Dentists' and doctors' independence could be casualty of proposed VHI plan

The announcement this week that the VHI is putting plans to introduce a primary dental care scheme on the long finger will greatly disappoint consumers.

Despite a general reduction in dental decay in the Republic, restorative and preventive dentistry remains a considerable expense. With scientific advances in the field, the cost of looking after our teeth continues to rise.

Costs in Northern Ireland do appear to be considerably less, when compared procedure by procedure. For example, a crown in the North will cost £200-£250 sterling, compared to £500-plus here. A dental implant will cost in the region of £1,300 sterling, while Dublin prices suggest a charge of £2,000.

Why the discrepancy? A Dublin dentist points to higher staff costs and overheads and says that when the sterling differential is taken into account there is actually very little difference in cost between the Republic and the North. Dental materials cost more in the Republic, he added.

A Northern dentist told The Irish Times that there was a two-tier payment system in operation there. NHS and private patients both receive the same-quality treatment, but the private patient pays 100 per cent more than the NHS pays. Despite this mark-up internally in the North and the sterling difference the private cost still represents a cheaper option for some patients from the Republic.

One Belfast dentist said the overheads in the Republic were indeed higher, and the tax system was less kind to dentists here.

An important explanatory factor is the historical context of dentistry in both the North and the UK. The original pre-Thatcherite NHS was a truly public service. Routine dental procedures such as fillings, crowns and extractions were largely paid for by the British welfare system.

Dentists were paid on a "per procedure" basis, which was a powerful incentive to increase productivity. Clearly, the dentist who could perform six procedures per hour made a lot more money than his colleague who worked at an average of four in the same time.

Although this payment system has been altered considerably in the last decade the legacy of working faster remains. A dentist whose early training and practice placed a premium on speed of work will not lose this facility just because the system has changed. To put it bluntly, the average dentist in Northern Ireland probably works faster than his counterpart in the Republic.

Which brings us to the quality argument. Can a dentist who works faster retain a quality of work?

If you are trained to a certain speed of work, you are likely to develop a facility to work at this rate. However, as in any other profession, some dentists are not comfortable with speed and will rightly argue that in order to maintain quality work they need to perform at a slower pace. Of course, this argument does not respect political boundaries, and one has to ask: how does a "slow" dentist survive in the UK system?

The other factor which dentists in the Republic point to is the principle of clinical independence. They have never been subject to a State system of control. This encourages variability of practice style and work rate.

Dentists point to the consumer advantages of this system, which allows for greater choice, and in theory at least, a greater variability in the cost of similar procedures from dentist to dentist.

Proponents of accountability and uniformity will, of course, be critical of the State's dentists for the very same qualities which the dentists themselves highlight as the advantages of the Irish system.

If the present discussions between general medical practitioners and the VHI yield a new primary medical care system, then it can only be a matter of time before the health insurers will reach a deal with dentists. The VHI will insist on pre-agreed protocols and a standardised payment system for both professions.

An immediate casualty of such an agreement will be the clinical independence of both doctors and dentists. This will not be an issue for the majority of consumers, but it could affect the dentists' ability to recommend the best possible procedure in a difficult and complex case. Doctors have been vociferous in opposing the advances of the VHI, arguing that they will be unable to prescribe the latest (and most expensive) treatments without breaking the health insurers' protocols.

There are interesting times ahead for healthcare consumers. Will the cost of care actually decrease? And will the changes bring a reduction in the high quality of service which currently exists in primary healthcare in Ireland?

The next year will tell whether the consumer has gained on the swings or lost on the roundabouts.

dochlth@indigo.ie