The golden age of dentistry has officially passed. Gone is the trusted, reassuring warmth of the local dentist, the pillar of the community, the comfort through the pain.
He’s been bought out, and his community practice consolidated and sold on to yet another City business. Instead of the family dentist, patients are confronted with the impersonal sterility of dental corporations with tens or even hundreds of chains across the country, run by business people who know nothing about dentistry, whose employees are mainly great value foreigners with variable fluency in English.
How did this happen? What does it mean for our future? The perfect storm
It all started when the General Dental Council (GDC) relaxed its former rules that restricted private partnerships to hide behind the corporate pennant. One day, medical and dental practices were run by registrants directly accountable to their governing bodies, who divvied up the roles of chair, CEO, and directors of finance, marketing, operations and HR. The next day, the suited City spivs had moved in, taking over established practices with steady revenue streams and valuable property assets.
This was swiftly followed by corporate executive diversification whereby cash rich institutions were looking out for new opportunities.
Land and expand
Boots, which had already acquired many of the independent chemists to establish its solid chemist base, suddenly expanded into dentistry. Notwithstanding, they messed up, but Specsavers quickly spied an opportunity and landed a bargain deal.
BUPA did the same before they got entirely out of providing medical and dental care and became what they are today: a pure-play insurance company with zero healthcare responsibilities.
Individual entrepreneurial practitioners also started acquiring multiple practices, and vertical integration even saw dental corporates acquiring dental suppliers.
Then three significant factors created the perfect storm that would shipwreck the Cutty Sark of dentistry and leave a giant fleet of cold steel ocean liners in its wake.
1. The introduction of the Care Quality Commission
In the late noughties, the Department of Health set up the Care Quality Commission (CQC) to regulate and inspect health and social care services in England. Suddenly vulnerable, senior practitioners had to switch from thinking about retirement, helping out the kids with their first home deposit and creative tax planning schemes for their inheritance, to instead heavily investing in separate infection control processes and other new, best practice protocols and administration.
The financial and cultural impact of the CQC was the first wave to crash over the small practitioner’s bows.
2. The global financial crash
It was around the same time that the bankers got caught with their pants down on the poop deck and needed the tax payers to bail them out. The crash would scar the face of dentistry forever.
Suddenly, overdrafts were reduced or called in with a few days’ notice. The hoops and obstacles of loans and mortgages put paid to the days when a young associate of five or so years could go it alone. However, the City was awash with private investors looking for new ways to get a decent return when interest rates plummeted. They had the cash to clean up, and buoy senior dental practitioners down a fairer course. One over-generous cash offer for their practices and three or five year contracts later, and the dentists found themselves unburdened of the responsibility for the new, tiresome and costly regulations. It also meant that the City now controlled 10 to 20 per cent of the market.
From Captain to deckhand
This new scenario brought its own problems. One fundamental conflict was that the dentist was no longer captaining his ship. He was an employee, a deck hand, carrying out duties at the command of a captain of business.
With the wind out of their sails, previously motivated dentists who would work late into the night to get the paperwork done, now had a clinical director calling the shots, steering the ship through the rocks of corporate governance and protocols. A practice manager straight from Tesco was holding the ropes and reporting back to head office.
Patients noticed the culture change immediately. The grumpy old man was now just counting the days to retirement.
3. Foreign imports: cheaper cargo and linguistic whirpools
The opening of Europe and the series of national bankruptcies blew many to the safer shores of the UK. First from the west, and then came the new diaspora of economic refugees from the former Eastern Bloc. They came flooding in: dentists, doctors and nurses who were well-educated, with an ambition to work hard whatever the circumstances, whatever the pay. At a time when British graduates were sparse, the European migrants filled the void at little cost.
Squalls at sea with GDC sanctions
In the GDC’s eagerness to endorse the migrant force, they set a language test to a standard so low that it seemed only to qualify these brave, new professionals to be able to buy a loaf of bread in a shop. Valuing the skill sets and economics, the corporates were nevertheless quick to recruit from this group. My guesstimate is that around 70 per cent of today’s corporate registrants don’t have English as their mother tongue.
The repercussions of these language barriers can cost patients dearly. If you don’t even understand the difference between could, should and would, how can you communicate clearly with your patients?
As an expert witness, I recently dealt with a medico-legal case in which the patient claimed the Spanish dentist did not explain the destructiveness of veneers
beforehand. However, on examination, I discovered the patient to have severe cognitive impairment. And when I read her dental notes, they clearly documented conversations about veneers over three appointments with all the risks and benefits clearly recorded in detail before the treatment was carried out.
My report concluded that our Spanish colleague had not grasped the mental limitations of the patient due the low level of English literacy and fluency set by the GDC. It was the GDC who sanction his registration, so it was the GDC who is to blame.
Not keen to pursue a no-win, no-fee battle against the GDC, the lawyer dropped the case. Here in the West Country, patients are beating a course to our clinic door, having lost confidence in their previous practitioner because of the language barrier – whether it’s because they haven’t been understood or because they feel excluded and unsure when the dentist speaks to the nurse in a foreign language.
Sink or swim: the Big Five fish of the corporate sea
But whether we like it or not, the corporates are here to stay. In 15 to 20 years time, I expect they’ll have scooped up more than 50 per cent of dental practices. The health authorities will have to negotiate contracts with very powerful bodies. Consolidation of the market will invariably lead to the ‘big five’, just like our supermarkets.
And the flare’s in the sky already. One of the world’s largest private equity firms, Carlyle, last year looked to float the UK’s Integrated Dental Holdings (IDH) on the stock market for £1 billion pounds. Senior corporate managers were anticipating a £150 million pay-day.
These new super cruisers will hold all the ropes before the box-ticking public authority servants realise what’s happening. The British Dental Association (BDA) will become a total irrelevance in the negotiating arena, although most of us have realised that’s already the case. The cosy relationship between the DoH and professional bodies will become irrelevant. Contracts will be controlled by tough business negotiators with MBAs and law degrees. The average public servant won’t stand a chance.
I am one of the lucky ones. I have practiced in the golden era of dentistry. My ship has sailed.