Once upon a time, as all the stories, good, and bad, start, a dental surgeon would have a chair of some sort in his (almost always his) south facing sitting room and ply his trade. George Bernard Shaw in the 1897 play “You never can tell” describes such a set up in the home of Dr Valentine, a “half crown” dentist. The half crown refers to the standard treatment fee, not his clinical technique.
I remember thinking that when Margaret Thatcher said those words, written by speechwriter John O’Sullivan, that it was thoughtful of a politician to mention dentists. Thoughtful and unbelievable.
The use of the ‘Epistrophe’, the rhetorical tool of repeating of a word or phrase at the end of each sentence was used to echo Churchill’s ‘Anaphora’ of “We shall fight them etc”. Rhetoric has given way to the sound bite of, “The NHS is safe in our hands” which has always been Fake News or as my schoolteachers would have called it “Lies”.
The majority of politicians when given the opportunity have repeated the “safe hands” mantra. I wondered if it was a stock phrase they taught you at MP elocution school along with, “Hard working families” and "Education, education, education”.
“La-La Land” has been defined as “a euphoric dreamlike mental state detached from the harsher realities of life”. Few dentist fall into that category but I believe there are many who may hope: “To think that things that are completely impossible might happen, rather than understanding how things really are”.
A definition of madness is to do the same thing again and again hoping for a different result. Since Mrs Thatcher, governments of every hue have sought to undermine the dental profession by repeated assaults and insults both specific and general.
In the UK, like the majority of countries, most routine dentistry is provided by small businesses with the owners taking the financial risk of failure but also any profits from success. For years there was a 3-way set up, patient, dentist and NHS; the first paid the second the fees that were decided by the third that also set the rules. There was the possibility of competition, expansion and genuine entrepreneurship within the system. 2006 changed much of that.
The 2015 saw the Tories return to government free of their Lib-Dem coalition partners with talk of SMEs (Small and medium sized enterprises) being the “lifeblood of the economy”. Promises were made of more investment in super-fast broadband for entrepreneurs, a review of benefits for the self-employed and a trebling for the start-up loans programme.
A commitment was made by Prime Minister David Cameron (remember him?) to, “slash red tape” and to change employment laws to enable greater competition. One promise that was kept was for referendum, an excuse for any and all procrastination for the foreseeable future.
Cameron not only promised “the NHS is safe in our hands”, but also, “there will be no top down re-organisation” before letting Andrew Lansley set about things like a drunken bull manoeuvring a JCB in china shop.
The (genuine) news that the Inland Revenue’s “Make Tax Digital” (MTD) plans will mean all self employed individuals and small businesses having to make some form of tax return and payment on a quarterly basis hardly bodes well for dentists looking to reduce their costs. It will involve far more time and increase accountancy fees.
Changes in Business Rates will have a profound effect on many businesses, with London rates set to rise by 35.5% over the next two years. The fact is these changes should be made every 5 years but were delayed from 2015 so as not to interfere (i.e. prove unpopular) with the general election is further evidence of interference with the truth. Mrs May quickly promised help, then admitted there is no more money.
For years the GDC said that they could not make any changes and an act of parliament was required. This happened in late 2015, I am not sure that anyone has felt the benefits of “a more streamlined complaints system with timelier decisions, and with appropriate safeguards for both patients and dental professionals”.
Finally on the Fake News front that (new) NHS contract. As the BDA says, “The 2006 dental contract is not fit for purpose. It rewards dentists for hitting government targets for treatment and repair, not for improving their patients’ oral health.
In the 2010 general election, the opposition Conservative manifesto pledged a new dentistry contract. The coalition agreement – struck between the Conservatives and Liberal Democrats – pledged the contract would be introduced by the next election, in 2015.
In August 2016 Lord Prior said, “I believe that we expect the new contract to be introduced fully in 2018.”
And lawyer, John Grant ,wrote after yet another debate on the proposed contract.
“At some point there will be a new contract, but at present no one knows at all what this is going to look like.
When it does come in the government – no matter which party is in power – is going to want an awful lot more from dentists and in return is going to pay significantly less.”
If you think things can only get better (see 1997) then you are not only living in La-La Land but still expecting it to win the Best Film Oscar.
If your best friend won’t tell you what do you do? A different problem.
“I’m feeling a little bit under the weather”. Another vague absence. Karen was good team member, a hard worker and, with the exception of a couple of days a month, punctual and reliable. The principal and the practice manager didn’t know what to do; they had tried the usual approaches mixing concern and compassion but had got nowhere.
A recent survey of 10,000 office workers has found that most one-off sickies are due to hangovers with “just hating the job” coming in second. Neither was the case with Karen, she never drank and clearly enjoyed her career.
