Humility, Hubris, Humanity.

For several years it was my honour to be the opening speaker at the annual scientific meeting of the BDA Western Counties Branch, Young Dentist Group (YDG). The challenge for me in, say, 2016 was to try to share some perspective on changes in dentistry. In 2016 it had been 43 years since I embarked on my university studies, rolling that back another 43 years would take us 1930. I wondered what someone from those interwar, great crash and depression, times could have said to me that would have had any relevance to me in my post-qualification years. Eventually I chose to major on the letter “H” and look for similarities rather than changes.

Another “H”, neurosurgeon Henry Marsh, has written one of the best medical autobiographies that I have read. In “Do No Harm: Stories of Life, Death and Brain Surgery” he writes of the cases he has treated successfully and otherwise and the lessons he has learned. He describes his mistakes both surgical and human and the frustrations of his life with an honesty and insight that I can only envy and attempt to imitate.

Back to the YDG where, in my fifteen minutes in the spotlight, I attempted to describe the roles of Humility, Hubris and Humanity in success and failure. My naive younger self believed that the path to success was mostly straight with the occasional glitch of disappointment. Before Dental School I presumed that my skills would grow and develop in a largely logical and linear manner, much like building a wall with Fletton bricks. I hadn’t anticipated the possibility of quantum growth, where I would feel stuck at a level of inadequacy before suddenly acquiring, whatever it took to move up to the next level of competence.

Nor did I realise that there could be levels of competence that I would never, achieve and to which I could not even hope to aspire. Perhaps it was a good thing that I realised, early on, that my own skills and my temperament would always be limited. I could also see that there were those who were naturally, instinctively skilled, even artistic. Journeyman level is honourable enough as long as you have the humility to acknowledge and accept your own limitations and to develop your skills as far as you are able.

There are far more problems in all walks of life caused by hubris. Defined as excessive pride or self-confidence, there can be a natural tendency with new graduates to run before they can walk and pride will come before a fall. With the fall should come learning of limitations, awareness of boundaries and hopefully acknowledgement of what we don’t know.

Henry Marsh describes the “Keynote Speakers” in his subject who, “Clearly had amazing results way beyond anything that I could achieve. People for whom self doubt is never an issue and whose post-op scans never showed a trace of residual tumours.” He then talks about Hubris driving him on, the risks of over confidence and the disasters that arose. I am reminded of the Key Opinion Leaders (KOLs) associated with newer Short Term Orthodontic and other techniques who are paid by companies and make claims and encourage use of one particular system whilst trying to maintain a veneer of independence.

Finally, we reach humanity, which I defined as the quality of being kind, thoughtful, and sympathetic towards others. In our early years this can be an overwhelming urge to help everyone and to treat each case to its limits. Experience should show us our limitations but there are some who do not acknowledge they have any, or are so intent on treating cases that they put the treatment before the patient. Marsh says, “On reflection you only get good at doing the very difficult cases if you get a lot of practice but that means making a lot of mistakes at first and leaving a trail of injured patients behind you. I suspect that you have to be a bit of a psychopath to carry on or at least have a pretty thick skin. If you're a nice doctor you'll probably give up, let nature take its course and stick to the simpler cases."

Perhaps our desire should be to become good surgeons rather than great surgeons. It can be difficult to balance pressure from patients to do something, especially if you have been looking for a case to do. The enthusiasm on the Monday to find a patient who matches the technique learned on Saturday’s course has led many to regret their actions.

Knowing when to treat, and not to treat, or instead to refer is a big skill itself and requires complete detachment from, and yet total compassion for, the patient and what is ultimately in their best interest. Awareness of Humility, Hubris and Humanity may help us to sleep at night.

This is not a plug for my friend’s laboratory. This an unashamed plug for UK dental laboratories. Because if we don’t support them in some way or another NOW, there won’t be any UK dental technicians left to complain about your lab tills to.

Being such a fan of the airway, I resolved at the beginning of my dental training that I was never going to be a butterfingers and compromise a patient’s right to breathe, by accidentally dropping anything down the throat. I was an even bigger fan of the butterfly sponge in the early days of post-qualification.

The more I think about the General Dental Council, the more I think they resemble the Peaky Blinders.

I don’t know about you, but I don’t believe I’ve ever met a ‘normal’ person working in dentistry.But that begs the question, what IS normal? My definition would be anything or anyone NOT connected in any way, shape, or form, to dentistry.

Now Where DID I Put That Enthusiasm?

Deep water

If all the world was a swimming pool.

I sat down to write something that would show insight or perhaps provoke a response if only to get the reader thinking about their situation and how they might improve it.

Of course I would like to impress or inspire enough for you to pick up the phone and employ my services as a coach and business mentor, but that is secondary.

This column was inspired by the behaviour of several clients. It struck me that the best metaphor was that of swimmers at a pool.

We all start unable to swim, as we know it, with poorly defined strokes and no style. Some are lucky to come from “swimming” families who visit pools routinely, or perhaps have their own pool. Others have parents who are frightened of water, have never learned to swim and avoid aquatic recreation.

We all eventually go through dental school where we are taught a version of the theory and practice of survival in the water. Depending on the school there will be an emphasis on different strokes and skills. After five years we can keep ourselves afloat doing our basic strokes - even if we still have to put the occasional foot on the bottom of the pool for security.

It’s what happens after that interests me; it depends very much on the individual, their attitude to risk, their ambition and luck.

Until VT arrived, new dental paddlers were thrown into the deep end of the pool, the wave machine turned on and, although they swallowed a lot of water, their basic stroke helped them to survive. Confidence grew, widths became lengths, a few strokes under water and duck dives.

With VT a lifeguard was assigned who checked they were still afloat and not dragging anybody under.

Many practiced in different pools until they found one that suited them, and the owner sold them a share, some wanted their own pool and built or bought it.

Some new paddlers throw themselves in not sure if it’s the deep or shallow end. 

Fewer still climb to the highest diving board jump in and somehow survive.

Some drown.

Some swimmers become perpetual associates. They never trust the water, are frightened of getting out of their depth, they swim widths and occasionally lengths but always stay within touching distance of the poolside. They move from pool to pool dreaming of the one that is warm enough, the water is calm and they can do whatever style they wish. They want their pool owner to supply designer swimsuits and send them for advanced swimming courses that teach skills, unusable in their home pool.

The 21st century has seen a new phenomenon. The individual who inevitably has the “abs & pecs” gets up on the springboard and bounces up and down a few times with great style and noise. They attract a lot of attention, take a few photos for their Instagram feed and head off without getting their hair wet.

There are nervous types who go on expensive courses on swimming. They listen to everybody, swimmer or not about how to swim best. They read books about how to swim. They walk round the pool, put their foot in to feel the temperature. Eventually they go down the ladder and swim but never, ever go out of their depth. 

Some become NHS (National Health Swimmers). They used to enjoy swimming, they felt they had a role in life and swimming was their duty. Nobody told them was that there was a wave machine at the end of the pool, the speed of which was inexorably increasing. As fast as they swim, as hard as they work they don’t make any progress. The depth of the pool is increasing, the flippers, worn for compliance not progress, are getting heavier and make things worse, not better. They’re frightened that if they make it to the side of the pool to leave their swimsuit will have holes in embarrassing places.

Who succeeds? The ones who work hard at being better swimmers, who know about all the strokes and concentrate on the one or two that gives them most happiness. They focus on being smooth swimmers, not fast, making as few ripples as possible. They understand that sometimes the pool can get uncomfortable, the water temperature goes up and down and that to be a successful swimmer you need to be fit and keep practicing.

They know that they don’t know all there is to know but they join a club and work with a coach or mentor they will be helped to improve. They talk to other good and successful swimmers and they learn how to stay afloat.

We learn in pools but we must now swim in the ocean. The riptides are dangerous the currents changing and the water deep and cold. This is no place for social swimmers. Only those who are 100% focussed on being successful swimmers will make it to the next beach.

What Dentistry Taught Me About People

Dentistry's Battle against Racism

A simple guide to General Practice in the 'Post' Covid-19 world

General Dental Council - Protecting our income and sometimes the patients.

They're all set for the off in the Dental COVID Sweepstake

After three months of lockdown in Dentistry how are the nags doing? Nobody quite knows where the finish line is in this race so the bookies aren’t paying out yet a while; but as far as the punters are concerned there are few surprises.

Let’s remind ourselves of the runners and riders.  First the two back markers involved in their own race, the dental mediocrity cup, these set off slowly and didn’t seem to want to take part in the race, in fact CeeQuooSee’s jockey went home as soon as the starter waved the flag.

First wearing the camouflage colours and helmet of the Whitehall stud is NashBasher with Sara Hurley on board. Not for the first time this runner is wearing blinkers, which have been adjusted by several committees and has trained on a diet of dogma. The rumour is that this poor creature has never recovered from its owners believing it could be a carthorse, a flat horse and a steeplechaser. In fact since its previous trainer, Barty Cockcroft, had it gelded without an anaesthetic in 2006 it has hardly capable of giving children a ride on the beach at Weston-Super-Mare. Rumour has it the glue factory beckons. A great shame because in its day its predecessors gave sterling service on all tracks and courses, whether the going was hard or soft.

Next up is CeeQuooSee. She is a mare from Compliance out of Paperwork. This is one that promised much when it first came on the scene but has repeatedly failed to deliver. Once again its owners were hoping for a Derby winner but as its sire had only ever delivered milk and its dam was used for dressage it looked pretty, but was ultimately useless. Distinctive coloured silks featuring red boxes and black tick marks. It is notable for travelling with dozens of trainers, advisers and stable maids; it often runs with two jockeys to show diversity and fairness. Loves attending these meetings but rarely performs. Uniquely it trains on a diet of tea and biscuits. Its stable mates, Policy document and Protocol feature in the carriage race that takes place after this meeting.

The third runner is GeeDeeCee. Nobody is completely sure of the parentage of this one, for years its line was full of pedigree and thoroughbreds dominated. Great names from his bloodline include Noble Nairn and Bradlaw’s Barstool. Unfortunately it is rumoured that at some time during the last decade the gene pool was adulterated and the resultant progeny have had less than noble characters. Certainly there have been moves amongst the racing followers to limit its appearances due to its spiteful and aggressive behaviour. It wears a muzzle to prevent biting, and the other jockeys give it a wide berth due to its habit of kicking wildly.

GeeDeeCee is trained and ridden by Billy Moyes who has a chequered past in many sports. He is wearing the characteristic hand made pink silks of its owners, a syndicate from the legal profession. For a horse that has a poor character it wins a lot of races probably due to the dodgy handicapping system. Shows great stamina, nothing seems to discourage it. Due to some arcane rule of the Jockey Club the owners get to keep all prize money but GeeDeeCee’s stable fees and costs are paid from donations from other owners and riders.

The fourth of our horses is Wimpole Wonder. The old joke said that to be a successful Dental Horse you needed the stamina of a shire horse, the speed of a Derby horse and the brains of a rocking horse. Wimpole Wonder was little fancied at the start of the year but has proved itself to be an absolute banker. Owned by the largest syndicate in UK dental history there is now a waiting list to buy a share. For many years it was considered to be a plodder with many detractors but during the current season it has shown to have class and determination. The recent change of trainer is probably a coincidence but the good habits learned at Ward’s stables in Herefordshire have come to the fore since the move to Woodrow’s yard.

Unique in training methods is the collegiate method espoused and led by Mick Strong-arm. Cometh the hour cometh the man. Thankfully he isn’t riding the horse, that duty is taken by Damian Apollonian who has come out of retirement for the race. Distinctive colours of pink and white checks representing healthy gums and teeth, with the prominent shield showing the staff and spirochete.

There were fears that a lot of late entries that tried to claim the BDA’s place in the race, Private Parts, College Boys and Facebook Shouters would have an influence. So far anyway the smart money is on Wimpole Wonder and she’s my tip as the stayer to take the honours in the Dental Covid Sweepstake.

General dental practice appears to have changed forever for both practitioners and patients, ‘post’ COVID-19.

The General Dental Council - Our Empathetic Regulator

You Can’t Be Brilliant At Everything! - Let The Nurses Take Charge

When the patients swan back in -it'll be here before you know it.

Where's the CDO? - The week when we could have done with a bit of guidance

When did you last have it? _ Leadership in dentistry.

The Chief Dental Officer issued advice to all NHS dental practices on Wednesday regarding the ongoing treatment of patients. Whilst these guidelines refer to NHS practices, in reality, all private practices will also want to consider their application.

What this means is that there will be less patients in practices moving forward, which will inevitably mean less work to do. This e-bulletin sets out the various options available to dental practices when considering the impact of COVID-19 on their workforce.

What if a member of staff is unwell?

This is the most straightforward situation. If a member of staff is unwell, they should be sent home immediately. In these circumstances they will be entitled to either the sick pay provisions contained within their contract, or if they are not entitled to contractual sick pay, they will be entitled to statutory sick pay (SSP). The Government have announced, but have not yet put into law, that the SSP will be payable from the first day (normally the 4^th) of their absence from work. They should then remain at home for at least 7 days from when their symptoms started.

What if someone in a staff member’s household is ill?

If your staff member lives with someone who becomes unwell, then the government guidelines state that they must stay at home and not leave the house for 14 days.

In these circumstances the staff member is eligible for statutory sick pay even if they are not ill themselves. This was bought into force by the Statutory Sick Pay (General) Coronavirus Amendment) Regulations 2020 on the 13^th March 2020.

The Government announced that businesses will be able to claim back any SSP paid from the State. However, the Government will only refund up to two weeks of SSP to businesses with less than 250 employees, albeit this has not yet been put into law

Employers do not need a sick note to claim this money back.

An employee decides not to attend work as they are classed as ‘vulnerable’, do I have to pay them?

The Government’s advice is that staff members should be ‘encouraged’ to work from home wherever possible. If it is possible for phones to be answered remotely, for example, then employees should be paid in the normal way. However, for dental practices this is rarely going to be possible.

Whilst practices may wish to exercise discretion and continue to pay staff, this is not currently a legal requirement.  The Government state that staff in these circumstances “should be supported;” they have not said how businesses will be supported in doing so, however. As they are not unwell, or isolating due to contact with a COVID-19 sufferer, they are not entitled to SSP.

However, the dental practice will need to carefully consider their obligations to protect the health and well being of a staff member. It would be considered unfair to dismiss an employee who chooses to self-isolate in these circumstances. A staff member who chooses to self-isolate because they are categorised as vulnerable is likely to be protected against dismissal (and deduction from wages) if they are asked to come into work and refuse to do so because there is a significant risk to their safety.

For those who are not classed at vulnerable, but chose not to attend, dental practices could offer unpaid leave, alternatively a good compromise would be to ask employees to take this as paid holiday.

I am worried about the safety of my staff, should I send them home?

Yes. Employers have a duty under the Health and Safety at Work etc Act 1974 (http://www.legislation.gov.uk/ukpga/1974/37)  to protect the health, safety and welfare of their workforce at work, as well as others who may be affected by their operations. Practice owners also have a common law duty to protect their workforce.

If an employee insists on coming to work despite exhibiting symptoms, or that they have been exposed to the virus, and the practice principal orders them to go home, they are technically entitled to full pay during this period as they are willing to work despite their ill health.

My nurse needs to take time off to look after her children as schools are closed, what do I do?

At the time of writing, it is not known whether dental providers are considered key workers, and as such their children will continue to be able to attend school.

An employee may be entitled to time off work if they:

• have a child they need to look after, or arrange childcare for, because their school has closed due to coronavirus, or

• need to help their child or another dependant if they are sick, or need to go into isolation or hospital

There is no statutory right to paid time off in these circumstances.

I no longer have sufficient work to occupy all of my staff members, what shall I do?

• Associate dentists are primarily self-employed, in which case they will have no rights to SSP. The Government announced that the self-employed will be entitled to Employment and Support Allowance (ESA). However, at just £73.10 per week this is unlikely to be of much assistance. Further, it is not possible to claim ESA if you have savings or investments of over £16,000.

Dental practices who have NHS contracts will have some assistance from the NHS. It being suggested that the global pandemic will be treated as a “Force Majeure” event, meaning neither dental practices nor dentists will be liable for a failure to complete UDAs under the contract. It is also anticipated that the NHS will provide some financial support to contract holders, which should in turn be passed through to Performers.

Unfortunately, there has been no support offered for private dentists or practices in the recent package of measures announced by the Chancellor, save some emergency loans.

• If you ask employees on fixed hour contracts to stay at home as you do not have work for them to do, then they will be entitled to receive their full pay and benefits during this time.

This is clearly a significant burden on all practices, and it is unlikely that practices will be able to sustain this for a significant amount of time. If this is unaffordable, dental practices will have to consider the following:

• Unpaid Leave: It is not possible to enforce unpaid leave on to staff members. This is an amendment to the contract and can only be done by agreement. Employees will have to very carefully consider what this will mean for them. Positives are that this will allow their continuity of employment to continue (this is important as they will accrue employment rights after two years and will be protected from unfair dismissal, entitled to redundancy payments etc). Negatives, of course, are that this will cause economic hardship and may affect their entitlement to certain benefits as they will not be actively seeking work.

• Lay off or short-time working: dental practices can only consider laying off employees or putting them on short-time working, where it has the contractual right to do so. Qualifying employees will be entitled to claim a statutory redundancy payment or a statutory guarantee payment from their employer.

• Redundancy: Unfortunately, many small businesses, including dental practices will need to consider making staff redundant should patient numbers fall significantly (as anticipated). For more information on the redundancy procedures to follow, you can read our earlier dental bulletin (http://jfhlaw.co.uk/need-downsize-staff-heres-part-1-redundancy/).

Many people are engaged on Zero Hour contracts within the dental services. If this is a genuine zero hour contract (i.e. there is no obligation upon the employee to do the work, and none on the employer to offer it) then the dental practice can simply not offer hours of work in the coming weeks. However, if staff members are obliged to attend work every week and are given the same, or similar hours every week, then the employee could argue that they have in fact got a guaranteed minimum number of hours through convention, not contract, and are entitled to continue to receive those guaranteed hours. In those circumstances, if notice is given, they must be paid for the same guaranteed hours during the notice period.  

