Abstract

Introduction

The share of the dental market held by corporate bodies continues to increase. With the profession currently facing many challenges it is important to understand their place in the profession and their effect.

Aim

This exploratory study aims to provide an insight into dental associates in relation to their working environment. Specifically, the differences between working in corporate and non-corporate environments in England.

Materials and methods

Secondary analysis of a self-report questionnaire examining demographics, pay, working conditions, job satisfaction and morale using a combination of closed and open-ended responses sent to randomly selected associate dentists who are BDA members. Responses from associates working in England solely in either the corporate or non-corporate sector were analysed.

Results

Significant differences were seen between associates working in corporate practice when compared to those in non-corporates practice, for example, significantly less corporate associates were female and corporate associates reported relatively lower levels of autonomy and control.

Discussion

The differences seen between sectors could be related to rationalisation and should this be the reality it could have far reaching effects on the profession and its ability to manage itself.

Conclusion

This study highlights some differences between the corporate and non-corporate dental sectors. Further work is needed to build a deeper understanding of the sector.

Listen to the author talk about the key findings in this paper in the associated video abstract. Available in the supplementary information online.

Introduction

Dentistry in the UK is attractive for corporate investment. Government decisions to open the market to competition and create a more predictable funding system were key drivers. NHS care is particularly targeted as corporate providers have the ability to lower costs, making them attractive to commissioners, and the knowledge that if they do not win contracts there is room for consolidation and opportunities for saving. However, investors invest to make a profit and how dental care is delivered is arguably secondary1 with investments focused on motivating dentists to increase revenues and operate more efficiently.2 There is little published evidence of the effect of dental corporates on dentistry in England though previous work has indicated differences between associate populations with significantly greater proportions of non-UK graduates and performers with less UK experience and fewer further qualifications providing treatment in corporate practices than non-corporate practices. This study works to provide an understanding of the experiences of associates working in this sector.

This paper is the final paper in a series aimed at providing context and developing an understanding of dental corporates and their impact on UK dentistry. The previous two publications examined the development of the corporate sector in the UK, the role played by the BDA and reviewed the corporate market abroad and in the UK. This final paper presents insight into the working environments of dental associates according to sector and suggests further work that could provide greater insight into dental corporates.

Materials and methods

Secondary analysis of survey data for associates working in England was conducted. The original surveys were conducted using a self-report questionnaire. The questionnaire is a well-established BDA survey, used to generate evidence for the Doctors and Dentists Review Board (DDRB) review process, and consists of approximately 25 questions covering demographic data, perceived decision-making abilities, motivation, career progression, job satisfaction and morale. To be eligible for the survey dentists must be associates and BDA members. The resulting data covers both the NHS and private sectors. Data from the 2016 and 2017 surveys are analysed and associates working in England exclusively in either a corporate or non-corporate environment are included. In 2016, 105 corporate associates fell in to this category and 213 non-corporate, and 88 and 159 respectively for 2017. Corporate respondents included those working at Bhandal, Centre for Dentistry, Genix, IDH, Bupa/Oasis, Perfect Smile, Portman, Southern Dental and Rodericks. Not all associates answered all applicable questions leading to missing data for some questions. As less than 6% of cases were missing, SPSS was allowed to default to its method of handling missing data.

Data were analysed quantitatively using SPSS (version 24, IBM, New York, USA). Open-ended questions were subjected to a thematic analysis and coded using NVivo (version 10, QSR International, Melbourne, Australia). Descriptive analysis was carried out and corporate and non-corporate associates compared using Chi-squared and Mann Whitney U tests. Data was weighted for response rate and probability of selection used when constructing the stratified sample. N values are weighted. The significance threshold was set at 0.001. Data are provided as supplementary online only material.

