Insight is a wonderful thing

It carries so many meanings.

The GDPs view

Many of you demonstrate it in your daily work, by understanding what makes patients tick. They say one thing to you and you apply years of experience, so that after a few moments of reflection, you translate what the patient just said into a proposal for treatment with a couple of options. Our younger colleagues of course find this the hard bit of clinical practice, but with experience time and dedication all Dentists and DCPs in patient contact can become masters of this art.

At the other extreme, when it all goes wrong and some of our colleagues face GDC proceedings, the ability to reflect upon your circumstances is critical. The ability to show insight at the events that led to the GDC may be critical to a Panel taking a benevolent view.

Insight is an essential attribute for any dentist.  For sure, lack of an ability to apply insight will often lead to trouble. It may compromise your relationship with your patient. You may finish up treating a patient despite the warning signs being there perhaps in the body language, or in the tone of voice used during a conversation.

Time? Not a lot of it about!

We recognise the application of insight as a skill and an attribute amongst our colleagues, and we admire those who have mastered the art of its use.

Of course the need to reflect and to gain insight require something that your NHS masters are reluctant to give you too much of: time

Even the GDC require time to reflect and gain insight. 

So why is it that I think the top of the GDC may lack leadership, and the insight that is required to be effective?

There are at the GDC six Registrant members of the Council and numerous panel members who all, in their work and their practice have to find time to reflect and develop appropriate insight into their cases of regulatory work.

The Times -  6^th August 2016

So it was with some surprise that the Chairman of the GDC, a certain Dr William Moyes PhD Esq, found himself demonstrating what seems to be a surprising ignoranceof the workings of NHS funded dentistry at the weekend, if The Times quote is to be believed.

Many of you will of course regard the summer as the season of slow news and will know that dentists are an easy target.  If I were you I should take it as a compliment.

What never fails to amaze me though is how the media absolutely fail to gain any true understanding, insight dare I say, of the problems associated with the Government offering for the nations dental care

And so it was in last Saturday’s edition of The Times. Front page news no less. It was probably pure coincidence that the de Mello case was about to be started at the GDC.  In fact, it was – a leading colleague single-handedly was trying to have the issue properly addressed. It is now behind a pay wall, but I have copied it below.

The Thunderer bellowed …

The article so nearly nails the issues, and in many respects it almost goes so far as to highlight “The Big Lie” and identify the lack of “Clarity of the Deal”.  A big up to our colleague, Dr Kotari, for getting “High Street Dentistry” on the broadsheet agenda. Patently he did not write the copy.

The message was clear though. Even someone without deep insight into the NHS Dental Service can see it is trying to do too little for too many.  There is only a certain amount of money, and the way it is spent simply does not allow for the provision of a broad range of highly complex procedures for everyone.  There is a very good blog on the BDA site reflecting after this article by a young colleague Dr Robert Chaffe at https://bdaconnect.bda.org/bad-dental-press/ .  The BDA through Dr Mick Armstrong were pretty robust in their reponse at  https://www.bda.org/news-centre/press-releases/bda-response-to-the-times .

And as FtP numbers prove, the dentist’s lack of time to reflect and develop insight into the problems of a patient cause that patient to feel abused and make that first GDC contact.

It’s not a difficult loop to get your head around, is it Dr Moyes?

Clearly, it’s about clarity

Anyone with half a brain can see that the future must involve a clear demarcation of what is and what is not available as NHS treatment. The post-code lottery that is exemplified by the extraction -versus- endodontic treatment fiasco reveals the problem that everyone is shouting about.  The only people who will not engage on this matter for no other reason than political fear are the dunderheads at the Department of Health.  Even the BDA recognise that it will have to come - but everytime it is mentioned at DH or NHSE level senior officials shake their heads. "Can't be done dear chap".

UDA Targets are set by …

The message is equally clear about high levels of UDA targets – the dentists do not set these. The Local Area Teams do.  In cases such as that of Dr de Mello, these colleagues may genuinely think they are doing the Governments dirty work for them in an efficient manner, bringing access to the masses at minimal cost.  That is what the Government want, isn’t it?  Dentistry is a broad church and while I would not poersonally be able to cope with a high UDA contract requirement, I know some can.  Does that make them wrong in themnselves?

When I wonder will NHS management be called to account instead of the dentist who is the low hanging fruit of accountability? 

What’s that you say? Never?

Soundbites

So when Dr Moyes, as GDC Chairman is reported in The Times as stating on behalf of the GDC, and I quote from the article:

The General Dental Council says that it cannot act because a lack of professional guidance allows dentists to claim that extraction is a legitimate option. “I’m sure that if patients had a full understanding they’d be quite appalled,” Bill Moyes, the council chairman, said.

What exactly can he mean? Is he saying there is a massive problem? Or is he demonstrating considerable ignorance similar to that which his infamous Pendlebury Lecture highlighted? Shall we assume Mr Chris Smyth, Times Health Editor, is including a quote relevant to the thrust of the article for now.