These are incredibly difficult times, but when dealing with your workforce, remember to be consistent, be fair, but most of all be safe. We will be providing as much advice and assistance as possible to our dental colleagues over the coming weeks and months. Stay up to date through our dental bulletin and our Facebook and Twitter pages.

Caring in crisis - Coping with the pandemic in dental practice

I was a Scaredy-Cat (Facing fears in Dental Practice

Ain’t Misbehavin’ - How DO You Deal With Disruptive Patients?

Feedback - (Friend Or Foe?).By DentistGoneBadd

Turn the clock back 40 years to the land where Mrs Thatcher was starting to flex her muscles, sharpening her deregulation scythe and readying to privatise any and everything. What changes do I see in Dentistry today? There is one element that dominates professional lives. Nothing to do with their talent, skills or clinical judgement. Even less to do with good working or patient relationships, teams or outcomes that matter.

I am talking about compliance. Defined as “The act of complying with a wish, request, or demand, a synonym is “acquiescence” or “passive assent or agreement without protest”, and a legal definition implies “the abandonment of a right”.

Last month I accused the GDC being a sledgehammer used to crack nuts. This time I am levelling my sights at another organisation better known by its TLA (three letter acronym), the newer kid on the block, the Care Quality Commission. Set up in 2009 with the intention of “regulating and inspecting health and social care services in England” it has rarely if ever been seen as an ally by those who it “governs or directs according to rule”.

It was parachuted into dentistry with little consultation, minimal clarity and maximal condescension. This is not an unusual occurrence for matters relating to dentistry, long considered the awkward mob by government and much of the rest of medicine. “Necessary when you need them but resented for their freedom” was how a Whitehall Mandarin patient of mine who commuted every morning from Peterborough to London having served his time in the Department of Health described Dentistry.

The CQC’s stated role is to provide people with “safe, effective and high-quality care, and to encourage them to improve”, yet without inspection of clinical standards how can they judge “care” properly?

This statement from their website, says much that is wrong with the CQC.

We inspect 10% of dentists in England each year. You can use our inspection reports to help you understand the quality of care. We do not rate dentist services but we do highlight if a service is meeting the standard of care we would expect.

It was always bad fit, the wrong solution to the wrong problem, a knee jerk reaction to medical tragedies, particularly the Shipman affair; it started badly when its disgraced first Chief Executive was forced to resign.

The fundamental problem (like the GDC in many ways) is that of it being a compliance-based programme where rules of conduct are put in place. Penalties, which can be severe, are waiting for anyone who is seen to be out of step from the norm. The rules are obeyed in order to avoid the repercussions, hence (like the GDC) fear becomes the driving factor.

The dental businesses are not judged on their moral compass, rather on a right or wrong tick box which, too often, is administered and delivered by individuals who, may be for the most part well meaning, but have little or no clear idea of 21st century dentistry.

How could this be improved? I know I have spent too much time in Ireland because the answer once again is, “You wouldn’t want to start from here”. The CQC is a massive bureaucracy little suited to examining dental practices and the systems for Dentistry should be clearly different from that for Care Homes and Hospitals.

Rewarding aspirational practice, understanding the real differences between good, less good and bad practices plus properly evaluating what is meant to be truly well run. I would like to see fewer “inspections” with all the connotations of confrontation and clipboards they bring. Instead there should be far more conversation, communication and encouragement to reach not just the basic but higher standards ethically, culturally and clinically.

Of course now we come to the elephant in the room. The NHS; committed to getting more bangs for its, ever diminishing and inadequate buck, to being in control of all things health related from education through research and education. It ensures the blame for bad news is always as far distant from the top as possible.

Dental businesses are for the most part separate entities, even large corporates serve different communities with different people. The quality of care (it’s about quality of care) cannot be measured by an “inspection” of an off-the-peg compliance system once a decade.

There must be clarity about what is expected, better two-way communications and some obvious effort to regain the shattered goodwill of a profession which feels compliance has been used as a weapon to control it rather than to improve patient care.

Dentists look at the CQC and how it deals with what they know then despair about the rest of the Health and Social framework where out-dated inspection methods are used to address the wrong problems.

Don't Panic! - You can handle the latest crisis...can't you?

The marketplace

We all, I would like to think, got into this profession for the reason of trying to help others and improve the health and wellbeing of patients. If we were in it solely for the money, there are plenty of other professions that can give the financial rewards without the types of stress that we face on a daily basis from all aspects of our wonderful profession.

Before I continue, I should note that yes of course we all need to make a living and there is nothing wrong with wanting to earn more. That is not my concern here, but more that I am worried that we are starting to see our patients as customers, and therefore trying to sell them a product rather than provide a health service.

A recent dental conference I attended had a stand hosting a lecture titled ‘How to earn an extra £100,000 a year through facial aesthetics’. Now my issue here is nothing to do with facial aesthetics at all, it could just as easily be swapped with dental implants, short term ortho, smile design or whatever aspect of dentistry one may be more interested in. For me, it’s more the headline like that got me thinking - are we becoming ever more financially driven and could this lead to us ‘selling’ patients treatments or rather a product they may not necessarily want or more importantly need. We are all part of the health care sector but are we making dentistry into an industry more than ever and forgetting that it’s actually a profession? I’ve even heard of undergraduates taking external courses on ‘how to sell private dentistry’ when they haven’t even passed their licence to cut exam yet so if that is the motivation from such an early stage, is there cause for concern?

There is already a misconception by members of the public that dentists are there to take patients money, so this made me think that we could be adding fuel to the fire.

This is not aimed at people wanting to be a successful practitioner and earn a good living or run a profitable practice, it’s a general concern about our profession losing its way a little bit and putting profits above patients.

We have all seen those cases on social media whereby unbelievably invasive dentistry has been carried out at both a financial and biological cost to patients, when really a much more conservative treatment plan would achieve just as good if not better results. I’m sure many of us have looked at those cases and thought that clearly there has been a financial objective here as why would a well-informed patient actually consent to some of these treatments.

That’s not to say that patients don’t have the right to elect to do these types of treatments and of course maintaining patient autonomy is key. However, with the continuing role and influence of societies’ obsession with achieving the perfect aesthetic (in many aspects not just dentistry), are we being lured into this type of dentistry by the financial gain and compromising our moral obligations to our patients? Is the ‘Love Island effect’ or the role of ‘social media influencers’ (not just celebrities but even dentists these days too) starting to influence us as dentists, not just our patients?

"Sunday in the City 338" by Carl Campbell is licensed under CC BY-SA 2.0

In The Spotlight - An Interview With The Secretary Of State For Health

Dental Burnout - Don't look at me, I don't have a clue how you fix it!

CPD - Will it ever catch on?

I’m not, by nature, a hoarder.

I chuck stuff out on a pretty regular basis and the only inanimate possessions I would risk my life to save in the event of fire or flood would be my treasured MacBook, iPad and iPhone – in short, anything with an Apple logo on it.

So, I suffered gargantuan cognitive dissonance the other day when I came across my massive folder of CPD certificates collected over thirty years in practice, in the loft. Why do I still keep it?

I’d been up in the loft because the gas engineer who installed our gas supply and heating system earlier in the year had been sent back by the safety people to fix all the bits he’d not done properly in the first place and after he’d gone I was just checking he’d not carried out some sort of ‘dirty protest’ as revenge for being called back to our house.

To say the gas engineer was a little ‘frosty’ on the morning he arrived, was an understatement.   When I saw him finally pull up on the road after a five-day wait, I went out with a cheery wave as he sat in his van, and started to back my car out of the drive to allow him to park closer to the house. He’d parked halfway across the drive and it was a bit tight getting out and I noted that I was quite close to him as I swung backwards. My car radio was quite loud as I reversed, but I was focussed on getting out of the engineer’s way and parked on the road. As I got out of my car, he was inspecting the front of his van. My “Morning Bill” was greeted by “Did you know you’d just hit the van?” I didn’t, but when I had a look, there was no denying it. There was no dent in his bumper, but there was a clear and undeniable smear of Peugeot 107 red on his immaculately matte black rubberised fender. If he HAD carried out a dirty protest, I would have understood.

Anyway, back to my CPD folder. I must have buried it up there a year ago, on retirement, though I don’t remember doing it. The folder lay under the bed for thirty years and it had about seventy elastic bands around it for fear that a valuable certificate proving I’d been on a day course on the use of Wizard Wedges in 1991 might inadvertently slip out from the pile of loose certificates on top.

For about a billionth of a nanosecond I actually thought about throwing the folder out, until I came to what passes for my senses and asked myself “But what if the GDC asks to see it retrospectively?” Yes I know, bizarre thought – why would they? But I was always a dentist scared of not only his own shadow, but the shadow of a hostile dental litigation lawyer carrying a sharpened writ. In my head I could visualise a scenario where the GDC demanded to see my CPD folder, realised I’d not followed the rules and retrospectively declared my career null and void. In consequence, every procedure I had ever carried out I’d done illegally and I’d be jailed for being a fraudulent dentist.

Torn, I realised that I needed guidance and so I went to my ‘go-to’ default advisor – Twitter of course. I asked whether I should: a) destroy the CPD records, b) destroy them, laughing or c) keep them in the loft. The results of my survey were closer than I anticipated. Fifty-five percent of participants thought I should destroy them with a maniacal laugh, but a surprising forty percent thought I should keep them in the loft. One Twitter wag, Rebecca Cox questioned my commitment to CPD. She said “One folder…in 25 years?” Fair point. Anyway, the loft it is, forever, until we find another house with another inaccessible loft, but hopefully, safe gas pipes.

I was sort of reassured that forty percent of the people surveyed erred on the side of caution and I was comforted by a Tweet from a dentist I follow, Adrian Walley, who said:

“This is sad, but 35 years qualified and I still have all my undergraduate files and coursework in a box in the loft. Every time I go to throw them out, I can’t quite bring myself to do it; all that work and if nothing else, (it) proves how neat my handwriting used to be!”

This Tweet struck a chord for my other confession is that I too have all my undergraduate notes still in the loft, sitting on piles of books ranging from Gray’s Anatomy to a worthless book written by one of my dental professors on restorative dentistry that seemed to have been aimed at dental students with ADHD.

I WILL admit that keeping my undergraduate notes is pretty much pointless. I also admitted on Twitter a few days ago that I used to write extensive notes during lectures. I’d then go back to my room and during the evening, write my notes up neater and add bits from textbooks. I always felt more comfortable with a fine black felt-tip pen and with every test we had during the course, I’d go back to my notes and highlight them in fluorescent pink or green. When we came to finals, I opened my files one day to find that the writing was unreadable, the black felt-tip having dissolved in the washes of fluorescent felt-tip. I was inconsolable, and for a while, hysterical. My fellow finalists found it pant-wettingly funny.

Despite all that, I still can’t throw the notes folder out. I’m really not sure why. I don’t know whether the CPD folder and the notes represent all that time invested and all that agony endured in order to qualify as a dentist and then keep the ball in the air. I suppose they’ll stay there till the ceiling starts to sag with the weight of them plus the folders we’re keeping for the kids for some obscure reason, from their ‘A’ level days, nigh on 15 years or so ago.

But flicking through the CPD folder made me think about the whole Continuing Professional Development thing and how it’s developed since the days that I qualified and how I may have had a lucky escape retiring when I did, before Enhanced CPD really kicked in.

Back in the late eighties, we didn’t have CPD, we had Section 63 courses. I don’t recall having to declare the fact that I’d done a course to the GDC but I do vaguely have this feeling that someone was watching my course activity. After every course, you had to collect a certificate and a form which you submitted to the local Family Practitioner’s Committee. In those days (I was reminded by someone I follow on Twitter) you could claim your car-parking fees back at least, but I don’t recall having to didn’t have to fill in a feedback form.

In those days you didn’t even have to stay the full day. They were simpler, more naïve times. You could go to the course in the morning, sign in, pick up your certificate and your Section 63 expenses claim form and slip out at the first coffee break, being home for lunch or grabbing a swift half at pub before you caught the bus to catch the second session of the cricket (Birmingham Dental School is VERY close to Warwickshire’s Edgbaston ground). Not that I ever did that of course.

When Section 63 courses were about, the UDA system wasn’t, and there seemed to be more time and less financial pressure to attend courses. If you went on a day-long course, although you knew you weren’t earning any money, you didn’t feel you were effectively going to LOSE money by risking not hitting targets. Consequently, courses seemed to be well attended and filled with the sort of people you would cross the M25 on foot in order to avoid.

Some of the most excruciatingly irritating dentists on the planet I encountered at Section 63 courses. There was one lecturer who I had to take my hat off to, just for keeping his cool. The course was in London and was on ‘Endodontics in Practice.’ There was a little chap sitting down the front and he must have had the lecturer bitterly regretting his rash words: “Feel free to ask questions as we go along.” When the lecturer said: “I can’t emphasise this enough, you MUST irrigate with hypochlorite,” the audience member asked “So do you ALWAYS irrigate with hypochorite?” When the speaker said “It’s critical to use rubber-dam to stand any chance of success,” the irritant asked “So do you think it’s important to use rubber-dam to be successful?” When the speaker emphasised the importance of recapitulation, the annoying dentist asked “So you’d recommend recapitulation then?” And on and on. By the end of the day, the rest of the audience had had enough and every time the hand went up, there were murderous murmurings all over the lecture hall. I can almost guarantee you have met this bloke at a CPD meeting at some point in your professional life.

When the GDC officially threw its their hat in the ring and CPD came in with its implied threat of erasure if you didn’t take an apple for your teacher, all the fun seemed to go out of practice awaydays. Courses were suddenly geared towards meeting legislative requirements and you’d be really struggling to find a course that DIDN’T involve cross-infection control or compliance. I missed courses with titles like ‘Fun With Mercury’ and ‘Who Needs A Perio Probe?’

The prospect of the new 100 hours verifiable CPD in five years target didn’t particularly bother me. Apart from my last year in practice, I usually far exceeded requirements. That may surprise some. I was fascinated by the science behind dentistry, it was just the idea of being in the same building as patients that I hated.

When it came to non-verifiable CPD declarations to the GDC at the end of the year, my attitude was a little more ‘relaxed.’ I mean, I did quite a lot of journal reading, but I can’t say that I scrupulously logged my hours, so when it came to putting in a non-verifiable figure to the GDC it had the accuracy you’d normally associate with Oliver Reed telling his GP how many units he drank per week.

My difficulties with enhanced CPD would have been associated with the production of a Personal Development Plan. Every PDP I’ve ever been asked to produce in the past has basically identified endodontics as my weakness and all my CPD would have been directed towards attending endless courses on RCT until I finally found the Holy Grail – a course that that said hypochlorite and rubber dam was totally unnecessary.

I would imagine the pursuit of UDA’s and economic viability has led to an increase in the number of practitioner’s carrying out a lot of CPD online. I have no quantitative evidence for that assumption other than I was often asked while I was practising which organisations provided the cheapest online CPD content.

And of course, online CPD has opened up the opportunity for taking shortcuts to attaining verifiable hours. I knew one practitioner who never read the content of the course, but ticked the multiple choices as he thought fit and repeat until he hit the 80% pass score required for his certificate - it took him way less time than spending the two hours the course providers reckon he needed to complete the course, and failing that, he’d photograph each page of text and then go to the test at the end. If he didn’t know the answers, he’d scroll through the pictures till he found the bit he wanted and ticked the box with confidence.

Another well-known CPD website apparently counted up the time you spent online answering questions and issued certificates logging the hours spent on each subject. One ingenious practitioner I know discovered an App for his computer called a ‘Mouse-Clicker.’ You could set the App so that it clicked automatically every few seconds. This registered with the website that you were still active on the page and he could go off down the pub while he was automatically logging verifiable hours without breaking sweat.

I say! That’s not quite cricket!

Abandoned Dreams - Which Career Dreams Did YOU Abandon?

It's a Question of Taste - (Practice Ownership - Love it or Hate it).

GDC and the dental profession

Happy 2020 to Dr Moyes and colleagues.

I hesitated before putting finger to keyboard on this topic, it’s too easy, and a real barn door isn’t it? In fact I wrote, rewrote, and finally binned, one piece and started again.

Here are some New Year wishes for the General Dental Council. They make demands and enforce what they say are patients’ expectations of the Dental profession; surely this should not be a one-way street?

Empathy. If there is one quality that is essential in any successful relationship it is empathy or “The ability to understand and share the feelings of another”. I have looked back through the last decade of the GDC and seen little evidence that they have made any concerted effort to either understand or share the feelings of the tens of thousands of people on their register. Lip service from the occasional survey perhaps, worded in such a way to avoid exploring the real fears of day-to-day clinical practice.

Context. All practices are different, all patients are different. There cannot be one rule for all. Yet it seems we are reaching a point where any treatment that is less than “ideal” is unacceptable and therefore negligent. I was able to convert my practice away from a reliance on the NHS in the early 90s. When I reached my personal ceiling and sold it I then did locums in different sorts of places and had my eyes opened. In some places the practice of dentistry is like working in a war zone with a shifting population, all with different wants, needs, expectations and budgets.

In the same way with the massive shift towards corporate and chain practices there can be pressures on, but little support for, younger dentists. When shareholder value, rather than patient care, becomes part of a company’s ethos the clinician is often caught in the middle between bean counters and patient expectations. It can take years to build an appropriate trusting relationship with a patient yet pressure to “produce” can put unrealistic and unfair expectations on clinicians.

Engagement. When was the last time any of the staff actually listened and responded face to face with a group of dentists and their teams about what the future has planned for them? The current (Corporate) Strategy is so full of “corporate speak” that any message is hidden behind paragraphs like this one, “Key to fulfilling our statutory responsibilities is ensuring that our resources are allocated to reflect our priorities and that opportunities to improve the efficiency and effectiveness of our operations are taken promptly. Much has been achieved in this respect, but there is more to do and we are actively pursuing further opportunities.”

Humility. Dr Moyes could learn a lesson or two from the Chief Dental Officers who put themselves in the (metaphorical) firing line at conferences and speak… and appear to listen. They have learned from the mistakes of predecessors, the GDC shows no such humility. This aspect is damning.

Leadership. The morale of many dentists, especially young dentists, in the UK is at an all time low, there is clearly a disconnect between what their expectations are and what the reality is that they encounter. The only body that has control over both education and daily dentistry wherever it is practiced is the GDC.