Results

Characteristics

The association between gender and sector was significant, in both 2016 and 2017 (χ2 = 31.07, df = 1, p <0.001, φ =.093 and χ2 = 25.1, df = 1, p = <0.001, φ = −0.086 respectively), with female associates less likely to work in corporate practice than non-corporate practice. Gender also differed within each sector with significantly more female associates than males for both years (χ2 = 10.94, df = 1, p = 0.001, φ = 0.068 and χ2 = 291.94, df = 1, p = 0<.001, φ = 0.253 for corporates and non-corporates respectively). Associates (2017) in the corporate sector were significantly more likely to have a UK qualification than those in the non-corporate sector (χ2 = 59.70, df = 1, p = <0.001, φ = −0.144) with 77.7% of associates overall holding UK qualifications, 15% EU qualifications and 7.3% qualifications from other countries (corresponding data not available for 2016). 2017 data showed corporate associates were significantly more likely to work mostly in the NHS (more than 75%) than non-corporate associates (χ2 = 64.84, df = 1, p = <0.001, φ = −0.138) though this was not the case in 2016 (p = 0.174) (Table 1).

Table 1 Characteristics of survey respondents.
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UDA values and remuneration

Associates (2016 only, data for 2017 not available) in the corporate sector were significantly more likely to have a UDA target than those in the non-corporate sector (χ2 = 83.03, df = 2, p <0.001, φ =0.152). 2016 data shows UDA values to be similar between sectors though the range was greater for non-corporates with both the highest (£29.15) and lowest (£8.00) values being seen. The mean UDA value in the corporate sector was £14.16 and £14.05 in the non-corporate sector. For 2017 the majority of associates in both sectors earned between £50,000–£74,999 (33.0% corporate and 34.4% non-corporate). Profit for 2017 corporate associates was significantly higher than that of non-corporate associates (U = 1,267,042, p = 0.001). This includes all associates irrespective of the number of hours worked or UDA target. Comparisons could not be made between years as questions were not asked for both years and profit bands differed.

Significantly fewer corporate associates, in 2016 and 2017, agreed that they were fairly remunerated in comparison to non-corporate associates (χ2 = 29.27, df = 1, p <0.001, φ = −0.102 and χ2 = 59.76, df = 1, p = <0.001, φ = −0.153 respectively). The majority of corporate associates in 2016 and 2017 disagreed that they were fairly remunerated. Non-corporate associates in 2016 agreed they were fairly remunerated but disagreed in 2017 with this difference being significant (χ2 = 11.29, df = 1, p = 0.001, φ = −0.056).

Working environment

The majority of associates in both sectors, in 2016 and 2017, agreed that they got support from their colleagues though corporate associates were significantly less likely to agree (χ2 = 20.09, df = 1, p <0.001, φ = −0.083 and χ2 = 33.33, df = 1, p = <0.001, φ = −0.111 respectively). Agreement that their practice was well managed was significantly higher in those working in non-corporate practices in 2016 and 2017 (χ2 = 22.46, df = 1, p <0.001, φ = −0.096 and χ2 = 149.65, df = 1, p = <0.001, φ = −0.242 respectively). Corporate associates believed their practices were significantly less well run in 2017 than 2016 (χ2 = 17.42, df = 1, p <0.001, φ = −0.100) while their non-corporate peers believed the opposite, though the difference between 2016 and 2017 for non-corporate associates was not significant (p = 0.005). The majority of associates in both sectors agreed that they were able to provide patient care to a standard they were satisfied with (2016 and 2017). The majority of non-corporate associates agreed that there was sufficient staff to do the work required in the practice (2016 and 2017) while the majority of corporate associates agreed in 2016 but disagreed in 2017. Corporate associates were significantly less likely to agree with both statements in both 2016 and 2017 than non-corporate associates (χ2 = 11.92, df = 1, p = 0.001, φ = −0.061 and χ2 = 82.00, df = 1, p = <0.001, φ = −0.171 for patient care and χ2 = 143.83, df = 1, p <0.001, φ = −0.212 and χ2 = 442.86, df = 1, p = <0.001, φ = −0.397 for sufficient staff) and corporate associate agreement that there was sufficient staff for the work required significantly declined between 2016 and 2017 (χ2 = 53.89, df = 1, p = <0.001, φ = −0.166).