“Alun, I wonder could you do her appraisal when you’re next visiting the practice? We’re struggling with what to do about her absences.” Sometimes a different face, voice or ear will bring results. This time was a success and I was able to get to the heart of Karen’s problem. I found her to be a sensitive soul, caring and concerned but in the horns of a dilemma.
The practice consisted of six surgeries with one principal, four full and part-time associates and part-time three hygienists. They operated an egalitarian system where, in order to ensure their were no opportunities for favourites or cliques, the nurses moved around on what appeared to be a fairly complicated rota. This way they worked with associates, principal, hygienists, did their turn in the LDU and had a share of being a “float”.
It turned out that Karen’s absences always coincided with her being due to work with Pam, one of the associates. Pam was experienced, had worked in a variety of practices, hospital departments and had also had a spell working in the community. It was acknowledged she could be a bit brusque with both patients and nurses, but her work was good, she ran to time and grossed well. She was recently divorced, had no children and lived alone.
I managed to get to the heart of things when I met Karen. She was under the impression that the visiting Business Coach was there to see her for some sort of disciplinary matter but I soon disabused her of this and she relaxed. We proceeded with her appraisal, which went well, and having gained her confidence I introduced the matter of her absences. She eventually shared with me the fact that Pam suffered from what used to be labelled as “B.O.” - in other words she was smelly. All the nurses were aware of it but for some reason Karen was particularly sensitive and had needed to run to the toilet to be sick the last time that she worked with Pam. She had now got herself into a real state in case the same thing happened again. She had started to believe that she was the one with the problem and hence the absences.
When I asked the principal and the practice manager they both admitted to having noticed Pam’s odour but had presumed that it was a rare event. Bromhidrosis or body odour, is a common phenomenon in post-pubertal individuals and can rarely become pathologic if it interferes with the life of the individual concerned.
So far, so good we had a diagnosis, but how to treat the problem?
As I was there, and Pam was there that day, it was felt that there would be less of an embarrassment if I were to broach the subject with her. Fine I thought, the client is always right and I have to earn my corn. It wasn’t something that I had done before and I am all for new experiences, if it went badly then I would get the blame and could walk away for another three months.
We met after work and I gave myself 15 minutes to achieve the objectives which were, to point out to Pam as subtly but effectively that there had been comments, to find out if she realised that there might be a problem and then work out a way to deal with it.
Her reaction, thankfully, was not one of denial or to attempt to blame someone for “sneaking” on her. She was horrified and visibly upset. It turned out that she had rather “let herself go” (her words) following her divorce and some days it was all she could do to drag herself out of bed and often didn’t get round to showering or bathing. She wore a tunic at work but wore it over clothes and we agreed that a change to scrubs might help. Most, but not all, of the clinicians wore them and as they were laundered by the practice it removed any home washing. An easier conversation than I feared with, hopefully, a positive result.
When I checked in with the practice owner during our regular coaching calls Pam had obviously had a bit of an awakening. The odour problem had gone and she had taken ownership of the problem by taking the time to ask each nurse at the start of her next session with them to please tell her if there was any recurrence.
After more than a decade of her successor, Barry Cockcroft, who could not be described as any one of personable, reasonable or eloquent she seemed a breath of fresh air. But, let’s face it, the bar wasn’t set very high.
In my article I reminisced about CDOs I had encountered, I would not claim to have known any of them. I encountered Brian Mouatt when I was doing the MGDS pre-exam course just after the Conservative government announced a new dental contract, which was intended to “sort out NHS dentistry for good”.
He gave a talk on the new contract and promised that he would answer our concerns when he had finished. However having completed his prepared address he muttered something about having a previous engagement and headed for the door, our angry comments and questions ringing in his ear.
I only knew Margaret Seward because she was married to my first boss, Professor Gordon Seward, she was in post for two years and presumably wasn’t able to leave much of a mark on things, people I have met who worked with her spoke highly of her.
The other CDO I met was of course the previously mentioned Dr Cockcroft who was the highly visible mouthpiece for the iniquitous UDA system and became the exception after a line of low profile CDOs.
In view of Dr Hurley’s ease with people and obviously understanding the need for good PR I was surprised to hear that the new CDO had been far too busy to answer questions on Channel 4 in the wake of their damning reports on UK dentistry. If an NHS dentist was similarly booked solid for 6 months it would be mismanagement.
There was something that kept nagging at me and that was the somewhat cynical conclusion we reached after Brian Mouatt’s sudden departure. The CDO is a civil servant and is there to do the government’s bidding. The current incumbent has spent her professional life in the services reaching a high rank, she knows all about chain of command and is used to taking orders.
