Another New Year rolls towards us with still nothing particularly concrete planned regarding the new new new NHS Dental Contract. Ok, so there are prototypes running, but there doesn't seem to be any actual date that will see the beginning of a brave new world where all things NHS Dentistry will be rosy once again.

Prototypes seems to be the new buzz word rather than pilots, but unlike a pilot flying a new course, a prototype seems to be something cobbled together that might just possibly fly, but then again might not. The British are pioneers at making prototypes actually fly, but usually in the aeronautical sense. For this to happen it involves a degree of advance planning on the drawing boards, before making models, testing them in a wind tunnel, before finally making a version that might actually fly. There are some occasions where a test pilot has taken the front seat in a prototype only to have met a swift end when something has not quite been right with the design. At least the engineers then can go back to the drawing board and hopefully redesign a problem out of the next version.

But this is where the analogy with the NHS prototypes ends. Instead of learning from the mistakes and problems with the prototypes and design out the problem, the DoH apparently just ignore the data they don't like and carry on with the data they do like. All still fuelled by the ubiquitous UDA. Going back to the analogy, this would be like the designing a solar powered plane expected to fly at 600mph where the wings fall off at 500mph and you can only fly it at night. But since it looks really really good and the Government like it, you can get loads of people on board, so they'll order them. Anyhow, if it crashes, the Government will always blame pilot error. 

People working in the prototypes seem to have varying experiences; those in the blend A models (having a capitation for all band 1 treatments and claiming band 2 and 3's)  are reporting more issues than those in the Blend B (Both band 1 and 2 as capitation and band 3 to be claimed). But what is being reported generally is that access is going to go down with these new ways of working, whilst it is increasing difficult to keep the capitation numbers to target. Access is the only mantra the DoH have, and whilst they pay lip service to quality outcomes, you can rest assured that the only bit of quality they will be interested in will be how much they can claw back when the quality outcomes can't be met. Some of those in the prototypes don't even know how the quality aspect is being calculated as there don't seem to be figure made available (particularly to associates). Given that this is 10% of the contract value, not having the information on what you are being measured on seems to be a significant problem to me.

Having an entirely capitation based system (which will be what the BDA will try for) is better for practitioners ONLY when you have a government that isn't obsessed with output and not interested in the actual quality. By expecting the practitioners to provide the quality as part of their obligations ethically to their patients, and regulated by the GDC, the DoH can quite happily still place the blame at the door of the individual performers on any contract. Its win-win for them still. Anyone who thinks any new contract will be a dental utopia should probably consider leaving the profession now. Almost all commentators say that there is already little enough time to provide the output expected to meet UDA targets; the new system seems even more geared to allowing practices to struggle to hit the new targets. Even successful prototype practices are struggling with the capitation element, as they need many ore new patients to ensure the targets are boing met, but with no space to treat these often high needs patients until 2 or more months down the line, one must wonder how these increase targets are going to benefit good patient care in the brave new world.

Here is now data that shows the amount of principals in practice is reducing, with the increase in associates being proportional to that. However the change is quite extreme, with something like 83% of dentists now working as associates. This will be the norm in the future in my opinion, as with a downward pressure on the income of dentists generally it will become more and more difficult for associates to begin to invest in a practice of their own. I can see parallels with the optical and legal industries here, and incomes of £30,000 for associates becoming routine. Not only that, with the change in the way the new contract may be calculated, and the 'UBER' ruling recently about when self employed might not actually be self employed, then I can foresee a time in the near future when associates become true employees, with the associated increase in liability the employer then has (national insurances, sick pay etc) to cover reducing the wage structure still further. I am also aware of practices who have had to make members of the team redundant, such as therapists as they cannot make the system work for them due to the economics and logistics that seem to be inherent. Still, that's not going to be the DoH's fault is it? Just the dentists who don't run their practice the way the DoH want them to.

Don't get me wrong though; there will still be some highly entrepreneurial dentists out there who will continue to make a very good income from the NHS, but they will be at the head of larger practices or mini-corporates, and backed either by the fortunes made in this system, family money, or outside investors who can see the business model working. There is nothing actually wrong with this either, because fundamentally dentistry is going to be a service industry in the same way as a mobile phone company is, and you don't see all the employees in that industry getting the same salary as the chief executive. It becomes almost irrelevant that many of the 'fee earners' in dentistry are highly educated individuals supported by a well trained team; dentistry is just another 'widget' producing industry for investors to make a profit out of at some point.