Motivation

There were no significant differences between sectors for motivators (2016 data, 2017 data not available) (p >0.001) and the most commonly cited factor in both sectors was patient-related factors, for example helping patients, with just under a third of each group citing this (31.3% non-corporate and 31.4% corporate). The second most cited motivator was financial (10.2% of non-corporate and 8.6% of corporate associates) and providing high quality care was third (approximately 6% of each sector).

Satisfaction and morale

Corporate associates were significantly less likely to report high morale than their non-corporate counterparts (2016 and 2017 data) (χ2 = 17.35, df = 1, p <0.001, φ = −0.083 and χ2 = 36.80, df = 1, p = <0.001, φ = −0.131 respectively) (Fig. 1). Job satisfaction fell significantly between 2016 and 2017 in both sectors (χ2 = 125.61, df = 1, p <0.001, φ = 0.241 and χ2 = 777.60, df = 1, p = <0.001, φ = 0.432 for corporate and non-corporate associates respectively) (Fig. 2). The majority of non-corporate and corporate associates were dissatisfied in their present job with there being a significant difference between the sectors in 2017 with corporate associates less likely to be satisfied (χ2 = 66.94, df = 1, p = <0.001, φ = −0.148). This corresponded with corporate associates, in 2016 and 2017, being significantly less enthusiastic about their work (χ2 = 63.86, df = 1, p = <0.001, φ = −0.162 and χ2 = 32.06, df = 1, p = <0.001, φ = −0.121 respectively). While there was no significant difference between the sectors for recommending dentistry as a career for 2016 or 2017 (p >0.001), associates in both sectors were significantly less likely to recommend dentistry in 2017 than 2016 (χ2 = 20.06, df = 1, p <0.001, φ = −0.103 and χ2 = 25.75, df = 1, p = <0.001, φ = −0.075 for corporate and non-corporate associates respectively).

Figure 1: Morale in corporate and non-corporate associates.
figure 1

All associates were asked this question. High and very high were collapsed. Low and very low were collapsed

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Figure 2: Satisfaction in corporate and non-corporate.
figure 2

All associates were asked this question. Completely, mostly and somewhat satisfied were collapsed. Completely, mostly and somewhat dissatisfied were collapsed

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Decision making and autonomy

The majority of associates in both sectors felt able to challenge the way things were done in their workplace (2016 and 2017), though corporate associates in 2017 were significantly less likely to agree than non-corporate associates (χ2 = 82.10, df = 1, p = <0.001, φ = -0.180) (Fig. 3a). Corporate associates' agreement with the statement that they were able to challenge the way things were done significantly fell between 2016 and 2017 (χ2 = 11.71, df = 1, p = 0.001, φ = −0.080). Significant differences were seen between the sectors with corporate associates less likely to agree that they were involved in decision making that affected their work (χ2 = 232.65, df = 1, p = <0.001, φ = −0.292 and χ2 = 165.38, df = 1, p = <0.001, φ = −0.254 respectively) (Fig. 3b) or that they had clinical freedom (χ2 = 24.59, df = 1, p = <0.001, φ = -0.086 and χ2 = 162.82, df = 1, p = <0.001, φ = −0.323 respectively) in 2016 and 2017 (Fig. 3c). Corporate associates were significantly less in agreement in 2016 than 2017 that they had clinical freedom (χ2 = 30.34, df = 1, p = <0.001, φ = −0.120).

