It is a fact that 90% of NHS dentistry is provided by General Dental Practitioners in practices which are standalone businesses. These businesses must pay their way and deliver a return on the significant investment made during their creation. We provide NHS dentistry on behalf of the Government, but the Government does not shoulder any of the fixed or variable costs, it does not take or guarantee the loans, these risks are for us to shoulder alone.
We bear the costs, but we cannot charge in relation to costs because NHS fees are set by the Government who neither know, nor have taken any steps to find out the cost of care. And here comes the DoH generated business paradox: the fees are now so low in relation to cost of care, that in reality, the more NHS dentistry you do, the more money the practice loses.
There have been recent announcements on investments in NHS dentistry, and below I explore how we got here and what this means for us and our practices.
A trail of broken promises
In June last year, the Permanent Secretary Peter May said that as we are a small country, a bespoke new contract was not possible, so Department officials were ‘looking to Scotland’ for next steps. And so, our profession watched the proactive Scottish Government devise and roll out their revised payment model where average root canal treatment fees are 93% higher than our current fees and extraction fees are 118% more than our current fees.
We waited in eager anticipation. Ultimately, the wait was long and fruitless, and nothing came of ‘looking to Scotland’ other than looking.
The BDA approached the DoH again in autumn to follow up on the Scotland conversation, highlighting the significant emerging underspend and pointing to the impending increased minimum wage. Department officials advised us that we would receive investment proposals utilising the ‘headroom in the GDS budget’ before Christmas. This failed to materialise.
In January we reminded officials of the promise of answers by Christmas, and we were advised that any proposals including emulating the new Scottish payment model would have ‘funding tails’ into next financial year and with the possibility of Stormont returning, we had to ‘wait until a minister was in post’.
A disappointing £9.2m
In January, drifting and directionless, 720 of us wrote to the Department to ask what the plan was for NHS dentistry. The answer from the incoming minister was decidedly underwhelming. £9.2m allocated in anticipation of another underspend in 2024-2025. This money is to be used to enhance select fees, to create a dental access scheme and on an enhanced child examination scheme.
In other words, here is some money to bring children into this broken service, here is some money for patients who cannot get access because the service is broken and here are a few crumbs to feed this starving service.
This £9.2m investment was loudly trumpeted in March, but to date not a penny has been delivered to practices with business cases yet to be fully agreed for all but the Doctors' and Dentists' Review Body (DDRB) uplift and the non-recurrent selective 30% uplift. And just for clarity, this 30% is in reality 25% as it is based on the pre-uplift 2023-2024 fees, which in reality should have already been uplifted in relation to the DDRB recommendation but were not.
In other words, the Department have taken advantage of their own delayed application of the DDRB to turn 25% into a headline 30%. And furthermore, it is only applied for the 2024-2025 year.
At the time of the announcement, Minister Swann asked that I did not publicly ‘rubbish’ the proposals and I did not. I do believe the Minister when he says that this is all his department can afford, but our spreadsheets do not lie and at a practice level, it is much too little, way too late.
What the DDRB uplift really means
In the same announcement, Minister Swann also confirmed the rate of DDRB uplift to be applied would be 6.47% for 2023-2024, with a lower figure of 4.92% to be recurrent on ‘affordability’ grounds. That means, the Statement of Dental Renumeration (SDR) will be uplifted by the lower amount, the higher figure being applied for last year (2023-2024) only.
This tortuous calculation allowed Minister Swann to state that he had ‘implemented the recommended pay uplift of 6%’. This is a disingenuous statement. Not only because the headline uplift is just for 2023-2024, but more crucially, because the Department does not know the costs of running a dental surgery; costs which are one half of the pay formula. If you do not know one half of a formula, you cannot state with certainty that you have got the right answer.
A flawed formula has been applied, this has delivered a retrospective pay cut and the process followed by the DoH is not in keeping with either the spirit or the actual wording of the DDRB recommendations.
Stability or the opposite effect?
Minister Swann hoped that this announcement would help to stabilise the service and provide some level of support to practices under pressure while also helping with access issues.
However, this announcement appears to have had the opposite effect. With hopes of implementation of the Scottish model shattered and the lack of a long-term plan clear, an orderly queue is forming at the door of the dental plan providers as practices prepare to further reduce or eliminate their provision of NHS dentistry. These difficult decisions have been forced on practices in order to protect their teams, their suppliers, their health, their families, their futures and ultimately their patients.