Brexit and more. It is clear from the cases that come before the GDC that many overseas graduates are not prepared for practice in the UK. The responsibility for that falls on the shoulders of the GDC. Or are they under such pressure to keep the dental lights on and the dental queues at bay that things could are fudged?

Blame game. Reports of meetings from official and unofficial sources say that the usual excuse for any lack of action is “it would take government intervention” which translates into “we don’t have the will”.

It is clear that large, unrealistic contracts, [like the famous cross infection control case in Nottingham] have been awarded, the profession has known that, why hasn’t the GDC taken steps to ensure things are running well and the mistakes remedied? Or would that be the clip-boarding, tick-boxers of the CQC’s responsibility?

Finally. I challenge you to grasp one simple nettle, just the one, only one. Allow registrants to pay their registration fees monthly by direct debit. It is one element that typifies the lack of listening, the lack of will to take action and the inability to appear to be anything other than a Dickensian schoolmaster who knows only wrong in others.

Happy New Year to you and to all who pay the fees that you collect, spend and keep in reserve. I wish you all the very best for 2020.

I won’t pretend for a second that the news stories breaking around dentistry in 2019 came up to the standard of those surrounding the world of politics. We didn’t have the dental equivalent of a Prime Minister resigning, the new one willingly calling a general election and that Prime Minister’s Pinky and Perky twin across the water being impeached. But it wasn’t completely without drama. The GDC, in particular, being the gift that keeps on giving.

January

The Daily Mail carried on its tradition of providing cheap and easy to read non-verifiable CPD, by highlighting the results of a Cochrane Review which found there was no clinical difference between patients receiving regular scheduled scaling and polishing against those not having a ‘scrape and brush-up’ (not the Mail’s term, my patient Mrs Cholmondsley of Milton-on-the Truss’s term for what our hygienist did to earn a living). The Dundee meta-analysis of two studies involving 1711 patients found that there was no difference in the two groups with regard to the development of early signs of gum disease. There was a noticeable difference in terms of calculus build up but the researchers didn’t think the build-up was significant although it was remarked that they didn’t know whether this build-up was more important to the patient or the dentist. As a dentist I always worried about munge building up around the gum margins, and fortunately Professor Damien Walmsley agreed with me. I also worried about stories like these in the general press, just in case people like Matt Hancock inadvertently see them while searching for their latest polling figures. It hasn’t happened yet, but just you wait for the government to reduce the number of scales NHS patients are allowed per year, with a concomitant reduction in fees.

Meanwhile also in January and in the same vein, the Journal of Clinical Periodontology published the results of a study which revealed that pregnant women are one and a half times more likely to go into labour prematurely, if they have gum disease. So here’s an idea – why not ensure pregnant women have closer periodontal supervision during parturiency by carrying out regular scale and polishes…oh!

But if the dental profession has less work to do because we ARE banned from doing scales, that will hopefully neutralise the effects of the inevitable reduction in EU trained dentists leaving the UK as a result of Brexit. The General Dental Council presented evidence that up to a third of EU qualified dentists on the dental register may quit UK dentistry after Brexit because of…Brexit and its associated uncertainties. Some of the EU-trained dentists also cited the difficulties of working under the NHS and dental regulation as reasons for leaving. I think these Europeans have their heads screwed on. Who could blame them for shunning a system which pays them a piddling amount for one filling and exactly the same amount for half a dozen fillings. Brexit means Brexit. Exploitation means exploitation.

Also in January, the British Dental Journal published a large-scale study of 2,000 practitioners which showed that almost half of dentists admitted that job stresses were exceeding their ability to cope. The study found that the most stressful aspects of their work was related to regulation and fear of litigation from their patients. It probably doesn’t help the mood of GDP’s that they’re being told that some of their ministrations are pointless (see above), that at some point a litigation lawyer might blame them for premature births and their workload is going to increase in 2020 when Manuel and Helmut escape back to the mainland.

February

February saw the revelation that practitioners were more likely to be struck off the GDC register if they didn’t have any legal representation at hearings. A Freedom of Information request to the GDC by Dental Protection showed that nearly two thirds of dentists who were erased from the dental register didn’t have a legal advocate speaking on their behalf. My first thought about that story was “What kind of fruitcake would go to the GDC without legal representation?” Having been a career-long member of one of the original ‘big two’ professional indemnity organisations, the thought never entered my head that such representation may be denied. But apparently, that’s not the case. Even though they often offer cheaper ‘cover’ to dentists, there are defence organisation or insurers who may decline assistance to dentists in personal conduct matters. You pays your money and you takes your choice. I personally preferred to pay a not insignificant amount per month in the hopes that if I got into trouble I would get Rumpole defending me rather than rely on my own inane ramblings that come out more like Elmer Fudd than Perry Mason.

March

Big news this month was that ‘British Teeth’ helped win an Oscar. Rami Malek won an Academy Award for his role as Freddie Mercury in Bohemian Rhapsody wearing prosthetic teeth made by dental technician Chris Lyons for British-based Fangs FX. Much to the mild annoyance of British dentists, Americans often use the denigratory term ‘British Teeth’ to describe not only our teeth, but British dentistry. Just a slight snag – Freddie was born in Zanzibar to Parsi parents. So they were more like Persian Pearlies than our pride and joy.

Birmingham University hit the dental headlines with its new dental model that reproduces the feel and ‘behaviour’ of real gums and the tongue. As well as helping to teach students how to examine the mouth safely and check for disease, the models reproduce the ‘feel’ experienced when checking pocket depths. In my opinion, this must be a welcome and invaluable teaching aid. The first time most dentists had to check for pocket depths was on a patient. Nobody can tell you how it feels to use a pocket probe or how much pressure to place on the tip.   This probably explains the squeamishness of a lot of dentists trained up to now, in tackling pocket depths. You simply didn’t know when to stop pressing – wait until the patient’s eyes rolled back into their sockets or simply sobbed and/or threatened litigation.

April

I warned you about this back in January. In April, the RAINDROP study carried out by the University of Newcastle proposed that ‘routine’ scaling and polishing of teeth should be stopped from the dental budget since the money would be better off being spent elsewhere. I personally felt this was poppycock. Since many NHS scalings, I would suggest, are completed on a Band 1 treatment with an examination, how is money going to be saved? The Nash gets a bargain out of dentists anyway for this service and money-saving will only be executed by cutting the fee for an examination I reckon. I repeat. I told you back in January and you wouldn’t listen, would you?

May

The GDC was seeking views on its consultation for its strategy for 2020-2 – “Working with the dental team for public safety and confidence.” GDC chair Bill Moyes boldly claimed that the overall decrease in GDC expenditure pointed to a significant reduction in the dentist’s Annual Retention Fee. My advice on that is – don’t hold your breath. Highly unlikely. I bet you believe in the tooth fairy as well, don’t you?

June

The Government’s Migration Advisory Committee announced that dentists would not be on the Shortage Occupation List, despite the BDA’s evidence that 63% of dental practices are experiencing difficulties in recruiting dentists and the GDC’s findings that a third of EU graduates may leave the UK in the next five years. A significant number of currently registered dentists are also thought to be considering retirement in the next few year – for ‘considering retirement,’ read ‘running for the exit like their backsides are on fire.’ One suggestion to alleviate the operator shortage problem – get a UK trained dental therapist before everyone catches on.

July

Thankfully, I never came close, but it was always something else to worry about. July saw NHS England and NHS Improvement (nope, I’d never heard of it either, I’ll need to Google it later) agreed to remove wrong-site blocks as a ‘never event.’ The British Dental Association had long argued that administration of wrong site blocks didn’t meet the threshold of a never-event. Although inconvenient to the patient and incredibly embarrassing for the dentist or student, giving a patient a dribble on the wrong side, is hardly likely to kill.

Removing the wrong teeth is considered a never-event and I would suggest that allowing your dog to bite a practice inspector really ought to be on the list. Dentist Aileen Hopkins was erased by the GDC after one of the three dogs she kept at the surgery bit an inspector. The dentist had 57 complaints about safety and hygiene also considered, but the dentist apparently thought the GDC was being a bit “nit-picky.”

August

Journalists know August as ‘the silly season,’ the time of year when people are on holiday and Parliament and public bodies uproot and go to the Algarve.   Hence, not a lot happens during August, which meant the The London Evening Standard reported on the UK’s first ‘healthy’ supermarket which was launched in Central London. In essence, the store was giving greater visibility to healthy foods such as fruit and vegetables and less shelf space to foods like chocolate, crisps and sugary drinks. And that was it really. Laudable though it is, it didn’t really press any journalistic buttons. Nobody was bitten by a dog and no one was brought in front of a disciplinary body for stacking M&M’s in front of the Monster Munch.

September

The British Orthodontic Society and Oral Health Foundation announced plans for a national campaign to warn patients about the risks of internet-based/DIY orthodontics. GDPUK had warned earlier in the year that patients are being prescribed courses of adult orthodontics without seeing a qualified dentist face-to-face or having a full clinical examination. Although one of the companies involved in providing internet-based ortho offers ‘scanning’ in various centres throughout the UK, you CAN have a traditional impression taken – providing you take it yourself. Curious, I approached an online advisor at Smile Direct Club for further information. Just don’t try the following if you are keen on hanging on to your registration.

October

Bad news for parents of teething children, hoping for restful nights. The British Dental Association revealed that 9 of the 14 teeth products licenced for use in the UK could have potentially harmful side effects. The nine products contained either sucrose, alcohol and or/lidocaine and there is apparently little evidence that the products are effective in reducing teething pain. Where does that leave dentists when confronted with a red-eyed, half-lidded mum begging for advice on how to relieve teething pain? My guidance for the desperate parents would still be alcohol. Forget the child, just drink the alcohol.

But great news for dentists. Early in October, the GDC announced the new levels of ARF fees set for the next three years, ‘barring any unforeseen exceptional circumstances.’ The new level for dentists is £680 and £114 for dental care professionals. Two thoughts: a) why did they bring reduced fees in after I retired? b) what does the GDC define as ‘unforeseen and exceptional circumstances?” There’s still three months to go. Don’t bank on it yet!

Also in October, Medical News Today reported on a study linking periodontal disease with hypertension. This didn’t surprise me. Patients with perio often caused my blood pressure to rise.

More concerning was the revelation that overseas dentists are being allowed to register as dental therapists by the General Dental Council, without any practical examination of their clinical skills. Normally, dentists qualifying outside the EU have to take the Overseas Registration Examination (ORE) or the Licentiate In Dental Surgery. An investigation by GDPUK.com revealed that there is a high failure rate in the practical element of the ORE and yet overseas dentists are being allowed to register and carry out operative restorative procedures on patients, with no further checks on their skills. The GDC is apparently convinced that its checking of the dental syllabus of these dentists is ‘robust’ and yet apparently NOT robust enough if they want to work as dentists.

At the end of October, the GDC was again in the headlines, when it was revealed that the regulatory body withheld evidence from its own Professional Conduct Committee (PCC) which resulted in the erroneous reinstatement of a fraudulent dentist to the dental register. Justice Julian Knowles criticised the GDC in a High Court hearing brought against the GDC and the dentist, by the Professional Standards Authority. He said the GDC had committed a ‘serious procedural irregularity’ in withholding evidence from the PCC. The evidence was withheld following its late submission to the dentist’s legal counsel because it had been mislaid by a GDC solicitor.

November

The GDC was probably feeling hunted by now, much like their registrants. It was early in the month that the Daily Telegraph revealed that the GDC had spent over £17,000 on hiring private investigators to ‘investigate’ registrants. BDA chair Mick Armstrong described the GDC’s investigatory method as ‘entrapment.’ One case involved private eyes attempting to induce a clinical dental technician to provide treatment without a dental examination by a dentist, by claiming she was too unwell to go to see a dentist for an examination. This revelation just made me feel slightly grubby. I mean, the GDC is supposed to be setting the profession’s standards and all they are interested in is in putting on a heavily stained Columbo mac.

December

It appears that the GDC only scares legitimate dental professionals. GDPUK.com ran a story that a Derby man who was fined for illegal teeth whitening in 2017 has been caught doing it again. A Derbyshire Live reporter set up a sting operation to catch Colin Vernall attempting to sell his whitening wares again. He told the reporter although he wasn’t registered with the ‘dental council,’ he did do a course. Mr Vernall, who prefers to be called ‘Vern’ Collins (sounds legit) is still taking money for his whitening service despite the £7,000 fine he received as a result of a court case brought by Derby City Council Trading Standards officers.  When the reporter revealed his identity, Vern said: “Teeth whitening has changed and it’s self-administered, I simply supply the equipment and you place the tray and products in your mouth yourself.” Thus abrogating all responsibility presumably. He added “I'm simply renting you the light to accelerate the procedure.” When it was obvious the reporter wasn’t going to use his services, Vern said: “I just got a taxi up here, it has cost me a tenner to get here as well.” Vern has gone ‘mobile’ since his £7,000 run in with Trading Standards.

As I write during the hiatus between Christmas and New Year’s Eve, the GDC hasn’t yet found any ‘unforeseen exceptional circumstances’ which will destroy our dream of having to pay a mere £680 quid a year to have our names placed on an internet list.

But there’s still two working days, so don’t spend the savings yet.

Distribute some Christmas Cheer - Ideas for Dental Christmas Gifts

Prolonging the agony? - My view on Slow Dentistry - By @DentistGoneBadd

If the BDA did not exist . . . . .

If the BDA did not exist…It would need to be invented.

I was encouraged as a student not only to join the BDA but also to join in. I have served in several roles at Section and Branch and, even as a non-clinician, I still read and enjoy the BDJ.

I remain, an advocate and a critic of the BDA. I am often reminded of the “What have the Romans ever done” sketch from The Life of Brian when dentists ask, “What has the BDA ever done for me?”. They often continue, “Why don’t they…?” the questions being the old chestnuts, “Sort out the GDC/CQC/Department of Health” or “get some action like the BMA does”. The same individuals usually disappear when you ask them to do something for themselves or others.

So what is the BDA’s role, how could it change and what benefit would that bring? The cliche goes, “You wouldn’t want to start from here”, but here is where we are.

The BDA’s mission statement is: “to promote the interests of members, advance the science, arts and ethics of dentistry and improve the nation’s oral health.”

Let’s accept that and start there.

A new organisation is a non-starter, it has been tried with little success, why reinvent the wheel? It could be a broader church, D stands for Dental not Dentist. Many successful sections actively welcome all team members to their meetings, we work in the same places and, if we want to truly embrace team working, why not?

An individual’s perception is their reality. The BDA is composed largely of people who work in general practice and, rightly or wrongly, they see the BDA through the lens of their silo. Their interests are different from one working in the community, academia or the hospital services. The main challenge is making sure that you are profitable, dentists like all small business owners run the risk of bankruptcy and ruin if they don’t get their maths right. Many practices run on very small margins of profitably, are undercapitalised and work from hand to mouth. More like corner shops than other professional businesses.

For many this has worsened since the imposition of the 2006 contract for which I most definitely do not blame the BDA. The then CDO did a whitewash job and the contract is deeply flawed, underfunded and bad for everyone.

Dentistry is a very stressful occupation. It can be a lonely place; being a medical professional has pressures upon it, having to make immediate decisions with patients that are awake and where you have finite time to complete procedures produces even more pressure.

Being the owner and main producer of a small business is lonely too. Many dentists are poor leaders and have problems separating management from leadership.

The stress of working under the NHS system plus an aggressive GDC is showing itself in rising numbers becoming burnt out and dissatisfied with their lot. In my role as a business consultant I meet many people at their wits end, not knowing which way to turn.

The BDA should be far more active in encouraging dentists to move away from a reliance on the NHS. In the past many elected representatives choose to be reliant on the NHS, have businesses that cope with the system and are so close to retirement they do not want to make changes. Change is happening there at last.

Education

Through the sections and branches the BDA is responsible for large amounts of CPD provision yet there seems to be little cross communication. Some sections shine like beacons, others hardly flicker. Newer CPD providers have adopted different ways to be more attractive to a changing audience and the BDA has been slow to embrace the change.

One of the advantages of local face to face meetings is the provision of “fellowship”. Traditionally the opportunity to share experiences in a non-confrontational way with senior and junior colleagues provides a great way to let off steam, to unwind to share and gain support.

The annual conference was an excellent source of CPD and a hub around which the Dental World rotated, yet latterly struggled for an identity and was eventually subsumed by The Dentistry Show. I know that decision was hard to make and to take.

Communication

The BDA has clearly listened to criticism and there is far more comment and reaction about dentistry in the news. We also see and hear about disagreements, the profession has a mouthpiece with an opinion.

The press office needs to be ahead of the game more often and on more topics. For this to work there needs to be more dentists willing to stand up and speak up locally.

Proactivity

I would like the BDA to take a long hard look at what the scenery of UK dentistry should look like in a decade’s time, to examine other systems and drive change. The only opportunity we have of being ahead of repeated government intervention is by inventing our own future. What will things be like under headings of personnel, science, economics and social? How will that be reflected in the BDA’s advice to members? What decisions do practices and individuals need to take now for the world of 2030 and beyond?

Representation

Some years ago I had to explain to a member that as section secretary I had little or no way of making direct representation, and he would have to approach the LDC or his GDSC rep. His reply, “You’re the “face" of my Trades Union, I have no idea who the other people are, they never come to our meetings and the LDC people are all 100% NHS why can’t you do something?” I felt useless.

The route of feedback from practices to “HQ” remains poor, the communication needs to be improved and to be seen to be improved. Members don’t know who their representatives are or what they do. Clarity is required.

Conclusion

Dentists - if you want someone to represent you then get off your backside, find them, tell them exactly what you want and demand feedback, otherwise there is a large chance that you won’t get it! Don’t ask what your BDA can do for you, ask what you can do for your profession.

BDA - make it easier to contact representatives. Ensure your offer is of interest and relevance to all members. Keep the messages simpler, don’t presume everyone knows everything, continue the website improvement and keep reinventing yourself.