Figure 3: The percentage of dental associates who agreed or disagreed with statements relating to autonomy.
figure 3

(a) I feel able to challenge the way things are done in the practice(s) I work in; (b) I am involved in decisions that affect my work; and (c) I have clinical freedom in my work. All associates were asked these questions. Agree and strongly agree were cotllapsed. Disagree and strongly disagree were collapsed

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Job security, opportunities and career intentions

There was a significant difference between sectors, in 2016 and 2017, with corporate associates less likely to feel secure in their job (χ2 = 28.23, df = 1, p = <.001, φ = −0.099 and χ2 = 79.63, df = 1, p = <0.001, φ = −0.178 respectively) though the majority of associates in both groups felt secure. Job security significantly decreased in the corporate sector between 2016 and 2017 (χ2 = 26.67, df = 1, p = <0.001, φ = −0.120). Associates in both sectors believed that there were opportunities for them to progress in their career, to do challenging and interesting work and that there were opportunities to develop their skills. 2017 data showed significant differences between the sectors with those in corporate practice less likely to agree to any of these three statements (χ2 = 26.05, df = 1, p = <0.001, φ = −0.101, χ2 = 47.77, df = 1, p = <0.001, φ = −0.137 and χ2 = 86.30, df = 1, p = <0.001, φ = −0.174 respectively). Between 2016 and 2017 there was a significant reduction in corporate associates who agreed that they were able to progress their careers and develop skills (χ2 = 54.46, df = 1, p = <0.001, φ = −0.175 and χ2 = 22.01, df = 1, p = <0.001, φ = −0.105 respectively).

Less than half of associates in both sectors intended to continue working in their current role for the next five years with corporate associates in 2017 being significantly less likely to continue than non-corporate associates (χ2 = 51.47, df = 1, p = <0.001, φ = 0.124). There were a number of significant differences, for both 2016 and 2017, seen with associates in the corporate sector more likely to intend to retire (χ2 = 40.52, df = 1, p = <0.001, φ = −0.106 and χ2 = 10.27, df = 1, p = 0.001, φ = −0.055 respectively), become a hospital dentist (χ2 = 12.53, df = 1, p = <0.001, φ = 0.059 and χ2 = 55.39, df = 1, p =.001, φ = −0.128 respectively) or reduce their work hours (χ2 = 24.36, df = 1, p = <0.001, φ = −0.082 and χ2 = 11.58, df = 1, p = 0.001, φ = −0.059 respectively) but less likely to intend to become a practice owner (χ2 = 110.71, df = 1, p = <0.001, φ = 0.175 and χ2 = 12.95, df = 1, <0.001, φ = 0.062 respectively). Taking a broad definition for those intending to leave the NHS (includes retiring, leave to work overseas or for a role outside dentistry, becoming a community or hospital dentist or increasing their private work) in the next five years, there was a significant difference in 2017 between corporate and non-corporate associates with those in corporate practices less likely to leave the NHS than those in non-corporate practice (χ2 = 22.55, df = 1, p = <0.001, φ = −0.081).

Discussion

Since DBCs have been trading in the UK there has been contention with commercial interests being introduced into healthcare and the possible effects. There is little published evidence of the effect of dental corporates in dental care and this study suggests there are significant differences between the corporate and non-corporate dental sectors in the workforce and work environment.

Data indicates that some factors including UDA value are similar between corporate and non-corporate associates but there appears to be a clear divide for aspects such as job satisfaction, morale, job security, decision making and control. Non-corporate associates in our study reported a significantly greater level of autonomy and a greater ability to make workplace and clinical decisions than those in the corporate sector. These findings are similar to those seen in pharmacy, which has had a great increase in the level of corporate presence and rationalisation, where the autonomy, decision-making capabilities and control needed to carry out the professional role appear most limited among corporate pharmacists.3,4

The divergence seen in this study may not be surprising as dentistry requires set processes to comply with regulation and protect patients and this will take some control and decision making away from clinicians. In smaller dental practices the amount of authority and control that is lost due to statutory requirements will be less than that lost in larger corporate practices as with larger organisations the need for, and level of, bureaucracy increases in an effort to organise the workplace and maximise profits.5,6 This is in line with anecdotal reports made to the BDA, and in the media,7 of the levels of control placed on associates. One way private equity firms realise value is by attention to detail and emphasis is placed on measuring and managing all relevant aspects of a business's performance.8 The work of dentists has a direct effect on the profitability and income of the business so it would be logical to introduce ways to maximise revenues and minimise the costs relating to the dentistry performed. Ultimately, a corporate wants to make a profit and evidence suggests that one target is the workforce,9 though the scopes of practice in dentistry may provide some protection as to the scale of this.