One of the reasons that the profitability of corporate practices has been lower has to be due to the income proportions taken by associates. I have no issue personally with what associates earn, but the days of 50% are long gone in this new world, and probably 35% is more realistic for the future. Many law firms expect their fee earners to generate at least 3 to 4 times their salary in order to justify their continued employment. Only in this way will the corporates become as profitable as they need to be to survive long term, and they know this. Coupled with an increased difficulty in earning the udas if the new contract is like the prototypes, with quality frameworks and increased access, then a downward pressure on the highest cost base that can be influenced is certain. In any dental business of a certain size with associates, then I would be pretty sure that the highest 2 costs will be associate wages and staff wages. Only by controlling this aspect, and in an even harsher manner than previously, will the profitability that is needed for continued business survival start to be produced. How fast this will then follow in the smaller practices which have proportionally higher cost bases due to the lack of bulk buying powers is an academic argument.

To finally top this, the BDA  released a press release in the last week indicating just how poor the morale is within the profession. Although this has been known by the profession since at least the time Sheffield United last won a football trophy, they have now decided to let the public know the blindingly obvious. Once again the BDA's public condemnation of a system has been about as vocal as a mute mouse with a sore throat. It should be front page news that half of the UK's NHS dentists are thinking of leaving the NHS, but I haven't seen it in the papers today, but if it does appear it will be spun against us. I was informed (as I was writing this piece) that the BDA are now threatening legal action against NHS England for the patient charge revenue deductions made due to their interpretation of the 2 month rule. But will they get the spin right when they tell the public? Or will the Daily Mail run the 'Greedy Dentists Sue Cash Strapped NHS for more money' headlines because we haven't got a good PR image? At least the BDA are starting to do something positive, but the message has to be managed to our benefit.

So it remains to actually be seen just what might happen in the brave new world of NHS dentistry. Is morale going to improve, or will the DoH continue the beating of the profession until it does? Will there be more time for the quality that our profession is expected to provide? Will there be the correct funding for a First World service?

 Sadly, I think we all know the answers to those questions if we are honest with ourselves.

The Health Select Committee will be holding an accountability meeting with the GDC on the 3^rd of March. It’s about time too, as they haven’t been asked to account at all to anyone but the judiciary recently (and they lost). It will be interesting to see if they try to spin that meeting in the same way as they did in the press release just after the decision in the high court in December.

It looks like the GDC have finally got to face the only people who they are answerable to. I wonder if they are going to try to wiggle out of the unavoidable truths?

I presume everyone reading this is going to submit his or her evidence to the HSC through this link before the deadline of 19^th February.

No?

Why not?

Are you scared?

Well actually, that is probably extremely close to the truth. I am personally quite worried these days that a GDC letter will arrive on my doorstep for some reason or another (and that is not because I know I have something to fear – my inherent belief structure tries to ensure I do the right thing by patients at all times, but I have also been openly critical of the GDC, which I’m sure they do not like – and they get to decide what is deemed as professional or not).  All someone these days has to say (even in jest) is “I’ll report you to the GDC for…” or ‘I bet the GDC have their eyes on you” and it feels like a letter from Wimpole Street is already winging its way to you starting the process of investigation and a potential loss of livelihood.

The lack of proportionality that has been written about previously means that a situation like this could be an increasing possibility for all of us. It’s why the ARF had to go up according to the GDC for goodness sake. To put a few figures on this, if you reckon on 40,000 dental registrants having about a 40 year career, and the current data from the GDC is that there were 1700 complaints in the first 6 months of 2014, then the maths shows that each registrant will have 3.4 complaints in a career. (3400 complaints x40 /40,000). Some of these complaints are against DCP’s, ok, and not all of them will go to the full Fitness to Practice hearing,  (but 40% of them currently do) but I’m sure you get the overall idea. Is it right that if this way of dealing with complaints continues, on average, every single dentist will have to face this career-wrenching possibility more than once? This alone tells the general reader that the regulator is going the wrong way about it.

Since the GDC are the initial arbiters of our standards and decide an investigation will run to see if there are any grounds to an allegation, and there is currently the interminable wait for a hearing, then I don’t honestly think I could mentally deal with that kind of pressure for that long with the fear of loosing all that I have put into patient care, this profession, and that of my livelihood and ability to provide for my family. Even if an investigation goes all the way to a hearing, is there any guarantee that there will be an understanding of the pressure we are now practicing daily under from the committee, especially when it is made up of so many lay persons?  Tony Jacobs wrote an excellent blog on this subject.

