A brief history of private dentistry

A brief history of private dentistry

Louis Mackenzie explores the history of private dentistry in the UK, highlighting its growth over the last 25 years and its future prospects. 

The last 25 years has seen continuous growth in UK dentistry’s private sector, and we are currently experiencing a significant acceleration in this trend.

A quarter of a century ago, the first major exodus away from NHS dentistry had already occurred. This followed the imposition of the first ‘new’ NHS contract in 1990 and the subsequent, unwelcome introduction of the term ‘claw-back’ to the profession.

Prior to 1990, virtually all UK dental care was NHS, with only about 500 purely private dentists, mostly working within London’s W1 postcode.

In the 1980s and early 1990s, a combination of factors effectively bounced the dental profession into the mixed NHS/private economy that we see today. They included:

  • Greater professional understanding of the importance of prevention of oral diseases, compared to the historical surgical/activity-focussed model
  • Reduction in per capita funding for NHS dentistry (the beginning of a generally continuous trend)
  • NHS patient charges more than doubled between 1980 and 1985
  • The notorious seven per cent NHS gross income clawback of July 1992
  • Introduction of private capitation.

Private capitation

Capitation (literally, payment per capita), had been in place for doctors since 1948. But this period also saw the introduction of the UK’s first private capitation provider.

Denplan was created by two GDPs in 1986 and was designed to align patient interests (better oral health) with those of clinicians (effectiveness and clinical freedom).

Growing to 6,500 member dentists, Denplan forms the biggest network of UK private dentists and leads a capitation sector that now serves 2.3 million patients.

a brief history of private dentistry
Louis Mackenzie. Head Dental Officer at Denplan. (25+ years ago!)

Landmarks in the private dentistry revolution

2005 saw one of UK dentistry’s most significant landmarks, when legislation changes initiated rapid growth in the corporate sector.

Prior to this it was illegal for a non-dentist to own a dental business. Sustained corporate growth means that 36% of all UK dentists now work as associates in dental groups (≥ three practices with one owner).

Although dental corporates are estimated to own over 40% of all UK NHS contracts, they also contribute significantly to the private dental economy.

Further growth is expected as corporates reduce their reliance on NHS contracts in the post-pandemic era.

While NHS dentists in Scotland and Northern Ireland have continued with a virtually unaltered contract, 2006 saw the imposition of the now universally vilified UDA system in England and Wales, heralding the second major exodus towards the private sector.

Over the last 25 years, innovations in dental materials, equipment, technologies and clinical techniques have also assisted the growth of private dentistry. This has increased the range of treatment options for patients and advancing the skill sets of clinical teams.

These developments include:

  • Promotion of prevention as the foundation for contemporary caries, periodontitis, tooth wear and mouth cancer management
  • Minimally invasive dentistry has become mainstream
  • Evolution of direct posterior composites as successful (and often superior) alternatives to amalgam and indirect restorations (posterior composites were not available on the NHS until 2006)
  • Improvements in materials, equipment, clinical techniques and training for anterior composite procedures
  • Continuous advances in implant dentistry
  • Continuous developments in rotary endodontics and obturation techniques
  • 2012 legalisation of tooth whitening in the UK (age ≥18) using products up with up to six per cent hydrogen peroxide (≤18% Carbamide peroxide)
  • Widespread adoption of orthodontics using aligner technology
  • Introduction of facial aesthetics/injectable cosmetic procedures
  • A revolution in digital dentistry, which has been boosted by pandemic conditions
  • Greater public awareness of the importance of oral health and evidence of links with systemic health conditions.

The private dental economy

From an economic point of view, the private sector has dominated UK dentistry for several years.

2017 marked a turning point when, for the first time, the total expenditure on high street dentistry (then £7.1 billion) was made up of a greater proportion of private (£3.6 billion / £3.5 billion).

This gap has continued to widen, with the latest statistics demonstrating that the total spend on high street dentistry is approaching 60% private (table 1).

Statistics and factors affecting this private sector growth are presented on table 2.

Table 1: UK Dental economy (BDIA Spotlight 2021)
Total expenditure on high street dentistry £8618 million 100%
Private dental economy £4938 million 57.3%
NHS dental economy £3680 million 42.7%

 

Table 2: UK dentistry statistics and trends
Total number of registered dentists 43,278
Dentists doing some NHS 29,491
Estimated percentage of dentists working in mixed private practice 75%
Purely private high street dentists 5980 (58% increase since 2008/09)
Reduction in NHS practices ↓26% (since 2006)
Reduction in profitability of NHS practices (BDIA, 2021) Wales ↓46% / NI ↓43.4% / England ↓42.7% / Scotland ↓35.4%
Reduction of goodwill value of NHS practices (NASDAL, 2021) ↓24%
Increase in NHS patient charges since 2010 ↑40%
Predicted five-year growth in the private sector (Mintel, 2021) ↑20%

 

The future of private dentistry

Having delivered over 1000 hands-on courses throughout the last 25 years, I’ve had the opportunity to chat to thousands of dentists about their working conditions.

Colleagues who have fully or partially transitioned to private practice report a range of common themes (table 3).

Future private growth will be driven by more widespread appreciation of these advantages, but also by continued tensions resulting from outdated NHS contracts that do not reflect contemporary patient needs and have been linked to the lowest levels of professional morale, even before the pandemic changed the world.

I fervently hope that the next 25 years will see oral health become a more central component of UK healthcare and that continued mixed economy developments will continue to revolutionise our profession.

Table 3: Advantages reported by private dentists
More time with patients
Greater job satisfaction
Better patient relationships
Clinical freedom (without targets or limits)
Improved morale (happier / ↓ stress)
Fifty per cent fewer patients per day e.g. 10 cf 30
Better life/work balance e.g. 4-day week / 8-10 weeks annual leave
Improved patient relationships
Improved quality clinical outcomes
Better equipment, materials and lab work
Preventive/ MI philosophy
Less admin / bureaucracy
Better teamwork / better staff retention and recruitment
Increased profit (£16,000 > NHS for typical private practice NASDAL 2021)

 


Find out more about Denplan.

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