While bureaucracy may be recognised as one of the most efficient organisation methods10,11 it is linked to the degradation of the work life of employees, job dissatisfaction, an inability to cope with unusual situations and the creation of conflict.11,12 Corporate associates, while usually not employees, were, in 2017, significantly less satisfied with their jobs and had lower morale in contrast to non-corporate associates. Possible further reflections of the negative impact of bureaucracy were corporate associates feeling significantly less secure in their jobs and having a significantly lower level of satisfaction with the standard of care they provide that increased from 2016 to 2017. They increasingly believed there were fewer opportunities to do challenging and interesting work. A significantly smaller number of corporate associates in our study felt their practice was well managed in comparison to those in the non-corporate sector. This may be somewhat surprising as corporate owners cite their ability to reduce the administrative burden, manage practices and provide comprehensive clinical and administrative support as benefits to selling to them.13,14,15,16

Loss of autonomy could be a sign of rationalisation. During the 1970s, pharmacy underwent great changes with the traditional functions of pharmacists steadily eroded.6 This led to pharmacists being over trained for their roles and underemployed. While there are differences between the two sectors, for example dentistry is a clinical profession and corporatisation is only one of the developments to threaten pharmacy, they are becoming increasing comparable in some areas. In large corporate pharmacy businesses, for example Boots/Walgreens, pharmacy may not be the core business. With a large company covering areas including pharmacy, optical care, beauty, photography and the selling of sundries, the pharmacist could be seen as having a supporting role for the work of the business as a whole. This appears to be creeping into dentistry with bolt on services, generating additional income, being added such as facial anaesthetics, minor surgery and vaccine provision. The sector is beginning to draw inspiration from less clinical and more corporatised and commercial sectors such as optical care, without necessarily taking into account the more demanding aspects of dentistry such as greater levels of invasiveness and intensity.17

Dentists are trusted with autonomy and follow standards placing the interests of their patients before any financial or personal gain or business interest,18 whereas corporates may be guided by the goals of the organisation. Loss of autonomy could lead to associates in the corporate sector falling in the business hierarchy and being reduced to a level of service to the broader interests of the business. Subsequently, any relative loss of professional autonomy in a sector that is consistently growing could be a concern, especially at this time of uncertainty, with the profession facing many challenges including funding cuts, changes to procurement processes (Dynamic Purchasing System), a possible new contract and potential changes to career, education and training.19,20,21

One aspect we did not explore was clinical care. We determined that associates in the corporate sector were significantly more likely to be UK graduates than those in the non-corporate sector. Non-UK graduate clinicians and performers with less UK experience and fewer further qualifications in the corporate sector have been seen, through audit, to refer more patients for secondary services and for more simple procedures than those in the non-corporate sector.22 Audits also show that 'high volume, well-trained, experienced operators get better results, are safer and have much fewer complications than inexperienced, poorly trained or low volume operators.'23 This leads us to suggest further work could include differences in patient care between sectors to provide further insight. We are following up this study with a qualitative examination of associates' working environments.

Survey respondents were limited to BDA members, which could introduce inherent bias, but we are confident this group serves as a reasonable sample of dental associates in England.

Conclusion

Since its conception, dentistry has risen to many challenges. For the profession to continue to develop it must adapt and in order to do this it needs to be aware of influencing factors. The competitive corporate dental market is still young and a true picture cannot be seen until the market matures. While this study illustrates that there are differences between the sectors it is evident that further work is needed to build a more definitive picture of corporate dentistry and the influence it has on the profession. Knowing more about dental corporates and the experiences of those working within them will allow the profession to support itself during this time of uncertainty.