The Honeymoon is Over

Political leaders are often said to have a honeymoon period at the very beginning of their new post. At a time where their political capital as at its highest, there tends to be a degree of ‘benefit of the doubt’ given and political opponents treat them well. I get the impression that due to the lack of political opponents to currently wrestle with means that Theresa May has had less of a honeymoon, and more like a ‘swift registry office wedding and straight back to work on Monday’ type of period. There has been no particular need to allow her into the post gently, and indeed she hit the ground running it appears.

It wasn’t quite the same with the new Chief Dental Officer. An initial period of cautious approval and hope that the new incumbent might be a less dogmatic and more approachable one than previously was supported initially by in increase in visibility, and the right kinds of sound bites the made many think this could be someone who is more in tune with dentists than was previously the case.

Well, it certainly looks like the honeymoon is over for our new Chief Dental Officer after the comments this week about routine examinations is anything to go by. Once again it appears the CDO has trotted out the underlying political message desired by the paymasters at DoH. What appeared to start out as a marriage that could work with the profession now appears to be heading for a divorce already.

The comments that were published in the Telegraph and the Daily Mail appear to rehash of those made in 2004 by Raman Bedi, and again in 2011 by Barry Cockcroft, both gleefully published by the Daily Mail, and no doubt trying to reinforce the opinion that the majority of the profession are money grabbing charlatans. The same old mantra is being rolled out by yet another incumbent of the CDO post, which despite its downgrade by government now to a junior supporting role, is nonetheless listened to by the press and therefore the public in order to give more ammunition to the incessant deprofessionalisation of dentistry as a whole. (Or so it seems to me).

In addition, the comments by former NHS Trust Chairman Roy Lilley in the same article that dentistry has become ‘a rich mans hobby’ provided in ‘lavish environments’ would be quite frankly laughable if it weren’t for the fact that they are so offensive. I’m sure he didn’t sit in an office furnished from a secondhand furniture store in a cold draughty office block, so why the hell should we? I could wax lyrical for a long time about my opinions of such people in NHS high office, but I’m sure much of it would give the legal profession many hours of extra work. Suffice to say the ignorance of comments such as this are what I would expect from a member of the ‘profession’ that continually commissioned excessive amounts of UDA’s year on year from D’Mello, and oversaw the disasters at Stafford amongst other things. Perhaps Mr. Lilley would be happier receiving his routine dentistry in the kind of environment that charities such as Bridge2Aid find they have to work in? Perhaps then he might be grateful for the small luxuries his salary allows him to experience. I would suggest he puts some of his money where his mouth is and donates to such deserving causes so they could ever hope to achieve a level of care that even the worse off in our society take for granted.

But I am more concerned the comments made by Col. Hurley seem to go deeper and are potentially more damaging to the profession than any crass comments made by an NHS apparatchik. Comparing the profession to garage mechanics is crude and whilst part of me can always find parallels with any other industry, it is highly disingenuous to make that comparison without thinking more closely. The analogy can be torn apart so easily on many levels.

With the GDC and CQC breathing down the necks of professionals all the time, I’m sure many of them would wish to have a working environment more akin to the relaxed nature (comparatively) of working in a garage. I can’t quite remember the last time the General Garage Council struck a mechanic off for using the wrong oil, or not explaining the different kinds of windscreen washer fluid before servicing a car. In addition, Col Hurley seems to forget that likening the situation to an MOT is also a bit silly, since it is a legal requirement that you have to submit your car for that test every year. Her comparison fails hugely at this point. Perhaps the situation with dental problems (especially that of the huge number of children admitted for GA’s) wouldn’t be as bad if people were compelled by legislation to see a dentist yearly as part of their responsibility to the others contributing to the cost of state run care? But then of course the state wouldn’t be able to afford it and would have to admit as such.

On the other hand, whilst continuing the garage comparison, preventative maintenance is the responsibility of the driver, and there is indeed a whole host of legislation in place to ensure this happens.  So if my garage (ethical and professionally run) recommend I get something rechecked in a period because the vehicle might be dangerous, then I would be foolish to ignore that advice both from a safety and legal point of view. I’m also not likely to blame the mechanic if my car breaks down because I haven’t looked after it.

That there are dodgy garages will be no surprise, but then we all know there are dodgy dental practitioners who, amongst other things, blatantly game the system because the lack of clarity in the current contract makes it possible for them to do so. I suggest however that there are a higher proportion of mechanics that are not ethically guided than dentists due to their lack of professional regulation, and to make an analogy between them therefore is somewhat clumsy and misguided.

Comments like these have more than likely damaged the working relationship between the CDO and the profession in my opinion, and shown that her

Honeymoon period is well and truly over

The open letter to the profession published in January in Dentistry from Col. Hurley suggested that budgeting the NHS funds appropriately was at the forefront of all the planned changes that she would suggest. No one would argue that this is appropriate and should be the way forward. In an era of austerity we have to look at how the finite funding is spent, and I personally agree that much of the NHS budget could be better spent than recycling the same healthy patients.