Her announcement this week at an NHS Expo (whatever that may be) that, “Going to the dentist every six months is unnecessary,” as the Daily Telegraph reported it, only undermines the position of Dentistry. The other statements attributed to her are more “austerity” fuelled DoH propaganda.
"You don't see your GP every six months so why would you see your dentist?” Dr Hurley said. Well, Sara that is because NHS medicine is an illness driven system that is reactive and gives only lip service to prevention.
“If you go to have your car MOT, and he says, come back in six months, do you blindly adhere to that advice?” Actually Sarah if I’m driving one and a half tons of complicated machinery that I want to be safe yes I do. What does the army do about recalling tanks for servicing at the correct intervals? I would suggest that if you do them “blindly” someone could find themselves being disciplined.
She was joined on the platform by Roy Lilley who described dentistry as “a rich man’s hobby” as a regular reader of Mr Lilley I know him to be anti-medic, and by extension dentist, who thinks that every ill in medicine can be cured with a “cuppa builder’s and a hobnob”. He criticised improved surroundings for dentistry, perhaps a return to upright chairs, woodchip wallpaper and lino; with queues on the stairs for gas sessions - would this suit him?
It has taken dentistry half a century to get the message across that regular attenders have fewer problems, stay healthier and actually prefer the reassurance. The good practices already tailor their recalls to suit patients and have been doing it for decades. Your statement is irresponsible and only fuels any criticism and scepticism of dentistry. You knew that your words would make headlines and that you were undermining the hard won confidence that most general practitioners face. However as you have never been a GDP how can you possibly understand what that really means?
It would appear that after a year in post gaining the fragile confidence of dentists, the directive has come down to the CDO, “get rid of your camouflage tunic, put on your hard hat and Kevlar, come out into the open and start gunning down your colleagues. That’s what we pay you for, not popularity - oh and Sara don’t forget there may well be a gong in it for you”.
Nils Bohr was a Danish hero who received the Nobel Prize for Physics in 1922. The national brewer, Carlsberg, built Bohr a house. The home was next door to the brewery and allegedly had a direct feed from it, he fathered six children thus providing an early inspiration for the Carlsberg “refreshing the parts” adverts.
He once said, “Prediction is very difficult especially when it’s about the future.” Difficult or not I’m going to look at the future for young dentists in (general) Dental Practice.
It would be wrong to stare into the crystal ball without a quick glance over my shoulder. A sage told me in 1988 that in the future in the UK, “There will be NHS clinics and Private Practices”. With hindsight I’m surprised it took so long to get to where we are now.
Post Brexit, one big hitter remaining in-post is the Health Secretary Jeremy Hunt. There is still no money. The UK doesn’t care what Europe thinks of it, I know, but sometimes you hear the truth. A medic on Irish radio this week said, “The Tories don't like the NHS and Jeremy Hunt is doing his best to dismantle the basic principles of it”. In dentistry many of those basic principles are long gone and the remaining ones are being eroded as we watch.
No more money for education either. University fees and associated living costs are on the rise. Without free movement across borders in the future, university incomes from overseas may fall and UK student fees must rise accordingly. Dentistry is one of the most expensive courses to run, why not make the fees reflect those costs? Dentistry may well become the domain of the privileged, whose parents can afford to subsidise their offspring or arrange the loans for them.
With the recent relaxation of University status perhaps “a large corporate” could create or take over one or more of the Dental Schools to provide cadetships. The armed services have done this for many years. Five undergraduate years in receipt of a bursary and the tuition fees paid. The opportunity for vacation work/internships getting experience of all sorts at flagship practices and the indoctrination / assimilation becomes complete. Post-qualification you commit to, say, 10 years of service or have to repay their investment.
It is possible with this model that corporate dentistry can provide the closest thing to a career structure in general practice, something that the NHS has failed to do and significantly prevented private practice from doing.
The status of NHS associates does not bear close examination. In England and Wales there are fixed targets. Countrywide, associates do not provide their own equipment, are not directly responsible for marketing, wages, materials and so on and by any stretch of the imagination cannot retain the privilege of being self employed for much longer.
A quick flick of the pen by someone senior at HMRC would convert the status of associates to salaried employees. This might be welcomed by many dentists, young and old, especially those who have responsibility for childcare or who have spouses or partners who are in reasonably rewarded jobs.
Time and attitudes have changed and full ownership or traditional partnerships aren’t for everyone. The baby boomers who qualified before compulsory VT/FD and are now the (predominantly) male/pale/stale retiring on the proceeds of the corporate cash which many once derided. They may well be the last of their species.