Some of you will have no doubt read the very eloquent and erudite blog written by Colin Campbell, a very well thought of colleague in my locality and indeed nationally. Colin is one of the most ethical and conscientious practitioners I have ever met. If you haven’t read it then it is a ‘must read’, because Colin is a person who wears his heart on his sleeve and this series of blogs are likely to be a wholly authentic and personal view of how HE felt during the process he went through.

There are many (most of us?) out there that fear the GDC, and not for the correct reasons. We need to respect our regulator, and know that whilst it absolutely MUST act to protect the public, it is not effective ‘right touch’ regulation to do this by ruling the profession with that kind of fear. Using a methodology akin to continuing the beatings until the morale improves is not how it works these days.

Mistakes happen; I was once told right at the beginning of my dental career by an older practitioner the reason he was more experienced than me is because he had made more mistakes than me. Nobody is ever going to excuse the type of mistakes that are so dangerous they have to be dealt with swiftly and appropriately. But if we are to be perpetually living in the fear that one minor transgression will bring the full weight of our regulator down on our backs then that is wrong.

There are also bad people in our profession; nobody is denying that, and I will certainly make no excuses for them. But the climate of fear that pervades the profession at the moment is no way to prevent mistakes from happening, and it certainly wont do ANYTHING to stop that minority who are out to damage people because  they probably don’t have the emotional or ethical values to allow them to feel the fear those of us that practice ethically and responsibly (and fearfully) do.

So at the moment I remain scared. But I will still be submitting evidence to the Select Committee because I cannot, and will not be made to feel this way for the rest of my practicing career. We care for patients every day, but we also have to care about our future health for the sake of our families. After all, we too are human, just like the public the GDC must protect.

We have to stand up to the GDC and now show them the true and high calibre of the vast majority of Dental Professionals.

Blog image Edvard Munch [Public domain], via Wikimedia Commons 

I wasn’t going to write any more GDC related blogs for a while, as I don't want to be seen as a one trick pony, but the situation with the GDC is the singular most important thing to have affected our existence as a profession, and continues to have more twists and turns than a white knuckle roller coaster, so my apologies for writing about it again.

Seriously, was anyone surprised by the GDC’s decision to increase the ARF to £890 on the 30th October?

After the sham of a consultation, it’s not entirely surprising that this should be followed by what was probably a sham of a discussion at the Wimpole Street Lublyanka (for those unaware, that was the name of the HQ and prison of the KGB), and an ARF of £890 has been set.

Nothing has really changed though; despite now slightly reducing the amount for DCP’s (the majority being nurses who I suspect have that actually paid for by their practices), this would appear to have been the classic “give ‘em 3 choices and they’ll pick the middle one”.

The BDA is now set on its path for Judicial review; and this will be heard before the 17th December. The BDA stops short of recommending what its members can do up to this point, but If I may suggest the one thing that absolutely everyone can do now is cancel their direct debit, and write themselves a reminder to pay the GDC before the 31st December. That way they CANNOT take the money early, and whilst it may only be three or four weeks more before they can get it, at least if the BDA win the Judicial Review then people wont have to be waiting for a refund from a regulator that has no sense of respect for the profession. You will not be acting illegally, just stopping the GDC from getting its hands on your money sooner. Incidentally, according to a recent freedom of information request, the decision to engage KPMG was a decision taken by the Executive of the GDC and not by the council. One would have thought that engaging a company like KPMG with its associated costs would have been something put to the Council to vote on. Anyhow, the GDC will need even more money to pay for the services of KPMG, and guess what? We get to pay again.

This brings me to the point of this blog.

Civil Disobedience.

What would happen if every one of us rang the GDC between Christmas and New Year to pay? If a few thousand registrants rang over that 3 day period it means hundreds of calls would need to be taken every hour by the GDC if they had an 8 hour working day. What if their systems collapsed under the weight of having to take so many online or telephone payments? Apparently they are so arrogant they do not have the facility to take payment in cash, so the very press worthy images of a few hundred dentists turning up with buckets of £1 coins in order to pay are not going to hit the pages of the Daily Mail anytime in the future.