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Dentistry's Got talents - Which ones, exactly? By @DentistGoneBadd

Medieval

The General Dental Council’s work in disciplinary matters is sometimes not fully understood by dental practitioners. The revelations over the past few weeks that the GDC is registering overseas dentists as dental therapists without a thorough check of their practical abilities, that they withheld evidence which resulted in a fraudulent dentist being restored to the dental register, and that they have used private detectives to entrap registrants, has opened the GDC’s registration and disciplinary processes to close scrutiny. These recent stories on the GDC suggest those disciplinary processes to be more mysterious than ever.

GDPUK has been fortunate in being given the opportunity to speak frankly with a recent ex-member of the GDC’s Fitness To Practice panel, which helps determine the professional fate of over 112,000 registrants.

Peter is a clinician with over 28 years of experience in dentistry. He is currently working full-time in private and NHS practice. We have been asked not to reveal his identity.

It sounds like a lot of hard work. What made you want to serve with the GDC?

Serve? An interesting terminology there. The GDC has the statutory function of regulating the profession and whilst to many it seems odd, I wanted to be a part of this. Someone has to do it. I thought it might as well be me. You can stand on the outside and criticise, or you can be on the inside and see how the machine really works

Briefly, what were your duties on the committee on which you served? What is the makeup of the committee on which you served?

I sat on the Fitness To Practise panel and as a consequence, you sat on all the statutory committees. They are independent of the GDC – which is a challenging concept, given the GDC writes the committee guidance. On the FTP panel, you read, listen to and evaluate evidence presented. The civil legal standard is used so you find evidence on ‘the balance of probability.’ I personally believe it should revert back to the criminal standard. Beyond reasonable doubt stops charismatic barristers winning you over.

What training do committee members get?

It really isn't as intense as it should be. There is far too much concentration on ‘soft skills,’ such as communication and people skills, rather than legal understanding. I often felt it lacked any real depth. That said, the whole selection process is (allegedly) designed to select individuals that are able to carry out the workload. I personally doubt that, and feel the recruitment process is biased since the GDC seeks to ensure diversity. That aim is incredibly important since the profession is diverse, yet there is a part of me that is convinced that the recruitment process is flawed for this very reason

What sort of cases did you hear?

I heard cases involving all classes of registrant. They were, in broad terms, clinical or criminal. In addition to this there are health cases. Some were easy, some were extremely challenging due to the nature of the allegations.

Did you feel the cases brought before you were justified?

Ah, well, that’s a very difficult question to answer. In some cases yes, in others, no. When a dental professional is convicted of paedophilia then there's no discussion, but when a registrant is in front of a committee with a huge list of allegations that were clearly gained after the original index complaint, then it becomes difficult to clear the mind. The committee can only hear the evidence presented to it (alongside the allegations) yet I personally struggled with the concept. Indeed, in some cases (more than ever should have been) the original index complaint never even made it into the hearing. This conflicts with my personal sense of justice. The GDC managing to amass a long list of allegations based on its investigation was, and remains, of concern to me.

There are some criticisms that caseworkers can be over zealous when preparing ‘charges’ against registrants. Are these justified?

My personal issue with the caseworkers is that they lack any real knowledge of the profession. It can be reasonably argued that they don't need it to just list allegations, but this argument is fundamentally flawed as their inability to understand what is important and relevant is only dictated by guidelines they work to. The system is evolving with dental professionals now involved, but it is currently still lacking serious input

Do you think the makeup of committee’s is balanced and makes for a ‘just’ system?

Committees have to contain various elements in order to make them work. Prior to 2003 the ‘old school tie network’ led to many cases that were serious, failing the patients. There was a time when committees sat with five members. Nowadays, because of cost-cutting, it is invariably three. (The cost per day, per person plus expenses, is considerable). A three-person committee is unbalanced. It comprises one Lay, one dentist and one Dental Care Professional (DCP). One strong individual can influence the other two in my personal experience and a dominant influence means the case will fall their way. It's inadvertent "bullying" and this is why there is a focus on soft skills in the training process. Reverting to the criminal standard would eliminate this bias and mean that an individual’s influence would be more difficult to exert. It's either that or revert to ensuring committees sit with five members. One strong personality has to try much harder to convince four other members of his view.

Do you feel that decision making is hampered by Lay people?

No. The Lay perspective is very important BUT this must be balanced. I have already suggested that a strong personality can influence a committee. The Lay person is potentially the most at risk yet, again, a five-person committee would reduce this bias.

Quite often, registrants complain that they can also face ‘dishonesty’ charges in addition to the main charge – why are these added?

The dishonesty allegation actually tends to be a "collection" of allegations. It seems to arise from (again) expert evidence where the report writer may suggest that a "thing" couldn't have happened. It tends to be termed ‘inappropriate,’ ‘misleading’ or ‘dishonest.’

This to me seems to be a ‘get you one way or another’ allegation. They are usually listed as individual allegations that seem almost a snare. The GDC has to work to the remit the Professional Standards Authority decides and that overarching organisation seems to take great store in allegations that demonstrate dishonesty. Apparently, it is extremely difficult to remediate someone one who is dishonest. I'll let people make their own minds up on that aspect, but will say, to err is human.

Do you feel registrants are treated fairly in the FTP process?

Yes. Whilst to many from the outside it seems a draconian process, as a tribunal it has to follow English law. It is a quasi-judicial committee and it relies on expert input. As a committee member, you are not party to the build-up of a case but as a process, it is probably far too protracted for the comfort of a registrant.

Is it justified or necessary to go outside the index complaint and delve into all aspects of a dentist’s practice?

In my opinion, no. Now, if there was a very obvious risk to patients then certainly. But one complaint of a seemingly simple problem seems to lead to an escalation of the issues by ‘investigating’ the individual. I personally believe that if the index complaint falls away then the investigation should be stopped. This is not a criminal court. It has no powers other than to stop someone practising dentistry. But, and this is where I struggle, many employers may ask if you have ever been subject to an investigation. It won't appear on any criminal record but you would have to declare it - potentially ruining someone's future prospects because they failed to record someone's smoking habits.

Do you feel lay members fully understand the seriousness of their decisions on the registrant?

That's extremely difficult to answer. I have worked with some outstanding people and a few challenging individuals. One thing they have to learn is that, the consequence of a previous decision needs to be put aside by committee members. You can't let previous decisions regarding a registrant influence your decision. An example would be a registrant convicted of fraud in criminal court, but you are not convinced they were as guilty as the court found them. You must take it at face value. As a committee member you can't hide behind a previous verdict and you can only base decisions on the facts presented.

I think it is important to remember that some Lay members are, in essence, professional committee members and may sit on several tribunals and be extremely competent in what they do. That has a flip side, because a ‘professional’ Lay person then ceases to be truly ‘Lay.’

Did you ever feel that you your views were disregarded or overruled by the GDC or other members of the committee?

Yes. But that isn't always a negative. The whole point of having a minimum of three people sitting is so that a majority decision can be made. Your opinion will be heard but not necessarily agreed on. The GDC never influenced my decisions other than the published guidance (which is a separate question).

Do you think the GDC is currently fit for purpose with regard to disciplinary matters?

It is very easy to be critical and I think we are no different to our nursing/medical colleagues regarding professional regulation. By that I mean as long as there is a process whereby a professional’s conduct is questioned then no one will be happy. I have already raised some points regarding this. I do find it very bizarre that committees sit and hear evidence even though a registrant has said they are not going to attend/engage and indeed, are no longer working within dentistry. I once asked the GDC about the costs of a case, in 2009. A three-day hearing for a dental nurse who was never going to attend (she had actually written in saying they could ‘stick’ dental nursing), yet the committee sat and suspended her for 9 months. It cost in excess of £50k to hear this. I never followed up the individual after the period of suspension ended. When this happens (another area that is far too common) then no, it isn't fit for purpose. That was (at the time) the equivalent of the ARF of 50 dentists.

There is another area that makes me question the ability of the GDC to consider itself fit for purpose. This relates to the whole world of eggshells that is inclusivity and diversity.

The drive for diversity and inclusion is extremely noble and proper but shouldn't be a reason to put people in to the role that are essentially carried by more illuminated individuals on panels. The drive to hit inclusivity targets has skewed recruitment into the role rather than ensuring individuals have the ability and capacity to deal with the huge amount of information they are fed"

Do you think the source of complaints has changed over the years? Are there more fellow registrants reporting on their colleagues as ‘whistleblowers?’ If so, what do you feel their motivations are. Could you estimate the proportion of patient-generated complaints vs dental professional-generated complaints vs those brought by health authorities?

I despise the term "whistleblower" but I do genuinely think that motives vary. They go from genuine concerns, to vexatious ex-employees, to other motivations. There was a time when it wasn't the done thing to criticise another individual’s work. I don't necessarily think this is right but I do think there seems to have been a drop in professional discretion. Simply criticising some previous work for personal gain is shocking.

A committee isn't there to judge whether a complaint is based on that, but you get some that come through and you know that the motivation was all wrong. Vexatious ex-employees should be simply filtered out. Part of the problem is that if someone decides to raise concerns then invariably mud is slung from one side to the other. This leads to bizarre accusations that damage everyone involved.

I think genuine concerns regarding safety of patients is important but those involved in the very early stages of a complaint should be more robust in filtering. When a legal firm is the initiator of a complaint then surely alarm bells relating to a litigation process should be sounding in the GDC s ears.

Do you believe that radical changes are necessary in the GDC? If so, what?

I'm not sure there is a need for radical change. Perhaps what is really needed is consistency. If you look at the turnover of staff at all levels then you realise there is a distinct lack of consistency in the executive function of the regulator. That can only lead to confusion over time.

It's a bit like Chinese whispers I guess. Over time, interpretation of the way things SHOULD be done, is diluted. That said, I am still puzzled why any dental professional would contact the GDC for advice on any matter other than their ARF. The shake-up maybe needs the GDC to again tell dental professionals they do not give advice. Go on, give them a call and ask for advice on something and they give it... especially interpretation of guidance. The only folk you should contact are your indemnity company

Despite the GDC’s stated intentions to reform their disciplinary processes, do you feel they will effect change?

I think change will be forced upon them. I think this is a little similar to something I've already said, without consistency then change will just be a hand grenade that will just cause mayhem. It also depends on what reforms they actually can make. What us registrants want would be very different to what they are allowed to do. The Professional Standards Authority is not blameless in all this. They (the PSA) have instilled a sense of fear in the executive function of the GDC by essentially threatening judicial reviews when it disagrees with a committee’s decision. They are the watchmen watching the watchmen. If they don't like something then they choose to challenge it. Change must happen top down, not bottom up

The GDC has recently been criticised for:

1. Registering overseas dentists as dental therapists without examining their practice skills
2. Withholding evidence from a PCC which resulted in a dentist wrongly being allowed back onto the register
3. Using private investigators to entrap registrants into acting outside their scope

What are your views on these recent controversies, if any?

The GDC should really hang its head in shame over certain aspects of these three areas.

I have read online discussions regarding all of these and have (unsurprisingly) formed an opinion on all three.

With regard to the registration story I read, it suggested that the GDC see no risk from registering overseas trained dentists as dentists despite the fact they may have failed aspects of the normal route of entry on to the register as a dentist. ‘Shocking’ is my only response. How long will it be before such an individual is in front of a committee? Will the committee have the kahunas to criticise the GDC for this? (Committees can criticise the GDC, I once sat on a case where we did and, as was stated in the determination, we would have awarded costs against the GDC if we had the power).

I sat on several cases where private investigators were used. I was always extremely uncomfortable with this process but was assured it was perfectly legitimate to attempt to get a professional to offer something they're not allowed to do. It feels wrong...very wrong and should be stopped and indeed, in cases where this evidence was used, I feel the cases should be re-sat without this evidence.

I'm no lawyer but withholding evidence is surely a miscarriage of justice? Remember it works both ways. In the case that has been highlighted, it has been demonstrated that all is not well at the GDC. Withholding evidence to prevent a hold (adjournment or postponement) is damaging to all parties involved. It's interesting how the GDC has been extremely quiet in not responding to enquiries in this and other areas. That is worrying because stonewalling only increases suspicion.

Do you believe the GDC uses the ARF money effectively?

I have never analysed the GDC accounts although there are many that do. I   think there may have been some mismanagement many years ago which left the GDC in a predicament. That aside, the ARF is, for all registrants, far too high. A dental nurse whose skill set is not comparable to that of a general nurse, pays far more yet is probably paid less - shocking and the hike up for dentists was shocking. The GDC is not ostentatious (any more) when providing lunch or accommodation so those outside the organisation that criticise this should be careful. The attempt to reduce costs is noble, but perhaps not severe enough.

Do you believe that it is difficult for individuals to effect change from within? Does the government need to take a role in regulation?

The GDC is attempting to reform but as an outsider it is easy to criticise. That aside, they really only have themselves to blame given that they choose not to answer enquiries and using underhand methods to gather evidence instils no confidence. They perhaps need to be open about their dealings with ministers and health ministry officials and about how they have to engage in order to ensure that the guidance they give reflects the changing nature of dentistry.

Endless consultations seem to only attract a certain type of individual to respond and they will never get a balanced response because that nineteen year-old dental nurse who works from 8 to 8 for £9 per hour just couldn't give a toss. And when she is called in front of a regulator that she isn't aware of other than they want money off her annually, she will just go and do something else if called before a committee. Who wants that stress when you feel like you're the bottom of the pile and getting paid peanuts? You are understandably not going to care. That is possibly where the GDC could easily reform. Look at how it manages dental nurses and dental technicians.

Employees and ex-employees often describe the atmosphere within the GDC as ‘toxic.’ What is your view?

I wasn't an employee. No FTP member is, so my fleeting visits to the various GDC locations would not give me an opportunity to assess the working environment adequately. But I do take websites that people post these comments on, with a pinch of salt. A vexatious ex-employee may put toxic postings on just to be mischievous or air a grudge.

Why did you give up your role with the GDC?

I realised that I had "done my bit" it is very easy to stagnate in the role. I think I intimated earlier, that there are essentially professional committee members. They're not all Lay. Whilst it is important to have a broad church on committees it is somewhat bizarre that academics and non-clinical registrants are making decisions about care standards in an aggressive UDA system or on private practitioners just trying to earn a living.

Now you are no longer involved with the GDC, do you have any views on the current state of regulation and the ‘fear’ that is said to be gripping the UK’s dental professionals?

Neglect, fraud and certain things need addressing for sure but sanctioning an individual for a speeding offence really pushes the remit. The GDC says these committees as not punishing individuals but I beg to differ. Suspend an individual for a year and you have denied them their income. These sanctions are punitive in even the simplest form. It was becoming, and continues to be, farcical – leading to protracted hearings for trivial matters that should be dealt with locally.

Back to the subject of reform, the GDC perhaps should engage an ombudsman in more cases to decide what the complainant REALLY wants. If it is retribution or just a matter of "where there's blame there’s a claim" then that doesn't protect the public. Look at the length of determinations for even trivial matters, amazing. The Professional Standards Authority forced that. No, I don't want to be a part of that anymore.

With regard to the culture of fear that has developed in dentistry over recent years - the professional indemnity companies are not playing ball either. Their fees are extortionate yet they have the audacity to criticise the GDC. In 28 years, I have had to contact my indemnification company just once. I wasn't impressed.

I actually believe the indemnity companies are mostly to blame for the culture of fear. Their courses are toxic and full of fear. “If you don't do X or Y then the GDC will have a case.” Having watched many, many cases I can hand on heart say, I often shook my head at the really useless arguments they would instruct the barristers to present. They use ‘expert’ evidence to counter GDC evidence rather than peer to peer evidence. The experts are invariably academics or specialists that are way out of touch with the pressures of general dental practice. There is a massive disparity there.

Finally, I would sometimes find the hypocrisy at the GDC amazing. The biggest example that STILL irks me to this day is in the Maintaining Standards document pre-2006. It clearly stated that “a dentist must not work to a target driven standard.”

Because of the new UDA-based contract, the GDC had to make sure that particular passage wasn’t included in the guidance following the introduction of the new contract.

And the GDC is independent of Government interference you say?

Image credit - Stefan Jurca under CC licence - not modified.

They've Been At It Again! - Your Weekly Update To The Activities Of Those Wacky GDC Folk. By @DentistGoneBadd

Dentistry is tough, I have written that phrase as an opening to several pieces in the past. Things haven’t got any easier, in fact quite the opposite. There is a crisis of confidence in many young, and not so young, dentists.

>A High Court Judge has criticised the General Dental Council’s Professional Conduct procedures after highlighting a “serious procedural irregularity” which allowed a fraudulent dentist to be restored to the dental register.

"I Vaguely Remember Him. Was That The One With The 'Tache?"
What Will Be YOUR legacy?

By @DentistGoneBadd

When You Take Your Problem Patients time With You - Treating Members Of Your Family, By DentistGoneBadd

The Charity helps dental students, dentists and their families when they face hardship, supporting those who do not have the funds to pay for some of the normal things in life, ranging from contributions towards food and daily living costs, funds to improve the quality of life for those retired due to ill health, to more specific needs like paying someone’s annual retention fee or indemnity, to help them get back on their feet and into the profession.

For many years Hull LDC stayed away from the national conference of Local Dental Committees (LDCs). Our preconception was that whilst the Conference might be good for networking, it punched below its weight. We were wrong.

LDC Conference is a fantastic forum, which provides the opportunity to debate Motions, to come to a consensus and to influence policy. In 2017 we saw the light and we decided to table a motion suggesting that we should solicit the support of Local Authorities for water fluoridation as part of Starting Well (SW) Programmes in relevant areas. We were basically “dipping our toes” in the (fluoridated) water. After all, SW is about investing in programmes targeted at the 13 worst areas for child dental health in England where need is greatest, including our “back yard”  - Hull.

The result of this motion was that it was supported by Conference – but not unanimously.

We’ve learned a lot along the way – including the importance of making the motion clearer which would have helped to avoid the voting result. Some delegates wanted CWF included as a short-term strategy!

The LDC also started to use the letters pages of the excellent BDJ to get their messages across. In response to a letter from Paul Connett of Fluoride Action Network¹ Hull LDC² highlighted the lack of credible evidence for his points that fluoride at 1ppm is chemophobic, neurotoxic and toxic as well as the emotionally charged language. This letter exchange was two and half years ago and   similar “tactics” remain the thrust of the Fluoride Action Network^3,4 position on CWF.

