Chris Barrow’s Blog

Let’s not beat about the bush – the question I am posing is:

“How will existing dental hygienists survive the changes that are taking place in UK dentistry?”

An article by yours truly in another journal speculated on predictions for the future of dentistry. I summarise them as:
1. The Death of the 50% Associate – remuneration levels collapse
2. The Death of the Hygienist – (see below)
3. The Dominance of Corporate NHS Practices – the biggest snap up PCT contracts
4. The Death of the Small NHS Practice – the smallest cannot compete
5. The Death of Goodwill – dental practices have no value
6. The Implications of Incorporation and the Rise of the Limited Liability Partnership
7. The Rise of Dental Litigation – patients begin to sue
8. The Death of the UDA
9. The Death of the New Contract – nGDS falls to pieces
10. The Rise of Licensing and Regulation in both NHS and Private Dentistry
11. The Arrival of Profit Disclosure to Patients
12. The Formation of Dental Producer Groups – networks of small private practitioners joining together to achieve economies of scale
And if you want to read a full explanation of each of these predictions then you can here
Obviously I expect you to pick up on Prediction number 2 – that rather dramatically titled “Death of the Hygienist” and I owe you an explanation.
In my original article I explained:

The continuing pressure from the Inland Revenue will force more hygienists into salaried contracts. At the same time, dental principals will discover that a more profitable partnership can be forged, either by asking lower-paid associates to include the S&P in their (salaried) work, or (in the private sector) to work alongside a therapist who carries out as much work as possible, leaving the dentist to focus on higher profit activities. There will be fewer hygienists working in the NHS and the survivors in the private sector will be therapists.

In a press release dated 9th March 1999 the Inland Revenue announced that

The Chancellor announced today that changes are to be introduced to counter avoidance in the area of personal service provision. This move underlines the Government’s commitment to achieving a tax system under which everyone pays their fair share.

And so, IR35 was born and, since then, rumours have been rife that both associates and hygienists who claimed self-employed status were about to be hammered by an increasingly aggressive Inland Revenue.
The National Association of Specialist Dental Accountants begs to differ and state:

Urban myth on associates scotched
Rumours are circulating in the dental profession that associates will have no choice but to be employed by a practice or partnership once the new contract is introduced after April of next year. But this isn’t true!
Nick Ledingham, speaking on behalf of the National Association of Specialist Dental Accountants (NASDA) said the rumour seemed to acquire more credibility every time it was told.
“This is a classic urban myth which has no foundation and it has got to be scotched. Both the Department of Health and Her Majesty’s Revenue and Customs (HMRC) has confirmed that they accept the self–employed status of the associate.”
So the way I’m reading that is less concern about taxation and national insurance and taxation – and more concern about making sure that the contract of employment (or for services) protects both parties.

Let’s move on and look at the second part of the prediction – concerned with the nature of hygienist activity.
If you trawl together the snippets of information that are littered about the dental press, there are some very noticeable trends:

1. Many PCT contracts are still “in dispute” and, perhaps more alarmingly, many NHS dentists are already complaining that they have failed to reach their UDA targets in the first 6 months;
2. The influx of (cheaper) foreign associates continues, with the number of dentists from outside of the UK record highs in August 2006;
3. The BDJ is now carrying recruitment adverts offering 35% associate contracts;
4. Time available for both dental examinations and hygiene visits is reducing – giving rise to another “urban myth” doing the rounds at the moment – the 2 ½ minute dental check-up;
5. There is no doubt that NHS corporates are gearing up to monopolize the market. In this respect, the most significant press release of the year has been:

26 April 2006
Legal & General Ventures (“LGV”) has acquired a significant shareholding in Integrated Dental Holdings (“IDH”), the UK’s largest owner of dental practices, for an undisclosed amount.
Headquartered in Bolton, IDH is the largest privately owned company operating NHS dental practices in the UK with more than 130 practices, 550 dentists and around 1 million patients.
Commenting on the investment, a spokesperson for LGV said:
“This is a very exciting opportunity for LGV. We are delighted to be supporting a company like IDH, which has worked closely with the NHS to improve access to NHS dentistry across the country. The management team is committed to NHS dentistry and we will be supporting their plans to continue to develop both existing practices and to create new practices in the years ahead. Around a million people per year benefit from treatment by IDH. We would like to double that number. ”

So just how is the smaller NHS practice intending to compete for tender, when IDH (and others) are steaming in with the lowest bids, having forged a “partnership of success” with many other PCT’s around the country – oh, and by the way, created massive economies of scale both internally with staff paid competitively and externally by using overseas suppliers?
Even if IDH achieve their target of 2 million patients, that will still leave plenty of patients to go around – but I’m pretty sure that the PCT’s will be squeezing their customers until it hurts to reduce costs and increase productivity.
Do you want to work in a practice like that?
Maybe so – maybe it’s just a job and you want to get home early.
But if you have pride in your work and want a career working with unhurried patients and colleagues in a “relaxed and comfortable environment”, then you will have to consider moving to the private sector.
Where, in my opinion, qualification as a therapist will be a pre-requisite.
And where the news is good:

• Total spend on UK dentistry – increased from £4.89bn (2004) to £5.3bn (2005)• 60% of this is private (£3.18bn)

• Overall market growth predicted at +24% by 2011 (+32% in private sector)

Dentistry magazine September 2006

I spend all of my professional life traveling around the UK listening to dental principals and their teams.
What they are telling me confirms my prediction – that the therapist will play a much bigger role than the hygienist did in the past.
Not just in terms of delivering more treatment (although that will help to improve profitability as therapists replace associates) but also by taking a larger role in the Patient Journey, in treatment planning and the discussion of financial options – and in the overall strategy and management of the practice and the team.
Even last week, I attended a meeting with a client whose hygienist is currently studying to become a therapist but who has also started to spend a day a week as marketing manager for the practice, involved in the development and execution of both internal and external marketing for the next 3 years.
Predictions are speculations – and even in the few months since my original 12 predictions were published, I am changing my view in some areas.
But you know what, the queen is dead, long live the queen.
This is the age of the dental therapist.