Are we heading for the end of mixed practice?

Are we heading for the end of mixed practice?

That three lettered blue and white logo over the door and on the website may not be quite the patient magnet that it once was.

For a long time mixed practice has been considered an excellent business model by many GDP’s. Despite the received wisdom of the dangers of standing in the middle of the road, the majority of practices chose to offer both NHS and Private care, and they thrived.

Not being reliant on one system of payment provided a form of income insurance. There was the steady, and in past times, almost guaranteed income of NHS work. Then there was the opportunity of more profitable private work, whether in terms of a better hourly rate for routine treatment, or delivering more elective types of care with potentially higher margins.

At one time the vast majority of the British public were used to NHS dentistry, and they expected it to be available. Efficient practices could make NHS work pay well and sometimes there was little incentive to offer alternatives. Seeing a ‘private dentist’ was something for the very wealthy, or on occasion to have a typically cosmetic item of care, that was not available on the NHS. The arrival of tooth coloured materials for posterior teeth provided one particular example. Hygienists in many practices were positioned as an enhanced service over the often brief scaling provided at a check-up appointment, by some dentists.

The contractual changes of 1990 initially provided an NHS bonanza as dentists rushed to sign up patients onto their NHS capitation lists. With a fee cut and then the new 2006 UDA contract, the appeal of NHS work began its comparative decline.

A fast forward to 2025, sees private care encompassing aesthetic bonding, aligners and implants, which are increasingly provided by many GDPs. The patients receiving these treatments come from a much wider demographic than the private patients of the 1990s. The value and proportion of dentistry provided in the UK under private contract has risen hugely in volume and value. Meanwhile the value of NHS care has been held back by frozen fees, with deep real term cuts.

For many years most dentists were happy to sign up to the required declaration, that the quality of treatment provided under their NHS contract was as good as their private work. The material going into the cavity might be different as might the appointment time, but there was nothing inferior about the NHS restoration. As NHS fees were squeezed year on year, and new materials and techniques became available, this became a harder line to hold.

This is not to say that there was not a great deal of remarkably high quality work delivered under the NHS, or indeed some work delivered under private contract that was not up to scratch. Nonetheless there was a direction of travel. Some patients could spot the difference, beyond the furnishings in reception, or the weight of paper used in the practice leaflets. Whether it was a full periodontal chart, a hygienist who had the time and could remove all of the stain, or restorations that they struggled to spot, their expectations changed.

In the last few years I have repeatedly seen new patients expecting that there would be issues with the dentistry they had received, because it “was only done on the NHS.” All of this makes offering both a full range of NHS and Private work under the same roof, let alone by the same dentist, difficult. Put simply if the NHS is so good why pay for private?

This difficult problem was largely solved by the combined effects of a workforce shortage, inflation, and of course the pandemic. NHS care simply stopped being available to many patients including those that had been quite satisfied with it. As we know, some patients stopped attending and others went private for the first time, and not just for individual items such as a more natural looking crown, but for their routine care. Many of these patients went on to become aware of what modern dentistry could offer and have then gone on to have bonding, aligners, and implants.

Back at NHS HQ there have been a series of whack a mole attempts to solve the access crisis. The direction of travel is clear, triage via 111, emergency hubs and sessions, less ‘routine’ check-ups and sooner or later more skill mix. If this was being provided by well supported teams who felt valued and were competitively rewarded it would offer very satisfactory care to those who were happy with the NHS definition of oral health.

The Public Accounts Committee (PAC) have been the latest group to demonstrate the ever present official blind spot around funding. The current NHS dental budget will never be enough to deliver even the 2006 range of care to 50% of the population. It is hard to imagine anyone seriously thinking that this or any other government will find more money for NHS dentistry, even in the longer term, let alone in the lifetime of this parliament.

In preparation for the PAC, the BDA calculated that there were now large cross subsidies from private to NHS work. NHS examinations were estimated to produce a 21% loss on an exam for a new patient. The overall cross subsidy was £332 million a year. Once the Chancellor’s growth budget hits payroll, it will increase to over £420 million.

Spare a thought for those private patients in the mixed practices that generated these figures. They pay their National Insurance, some of which is supposed to fund the NHS dental care that they were told would be available to all. Then they pay their private fees from their income – or what is left after deducting the tax and national Insurance that they once thought would fund their dental care. And now they are paying a premium on those private fees to help subsidise the NHS treatment of other patients.