In 2018 we decided to build on the first motion and call for funding reform for CWF- because Councils simply don’t have the resources to implement schemes following years of central government budget cuts. This is also fair because as the motion explains, the majority of the return on investment⁵ falls to NHSE.

This time the motion was unanimously supported and the BDA picked up the baton:

The successful motion reflected the support for CWF at the sharp end of Primary Dental Care and created opportunities for the BDA to take forward issues generated by LDCs. Conference motions are effective and with support from the LDC community and BDA leadership, the momentum for change is building. This is huge credit to LDCs whose members work at the coalface and who over three years have supported CWF motions again and again.

The letter the BDA refers to was sent to Simon Stevens. It called for the reallocation of the recurrent costs of CWF schemes from Councils to the NHS. Interestingly, this concept was further developed in this year’s Prevention Green Paper where it was suggested that we need to look for ways of removing barriers to CWF. Councils should be encouraged to come forward and seek cost-sharing partnerships⁶.

In 2019 Hull LDC built on both of the previous motions to ask conference to support those local authorities moving forward with CWF.

Once again Conference supported the motion 100%.

At the beginning of 2019 Hull LDC began to work with the British Fluoridation Society and the BDA to form the National CWF Network. This alliance now has a large membership of dental organisations and a growing membership outside dentistry including the National Children’s Bureau (NCB). The partnership with the NCB is especially powerful, as this organisation exists to support change in society and deliver better childhood.

So we also began to learn that forming wider alliances off the back of campaigning for CWF could be powerful and effective. Working with partners or campaigning with fellowship is the way forward. The LDC national conference is a great organisation and an effective platform for change - it just took Hull LDC a while to work this out. So over time campaigning with fortitude has grown in to campaigning with fellowship.

1). Water fluoridation :Is fluoride chemophobic? P. Connett
https://www.nature.com/articles/sj.bdj.2017.198.pdf 

2). Water fluoridation: It really is this simple: Hull LDC
https://www.nature.com/articles/sj.bdj.2017.383 

3). Fluoride Action Network
https://fluoridealert.org 

4). https://ilikemyteeth.org/closer-anti-fluoride-leaders/

5). Return on investment of oral health improvement programmes for 0-5 year olds
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/560973/ROI_oral_health_interventions.pdf 

6). Advancing our health: prevention in the 2020s
https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s/advancing-our-health-prevention-in-the-2020s-consultation-document 

Please Don't Make Me Cluck Like A Chicken" - Hypnosis In Dentistry. By @DentistGoneBadd

"Beware That Patient's The HS2" - When Patients Act Like Express Trains. By DentistGoneBadd

See the future . . .

April 1st 2035. On her 40th birthday Alice was taking stock of her career and professional life. Her initial dislike of working as a dentist for GleamDent had mellowed, she was still there, and life was good. The dental arm of a European health corporate had treated her well and she had responded by being a good employee. Her early days of ersatz self-employment had been swept away in John McDonnell’s first coalition budget.

The job had privileges including free health care, crèche and kindergarten facilities at work for her two children and six weeks paid holiday a year. In addition the profit sharing scheme allowed all employees to purchase shares in the company and provided bonuses related to personal performance and length of service.

The deep economic depression in the wake of the exit from the EU had a profound effect. Many universities failed financially and tertiary education was re-structured. Vocational degrees were reimagined and medicine, veterinary science and dentistry became graduate entry, usually via the new modular medical science degree.

Teaching in dentistry took place through an apprentice like system at one of the four English dental schools each of which was associated with a corporate body. Students, or dental cadets, were taught theory “in block” and practiced in outreach clinics. The cadets received their education, accommodation and a stipend in return for their commitment to the career structure for 10 years after graduation.

Experiments with on-line delivery of all teaching at undergrad and postgrad levels had failed when it was seen that isolation and lack of personal contact contributed to mental health problems. Psychometric assessments became as important as practical evaluations before prospective students were admitted to the course.

The financial crash led to the creation of a new National Health Care system, run mostly by large groups and funded by clear and compulsory insurance cover. All practices were effectively privatised and during the last decade the, quaint, old style of practice based in converted houses had nearly disappeared. They were replaced either by stand alone new builds in office blocks or, more often, in “Hurley centres” alongside medical colleagues with the onus fixed on “putting the mouth back in the body”.

Some of Alice’s friends were exceptions. These “Artisan Dentists” had solitary practices where they worked with only a nurse and some even did their own laboratory work. Alice herself had relied on digital technology for all her restorative work for a dozen years.

These Artisan outliers were not able to sign up to any of the main health insurers and depended upon on direct payments from patients. Like many of her colleagues Alice had been suspicious of their approach but after spending a few hours with an old friend had found the personal attitude interesting but not attractive.

Every GleamDent treatment pod was well equipped. Magnification was standard, the lighting excellent and state of the art patient distraction systems, long proved to be essential to obtain relaxation and co-operation were a huge improvement on local anaesthetic alone.

In the early days Alice, like many others, was uncomfortable to find that direct feeds from her loupes, in-surgery cameras and monitors meant that all clinical and non-clinical procedures were recorded. Feedback from the sensors measuring Blood Pressure, pulse and cranial activity, of dentist and patient was also monitored. It was easier to defend the increasingly rare allegations of poor treatment, and operator quality could be assessed and constructive feedback given. Plus, reflective practice in such a practical subject was easier when one could see one’s own work and reactions.

Since 2030 much of the adversarial legal system had been taken over by Artificial Intelligence, this removed the need for involvement of the discredited General Dental Council.

Vaccinations against caries and aggressive forms of periodontal disease plus genetic intervention had resulted in 95% of people being bacterial disease free, with ideal jaw and teeth relationships.

However there was a TSL (tooth surface loss) “epidemic”, due to people living on a 90% plant and fruit based diet. The consequences were that many people needed extensive reconstructions during their lifetime. These were mostly performed, like implants and orthodontics, by dental robots, using computerised treatment plans and 4-D printer generated restorations.

Alice found that these cases fulfilling and challenging. The rest of the time she spent supervising via the in-surgery monitors and mentoring junior colleagues whether they are therapists, dentists or students.

Would she choose dentistry for her children? She already had, thus earning herself a share of the GleamDent finder’s bursary.

[See a blog post about Alice, earlier in her career]

Like many dentists I know, I absolutely love new gadgets and innovations in dentistry. I was therefore excited when the Daily Mail headline proclaimed “The End Of Dental Fillings” the other day. Of course, it isn’t. I couldn’t accurately estimate how many times I’ve read “The End Of Dental Fillings” or “The End Of The Dental Drill” over the years, only to have my hopes crushed by scientific reality and human trials.

Professor Damien Walmsley squished my hopes like a bug when he projected that the in vitro growth of an enamel-like material by researchers at Zhejiang University’s School of Medicine wouldn’t be ready for practical use for “ten to twenty years.” Drat! I’m still waiting for a fully-formed Boots own home tooth-growing kit promised by researchers back in the early 1980’s.

This latest breakthrough does sound exciting though. I won’t bore you with the details but the Chinese scientists found that a material composed of calcium phosphate ion clusters could be used to produce a precursor layer to induce the epitaxial crystal growth of enamel apatite. This then mimics the biomineralization crystalline-amorphous frontier of the hard tissue developed in nature. They also found the CPIC-caused epitaxial growth recovered the enamel strength, with H and E values of 3.84 ± 0.20 GPa and 87.26 ± 3.73 GPa, respectively. I was staggered.   Oops. I bored you.

I’m such a sucker for gadgets of any description, I once couldn’t help buying them. Years ago, the practice manager of my own practice banned me from going to Dental Showcase for my own financial safety. I seem to recall that was triggered by me coming back from a show with my arms full of boxes of disposable spring-loaded BPE probes, which I never ever used. Just last night I was glued to the Apple iPhone launch event, salivating, more like drooling over a phone that looks identical to the one in my pocket except the new one has three knobbly bits on the back.

I think I can say that during my career I kept fully abreast of new developments and never feared embracing a piece of kit with a warning beep built in. I don’t know if that was a good thing or a bad thing, a total waste of money, or just plain scary.

I was lucky enough to be given the opportunity after about four years post-qualification, to work with the dentist who first inspired me to become a dentist. My dentist and his partner were two forward thinking professionals who were constantly on expensive courses and they picked up hundreds of tips which they imparted to me and the other associate, as well as spend thousands on bits of kit which they occasionally let us use.

One day, the senior partner appeared at my side, wearing a pleading face, despite the fact he was about to give me the opportunity to try out his latest purchase.   The new addition to the practice’s armamentarium was a crown removal system, which I believe is still available. I can’t remember the name of the product, but I can say it was incredibly effective - maybe TOO effective for my liking. After giving me quick instruction on how to use the device, I suddenly found a consultant medical surgeon in my chair, one of my boss’s best private patients.

The ‘device’ was basically a cube of what looked like solidified Rowntrees jelly. You may have come across the material – I don’t want to teach my grandmother to suck eggs (to be honest it was the only way my grandmother could eat eggs because I made her dentures) - but it was a very hard material and had to be softened in hot water.   After it reached a nice pliable consistency, the material was placed by the crown and surrounding teeth on the occlusal surfaces and the patient was then instructed to bite down and hold it. The idea was that you let the material cool and once it was set, the patient opened the mouth violently. The desired result was a detached crown in the set jelly.

I could detect that the crown in this particular patient (an upper right 4) was very slightly wobbly but just as I placed the material, I realised that the unrestored UR3 and UR5 were also slightly wobbly. My blood ran cold. I was already committed and I braced myself for the embarrassment of having a consultant surgeon let out a blood-curdling scream as his teeth were ripped out without local anaesthetic, and the trial of having to replant them back into the sockets. Mercifully, only the crown became detached and I marched the patient back downstairs to the private part of the practice. Afterwards, my senior male colleague said “Phew, close call. Well done, my dear.”

It was while I was at this practice that I was also introduced to a miracle product.

The bane of any dentist’s life, in addition to all the other banes, is failed anaesthesia. Particularly miserable, is the inferior dental block, especially when you have a patient who doesn’t like needles. My two bosses came back from a course one Monday and announced that all our blocky worries were about to be over. Ten days or so later, the other associate and me were introduced to something called Lido-Hyal. The drug was administered in a dental syringe the same as anaesthetic and it worked by virtue of it containing hyaluronidase. The enzyme facilitated permeability within the tissues so the anaesthetic could penetrate easily to where it was needed. I can’t honestly recall which way round I administered it, but I think I probably gave the local first, followed by the Lido-Hyal. Even the most resistant patients in the practice succumbed to deep pulpal anaesthesia within a couple of minutes and it seemed worries about local failure was banished forever. The only contraindication was that you couldn’t use if there was any suspected infection around for fear of spreading it deeper into the tissues.

I pretty much used Lido exclusively for ID blocks and it never let me down. The problem with Lido was that it wasn’t licenced in the UK and it had to be imported from Switzerland. When I moved to my own practice in the early 90’s, I found that I couldn’t live without it, although I used it rarely. I had probably about three shipments until one day I received a caution from Her Majesty’s Customs and Excise henchmen, who issued a stern warning and a demand for the import tax I’d apparently been wilfully avoiding. I hadn’t, I was just someone who hadn’t previously imported anything in his life and was also a completely incompetent businessman. That put me off, as did an off-the-cuff remark from my associate who reckoned that using Lido would dissolve patient’s condyles. It never did, but it planted the fake news seed and that was enough for me. I never used it again, for fear of turning local patients into drooling, rubber-jawed yokels.

Before my bosses discovered Lido, one of them experimented with intra-osseous anaesthesia. He reckoned it was great for ‘hot’ pulps and avoided the post-op dribbling associated with ID blocks. I never tried the technique myself, the demonstration patient being enough for me. I think the system I saw being used isn’t available any longer, but it involved using a hollow trephining drill to sink a hole in the cortical bone that went through the cancellous bone of the alveolus. The outer part of the trephining drill was left in situ and the local was administered through the hollow tube.   My boss reckoned the procedure was less painful than delivering an ID block, but I saw the patient squirm when he numbed the intra septal gingivae and saw the patient slowly wriggle down the chair when his cortical plate was being drilled. I’m sure it works perfectly well in the right hands but it turned my stomach, and apparently his. The system was in a cupboard gathering dust within what seemed a fortnight.

An innovation that I DID think might change my professional life, was jet anaesthesia. I was an early adopter, grabbing jet anaesthesia enthusiastically, with both hands. You needed to use both hands because if you didn’t, the retort was like that I would imagine you’d experience from an AK-47. The patients loved the idea of no needles, but they didn’t like the thud and kick-back from the unit, despite the ineffective rubbery cushion on the end. I found the unit difficult to use, particularly getting the large business end flat against the buccal bone of the upper molar areas. The main problem was although it got the soft tissues numb, it rarely got the pulp numb enough to work on the tooth. Most patients ended up screaming for ‘the proper needle.’ Having read a couple of papers on the modern units, it would seem they are pretty ineffective, though I would be first to admit it could have been operator error in my case.

I was also one of the first customers for surgical loupes with built in fibre-optic lights. These particular units were built in the USA and cost a packet. They were wonderful, but… In those days the light generating unit was a box which to my recall was about the same size as a small fridge which sat on the work surface behind me. The loupes were connected to the light unit by a reasonably lengthy fibre-optic cable and to be fair, it allowed quite a bit of free movement – except if an idiot was wearing the loupes. One day a patient asked me a question during treatment. I couldn’t make out what he was saying and I pulled my mask off and moved to face him so I could lip read as well, forgetting I was still tethered. Fortunately, that act didn’t pull the light unit off the work surface because my nurse dived on it, but my loupes were pulled off and they smashed on the floor. After a couple of weeks on their holidays in the USA, they returned as new. The kind suppliers repaired them free of charge. About two months later, they took a flight to the States again – pretty much the same reason. This time there was a modest charge with an accompanying note asking me if I would like a representative from the company to come and give me a free demonstration on how to use the loupes. I thanked them, but politely refused their offer. My motto over the years seems to have inadvertently been, ‘Once bitten, twice bitten,’ so when my loupes, which I adored, finally hit the deck again, I gave up on them. Eventually I found a local optician who gave me decent magnification in prescription specs, which served me well till I retired.

There were quite a few gadgets I DID resist over the years. Lasers were one of the innovations I shunned. I knew of a good practitioner locally who had spent a lot of money on one and shelved it within a month, advertising for it sale in a dental journal for nearly a year before the ad disappeared. I had heard he failed to shift it.

The early Cerec machines I also dismissed, though mainly on the grounds of cost. In my opinion, the results I saw when they first came out had all the aesthetic beauty of a toilet bowl created by Armitage Shanks. I’d call the shades available in the early days as ‘Comfort Station White.’

Ozone healing was the other ‘breakthrough’ I pretty much ignored. It was promoted originally as being effective way of treating early caries, particularly in pits and fissures. Being old-fashioned, I preferred to witness that I’d dealt effectively with the caries and regarded ozone treatment as snake oil. I note that it’s not currently recommended for the treatment of decay, by NICE.

As for ‘breakthroughs’ like the elimination of filling and drilling, I am a sceptic. Back in the 80’s, at the welcome address by the Dean of my dental school, he told us that caries would be eliminated in the developed world within ten year and that our futures lay in the ‘Third World.’ It was a pretty dour introduction to dental school. I note we are still waiting for the caries vaccine he promised.

I’ve just noticed a tiny chip in the back of my mobile. I think I need a new phone. The iPhone 11 looks nice.

"Roll Up! Roll Up! Get Yer Teeth Fixed While Stocks Last!". By @DentistGoneBadd

Negative reviews can be upsetting. Could the answer be an App? "We'll Be With You In Ten Minutes Mate" Should We Adopt The Uber Model? By @DentistGoneBadd

Trust

One of the main tenets of Professor Onora O’Neill’s arguments around the theme of trust is that we must aim to have more trust in the trustworthy but not in the untrustworthy. She says, “I aim positively to try not to trust the untrustworthy.”

Which brings around the questions. Who can you trust? Who do you trust? And then by extension, Who can trust you? Who does trust you?

All of us exist in different circles. At the centre is the Circle of Control. Sometimes when I talk to dentists and their teams they say that they feel they have little control over their lives, I can understand those feelings but they are not correct. We have control on where our focus is from moment to moment. We choose and can control our reactions to events and to others. We control where and how we spend our time and energy. We control how we turn up every day. We also control how trustworthy we are.

The next circle is The Circle of Influence. In here are the things that concern you and that you are able to Influence. When we look at this closely many of the things that cause us concern are beyond our control and influence.

Finally the outer circle is the Circle of Concern. In here lie all the things that concern you in your work and life, including health, family, finances, the general economy and so on. Everything inside the circle matters to you, everything outside the circle is of no concern to you.

The lesson around the circles is to “Focus on what you can control and don’t waste energy on the things that you cannot.” To take a topical theme, it is very unlikely that any of us can control the outcome of the UK’s proposed Brexit deal - yet many are losing sleep, getting anxious, losing friends and letting it dominate their thinking.

To return to trust. Dentists often say they feel they have lost trust in successive governments, in the GDC and, increasingly, their colleagues. They will often give me evidence of things that have happened where their trust has been “betrayed” by an associate, a principal or an employee. When a patient makes a complaint we feel our trust has been betrayed in some shape or form and it hurts, of course it does.

Often when we analyse the situation we find that the relationship had not been founded on trust, that there was not complete transparency between the parties. In the past when deference was given to professionals there occurred “blind trust” which now, quite rightly, plays little role in our lives.

Unfortunately too many of our relationships have to be with the slab like nature of organisations, where trust is replaced by unintelligent accountability. This is based on managerial concepts of controlling performance by setting targets for individuals and institutions. Success, or not, is measured by whether targets are attained.

For the majority of dental team members, gaining trust with patients and each other is built in gradual stages. The speed depends upon the individuals involved. Bud Ham described the stages involved as a five-step process, Acquaintance, Rapport, Mutual Acceptance, Mutual Respect and Intimacy. The requirements for each stage are “Others’ Conscious Attention, “Friendliness”, “Shared History”, “Disclosed Beliefs” but for the final stage we need to take the risk of sharing “Secrets”.