So what’s wrong with paying £10 on each of 89 cheques, and requesting a receipt for each one?  Or making multiple credit card payments of the same amount? Given that it is also legal to write a cheque on just about anything, may I suggest that a few 6’x4’ pieces of chipboard, properly filled out with sort codes etc delivered to the GDC in Mid-December from registrants wouldn't go amiss. How about arranging a mass payment in between Christmas and New Year, and on the days that the LAT’s insisted we should all be open for normal business? If just 100 of us turned up and wrote cheques out on pairs of boxer shorts (new ones obviously!) that might get some press attention. All at the same time as they're manning the phones taking the card payments above. One idea being floated on Facebook is getting the GDC’s bank account details and paying them directly by BACs. Its actually quite difficult for the GDC to trace who has paid at their end, but we will all have documentary proof at our end that it has been paid.

All a bit tongue in cheek admittedly, but with a serious side; if the judicial review fails, then we will have to pay this ARF. The BDA will continue the fight I know; but this particular avenue will then have closed, so a little bit of civil (legal) disobedience would show the GDC we are still up for a fight, but just looking for the next opportunity to open up a chink in their armour.

I also think that with Thursday’s decision the position of the remaining dental registrants on the GDC has now become untenable. I’ve stopped short in my past blogs of directly levelling any personal criticism at any members of the council, including the Chair and the Chief Executive. But with the emasculation of the profession so effectively by this council structure and those at its head, and the lack of any PUBLIC individual vocal defence of the profession by those who are members of it on the council, then they can no longer use the excuse of trying to change it from the inside. Thursday’s outcome should surely have delivered that message resoundingly to them. If they were against the ARF rise then they cannot now remain in the council; if they were for it, then they are not representatives of the profession. Either way, that makes their positions untenable. They look to be completely sidelined in the council processes that seem to be railroaded through at the whim of those who appear to be building a personal fiefdom with the seeming remit to destroy the entire profession it regulates. Indeed, they don't appear to write their own articles, as those published recently in the dental press which purported to be from them were 80% similar to one another when run through anti-plagiarism software. I also understand a large amount of the council business is now held behind closed doors, and only lip service is paid to the public aspect of the meetings these days which generally give the appearance of being stage managed for those observing.

As a Yorkshireman from the Loxley valley now living in Derbyshire, and working in Nottinghamshire, one legend that has been very close to me throughout my life is that of Robin Hood. I was brought up a stones throw from one of the reputed birthplaces of Robin of Loxley, am now living near the reputed burial place of Little John at Hathersage, and work close to the Major Oak near Mansfield, and I can see a huge analogy in this story.

We have a Sheriff of Nottingham, collecting taxes from the downtrodden masses, ruled over by a King John figure who’s got no real chance of a proper throne. The peasants don't like either of them but they don't care and keep finding more and more reasons to persecute the peasants whilst charging them for the privilege. This makes the remaining members of the GDC the barons at the table of the Sheriff with no real power whilst paying lip service to the Sheriff and King.

We've then got our Little John and Friar Tuck rolled into one, (ok, so its actually Fat Mick but the sentiment’s the same), and the BDA collectively as our Robin Hood (probably the Errol Flynn one rather than the Kevin Costner one given the size of its cojones recently!). That makes the profession the downtrodden peasants (metaphorically), some of whom became the Merry Men and Women. GDPUK is a collective Will Scarlett as the mouthpiece of a storyteller and bard. Hopefully the righteous King Richard is going to be the judiciary who will hear the BDA’s case.

Robbing the rich to give to the poor? How much money has the GDC had from us over the years? Having enough money to spend on QC’s and £78,000 Fitness to Practice cases over silly matters that should dealt with locally at lower cost to the profession shows it has no respect for the money it is given. It has become like a like a rich man who knows the cost of everything and value of nothing. Whilst its remit is to protect the public, this does not mean it should have the sort of reserves it wants. It should have enough to function effectively and no more.

Legend or not, every version of the story ends the same; good always triumphs over evil; a disorganised band of individuals becomes a force to be reckoned with after starting out with a bit of Civil disobedience and brings down a brutal Fiefdom that sees its subjects as legitimate source of money for its own ends, and for summary punishment at its whim.

At first the people can’t see how they will defeat the Sheriff. But up steps a leader and a small number of supporters. The impetus grows and grows until eventually a tipping point is reached. They eventually win by sticking together and keeping up the pressure. King Richard steps in and justice is restored.

Only we can decide if we let the Sheriff and King try to divide and conquer us. It’s still up to us to unite the profession against the GDC.