Can Dr Moyes really have so little insight into the working of dental practice?  It certainly looks like it.

Did Dr Moyes not reflect upon the magnitude of the meaning of his comments?  It certainly appears not. With that one comment Dr Moyes has revealed all that is wrong with his Chairmanship of the Council.

We now have a decent working team in the GDC Executive Leadership. But the Chairman has revealed that he is not neutral, and strategy driven. Instead, he appears to be a simple supporter of that broad-brush vox-pop opinion that “all dentists are trying it on”.

Last call for Dr Moyes…

The time has come for the Chairman of Council to shape up, learn about the long standing problems of NHS funding of dentistry and take on the causative Department of Health as part of the GDCs Strategic role.

Or he must step aside and let a more capable person take the role on. 

It IS clear that it is time for Dr Moyes to reflect upon his position, for the sake of the profession he seeks to regulate and yet for which he patently has scant regard.

Slow news day my foot – have a great break if you are away.

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TIMES INVESTIGATION
The great dental rip-off
Thousands of teeth needlessly extracted as surgeries accused of putting profit before patients

Chris Smyth, Health Editor | Katie Gibbons
August 6 2016, 12:01am,
The Times

Regulators said that dentists were extracting teeth to avoid offering complex treatment, for which they are paid the same by the health service

Thousands of people are losing teeth needlessly because it is more lucrative for NHS dentists to take them out than try to save them, an investigation by The Times has found.

Regulators said that dentists were extracting teeth to avoid offering complex treatment, for which they are paid the same by the health service. The investigation has also found that some dentists earn almost £500,000 a year in a system that rewards them for cramming in as many patients as they can.

Dozens are claiming for the equivalent of more than 60 check-ups a day, in what has been condemned as an unethical conveyor-belt approach to patients. The upper limit is considered to be 30 a day for one dentist.

Under reforms introduced a decade ago, dentists are paid about £25 for every “unit of dental activity” (UDA) that they carry out. Each check-up, or simple examination, is classed as one UDA; tooth extractions count as three, along with fillings and root canal work, irrespective of how long the treatment takes. Root canal treatment usually lasts more than twice as long as an extraction.

NHS figures seen by The Times show that 30 dentists were paid for more than 15,000 UDAs last year — the equivalent of about 60 simple appointments a day over a standard working week. Ten dentists were paid for more than 18,000 UDAs, equivalent to about £450,000.

Alex Wild, of the TaxPayers’ Alliance, a public spending watchdog, said: “The amount of work dentists do will obviously vary significantly, but the figures at the top end appear totally implausible . . . an urgent review is essential.”

Dentists routinely weigh up how much time and treatment a patient needs against a desire to maximise earnings, say professional leaders who concede that the payment system is causing an “ethical compromise”.

The warning comes before the disciplinary hearing next week of the dentist responsible for the biggest patient alert in NHS history. More than 20,000 people treated by Desmond D’Mello, 62, were called for HIV and hepatitis testing after he allegedly failed to change gloves or clean equipment between appointments in an attempt to see as many patients as possible.

Mike Waplington, president of the British Endodontic Society of root canal specialists, said that extractions had jumped by a fifth and root canal treatment had fallen by almost half after the contract that paid the same for both was introduced in 2006. Root canal treatment could take three times as long as an extraction. “There is an incentive from the system and some dentists may say to patients ‘I can take this tooth out simply’.”

More than two million teeth were taken out on the NHS last year, but Mr Waplington said that many could have been saved, estimating “over the lifetime of the contract it would have affected tens of thousands of teeth”.

Many dentists also feel more comfortable taking teeth out, as only 277 out of more than 40,000 are registered as specialists in root canal work.

Trevor Lamb, co-founder of the Saving Teeth Awareness Campaign, said: “The public are too quick to accept that teeth should be removed. They are unaware of the alternatives and some dentists exploit this. You wouldn’t go into A&E with a broken arm and expect it to be amputated.”

At least 2,000 dentists claimed for more than 8,000 UDAs, equivalent to the upper limit of about 30 check-ups a day. Neel Kothari, a Cambridgeshire dentist seeking reforms, said that it was difficult to do more “in any ethical sense”, with 60 patients a day impossible without cutting corners.

He warned that dentists intent on maximising income might skimp on treatment as well as hygiene. “It’s as if you went to a top restaurant and they served you a Big Mac disguised as a gourmet burger,” he said.

Nigel Carter, chief executive of the Oral Health Foundation, said: “To do a proper assessment of the patient would probably take 20 minutes. But that hasn’t been what the health service has been paying for. There is a bit of an ethical compromise.”

The General Dental Council says that it cannot act because a lack of professional guidance allows dentists to claim that extraction is a legitimate option. “I’m sure that if patients had a full understanding they’d be quite appalled,” Bill Moyes, the council chairman, said.