Most teaching on good communication is “sales based” and stops at “Rapport”. I think it’s only just starting and would suggest that if our relationships are to be trustworthy they must, as Bud says, get closer to the Risk of Intimacy; emotional, mental or spiritual intimacy.

To return to Trust and to wrap things up.

• If we want to be able to trust we must ourselves be trustworthy.
• In order to be trustworthy we must acknowledge what we can control in our lives and focus as much on that as possible.
• Identify those organisations and individuals who are untrustworthy as early as possible in your relationship and do not waste time and energy relying upon them.
• The better you know someone the greater the trust between you and the less the risk of disappointment.

Well, what do YOU think would help the NHS General Dental Service Survive? A It More Posh Would Be Nice - Saving The NHS by @DentistGoneBadd

They sell tooth whitening kits on the Internet. You can even buy temporary crown kits from the web. Guess what you can buy now? Brace Yourself - DIY Orthodontics Via Webcam By ADentistGoneBadd

Believe it or not, it’s just over ten years since the CQC came into being.

I know! It doesn’t seem five minutes since the CQC burst into existence. Sometimes it seems like it’s been hanging over dentistry forever - like the extended impact winter that wiped the dinosaurs out after that postulated asteroid crash-landed without warning – which was a bit like the CQC itself really.  

In England, the CQC is the independent regulator for the quality and safety of care, although to many practitioners, it’s more regarded as a major irritant – another regulatory body to which you have to kowtow, pay an exorbitant fee and produce a forest’s worth of paperwork.

I vaguely remember that the CQC landed on dentistry’s doorstep in about 2011. I was a practice owner in those days and I remember only too clearly, spending most of my spare time writing policies to fulfil forthcoming CQC requirements and being too busy to notice I could have just downloaded them from the internet.

I didn’t have any direct contact with the CQC until I had to go down to one of the organisation’s regional headquarters in the Midlands, for the registered manager’s interview, sometime in 2012. I seem to remember then having to go again a few months later, when the bizarre individual who was about to buy my practice had to have his registered manager’s interview and we had to tell the CQC how we were going to effect the ownership changeover. Naively, I had thought he would simply give me the dosh, and I would skip over the horizon, happily whistling the ABBA hit, Money Money Money. But no, the CQC wanted to make it more complicated and we had to outline our contingency plans for provision of treatment if the practice was consumed by a flood or a volcano. I thought I’d made that clear at my first interview – canoes and a Dyson.

I finalised my practice sale in 2013 so I’ve had no real exposure to CQC fees since, but I seem to remember a registration fee of £1500 or thereabouts.   I had a quick Google this morning and there nowadays seems to be a complicated formula for working out how much dental practices have to pay in fees, based on the number of chairs the practice has, and if you are insane enough to work at more than one site.

I remember that there was a lot of resentment among dental practice owners around

2011-2012 at the introduction of the CQC to the dental field. Many questioned the need for yet another authority to oversee the profession. We’d already got the Health and Safety Executive, the Primary Health Care Trusts (as they were then) and the General Dental Council. Did we REALLY need another?

Yes. We certainly did.

Over the 19 years I had my practice, I had only a couple of informal routine visits from an NHS dental practice advisor. Near the introduction of CQC registration, I had a visit from the area infection control coordinator (until that point I didn’t know such a person existed) to ensure we were complying with HTM-01-05. As it happened, we weren’t - a sink in the decontamination room was in the wrong place and we had to move it to comply with the rules. Apart from that, there was no real oversight of the practice. In most of my ownership days, we still had the random checks from the RDO where the Dental Practice Board would choose a few patients for inspection at the local correction facility (as I liked to call the community dental clinic), but that was it. What went on in your practice was very much your own affair. Nobody randomly checked to see if you were boiling the instruments properly in new saucepans, or diligently spraying the reusable patient bibs with Febreze.

As it happened (and it was probably more luck than judgement), apart from a few bits of paperwork we needed to spruce up, we were pretty near compliant before the CQC came-a-calling. But having worked in a number of practices as an associate before I bought my own place, I can attest that there were a lot of places that would have really struggled to come up to basic CQC expectations, let alone those required by the CQC.

I will describe ONE such practice that I worked at.

It was 1990 and I’d been qualified a couple of years. I joined an old established practice on the Cotswolds border as an associate. The practice had five surgeries and was manned by a husband and wife who were the owners, a long-term associate, a hygienist and moi. The bosses had taken over from two very old school and respected dentists, one of whom appeared to have been grandfathered on to the dental register from his primary job as a barber and blood-letter.

The practice was set in a grand Georgian terraced house, and once you went above the surgeries on the first floor, it appeared that the last vacuum cleaner ever to be used on the 2^nd and 3^rd floors, was the Batty-Fang Carpet Beater 1900. I never saw those floors during my interview, and neither did I see my surgery. When I turned up for the interview, my surgery was in use by the hygienist (apparently) and I couldn’t see into it, the door being solid wood. When I arrived for my first day of work, my surgery was decorated in the style of a 1940’s London Underground station lavatory. Every square inch of the walls, ceiling and floor were tiled in a faded turquoise and the pipes for the aspirator and services lay on top of the floor, presenting a tripping hazard to anyone entering the room. I found out later in the day that the practice was supposed to be haunted. The legend went that the house was originally owned by a well-to-do family and the man of the house had an affair with the housemaid, who I shall call ‘Flora.’ When it all went pear-shaped and Flora became pregnant and was shamed, she hung herself in my surgery (which was the kitchen originally – the fireplace was still in the one wall). Her feet would have dangled over the reclining headrest.  It’s another story, but my associate colleague heard Flora singing late one night on the top floor, and truly I saw an outline of her brushing her hair through a window, one dark winter’s afternoon.

After a week I could stand no more. I discovered that Tanya the hygienist only worked in the practice two days a week and although not spectacular, it at least had an acceptable, if dirty wall-covering. I asked if I could swap rooms and poor Tanya found herself in the lavatory. She never thanked me.  I asked the practice owners if I could decorate the room myself and at my expense. The bosses agreed. I did it in a nice bright pink and I put some decorative borders up. The husband came in first thing on the Monday after I had decorated, put his head around the door and said without a hint of humour: “It looks like a bleeding tart’s boudoir in here.”

Unfortunately, the equipment was as old as the building and the delivery unit was the size of a modest Buckingham Palace fridge and it was about as manoeuvrable as trying to get a Dalek up the stairs. It had polyoxybenzylmethylenglycolanhydride (Bakelite) control switches and buttons and piping that had been repaired by shortening so often, when you moved the drills in a patient’s mouth, the unit was dragged with it. In the two years I was there, I never saw an engineer come in to service the equipment (not that the spare parts were still made for the units). I’m sure it would never have come through a thorough PAT test with flying or even submerged colours. My unit had a dodgy connection with the handpieces and every now and then there would be an explosion of air and what remained of the air-tubing would fly off and snake wildly about the room like a twerking cobra. I point blank refused to have anything to do with fiddling about with the equipment and so my nurse would go and fetch the husband. I REALLY want to name him, but I can’t, so I’ll call him Boris. Anyway, Boris would invariably come with a pair of scissors in his hand and a cannister of sturdy floss, and tie the tubing back on to the handpiece coupling until the perished rubber broke again.

Fortunately, the CQC also ensure premises are safe and up to the mark these days. Boris’s place wasn’t. I doubt that the electrics of the practice had been checked since Thomas Edison was a lad. One day I was doing a full denture try in. I had just given a deaf lady a mirror so she could have a good look and the small, white, straight set up. There was suddenly a loud bang and a flash from behind her. A Bakelite electrical socket (without anything plugged in) had just exploded with no provocation. I jumped and my nurse shrieked, but the patient just sat there wondering if the shade was maybe a little bit dark. She even carried on looking intensely at the denture while Boris ran into the room behind her with a fire extinguisher and started spraying powder all over the place. I can’t remember off hand if the socket was ever dealt with afterwards. We were probably told never to use it again.

One of the worst incidents that happened at this place and inspired me to look for a job elsewhere was when I was treating a patient and Boris’s nurse flew in and said “Can you give Mr Aguecheek a hand…NOW!”

I went into the lavatory-surgery to find Boris was struggling to keep a child anaesthetised. “Just pop the E out for me” he shouted.   I went cold but did it. I hadn’t realised until that point that he was doing child general anaesthetics acting as operator and anaesthetist. I knew for a fact that his nurse wasn’t trained at all, being a newby. I rarely lost my temper, but told him as soon as the opportunity arose, that he was never to involve me in GA’s again.

But that probably wasn’t the worst of it. Oh no. I discovered while I was working my notice, that Boris and his wife Priscilla didn’t dispose of sharps through a clinical waste company. He apparently used to box them up and dispose of them just as the local tip was shutting and it was getting dark. I found that out from one of the receptionists as I was having a chat between patients. I had only just muttered “That is absolutely disgusting” to turn round to find Priscilla was standing behind me. Well it WAS disgusting and again, I told them that I would have to report them to the local Family Practitioner’s Committee (as it was then) if I witnessed them doing it again.

Suffice to say, they also ignored employment laws. A trainee nurse who had gotten fed up with £2.40 per hour they paid, handed in her notice. At the end of the first week of her fortnight’s notice, they withheld her wages, only giving them to her after the rest of the nurses and I, threatened to strike. After I put my own notice in, I found two of my monthly payments were delayed and Boris used to sneak out of the practice so he didn’t have to see me. He worked on the first floor and I was told by his nurse that he daily tiptoed down the stairs quietly so I wasn’t aware he was leaving. One morning, I finished early and waited for him. I flew out and ran at him, catching him halfway up the stairs. I’m not a big bloke, but when I get angry, I can make myself big. When he came back from lunch, he gave me two cheques.

The thing that was interesting here, and it accounts for the fact that I am not impressed by people on committees is that both Boris and Priscilla were ‘upstanding’ members of the local dental community. Both were big in the British Dental Association locally, and both had been LDC members, yet they operated like that.

So do we need the CQC?

Yes we do. The pally pally relationship they must have had with the local dental practice advisor obviously didn’t address major problems with their practice. In these days where we are all faced with a torrent of potential litigation every day, at least complying with the high standards set by the CQC reduces risks marginally and prevents inadvertent swamping by an avalanche.

But it all turned out okay in the end for Boris and Priscilla.

They both dead now.

Removing a pair of latex gloves in a single movement with a “pop” is an art form and takes practice. Two deciduous teeth out, bite on this, a satisfying pop and I’m marching through to reception to take a call. “Mike Lennon here” said the voice at the end of the line. The last time I heard that voice was on the child dental health clinic at Manchester University way back in 1984.

So hop into the De Lorean for a quick spin. Mike, regional director of dental public health, was affectionately christened “Boss Hog” for his striking similarity to the character in The Dukes of Hazard and his straight talking. Fast-forward to 2012 and Mike, a Chairman of the British Fluoridation Society (BFS), had read my letter in the British Dental Journal and wanted to make contact with Hull LDC. The BFS as a Group are world experts on fluoridation and were keen to help and advise.

In 1984 Orwellian language, Mike talked in “old speak” and in 2012 he wanted to hear about my theory that CWF had indeed fallen in to a “memory hole”. Mike must have done something right at Manchester in 1984. Tom Robson leading the CWF campaign in the North East in 2019 is also one of Mike’s Manchester graduates. As Tom says – we all have the same hairstyle now.

Returning to the TV theme, the BFS are the Dental Public Health equivalent of the ‘New Tricks’ retired detective team. Not wishing to be age-ist, certainly mostly 65 plus but all of them with brains the size of planets and huge commitment. They have forgotten more about fluoridation than we have learned over the last seven years and, to be very honest, without them the towel would have gone in years ago. And boy they work hard at it. To say the BFS are inspirational is an understatement.

Mike was, however, a realist. Having been round the proverbial fluoridation block – the F-block - for many years he wanted to know if Hull LDC were in it for the long haul. I think we convinced him we were.

Alan Johnson was one of Hull’s MPs at the time and still the only Secretary of State for Health to state his clear unequivocal support for CWF so Mike suggested I contact him and try and set up a meeting in Hull to get the ball rolling. At this point in time the F-Word was not exactly a thought crime but it tended to be hidden in a “basket of measures” in new speak terms.

We were going for direct action – so we sent out a letter inviting local councilors to a meeting on Oral Health in the City to discuss how to improve the situation.

So in attendance at the Hull Ionians Rugby Club we had: a former Secretary of State for Health, several Councillors, NHSE Dental Commissioners, PHE representatives and this was the moment when Hull LDC made it’s pitch beside the pitch.

It was an important first step in bringing CWF to the attention of local Councillors who, at the end of the day, have the final say on policy. This is only right and proper. After all, targeted fluoridation is a local issue. The challenge for Hull LDC was describing the challenges we face daily, the poor oral health, the high numbers of child GAs, the very poor child dental health statistics, all in human terms and offering CWF as part of the solution because it is safe and effective. Councillors want to do the right thing but are also nervous about doing the wrong thing. It takes time and an attentive audience to provide the science and to reassure that most of the “googled” information needs to be critically evaluated. The best reassurance though existed across the Humber where parts of North Lincolnshire have a fluoridation scheme. As is often the case with CWF – the numbers speak for themselves.

The meeting went well and we knew we had Councillors who were supportive and understood the benefits fluoridation could and would bring to the City. But progress seems agonizingly slow, tedious and   frustrating for Dentists at the front line of Primary Care. In fact it is a necessary part of following the correct procedure and rightly so.

So, in the meantime, Hull LDC chose some direct action. We pledged to try and raise CWF at every opportunity and at any meeting we attended. So we quizzed Andrew Lansley at the BDA Conference and asked questions around fluoridation on every possible occasion. Hull LDC members attended an anti-fluoridation meeting in Hull and had the first of many encounters with the “Ministry of Truth” which bottomed out at CWF turning the public in to waste disposal units for the aluminum industry and boosting the profits of the Rockefeller pharmaceutical companies. By the end many of the more neutral in the audience were leaving incredulous. At first we were the “odd” ones at professional meetings but over the next few years we could sense that slowly but surely the F-word was no longer being avoided or whispered but was slowly making it’s way out of the basket of measures to become a single measure in it’s own right.

Slowly the “double speak “ of CWF being recognised as being one of the ten greatest public health achievements of the 20^thcentury ⁽¹⁾. but being too “hard” was being countered and challenged 2+2=4.

1. Centers for Disease Prevention and control: Community Water Fluoridation: A vital 21^st Century public health Measure

https://www.cdc.gov/grand-rounds/pp/2013/20131217-water-fluoridation.html
https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm
Ten great public health achievements - Us 1900-1999
Community water flouridation a vital 21st century public health intervention

Image credit: "retro" is licensed under CC0 1.0 

Have you ever regretted a decision? Have you ever leapt at a chance only to end up slipping on a banana skin? That pretty much describes my dental career. "Do I Get Another Go?" Rethinking A Dental Career After Retirement By @DentistGoneBadd

Part V - social media marketing in dentistry - Mark Oborn

Considering online marketing it's useful to look at:

• Traffic optimisation to a dental practice website, this typically includes:
  • search engine optimisation
    • On-site search optimisation using words and phrases
    • offsite search optimisation with articles linked back to your website which Google sees as votes
  • paid advertising (PPC)
  • social media marketing
  • e-mail marketing via permission-based list building on your own website
• Conversion optimisation to get more of those website visitors converting into patients, this typically includes:
  • calls to action and wording on the website
  • things for prospects to do, typically these are downloadable guides which are handed out in exchange for an e-mail address
  • e-mail marketing
  • social media campaigns

For a dental practice website to be effective in attracting the right type of new patients we need both traffic and conversions. In previous articles we’ve looked at various forms of traffic optimisation as well as conversion optimisation and e-mail marketing… In this final article we will take a brief look at social media which you may notice appears in both traffic and conversion optimisation.

Everyone knows that the best form of new patient attraction is word-of-mouth marketing, social media is simply word-of-mouth marketing on steroids. Social media gives us the ability to communicate with the widest number of people in one go.

In order to understand social media marketing and relationship building we need to understand some basic business marketing theory.

In a product-based industry (which dentistry is NOT) consumers can evaluate the product before purchasing by trying it out in the store. They can also take back that product after purchase. Marketing for a product is about encouraging the consumer to make a snap decision, product marketing is therefore special deals, offers and incentives such as buy one get one free, 50% off sale today etc.

This is what is known as transactional marketing.

Dentistry on the other hand is very definitely a predominately service-based industry. Let’s take a white filling for example, consumers are not able to evaluate what that filling is going to look like prior to purchasing, nor, after you have completed it and if they dislike it are they able to request you put back any removed tooth and give them back their decay back!

Because of this basic difference between a product and service it means that service based marketing is entirely focused on building trust and reducing risk… when a consumer purchases a service they are (on the whole) unable to make a snap decision and the marketing should reflect this by seeking to build a relationship with them.

This is what is known as relationship marketing. [1]

If we are to use relationship marketing, which happens to be almost tailor-made for social media, then we need to understand the core of how a relationship develops… When we understand how business relationship forms then we can take our social media marketing to the next level.

Business relationships, indeed almost all relationships, form in 3 distinct stages.[2]

1. Actor bonds.
2. Activity links.
3. Resource ties.

Actor bonds.

In order for any relationship to move forwards there need to be bonds between the actors, bonds between yourself and your prospective new patient. Basic human psychology means we tend to like people we are like… So help patients to like you.

This is where sharing personal stories and information really comes into force. Great examples of this are:

• Books you like
• Films you like
• Restaurants you like
• Practice birthdays
• Practice weddings
• People having babies at the practice
• Practice anniversaries and celebrations
• etc

Indeed, any type of invent at the practice which allows someone to say “Ooh, I’m just like them, I like that too…”

These are conversation starters, they opened the door to take the next step in the relationship building process.

Activity links.

The next stage in the process will only occur when someone feels as though they like you, this next stage is giving people something to do.