According to the Nuffield Trust, in December 2023, there were nearly six million fewer courses of NHS dental treatment provided than in the pre-pandemic year. It may be convenient to blame Covid-19 for this, but the Trust speaking of “a clear trajectory of decline,” calculated that funding in 2021/22 was £525m lower in real terms than in 2014/15. Some of that gap has been filled by the reduced earnings and salaries of dental teams, and now as the BDA figures demonstrate, some by the cross subsidy from private patients in mixed practices.

The BDA provided examples of the losses typically experienced providing NHS treatment, with a ‘simple’ new NHS patient exam losing a typical practice £7.69. In the case of a denture the loss was calculated at £42.60. As for the £40.60 loss on each surgical extraction involving bone removal, ‘world class commissioning’ might think about the implications for secondary care, if not for practices.

To pay twice for the same service may seem a public spirited act of kindness, but there must be a limit to how many patients will elect to pay three times for the same treatment. Perhaps somewhere a 100% private practice is getting ready to use the BDA figures to explain to its patients that they get a more competitive fee structure than at the mixed practice up the road.

As government and the NHS continue to try and deliver NHS dentistry within the available funds, they remain imprisoned by one particular inconvenient truth; this is that the current NHS dental budget can never provide even a moderately comprehensive range of dental care to most of the population. Short termism and an aversion to difficult decisions will continue to mean that avoiding grim DIY dentistry and pensioners-in-pain headlines, will drive policy. That means slicing off more of the overall budget for emergency care and priority groups.

To achieve this, there will be different payments for doing the work that government really wants done. GDPUK has recently carried a thread where the payments for emergency sessions were discussed. Run with great efficiency these can be profitable.

There is usually a profitable business model to be built around giving government what it wants. In dentistry it is now about emergency and priority care. There is another proven model around private care. And for many years, there was mixed practice as a ‘best of all worlds’ option. This will change, and is beginning to be reflected in practice valuations.

According to Mintel current total expenditure on UK dental care was estimated to be 10.6 billion in 2024. An NHS contribution of 2.3 billion (NHS England) in 2021/2022 will have barely risen since. Meanwhile Mintel estimate the total UK market to grow by nearly 20% from 2024 to 2029. Clearly it is the private sector that offers the lion’s share of growth opportunities.

Looking at the current pathway for patients underlines the growing gap.

Patient A develops toothache. They look online and find details of local private dentists. They probably have a choice of practices in terms of locations, services offered, and fees. After a few calls they have a conversation with a well-trained receptionist who wants to convert them into a customer. From here, the practice has the option to deliver a positive experience and potentially make them a life-long client.

Patient B also has a toothache. They call local dentists who are unable to see them under the NHS. They call 111 and are directed to the local emergency provision. This is funded by some of the money that was originally intended to provide comprehensive and routine care via UDA’s. The emergency service is efficiently run to meet specific criteria. Both parties will know that there is not much in the way of choice.

These are very different scenarios. As with the differences between a long term relationship and a one night stand, it will all depend on what both parties are seeking.

The Nuffield report from 2023 concluded that: “Full, universal access to NHS dentistry has probably gone for good, and a drift to the private sector has been taking place for years.” They went on to suggest actions to try and prevent further decline, but the example of extending NHS recall intervals will not stop new patient examinations being loss makers. Indeed, the reduction of cost neutral or even possibly profitable NHS recall exams, will simply clear the diary for more loss making new patient exams.

Industry and business analysts Ibis World offer one of the most recent analyses of the UK dental market, updated in March 2025. It concludes “Prices across all NHS services in England and Wales are fixed. Competition between dental practices is based on location, fees, reputation, the range of services provided and private health insurer links.”

Whether they are delivering NHS or private care in the 2020’s and beyond, practices will require considerable investment, skills and training. The problem for mixed practices is that these will have far less in common. NHS treatment will be focussing on urgent and emergency care. Those that still doubt this should look at which of the pre-election pledges are likely to be delivered, at present only the 700,000 specifically urgent appointments are to be commissioned.

Private care will be represented not by a single model but a range, from simple preventative care delivered as part of a patient clinician relationship, to cutting edge restorative and aesthetic procedures, as well as everything in between.

The trend is that NHS and private dentistry will have less and less in common, and mixed practices may run the risk of being seen as jacks of all trades. There are good reasons why VW and Audi cars stopped being sold from the same dealerships when the Volkswagen Group Board instigated a clearer separation between the two marques in 1995. That decision has not held either brand back in the years since.

The profession and public may both be about to fall out of love with mixed practice, as they realise that it discriminates against private patients, and weakens the viability of the business.