the tail.
However, it has also brought sharp focus on the vulnerability of having only one customer who can effectively call the shots.
The stress involved in waiting for the latest proposals from the NHS, added to hugely by the incentive timing of communications, highlights the lack of control, despite being independent contractors, that NHS dentists have over their businesses.
That’s not to say that private practice is without its challenges.
The income shock that came with the shutdown of practices is testament to that. Of course private practices still have to deal with demanding patients, economic pressures, and the CQC. As well as being far from immune to the impact of skills shortages in dentistry.
However, the sense of freedom of how best to respond to such challenges, freed from the treadmill of NHS dentistry and its associated constraints, is hugely appealing.
Time with patients
A case in point is the risk of complaints and litigation.
Pre-pandemic research shows that private dentists felt able to build in sufficient time during appointments. They could communicate with patients and build strong relationships. Such that they felt able to mitigate this risk.
This contrasted strongly with those working in the NHS. It was clear they feel caught between the rock of meeting activity expectations and the hard place of needing to invest time in patient rapport and expectation management to minimise the risk of complaints.
The SOPs have given NHS dentists more of an insight. They can see what the pace of life as a private practitioner is like. Heads are now filling with the sense of what is possible in terms of shaping a truly independent business. And in a manner that fits with a myriad of visions about the ideal dental practice.
The tide already seems irreversible
In many ways, this is nothing new. And this begs the question why so many dentists have remained committed to the NHS. Despite compromising on their health and wealth.
Clearly, there is an element of loyalty to the ideals of the NHS. But this has been eroding for many, many, years.
The reality is that what kept many, not all but many, dentists in the NHS, was a lack of self-belief. A lack of belief that they could make a success of private practice.
However, in a climate where demand for dentistry is far outstripping supply, and all practices, private and NHS alike, are reporting waiting lists, the fear about a move to private practice is ebbing away.
Every dentist or practice that chooses to go private and reduce the number of patients they see, effectively increases the demand. This strengthens the position of those to follow.
No improvements without more money
So, if the government can no longer rely on fear of failure to retain dentists within the NHS and the loyalty to the ideals of the NHS have become overstretched, it will have to find a way of increasing the attractiveness of NHS dentistry if it truly wants to return access to NHS dentistry pre-pandemic levels.
The prototype contracts tested in England as part of the contract reform programme showed a lot of positives. Those involved in the early pilots report high levels of professional and patient satisfaction, so it isn’t impossible.
However, the prototypes have ended. Presumably due to the much anticipated difficulty of squaring the circle of trying to find a way forward that does not rely on any increase, let alone a significant increase, in the financial resources the government is prepared to make available for NHS dentistry.
With the pain of NHS dentistry growing, the appeal of private practice strengthening and ease of developing a private practice improving, NHS dentistry is in a fragile state.
The next few months is decisive. It will show whether the growing stream of NHS dentists redirecting their energies towards private care becomes a flood.
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