Dentists are understandably stepping away from a system which has exploited the bond they have with their NHS patients, procuring as much dentistry as possible for as little money as possible. For years we have been cross-subsidising NHS dentistry with private revenue so the Department have got used to cheap dentistry. Now the time has come to run our businesses as businesses should be run, where revenue exceeds costs for each and every treatment we provide.
Form an orderly queue
Indeed, the figures show that the exodus is already underway, last year 22% less NHS dentistry was done and the primary reason was cost surpassing fees. The future is mapped out with almost 90% of dentists stating that they intended to do less NHS dentistry going forward. In fact, almost half have stated that they will likely go fully private.
The volume of WCA966 (deregistration) forms being submitted in recent months has grown to the extent that a deregistration spreadsheet has been created to process them all. The BSO electronic portal is ‘inundated’ for requests for these forms to the point that there is a wait. So if you are planning to reduce or leave NHS dentistry then form an orderly queue.
And then there is the amalgam ban
Ultimately, we all want mercury-free dentistry, but at the minute there is no ideal replacement that can compete across all the properties of an ideal filling material - especially on price, speed of placement and longevity in challenging circumstances. It is not pretty, but it is useful, and we have a century of experience with it.
We are reducing our reliance on amalgam with these fillings down by 43% in the last 7 years, but we still need it. We will not get it to zero within 6 months without significant negative effects on patients. In a service where there is not enough access and a severe shortage of money, to change to a filling material which takes longer, and costs more has the potential to break the service.
This EU imposed legislation is marching towards implementation. If it is applied here, the Department must show decisive leadership in measuring and managing the full extent of associated increased costs and decreased capacity - including displaced private income. Their track record of not measuring and not adequately mitigating costs is very evident, so it is not surprising that few in the profession believe that the Department will act fairly to mitigate all new costs associated with an amalgam ban. The trust is gone, and without a clear sign that this will change, the current exodus will become a stampede.
The clinical, financial and access risks are manifold. The likely victims are the most vulnerable in our society, not to mention the knock-on effects in other services of displaced dental patients with nowhere else to go turning up in A&E.
Stormont Health Committee
We are due to appear in front of the Assembly Health Committee in June and we will use this opportunity to dissect the £9.2m headline, exposing its inadequacy, and asking that the committee query the DoH on why they believe it will stabilise HS dentistry. The Department have ignored all the red flags waved by BDA over many years believing that ‘he who pays the piper calls the tune’. They have set policies and fees according to their spreadsheets and their affordability. But affordability works both ways. The pay is now so inadequate that the pipers are leaving, and the music is waning. Department officials are understandably and justifiably concerned by the decline in delivery of NHS dentistry, but they alone are orchestrators of the demise of this vital service.
But what about practices who have no choice and what about patients who cannot afford to pay private fees?
There is a solution. If the DoH want to have a service then they must ‘cut their coat according to their cloth’. And they must do this quickly.
They must decide their budget. They must measure the costs of care (or believe us when we tell them) and then commission this care to align with their priorities, within their budget and at a fee that makes NHS dentistry viable in its own right.
Time is not on their side. Experience has shown that once practitioners move away from NHS dentistry, they do not go back. We have warned for years that this would be the outcome of belligerent ignoring of costs of care and so it is coming to pass: the exodus is well underway.
What to expect from BDA going forward
There are around 365 practices and over 1100 general dental practitioners in NI, all with different personal circumstances, aspirations and career plans. The Northern Ireland Dental Practice Committee have been discussing what additional practical support the BDA could offer to members in Northern Ireland who may be interested in moving into private practice.
The BDA team have updated Moving to private practice in Northern Ireland advice; colleagues are looking at ways of demystifying the steps involved in moving away from Health Service dentistry, to make this better understood and more easily followed, and to make content more accessible.
The BDA’s private practice advice by necessity is general, and so we also want to explore how we can utilise our local NI Branch/LDC networks to support individual practitioners. We want to create a platform where those who are either well on the way or who have completed the journey into private practice, can share their experiences and provide a sounding board. We will keep in touch as this work develops.
And for those practices who have no choice but to remain HS committed, as both your trade union and your professional body, we will never stop standing up for you, via our work with MLAs, the media and the Health Committee, we will fight your corner.
As Kevin Lewis said at our Life Beyond the SDR event last October, remember that “the door is not locked.”