This is typically handing out useful, free and relevant generic dental health advice, great social media posts that fall into this activity link category are things like:

• When should I take my children to the dentist?
• How many dental implants that I need?
• How to overcome dental anxiety
• What to do if my gums bleed when cleaning my teeth
• How to overcome bad breath
• What’s the difference between a dental implant and dental bridge?
• Etc

The key here is to put a clickable link into your social media post, that link can either be to an image or to a website which has the answer to this particular dental question.

The key thing to understand here is that it DOES NOT have to be your own resources… You could link out to the British Dental Health Foundation, or Colgate or any other dental resource. The point of this type of post is that you are demonstrating that you care about solving patient’s problems over and above making a profit as a dental practice.

If you are trying to sell them something by deliberately pointing them to your website all the time it does not necessarily build trust.

Once we have spent some time building trust we can then move onto the final stage of the relationship building process.

Resource ties.

And this is the part of relationship building marketing which feels like conventional marketing, it’s the part where we tell people how great we are and how well we can solve their dental problems.

In the resource ties section of the relationship building process we are asking a prospective new patient to commit some form of resource to us, either money or time.

Time resources could be reading a blog post you have written (answering one of the questions listed above) or it could be to come and see you for an initial consultation.

Patients are not going to jump to the resource ties section of the relationship building process if you haven’t spent time developing that relationship in the first place and they don’t trust you or view you as a low risk option.

Too many practices can’t resist the urge to jump up and down, shout loudly and wave their hands talking about how great they are, how fabulous their free consultation is, how much they want to give patients 50% off for a particular treatment on a certain day of the week… Completely missing the point that social media is about RELATIONSHIPS, not TRANSACTIONS.

My recommendation is to keep posts in the following percentages.

• Actor bonds 40% of your posts
• Activity links 40% of your posts
• Resource ties no more than 20% of your posts

Each time you go to write a social media updates, think about which of these categories it falls into, it’s absolutely fine just to seek to deepen the relationship with someone… Not all of your posts need to be about teeth -  posting a picture of your dog, or a book you are reading, or restaurant you have recently visited may be the right thing for a person to see for the very 1st time on social media… You can then develop their relationship with you over a period of time as they see things about you in your practice that they can connect with.

Social media is about connecting with people as human beings, developing the relationship by increasing trust and lowering risk… Follow this advice and your social media marketing will work incredibly effectively.

[1] Gummeson E. (2002), Total Relationship Marketing, (2^nd edition), Oxford, Butterworth Heinemann

[2] Hakansson, H. and Snehota, I. (1995) Developing Relationships in Business Markets, London: Routledge

It's the summer, and soon you'll all be inundated with patients wanting their teeth fixed before they smile nicely for the border control people. Brace Yourselves, People - The Holidays Are Coming. By @DentistGoneBadd

It's Dreadfully Confusing

I'm sure I'll take you with pleasure!" the Queen said. "Two pence a week, and jam every other day."

"Well, I don't want any to-day, at any rate."

"You couldn't have it if you did want it," the Queen said. "The rule is, jam to-morrow and jam yesterday – but never jam to-day."

"I don't understand you," said Alice. "It's dreadfully confusing!

Poor Alice, life had seemed much simpler when she graduated BDS, two years ago. A sunny summer passed living on her parents’ credit card visiting her friends from university. But the confusion had already started.

Alice was qualified and fully GDC registered so could work privately. She must wait 8 weeks until September to start her FD job post. She kept hearing about the shortage of NHS dentists but this was the “system”.

Her FD year went well, learning new skills with a supportive trainer, and then she failed to get either of the associate jobs in “mixed” practices for which she had been interviewed. The successful candidates were people who called themselves “Cosmetic Dentists” with portfolios of perfect photographs of composite restorations and who boasted about how many Invisalign cases they had done.

Soon, she was back living at home to start her first “proper” job; working in Mr Jackson’s practice where she had done her work experience from school. Mr Jackson didn’t own it any more and it wasn’t quite the same, being part of the “GleamDent” chain where everyone wore identical, shapeless “scrubs”. It didn’t seem as friendly as she remembered.

Her interview had been OK, although they didn’t seem keen on her charity work and hobbies nor did she didn’t get to meet any of the other dentists. The practice manager, “Queenie” as everyone called her, seemed a bit brusque and insisted on her signing her employee contract before she left the building, although she was sure they had told her on her FD course days that wasn’t best practice. Queenie said that was what GleamDent did and it was a standard “BDA” contract, so it should be OK.

The confusion continued. When she was eventually paid, four weeks after the month end, she hadn’t earned as much as expected. There were so many deductions! Laboratory work she understood, but laundry bills for those awful scrubs? She had made a couple of private crowns for an old friend using a different impression material, so she must pay 100% of the material cost as it was a “non-standard” GleamDent product. Hadn’t she read the employee manual listing what was acceptable and what was optional? Well no, she hadn’t because it wasn’t available.

CPD provision and certification was available in-house, at a cost. £100 for someone from GleamDent HQ to recite Prof Welbury’s child safeguarding manual, seemed a bit steep.

She did at least have a GleamDent online mentor and coach. He worked at a practice 150 miles away had seemed encouraging when they first met via Skype, “the first five years are the worst!” he had joked, she presumed it was a joke. She hadn’t been told that she would have to pay him too.

Alice had been a diligent student and enjoyed statistics but “practice KPIs” were a mystery all of their own. She received daily, weekly, monthly and quarterly reports, which usually arrived in the early hours of the morning. Queenie expected her to have read and understood them by the time of the next team morning huddle, or “The naming and shaming session” as the other associates called it.

Whatever the KPIs said, Alice felt as if nothing could improve. She couldn’t grasp why patient’s late cancellation of hygienist appointments could be her fault or why she was then expected to make a contribution to the hygienist’s wages.

Twelve months later and the promised “loads of private patients” was rarely more than a trickle of challenging full denture cases. Alice was the last to arrive and got the highest needs NHS patients, she had trouble making her UDA targets and was now facing subsidising any practice clawback. “Your problem”, said Queenie during one of her little “pep-talks,” is that you care too much. You spend too long with the patients; the chatting and consent should be done by “TCO Jackie”, the treatment coordinator. “You must learn how to become a more effective operator, you’ll never be a success unless you cut corners. How do you think Dr King, (the founder of GleamDent) made his money?”

Alice remembered a line from her FD Information Handbook, warning about social media blurring the boundary between public and professional life. She hadn’t realised that there could be a similar blurring between ethical and less ethical behaviour.

It all seemed dreadfully confusing.

NHS hospital doctors are understandably concerned about refusing treatment if overseas patients can't pay. But is it that hard to deny patients treatment?

I'll Do Anything For Teeth But I Won't Do That)
By @DentistGoneBadd

If your patients feel more confident using a bit of glue on your superb denture, do you despair? Well you shouldn't. It's all cool according to a new white paper.
Meeting A Sticky End
Why Dental Fixatives Are No Longer Taboo
By @DentistGoneBadd

If you check out the word fortitude you get a sense of the characteristics necessary to campaign on Public Health. Resilience, endurance, perseverance, patience, tenacity, resolve, determination, grit and pluck. I wish we’d looked this up in 2012 when we started all of this – we may have decided to duck the challenge. We didn’t, and now we know why fortitude is essential, necessary, imperative, obligatory paramount, courage over a long period, plucky………

Back to 2012 then - let’s fire up the De Lorean although for the petrol heads it’s a metaphorical one as we know they stopped making them in 1983 which coincidentally was the same year that McColl v Strathclyde set a 201 day record for any legal case in Scotland over you guessed it Community Water Fluoridation. Manchester City win their first league title in 44 years, the Olympics come to London, Bruce Springsteen releases Land of Hope and Dreams and Hull LDC wake up.

Hull LDC met at the Ionians Rugby Club back then and that evening we meant business. Ionians were known for their love of democracy, philosophy the arts and pleasure. We were more in to treating our patients and staying healthy and solvent as NHS Practitioners but we did enjoy a beer. That night we were fed up as usual. Fed up with the tsunami of decay and the human consequences, the pain, the extractions the relentless tide of poor dental health. We were all very committed to prevention. We were all very committed to our patients and to the community of Hull. But we felt powerless and we knew we needed change. Hull has very poor oral health and is one of the most deprived areas in England. We understand the social health gradient now, but we were embedded in it in 2012 (as we still are) and we finally decided to do something. This isn’t surprising. People from Hull have a track record of standing up. In 1642 Hull refused the King entry to the City even though he turned up personally, endured a long siege militarily outnumbered by 2:1 and finally saw off the threat. That definitely takes pluck, grit, and fortitude.

Over a pint of bitter and a sandwich we voted to try and drive a Fluoridation agenda. We would start with a letter to the BDJ and publish an e – petition. So we did, convinced in our own minds that by the next AGM we would have cracked it.

We even developed a QR code link to the e- petition on the Petition Parliament site. Like a deluded punter down the bookies – we couldn’t lose could we?

The BDJ printed the letter and we waited for the e-petition to take off, soar,go viral. But it didn’t and in October six months after our rallying call for something to happen, it closed on 315 signatures.

So in October 2012 it seemed like Hull LDC were standing at the Fluoridation barricades alone or at least there were only 315 of us. Then the phone rang in Reception and my Nurse whispered in my ear – “there’s a Prof on the phone who wants to speak to you about your letter in the Journal.” I finished my fifth extraction on a child that morning and took the call.

To be continued...

Domiciliary dental care was in the news the other day — or rather a lack of it. Hopefully there may be some discussion now on adequate funding for treating the housebound. "Sorry. Don't Do House Visits"

I was initially quite scathing of the Tory Leadership selection process, but when I looked back critically at the way that I chose members of practice staff, I thought better of it. "You'll Do" How NOT To Choose Practice Staff By @DentistGoneBadd

Beware - Crisis in Progress.

The phrase “Existential Crisis” has been used a lot recently. In an individual it is defined as, “a moment at which one questions if their life has meaning, purpose or value”. Often it occurs at a point of depression or negative speculations on ones purpose in life.

Extrapolate that to a country and you have UK 2019 where political leaders in both government and opposition seem to have lost their perspective on many things, not least the word beginning “Brex”.

Dentistry like much of healthcare, is no exception. There are many dentists examining themselves and their motivations, trying to make sense of the direction they thought they were heading and the reality. Are these individuals really symptoms of a far bigger crisis or crossroads within the profession? And is it limited to the UK?

Examine the traditional career pathway. Dental student, FD, perhaps a little hospital work then an associateship or three, find a place that suits you and either buy into a partnership or buy a practice of your own. The financial pressures of ownership led to a focus on the reality of running a tight ship making the years of relative sufficiency and comfortable associateship feel like a dream. It all seems so simple.

With hindsight 2006 was a far greater watershed than we could have imagined. Fixed contracts have brought associates to the verge of employed status. Scarcity of contracts has led to massive inflation of their value. Most agree that the contract remains bad for everyone involved excepting those who hold the purse strings and make the rules. Yet there are no shortage of takers.

Looking at it from more than a decade and a half, the one outstanding thing was the independence of practitioners. Even those who chose to be “career” associates (including those who worked part time with family commitments) had stability with their own contracts and patients. The DoH write the rules, they wanted control and they have taken it.

Add to the mix the onus on universities to produce graduates to work in the NHS as opposed to being safe to provide care under any arrangement. The change in emphasis appears small, but is significant.

The fall out from Shipman has brought about a broad brush approach to the need for compliance, adding yet another contribution to the erosion of morale. The Care Quality Commission was never suited to Dentistry and remains a poor fit. Yet the tank trundles ever onward, distracting and crushing dental teams under its tracks.

There has been a growth of larger practices and the pervasive influence of corporates, some, not all, with a culture of command and control management which puts the investors’ interests above those of the patients and workforce. New graduates, taken in by piecrust promises and unable to find other posts are discovering that there is no line on a spreadsheet for empathy and care.

The commoditisation of orthodontics, led by the Align corporation, far from increasing individual skills is leading to an A.I. world. How many  steps away are we from photographs taken with an app on an iPhone transmitted to a central hub for diagnosis, treatment planning and subsequent appliance delivery direct to the consumer. Why bother with those pesky dentists with their expectations and sense of entitlement?

Diagnosis of disease will be done more accurately using computers, treatments that can’t be carried out by robots will be performed by Dental Therapists. The headlong rush to being “Dental Beauticians” opens the market to many. Just because something has always been safe and controlled doesn’t mean that it will remain so. Remember coal, steel and newspaper typesetters.

In their book “The Future of the Professions”, Richard and Daniel Susskind predict the decline of today's professions and introduces the people and systems that will replace them. In an internet-enhanced society, we will neither need nor want doctors, teachers, accountants, architects, the clergy, consultants, lawyers, and many others, to work as they did in the 20th century.

The authors challenge the 'grand bargain' - the arrangement that grants various monopolies to today's professionals. They argue that our current professions are antiquated, opaque and no longer affordable, and that the expertise of their best is enjoyed only by a few.

Perhaps we should all embrace Dentistry’s Existential Crisis and plan for our futures.

The poet Philip Larkin wrote words to the effect of "They mess you up, your mum and dad." They may very well do, but I think dental school has exactly the same effect on dentists.
Happy Days
Dental School. The Worst Days Of My Life
By @DentistGoneBadd

Sometimes, keeping quiet is the best way to remain diplomatic in dentistry. There are various ways of stopping yourself from putting your foot in your mouth. Here is my favourite.
Stock Up With Lip Balm
When Biting Your Lip Is The Best Policy
By @DentistGoneBadd

Email marketing works!

In the last blog post we talked about ensuring that your website had some form of longevity. One of the biggest problems of a website is you spend so much time and effort attracting visitors to the site yet when they visit the simply bounce and leave again, off to go back to doing whatever it was they were doing before.

To get the most out of digital marketing we really need to work to ensure that your website has ongoing marketability, even if people don't visit the website any longer!

Sounds strange… So how do we do that?

Let me introduce you to gentle e-mail marketing. If we can collect someone's e-mail address whilst they are on your website, whilst they are a hot prospect and interested in your services then we can continue to communicate with them after they leave your website.

I can almost hear you groan, “e-mail marketing is spam”, I can hear you saying.

Wait one moment – here’s an example…

If you do the National Lottery online you will know that if you win something then they send you an e-mail.

Every Saturday I'm avidly checking my phone waiting for that e-mail notification that I'm a lottery winner… I've occasionally received an e-mail which tells me I need to log into my account and check, my heart is racing as I visit their website to find out I've won an almighty £25!

This example shows the e-mails per se are not spam, it is the CONTENT of that e-mail that makes it spam, some e-mails (like ones from the National Lottery) we are eager to receive and waiting to turn up. How great would it be if you had a prospective patient anticipating the next e-mail from you?

Let me show you how.

The trick is to turn marketing backward, rather than ask “what can I get out of this prospect?”, ask the question “what can I give this person for free that will build trust and reduce risk?”

The answer is generic dental health advice and information.

If you create a free guide, place it on your website on relevant pages and allow people to download the guide for FREE but in exchange for an e-mail address you can help to demonstrate you care about the readers of your site at the same time as collecting their e-mail address. You can then follow them up with a gentle series of e-mails which continues to build a relationship and answer their dental questions.

Here's an example.

On your dental implants page create a free guide entitled “Everything you need to know about replacing missing teeth.” In your guide you can talk about

• dental implants
• dental bridges
• dentures
• not doing anything at all and the consequences of not doing anything at all on the adjacent and opposing teeth, retention of surrounding bone and possible consequences of restoring at a later date with a compromised bone quantity and/or tooth position.

We can then follow-up that free guide with a gentle series of e-mails which looks at:

1. How comfortable is it to replace missing teeth? (Notice we don't talk about pain or discomfort rather, how comfortable we can make it)
2. How much does it cost to replace missing teeth? Here's your opportunity to talk about the various different options.
3. Where else to go to find out more about replacing missing teeth? Direct them to various dental implant company websites and other useful resources.
4. How many dental implants might they need? this is a great opportunity to talk about different options and how you can help.
5. What's the process for replacing missing teeth? This is where you can talk about planning stages, diagnostics and allow the patient to understand more about the process.

I could go on, but you get the picture…

As you can see, each e-mail is simply answering various patients concerns, each e-mail may not be entirely relevant to that person depending upon what their particular question is, but because we've written a series of e-mails we can be assured that at least one e-mail is going to be absolutely applicable to that person.

Now, we don't send all of these e-mails out in one go. We want to make sure they look natural and don't clog up someone's inbox.

The best sequence to send these e-mails out is based upon the Fibonacci series of numbers and the golden proportion, exactly the same formula you would use to calculate the width of centrals, laterals, and canines when doing cosmetic dentistry. This sequence of numbers is a beautiful sequence which appears often in nature and looks extremely natural.

So send your e-mails out with the following number of days between each e-mail 0, 1, 1, 2, 3, 5, 8, 13, 21, 34, 55 etc continuously add the previous 2 numbers to give you the 3rd number and then continue to repeat this process will give you the full Fibonacci series of numbers.

As you can see the e-mails get further and further apart as the prospect gets further down the e-mail series. I get a HIGH open rate of 70-100% using this system, so I know it works.

In each of the e-mails resist the urge to sell, sell, sell, rather handout your useful free and relevant advice to build trust and lower risk and at the same time give the patient a simple way to move into the next stage of the process, typically this may be a discounted dental health check or free consultation.

Make sure your e-mails have a button which is clickable that drives the person to this consultation. Again, this should not simply be phoning you, this should be a free consultation which is claimed by downloading a voucher from the website, this voucher then means that this marketing is then trackable when people come in to the practice but also if you have a voucher downloaded from the website means that we are again collecting people's e-mail addresses rather than simply suggesting they phone us which they probably won't remember to do the next day!

If you are then really clever you can use e-mail automation to drop people into additional campaigns, for example, let's say they click the free consultation button in one of the follow-up e-mails but do not take action, we can have an intelligent e-mail system recognises this and then drops them into an additional campaign letting them know the advantages of a free consultation, how gentle you will be, how much you will listen to their concerns and how easy it is to book.

All of these e-mails should be run from an e-mail management system, I recommend Aweber which starts at $19 per month (a highly affordable option) if you repeat this process with straightening crooked teeth, dental health, cosmetic dentistry and facial rejuvenation you will have built a robust marketing strategy which works off of your website 24-hours a day, 7 days a week never sleeping.