So to coin Moyes’ phrase of yesterday; ‘Are We Comfortable with that?’

I am.

* Image from Wikimedia Commons.

The revelations of a recent FOI request showing the cash reserves and short term access assets of the GDC potentially raise questions of the financial fortitude of our regulator.

If indeed the figures supplied by the GDC are correct, and represent the full and correct answer to the question asked, then it would appear they have access to about £11.9million of funds within a 5 day period. (I’ve got that figure from 10.5m less 4.8m at 22/7/14 added to the 6.2m at 1/8/14)

Given that the GDC costs £104,000 per day to run by their own admission, then this sees us with a regulator that looks like it is going to have no more cash by the end of November 2014. Coupled with the £7.1million that it is spending on refurbishing its HQ on Wimpole Street, it doesn’t seem all that surprising now that the GDC is threatening the BDA with its losses if the judicial review fails (if it goes ahead).

The GDC usually takes its run of Direct Debits for the ARF in the first week of December, so this would then have the effect of restoring its cashflow straight away.

However, what if all the registrants cancelled their direct debits? What if the BDA were to lead a concerted effort to get us to do this? It won’t fall foul of the legality of having to pay the ARF, it’s just that the GDC won’t be able to actively take it to help their cashflow; we will give it to them when we decide. As long as it is paid before the end of that month, then we cannot be erased for non-payment of the ARF. Wouldn’t it be great for the BDA to suggest ALL registrants cancel their Direct Debits with the GDC?

If this is the case and the GDC is running out of money, then in all likelihood they will just delay the FtP cases and other hearings until the cashflow looks better. Since these equate to the majority of their expenditure this would be a fairly easy way to massage the situation swiftly;  but this then becomes even more intolerable to those stuck in the ever increasing queue for the March to the Scaffold. That means that yet again there will be  practitioners that indeed represent a danger to the public still unpunished and still working, along with those in the queue probably because they used the wrong grade of soflex to polish a composite. Is that any way to protect the public?

But what happens if a regulator is effectively insolvent? Has this ever happened before, and if it is boracic, will it get bailed out by the Government?  What happens to the role of protecting the public if this happens, and how does this square with the requirement in the Dentists Act to have a regulator? If it does indeed become insolvent and is bailed out by HMG, then this shows us that it is indeed a wholly owned subsidiary of HMG, so if they want it to remain solvent , then they and not us should fund it.

Many a profitable business has gone bust in this and the recessions before due to a cashflow problem, so why should any other type of organisation be immune from this when it gets its sums wrong or experiences an increase in its expenditure?

Would the duty of the GDC then be better served by the CQC instead? After all, the CQC now realises dentistry isn’t that bad, and that it recognises the need for experts to be involved in its inspection processes. It appears to have grown a pair of ears more recently. If we are going to have a super-regulator foist upon us, wouldn’t we rather have one that whilst it still seems a bit dim, does  appear to be learning from its mistakes, or continue with one that treats us with arrogance and contempt whilst (possibly) overspending its funding? That’s discussion for another day.

This is all probably hypothetical and the figures have been interpreted incorrectly and they don’t include the contingencies for the refurbishment etc;  if so the GDC isn’t going to run out of money .

But if this IS the situation, the GDC isn’t just Broken, it's Broke.

Having just read the response from the GDC to the BDA’s questions about the Telegraph advert, it would appear that there is a distinct tone of avoiding answering the legitimate questions posed.

Coming from the Chair of the GDC, with his background at the Office of FAIR Trading, this again seems to be at odds with a desire to be open and transparent, and indeed with his recent comments about ‘doing the right thing’.

The admission that the cost of the advertising campaign cost over £27000 should now start a new round of questions to the GDC, since we as registrants are funding this exercise in awareness (the adverts were in Saga Magazine and The Guardian) to a demographic who are largely likely to already know of the mechanisms available to them to complain. In addition, in order to justify any money spent on advertising, this requires some form of review as to its success, so there will be yet more expense following this, otherwise it will have been a total waste of our money. Even if it is reviewed by salaried members of the DCS, whilst doing this pointless analysis, the time spent on this would be better utilised elsewhere.

But more importantly, how would we be treated by the GDC if we avoided answering their questions?  We have a regulator who now seems to run itself by a different set of values to those it expects its registrants to adopt.

Far from allaying any of the concerns of the profession, I feel the response from the chair has once again shown the contempt dentists are held in by the GDC.