Many young dentists look at the price of practices, the bureaucracy and the day to day pressure of practice ownership and decide that is not for them. The NHS has evolved into “turn up, get your UDAs, keep your nose clean from the GDC & CQC and go home”. Sounds like a job to me - not a vocation. The millennials are, allegedly, not keen on being tied to one particular practice.
In 2015-16 the admission target, for English dental schools only, was 809, presuming a 10% drop out rate and excluding overseas students there will be another 700 new dentists joining the ranks of the profession year on year. Of these about two-thirds will be female. At present the profession’s mix is 50-50 but it’s a fact that women work less than men over the course of a career, men don’t have babies and predominantly childcare duties fall to mothers not fathers.
This trend started with medicine and has had a profound effect both in general and hospital practice. Interestingly the sex-mix pendulum has swung back in some medical schools.
One reaction with medical GPs is the change in status in response to the difficulty in recruiting partners by expanding the number of salaried doctors. The government sees this as easier to control and privatise. Those GPs in favour of becoming salaried has now reached nearly 30%, nowhere near a majority but significant numbers are beginning to think the unthinkable.
In my last piece for GDPUK I wrote, “Meanwhile many quiet, thoughtful young dentists are taking a long view and working at their skills.” They are realising that to escape the mire of the NHS demands a commitment to growing themselves and that the sacrifices don’t stop with a BDS. In fact the years of serious dedication are just starting.
So the future, NHS clinics run by a handful of large corporates with salaried dentists and therapists, and private practices where an M.Sc is the starting point for consideration.
Your choice.
Once upon a time someone started to blow a bubble.
All Pixar films have a simple story structure which can be summed up as:
“…Once Upon a Time…
Every Day…
One Day…
Because of that…
Because of that…
Until Finally….”
So if Pixar did the story of recent Dentistry, here’s the movie storyline.
Once upon a time nearly every new dentist went and worked as an associate in General Dental Practice with an NHS contract.
Every day, 5 days a week, they worked for 8 hours and had an hour for lunch. Some of them were better than others and some were worse. Some were faster than others and some were slower. The faster they worked the more they earned. Every month encouragement came from the practice owners, “get your backside in the air and get your gross up”. Every dentist in every practice did the same thing - they repaired broken and diseased teeth. Some liked to spend half a day a week making dentures or braces or using a scalpel - but that was just a diversion from drill’n’fill.
At the end of the month the owner let the associates keep half of what they had earned. This was often a lot of money for a young, newly qualified person. Their friends from university who had studied medicine, accountancy and the law couldn’t understand how dentists could justify the amounts they earned when they were so young and inexperienced and were envious. Secretly many young (and old) dentists agreed, but they couldn’t bring themselves to suggest a change. These were the golden years, there was lots of disease, plenty of patients and the Prime Minister’s purse was bottomless. In fact there were too many patients so in some places people queued to have their teeth out or tried to do it themselves, or so the TV said.
One Day the Prime Minister, Mr Blair, an ex-lawyer, said, “This is not good enough, something must be done”, and he decided that market forces must be applied. But firstly he made the NHS the National Religion and everybody must be an acolyte, for to speak against the NHS was sacrilege. Then he applied the rule of supply and demand, so he opened up lots of new dental schools where intelligent young people could become noviciate monks and nuns of the NHS. Although the words “private” and “dentistry” were considered blasphemy “private” and “university” were compulsory so the novice dentists were made to pay for the privilege of half a decade of confrontation and humiliation. Saint Tony also sent messengers out to all corners of Europe welcoming dentists to England and Wales where the NHS was the envy of the world and the dental streets were paved with gold.
Next his Grand Vizier, HenHouse and his Lord High Chancellor, Broon, said that the purse was closed, there would be no more money, each dentist must make do with what they had last year and the year before that.
Because of that even the fastest of new dentists were not able to get their backsides in the air and the slow ones earned the same as the fast ones. The practice bosses saw that where there had been queues of patients there were now queues of new dentists who had to repay their loans and were competing to work in the NHS churches. Some of these bosses saw this as an opportunity and competed to see who could pay the least. Some were allowed to keep a quarter or a third of what they earned. In his retirement villa St Laurence de Lando looked down, smiled broadly and said, “I told you so”.
Because of that lots of young dentists said, “We must buy our own businesses. We shall become dental entrepreneurs, what ever that is.” So they hocked the family silver, mortgaged their future earnings and sold their soul to the NHS (praise be its name), and in the subsequent sales frenzy this let St Laurence’s contemporaries buy much bigger villas on golf courses than they had ever dreamed possible. “We are the bosses now” trumpeted the new owners, “we shall buy lots of practices and screw down those associates who were not clever dental entrepreneurs like us. Then we shall sell out at the top of the market and make a shedload of cash.”