What you will find is that your return on investment from the website goes up enormously, no longer are people visiting your site and bouncing off again, they are now interacting with your site, we are collecting their e-mail address and we are using your website as simply the starting point in building a relationship with your prospective new patient.

Everything gentle.

Everything with the patient at the centre and not you.

If you treat e-mail like this, as a way to help people you will find e-mail can be one of THE best ways to maximise the benefits of digital marketing.

GDPR: One year on.

25^th May 2018 is a date etched in the memories of all dentists and practice managers; the date when the General Data Protection Regulations, and the Data Protection Act 2018, came into force. A little like the millennium bug, the furore surrounding this data protection revolution was immense. Was this just another layer of regulation for an already over regulated profession, or a fundamental change in the way that we treat personal data?

12 months on we look at the effect of the regulations and whether dental practices have got to grips with the changes and how the Information Commissioner’s office has been dealing with data breaches. 

The General Data Protection Act, a brief history.

The GDPR and the Data Protection Act 2018 came into force on the 25^th May 2018. The regulations were intended to provide Europe wide rules to protect individuals with regard to the processing of their personal data, and to regulate the movement of European citizen’s personal data across the world.  The regulations included:

• · Enhanced rights of individuals
• · Increased transparency
• · More accountability when record keeping
• · Changes to the legal basis upon which data can be processed
• · Introduced the new role of the Data Protection Officer
• · Significantly increased the sanctions in the event of a breach.

In practical terms the changes saw dental practices having to thoroughly overhaul the way in which they managed their patients’ data, adopting a much cohesive and considered approach to handling the personal data of their patients.

But has GDPR made a practical difference?

What do the statistics tell us?

The ICO data shows that between January 2014 and December 2016 Healthcare Organisations accounted for 43% of all reported data breaches to the ICO. In 2017 there were 2877 reported breaches, 1062 were from healthcare, 37%. The main types of breaches related to loss or theft of paperwork and data being sent to the wrong person by email or letter.

For the first “Post-GDPR” quarter, April to July 2018, healthcare data breaches accounted for 677 of 3146 reported breaches; just 21.5%. In the second quarter, August 2018 to November 2018 healthcare breaches accounted for 619 of 4056 reported breaches; just 15%.  However, whilst the percentages may be going down, the overall number of breaches complained of has gone up significantly for all areas, including healthcare.

Does this mean that all the changes implemented by dental practices have been a failure?  No, one reason for the significant increase in reported breaches is the general public’s greater understanding of their data protection rights. The message that your data is owned by you as an individual, and therefore should be controlled by you, is finally getting through. People are much more alive to the dangers of sharing their data freely, and know their rights. The ICO is now in the public lexicon and people know how to complain.

What the statistics do show is that there is still a great deal of room for improvement in our data processing systems and the training that we provide to team members.

What have the ICO been doing over the last year?

The short answer is, working very hard. The regulators have had to deal with the biggest changes to data protection laws in a generation, and are now coping with a significantly higher number of complaints. But along the way they have managed to catch a few of the major offenders.

In October 2018 the ICO issued the maximum fine possible (under the old regime) to Facebook for failing to protect its users’ personal information. The investigation found that between 2007 and 2014 Facebook processed the personal information of its users unfairly, by allowing application developers access to their information without sufficiently clear and informed consent, and allowing access even if users had not downloaded the app, but were simply ‘friends’ with people who had. Facebook failed to check the way in which app developers were using its platform. One developer harvested the data of over 87 million people worldwide.

In November 2018 the ICO fined Uber £385,000, again under the old regime, for data breaches that occurred between October and November 2016. A series of data security flaws allowed the personal data of around 2.7 million UK Uber customers to be accessed and downloaded by hackers. The records of almost 82,000 drivers were also stolen. Uber made matters much worse by failing to tell their customers or their drivers about the breach for over a year.

Whilst these fines may have had little impact on either of these multi-national companies, under the new regime the ICO can impose fines of €20 million or 4% of the company’s global turnover, whichever is higher. To put this into perspective, Facebook’s annual revenue for 2018 is reported as being $55.8 billion.

And whilst the ICO has not yet concluded any large scale investigations under the new regime, in January 2019 the French equivalent, the CNIL, fined Google €50 million for its lack of transparency and information regarding the processes it uses when processing data and the failure to provide data retention information. Furthermore, Google had not obtained valid consent, as users were not sufficiently informed, nor was the consent obtained specific or unambiguous. Google had continued to use pre-ticked boxes in certain circumstances, which drew particular criticism.

The Future

In reality, the 25^th May 2018 was the start not the end of GDPR preparation. Practices must ensure that they are fully compliant and can evidence compliance in the event of a breach. Records of processing activity, privacy policies and notices must be reviewed and updated where appropriate. Staff must continue to be alive to the risk of breaches. Systems must be put in place to ensure that the risk of data breaches is reduced.

GDPR Training

On 24^th July 2019 JFH Law will be holding a one day seminar on GDPR for dentists. This course will look at GDPR a year on, setting out any updates since implementation and providing practical tips to ensure your practice is compliant with data protection laws. To register your interest please email This email address is being protected from spambots. You need JavaScript enabled to view it..

Julia Furley, Barrister

Image credit - Linda Hudson under CC licence - not modified.

Dealing with dental complaints

Although dentists may feel under attack a lot of the time, the risk of litigation is actually (relatively) low. Complaints can often be dealt with through excellent communication skills and a willingness to listen and respond sensitively to the concerns raised by the patient. Unfortunately, it is not always possible to resolve disputes or complaints by patients internally. This can be the result of a number of factors, from the dental practice’s internal complaints procedure, lack of staff training to patient demographic. If all reasonable attempts to resolve the complaint internally have been exhausted, then dentists should be signposting other, objective complaints handling services. This not only assists the parties in moving forward from sometimes intransigent positions, it avoids patients turning immediately to lawyer for advice on resolution.

Complaints about NHS treatment

Every NHS practice must have a copy of the NHS complaints policy and must provide it to a patient if a complaint has been made regarding NHS treatment provided. Patients should also be advised that help is available to them via the NHS Complaints Advocacy Service. Bear in mind, patients are not obliged to complain directly to a practice first, the patient can go straight to the NHS; although following the internal complaints procedure should be strongly encouraged, and patients should always be provided with access to a clear and comprehensive internal complaints procedure. A complaint to the NHS will be made directly to NHS England and must include the patient’s contact details, a clear description of what is being complained about, the name of the service being complained about and all relevant correspondence. The patient will be asked to give their consent to the practice being contacted regarding the complaint.

Complaints must be made within 12 months of the date on which the subject matter of the complaint occurred, or 12 months after the date that the subject matter of the complaint came to the notice of the complainant. Complaints are acknowledged within 3 days of receipt. However, the NHS has a 40 working day target to investigate (this can be extended where appropriate). Investigation A case officer will be appointed and will obtain the relevant information about the case and make sure that it is accurately recorded. The process of the investigation itself is reasonably flexible, and the case officer will take necessary steps to properly investigate the complaint. They will prepare an investigatory report and thereafter send a formal response to the patient. During the investigation the practice may wish to consider both mediation and obtaining a second opinion if appropriate. The response will contain: An explanation as to how the complaint has been considered. Conclusions and an apology if appropriate. An explanation as to why the decision has been reached. Whether the complaint is upheld (in part or in full). What remedial actions are being recommended. Confirmation from the dental practice that action has or will be taken. A response regarding “lessons learnt” if appropriate. Contact details of the ombudsman. If the patient remains dissatisfied with the way in which the complaint has been dealt with, then they can ask the Parliamentary and Health Service Ombudsman to review the case. The dentist should cooperate fully throughout this procedure; however unmeritorious a complaint may be. The case officer can decide to report matters to the GDC if they feel it necessary to do so. Keeping an open and positive approach to the investigation will limit the risk of further complaints being made.

Dental Complaints Service

The dental complaints service (DCS) is intended to provide a similar complaints service as that provided by NHS England. The GDC funds the service, its staff members are employed by them and it is accountable to the GDC Council. However, investigations are run independently of the GDC. That being said if the DCS do become aware of any issues regarding a practitioners behaviour or competency, then they will (like the NHS) refer the matter to the GDC fitness to practice team.

Again, complaints must be made within 12 months of treatment taking place or 12 months of the patient becoming aware of the issue. Initially patients are referred back to the practice to attempt to resolve matters internally. If this is not possible, then a complaints officer will be appointed and work with both sides to try and reach a resolution. If a resolution is not possible, then the matter is referred to the DCS panel; the final stage of the complaints process. The panel consists of two lay members and a dental professional. Both the patient and the dentist will be invited to attend a meeting. The parties will have an opportunity to put their side of the complaint, and to work towards reaching an amicable resolution. If no agreement is reached, then the panel will make a recommendation.

Feedback from users of the DCS is generally good. The last annual review of the service was in 2014, but this showed of the 1068 cases considered, 95% of patients who provided feedback were satisfied with the recommendations offered, compared with 64% of dentists. Whilst this may reflect a tendency by the organisation to prefer the accounts of patients, it may also reflect a willingness of dental professionals to refund dental fees as a business decision, as opposed to admission of liability, once the DCS gets involved.

This type of resolution, whilst frustrating, can be a much quicker and cheaper option than defending a clinical negligence claim.

If you have are concerned about an ongoing patient complaint contact our lawyers on This email address is being protected from spambots. You need JavaScript enabled to view it.

Julia Furley, Barrister

"Justice"by mag3737 is licensed under CC BY-NC-SA 2.0

Patients do some strange things, but so do dental product manufacturers sometimes. They're as bad as each other in my book. You're putting WHAT In Your Mouth? (Some DIY Dental Tips) By @DentistGoneBadd

At long last, the mental well-being of dentists and dental professionals is being discussed openly. Hopefully the discussion will lead to practice help and support.

Dental Corporates and their responsibilities

I might start off by actually saying the title of this blog is probably one of the most Oxymoronic I’ve ever thought of, but then that would probably give away the content and the thread of what follows.

However, I don’t really care if it does give away what follows; because I’m sure that many of my readers will understand just where I am coming from and why there needs to be something done about the environment we currently have in UK dentistry.

No-one can deny that corporate dentistry generally is becoming bigger and bigger as the years pass. I can remember the original clamour back in the mid 1990’s to buy the original corporate ‘shell companies’ that were legally able to provide dentistry under the 1921 re-organisation of the profession. I’m not sure anyone who was in practice in those times could have then foreseen the huge growth of the corporate, but the real change came when all practices were allowed to incorporate (as an aside, does any one else think it’s funny how the Dentists Act 1984 allowed this but still can’t work out how to take a monthly direct debit from us instead of an annual payment, but I digress…..). What is true however is that there is a significant amount of dentistry now provided under the auspices of corporate dental companies, of which some of them are quite large players. I will say here; this blog is not about any specific company; I am sure there will be some out there who have good stories to tell. However, there is no doubt that in some corporates in some places and some practices there is a culture that is not good, not healthy, and downright nasty.

Those of you on Facebook may well also be members of the ‘Mental Dental’ page. This is a hugely important page that has become an important outlet for its members to vent their concerns about a multitude of issues affecting them. By simple extrapolation, many of the issues floated here are likely to not just be unique to the original (often anonymous for good reasons) poster, but relevant to other professionals finding themselves in similar positions.

A good many of the posts on this page (and indeed on most dental specific social media groups) seem to revolve around issues that associates are having with their corporates. Whilst I am the first one to consider that there are always two sides to every story, there is also a common theme to nearly all the threads posted. Note that I didn’t actually say “Corporate Employers’ at this stage; but more of this later.

It is apparent that even if you take into account that not all the stories are likely to be entirely balanced, there are a significant amount of associates who are having problems with the working environment of the corporates. From faulty equipment not getting repaired, running out of materials, a lack of clinical freedom in referring, to outright bullying, the same themes come up over and over again. This can’t just be put down to only having one side of the story surely? The fact that these threads appear so often, from so many different contributors shows that there has to be something more behind the threads.

Some of the more concerning posts often involve bullying of associates. From target driven issues, to ‘you make waves and we’ll report you to the GDC’, this seems to often be driven by management teams within the corporate environment. There is NO place for bullying in any environment, and the fact that some people feel that it is acceptable to disguise this as performance management doesn’t make it in any way acceptable.

But how has this environment come about? I’m pretty sure the dental registrants at board level haven’t issued dictats to their managers condoning the bullying of their teams? However, the need to make money for the shareholders means that these directors have to ensure the business is profitable (although there’s another oxymoron – the profitable corporate..) and the ideas discussed at board level eventually filter down to the teams regionally and locally,

This is where the problem lies in my opinion. When the board comes up with an idea, it is down to those below it to implement this, and the board is not necessarily aware of the fine details in how this is done; just how that it needs to be done. It is down to the teams on the ground to implement that desires of the board. How they therefore go about this is part of the problem. With management teams that are often not fellow dentists (or even registrants on occasion), there can be a lack of understanding of how the profession truly works. Yes, these people can be given training in the dental industry, but they may not have the same ethical and moral compass, or even the need to be registered by the GDC, and therefore do NOT know what it means to be a real professional.

When you hear stories of associates raising concerns to management about slack appointment books causing them to not meet their UDA target, to then be shown edited data showing the books are now full, and threatening them with a counter concern about clinical treatment (that the managers know full well can result in a GDC case and a livelihood threatening result), then you have to consider that the whole structure of corporate dentistry needs re-addressing rapidly. This threat has been real, this is not hypothetical, nor fictional.

Now I’m fairly sure most of the REGISTRANT directors of the corporates are very ethical and still have the moral compass that is needed; but they don’t seem to be getting the message down to their teams very well. Whether this is because they are not being heard above the voices of the non-professionals who have no regulator to fear, or whether the management structure is so poor that the message is not getting through I don’t really care. What is certain however is that a good many of these registrant directors seem to be unable, unwilling, or unprepared to step in to deal with the problems that we hear about, otherwise we would stop hearing of them almost on a weekly basis.

Have these directors forgotten they can be held vicariously responsible for negligent acts and omissions? They seem to rely on the self employed status of associates in order to deny all knowledge of the problem. However, it is becoming more and more apparent that the associates who work in these organisations are less and less likely to be seen as truly self employed as a result of various court cases (Pimlico plumbers, UBER, to name but 2), and it is about time that they took their corporate responsibility a lot more seriously than they appear to. I’m sure a few minds would be somewhat more focused on their ultimate responsibilities if a few of them were found to be vicariously liable for a few clinical issues, or taken to an industrial tribunal by a disgruntled associate (which if you believe the stories on social media might not be a small number).

They cannot hide behind the excuses that they don’t know what is going on. There is enough spoken about in the profession about corporate issues that this is about as believable as saying they aren’t aware Elvis is dead. Whenever there is a problem posted on the various groups, I always recommend that the highest level clinical director be notified, rather than the middle management (which is often the source of the problem) in order to ensure the problem lands at the door of a registrant rather than a (sometimes over-promoted) manager. Recruitment seems to rely on the fact that younger registrants often have ludicrous debts to pay, and therefore will end up working for these organisations as they appear to have little other choice.

Registrant directors need to step up and take the responsibility for the mismanagement and bullying that appears to be a problem in their organisations, and deal with it decisively. If this costs money and time then so be it; but if it does it may well show some of corporates for the shallow and non-profitable businesses that they really are. Alternatively, if they don’t act, it’ll show the profession that these people might not have the integrity, ethics, and morals that are required to be members of our profession.

But if the latter is the case, then the GDC should be told. They should ensure that the need to act in the best interests of the patient is drummed into all those registrants who sit on the boards of the corporates. There should be no hiding behind the corporate structure of these businesses and claiming ignorance of the problem. When the majority of the entire profession seems to be aware of the magnitude of problems with some corporates, then the directors cannot feign ignorance.

The elephant (so big its actually more likely a Mammoth) in the room however is that if these directors were to be removed by the GDC, the remaining non-registrant directors would no longer be able to continue the practice of dentistry and the corporate would no longer be able to function under GDC rules. What this would do for the provision of NHS dentistry would be potentially shattering, with the loss of these businesses. Additionally, is there anyone reading this in any doubt that some corporates would seek to protect their viability by cutting loose the registrant directors and replacing them at the first sign of the GDC taking an interest in them? That would really show the profession just where the priorities of some of these companies lie.

Perhaps this is why there is no appetite to deal with the problem decisively, and instead this will continue to be a problem for years to come, with neither the Registrant Directors OR the GDC taking any form of corporate responsibility for the problems that seem to be within this area of the industry.

Image credit - Maria Eklind under CC licence - modified.

If you have a dental practice website then you want it to work, otherwise it's a completely wasted resource!

For a website to work, in my opinion you need to have 2 primary functions in place.

1. Traffic optimisation.
2. Conversion optimisation.

Without either of the above the website becomes ineffective.

If you had wonderful traffic optimisation and 100,000 visitors to the website per month yet only had a 0.001% conversion rate then you would only have 1 new patient per month. This scenario is highly unlikely to give you a good return on investment on your website.

Equally, if you had wonderful conversion optimisation with a 100% conversion rate yet only had 1 visitor per month then you would still only have 1 new patient per month. This scenario is equally highly unlikely to give you a good return on investment from your website.

You ALWAYS need traffic and conversion optimisation working hand in hand. If you work with a search engine optimisation company and all they do is get more traffic to your website then, in my opinion, this is completely worthless unless conversion optimisation is also worked on.

In my experience I have found that a dental website needs to be performing in the following areas:

Each of these five key areas provides an excellent way to audit your own website, so open your website now and compare your site with these performance areas.

Findability.

This is pure search engine optimisation and includes (but is not limited to) the following areas:

Website title, description & headers - these should accurately reflect the content of each page. Every single page on your website should have a different title, description and headers.

Image alternate tags - these describe images for people with visual impairment, Google is able to read the description and may give a slight boost your website if the descriptions are relevant.

Text - Google is (currently ) unable to read text on images. For the moment at least we need to ensure that we have excellent and expansive content on your website which uses a range of keywords and phrases that people type into Google. If Google isn't able to understand what your website is about and/or it is not relevant to what people are actually looking for then Google will not send traffic to your site.