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GDPUK Topic

https://www.gdpuk.com/forum/gdpuk-forum/the-saturday-times-front-page-the-great-dental-rip-off-22696?start=50#p250635

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Letter to The Times, Tuesday 9^th August

Sir, Your report and editorial suggest that dentists can claim as many UDAs as they like. On the old system, dentists could earn more by carrying out more treatment, and the annual dental budget could only be estimated. The current contract was designed to allow a budget to be set in advance. Each dentist is contracted to carry out a certain number of UDAs a year. If a dentist exceeds the number of UDAs contracted to them they get no additional pay. If they fail to complete the contracted number, their fees are clawed back. The dentists have to tender for contracts each year. Whose fault is it if dentists are paid for a large number of UDAs? However, to claim that the upper limit of patients is 30 per day is unrealistic. In the 1990s I used to work with three staffed surgeries and treated 70 to 80 patients a day. That would equate to more than 30,000 UDAs a year. On a four-day week, I hardly ever ran late.

William Eckhardt

Retired general dental practitioner

Haxey, S Yorks

“If we’d asked people what they wanted, they would have said faster horses”, Henry Ford is famously quoted as saying.

And this week we have news reports about the car insurance industry being subjected to further “market reforms” in order to deliver cheaper end-consumer prices.

But this is a fundamental misunderstanding of the markets.

If you look at the résumé of our first appointed chair of the General Dental Council [GDC], Bill Moyes, you will see that he has led several market-driven initiatives in various roles, and it wouldn’t be a leap of the imagination to consider that he has been appointed into the GDC to fulfil a “market-driven” reform. Dentistry has long suffered an image problem; consumers feel that prices (and pay) are too high, that dentistry delivers poor value to the consumer and that there is a conspiracy of the profession against the public – it is only necessary to have the briefest of reads through the comments section on any newspaper that publishes a dental article to see that the accusations of “rip-off” rear their head at a very early stage.

But this premise is entirely wrong. The problem with a free market is that the results are entirely unpredictable. Economic journals are full of perfectly logical explanations as to why markets behaved in a certain way – crucially, behaved and not behave. That is, the analysis of the markets and the rationality of them is done post hoc.

One of the most fundamental problems I can see with the approach of trying to manipulate markets in order to deliver a specific outcome is that it rarely works, or often, even where it does work, often this is not what the consumer demands or buys, although they may insist at the outset that that is what they want.

In our particular dental industry, I would hazard a guess that many people (of a non-dental nature) believe that market reforms will deliver cheaper dentistry, through increasing the supply of the dental workforce. I would suggest that this is unlikely to work for a variety of reasons. Firstly, costs represent some 60-70% of the price that the patient pays. Given that the average pay for dentists has been declining in real terms for some time, if we were to cut pay for dentists by 10%, then this can translate into only a 3-4% price saving for patients. And I don’t believe that we can cut pay much further without running into another economic problem – that of a shortage. If you pay too little for something, you create a shortage. In this case, how many dentists do you think would leave the profession if average pay drops below a certain point? (I would suggest £50,000 for associates, on average, and £75,000 for principals)

So if cost savings are to be made for the end consumer prices, this will have to come from reduced costs. And here we already have an idea of what happens from another industry – the British car industry. Throughout the 60s and 70s, the British car industry suffered a slow and agonising death over many years, selling outdated cars, with poor workmanship and a reputation for declining quality, and in some cases, with cars selling at less than the cost of manufacture. Do these problems sound familiar?

Of course the British car industry eventually collapsed, superceded by German and Japanese competitors who were operating on free market conditions, and produced innovation and rapid improvements in delivering things people wanted rather than what they told government-led focus groups that they wanted. The eventual death of Rover marked a turning point and renaissance of the British car industry, and now we have world class manufacturing and design, but for this to happen we had to see the government leave the industry and several companies to go under.

I sincerely hope that dentistry has its “Rover moment” soon. I believe in the free markets, but a belief in the free markets also means accepting when they don’t deliver quite what you thought they would. And that doesn’t always mean that what will be delivered will be cheaper: sometimes, what is delivered is “better” rather than “cheaper”. I believe that health and dentistry falls into this camp.

After all, when was the last time you saw a car maker advertise how cheap they’d made the braking system?

Free markets tend to deliver better healthcare, by and large, which is often but not always cheaper. I would therefore issue a challenge – if this is truly the purpose of Mr Moyes’ appointment, I would suggest that he can best serve the public by completely withdrawing any government interference in the market, but only on the proviso that he and they MUST accept that prices will almost certainly rise, but also must accept that this may result in longer term reduction of cost. Otherwise we run the risk of delivering the cheapest horses in the world when the rest of the world has moved onto cars.  

Image credit - Coen Dijkman  under CC licence - not modified.