Meanwhile many quiet, thoughtful young dentists took a long view and worked at their skills. They saw that in the long term the religion would be exposed for the sham that it was and patients would choose between private practices with personal service and Nash clinics where they chose a number and waited their turn for the announcement, “dental cubicle number thirteen please.”
Until finally, one day the bubble burst, NHS dentistry was handed over, lock stock and barrel, to Tesco and many churches became empty shells, a testament to a great failed experiment.
Image credit - Isabelle Acatauassú Alves Almeida under CC licence - not modified.
What about the wicked Witch?
What about the wicked Witch?
Is this really what you want to do? You don’t have to.
Many students have made their decisions to study dentistry at university in their mid-teens, an age when they are neither mature nor in possession of great insight.
Parents, family and teachers see dentistry as a well-remunerated, successful profession with a secure future. Well positioned on any socially acceptable list that makes it traditionally attractive to the children of immigrants. My mother, a migrant from Ireland was determined that both her children would have professions, her background, in nursing, favoured the medical. I became a dentist, my brother a doctor.
How many of us have the nerve to say that it’s not what they want? Many dentists are ill suited to a profession that makes extensive physical, mental and emotional demands on its members. I am not convinced that the undergraduate course prepares students for the rigours of general practice.
After 5 undergraduate years and now carrying a large student debt it takes a brave new graduate to dare admit to parents and family that they have studied the wrong subject. If you have a degree in humanities or pure sciences you are fortunate to be able to continue with your subject. Only with a “vocational” degree is the graduate able, and expected, to follow a career pathway.
Socially, turning away is akin to failing to show up at your own wedding. An individual might be secretly admired for admitting that they don’t feel the commitment needed for a happy marriage but it’s a brave dentist who says that they have done the wrong thing.
Turn things on their head, if you know in your heart of hearts that you are going to be unfulfilled and unhappy being a dentist isn’t it better to say so sooner rather than later? How many more miserable years can you tolerate? How much stress and heartache can you endure once you have admitted to yourself that you’re in the wrong place?
Far too many dentists have plodded on through degree, foundation training, associateship, partnership, marriage and children all carrying with them increasing financial pressures.
They thinking that this is the way that it has to be, that it will get better, easier, less of trial to get out of bed in the morning - next year. They live from holiday to holiday and get absolutely no fulfilment or satisfaction from the clinical work that they do or the people for whom they are supposed to care.
Often they succumb to the stressors. One of my contemporaries only accepted that he had a problem when he needed a quarter bottle of vodka to start work in the morning and was facing his third drink driving conviction.
I have attended funerals of successful and apparently happy dentists who have taken their own lives because they could only see one way out.
These problems are not unique to dentists and many people “live lives of quiet desperation” so I would encourage them to change also, if they can.
What else is possible?
The answer is anything that you want to be. There are ex-dentists who are successful architects, writers, lawyers, musicians and businessmen. I know of one former specialist orthodontist who now builds dry-stone walls (and will also teach you how to build them). The discipline of your training means that you are suited to re-train in many disciplines.
Let’s not forget those people who are stuck in a rut. NHS dentistry has never embraced excellence, though lots of good work is done in spite of the system. You will never perform at the highest level on the conveyor belt of UDAs or whatever imposed system of production is in vogue this year.
If you are having second thoughts then I suggest that you examine your reasons. If you feel that you aren’t right for a job that demands a high standard of manual dexterity in order to practice at its best then you should explore your options.
Darwin says that empathy is instinctive not learned, so if you are not a person-person will you be happy going against the grain and attempting to gain the trust of your patients day in day out for the next 30 years?
If you are doing it just for the money, you will probably be disappointed at the amount of further training, dedication to a career pathway and sheer hard work that it will take. You might get a better return on the invested time in some other field.
On the other hand if you stay and you choose to dedicate yourself to a unique discipline, then every day will give a new challenge. You have the opportunity to grow as the leader of a team in a niche where you help your patients not only to achieve and maintain an important element of their general health but also to have an enhanced sense of confidence, comfort and function.
If you want to be happier then say so, and do something. This isn’t a rehearsal, there is no second chance, no re-run, no “it’ll be all right on the night”. If you want to be better nobody can do it for you. If you need help ask those who have already done it, study excellence and embrace it.
Polonius said to his son:
“This above all: to thine own self be true,
And it must follow, as the night the day,
Thou canst not then be false to any man.”
Great post....