However, these are often those patients who take an interest in their dental care. When we have 50% of the population not attending a dentist at all, then the budget is going to be spent on those that do. Couple this to the failed UDA system that makes it a financial risk to take on too many high needs patients (who are often those who don’t value the service and miss appointments), then is it any wonder that the small businesses of dental practices need the repeat business of regulars to survive? The screaming lack of clarity that is present in the current contract, and in my opinion will remain in any new contract (purely because of the benefit to the Government and no-one else) is not likely to be addressed anytime soon. There is no appetite for the Government to officially admit dentistry is rationed, yet we all know it is, and instead a press release such as this could have helped both the patients and the profession by being honest about the amount of money the NHS has to spend on routine examinations.

For the first time, it appears an NHS manager (Chris Hopson writing in the Observer) has this weekend finally admitted that that aspirational wishes of the NHS are not met by the funding needed to provide them and rationing is likely in the future. Perhaps the ‘worried well’ that Col. Hurley is referring to as being seen so regularly should actually make way for those who cannot access treatment. Perhaps by publically endorsing a core service that is equitable for all would go a long way to meeting her desire to target the resources of the NHS more appropriately rather than once again making it the dentists fault as usual for the perpetual lack of funding to provide ‘world class’ healthcare for everyone.

So, instead of therefore criticising the dentists for seeing patients more often ‘than needed’, why didn’t she take the opportunity to actually say that the NHS can’t actually afford to fund this type of regular recall, and that it only has the funds to see patients once every two years? A comment such as this is more likely to get the support of the profession since we all know how poorly funded the system is, and yet it doesn’t alienate the profession so much. Suggesting then that the patients are still free to see their dentist 6 monthly, but under a private arrangement, would both inform the public of the truth about the parlous state of NHS funding, and gain the support from the vast majority of dental professionals by talking it out of their hands. Instead of encouraging the patients to question the integrity of the professional caring for them this would be more appropriate surely? It is a chance for her to stand together with the profession she is part of whilst still fulfilling the government need to obtain value for money with its funding.

What is amusing is the same papers ran a story only the week before stating that soldiers face a week in jail for missing dental appointments in a bid to reduce the amount of personnel unavailable for military deployment due to dental disease. Is this a not double standard? Coming from the military back ground she does, I’m sure Col. Hurley was aware of this issue before she became CDO. So when the public read these conflicting stories, how are they to make a decision? Is it that dental problems can be so bad that the army punishes offenders who don’t take responsibility for their dental care with jail; or that you don’t actually need to go to the dentist for 2 years? Which is the message about dental health that is correct?

We all have cases to robustly shoot down the 2-year interval theory. For instance, I have a low risk patient who I have been seeing for many years now. Probably one restoration every 6 or 7 years, good oral hygiene etc., and is in the early 40’s. At a routine 6 monthly I spotted a lesion under the tongue. This turned out to be a squamous cell carcinoma. It wasn’t there 6 months previously. They would be one of the patients that fit in the criteria of a biennial examination. I’m sure that would be of great help to a spouse and children if the patient had listened to the advice. Fortunately for the patient we expedited the referral appropriately. However, at the next 6 monthly, there was still some nodal involvement that we picked up. This fell between the review appointments at oncology, was pointed out to them, and now a neck dissection has been performed. Once again, the DENTAL problems were minimal.

What about the increase in the HPV+ types of Oral Cancer that are now being seen in younger lower (traditional) risk patients? Or subtle diet changes that misguided approaches to a healthier lifestyle involve that create more dental problems and more long term cost to the state? I can go on, and I’m sure there are many other examples that people can give.

I can think of NONE of my patients that I would be confident leaving for 2 years without some form of assessment. When you ‘get out of the mouth’ and look at patients as a whole it is astounding how many things can impact their oral health in so many ways, and 24 months is a long time indeed…Whilst I admit there are those patients who never seen to need anything doing, how do we know they won’t suddenly suffer a need for medication or have health issues that change their dental risk? Since the Government seem to fail to take responsibility for educating the population about the risks of the links between health and dental issues then many patients will not automatically seek our advice. When they then return with a mouthful of problems because of some misguided attempt to save the state money because we’ve had to accept the demand for a longer interval between assessments, then I know that we are going to get the blame, and the GDC and ambulance chasers are going to be rubbing their hands together in glee, whilst the DoH wash their hands of the responsibility.

I unfortunately have to keep hammering out to many of my local GMP colleagues that we are not blacksmiths any more, but highly trained medical and surgical colleagues who take a full view of the patient in a holistic manner, but concentrating on the head and neck. It would appear that solely concentrating on just the teeth and gums is what even our CDO feels we are doing given the tone of the comments in the press. I wonder when the last time she actually fully assessed and treated a patient from start to finish, and whether of not the pressure of a real (and not with an institutionalized cohort of patients) dental practice has been experienced.

The BDA press release the same day was suitably pithy; but in reality the message wont be important to the public given they usually jump on any chance to further hate our profession.

But if the headlines actually said something like ‘Dental Trade Union refuse to negotiate with Government’s ‘Top’ Dentist’ then this might allow us to start to get our message across. The DoH is perfectly happy to sensationalise headlines to further their own ends, so it’s about time we did.