21 Nov 2018  •  Blog, NHS  •  11min read By  • Nigel Jones

Dentistry debated – is the NHS’ delicate balance about to be tipped?

Nigel Jones discusses some of dentistry’s big issues with a panel of big hitters from the profession…

How do you balance professionalism with delivering the requirements of an NHS contract? In all the conversations I’ve had with dentists during this year, this is a question that has come up time and again in one form or other. One conversation that particularly stuck with me was with a young dentist who said she went to bed at night ‘negotiating with herself’ about the compromises in care she’d had to make that day. I suspect that there are many others having that same internal debate with themselves.

It was of little surprise, then, that this was a recurring theme during a discussion panel I hosted recently about what the results of the latest NHS Confidence Monitor survey reveal about the state of dentistry with some well-known faces from the profession. Whilst I’m afraid that we didn’t come up with the answer, there was a robust debate around this issue including how those in the NHS are often relying on income from elsewhere to make their contract work, and the sustainability of such an approach.

Joe Hendron, an NHS dentist who pulled out of the prototype programme in March, described his experience of this situation, ‘I think that most prototype practices that are successfully hitting their targets have got some type of alternative income to make it work. That was the case for me – my wife has an orthodontic practice in the same building that I am a director of, so I didn’t need to draw from our NHS practice in order to oil the cogs and meet the prototype targets. But that is not a long-term solution, which is one of the reasons why I pulled out.’

Private dentist Simon Thackeray highlighted the strain this approach can cause, ‘We should be asking, hypothetically, why are people putting their business at such risks for a system that is effectively a circle that can’t be squared? If practices are struggling in the way they are, then why would you put your investment, your family’s livelihood and your mental health at risk?’

Eddie Crouch, Vice Chair of the BDA’s Principal Executive Committee, said the situation was the same for every NHS practice, not just prototypes. He added, ‘Every single NHS practice now, and probably for the last ten years, due to factors like stagnation from the Doctors and Dentists Remuneration Body and the rise in patient charges, is subsidised by their private work. There’s been no money to invest in new equipment or enhance their practice except from private income.’

Joe Hendron, who has one of the larger NHS contracts in the country, said that a crisis would be the only way to secure such financial investment, and that one was potentially looming.

‘We had a meeting recently in Yorkshire where NHS England said that last year there was £10 million clawed back and that they’d been working to reinvest some of that into South Bradford and Keighley,’ he said. ‘But two-thirds of that £10 million had disappeared into the wider NHS. This year’s indications are that in that region there will be £20 million clawback – so that means £14 million lost from local NHS dental services.

‘The last crisis, to my knowledge, was when people were queuing around the corner for an NHS dentist in Scarborough in 2004. A contractor in Scarborough recently handed back their contract, and perhaps this will be the tipping point.’

The feeling that a crisis is the only way forwards to improve the situation within the NHS is another topic that has cropped up in many conversations and forums over recent months. Indeed, this is the standpoint of the BDA, whose chair Henrik Overgaard-Nielsen recently described the NHS as ‘running on fumes’ following statistics from NHS Digital which showed further falls in taxable income for dentists.

The dentists around the table discussed how many associates have accepted a 35% cut in real terms income, and that as long as they can continue to make it work – they will; the feeling was that the profession has become very adept at working within the parameters of the system. However, whilst many are often willing to make sacrifices to their income and personal life – as Joe highlighted – there is the sense that dentists are feeling ever more squeezed by those parameters, leaving some, like the young dentist I mentioned earlier, feeling that they need to compromise on quality of care to meet their NHS contract obligations.

Simon suggested that one of the issues around this is a lack of definition of professionalism for both NHS and private dentistry by the GDC.

He said, ‘The GDC just say “you will provide dentistry of suitable quality”. That’s it. It doesn’t say “if you’re in the NHS we’ll take this into account”. I think that the GDC should bring to the attention of the public, who it is meant to be protecting, that there are failures within the contract which mean that there is a potential issue with quality. But if the GDC did suddenly say “really, we will accept two different standards in dentistry”, it would probably destroy the entire population’s faith in our profession.

‘It’s no wonder that dentists are upset when the GDC comes down on them like a tonne of bricks and says they’ve not met those standards. It doesn’t matter whether you can do it on the NHS or not, you’ve not met the standards and that’s the end of it.’

Paul Worskett, owner of a prototype B practice, said it was time to change the binary perception of dentistry. He said, ‘It always seems to be a question of NHS or private, when really shouldn’t it be a matter of NHS ‘and’ private? Because, we should be talking to our patients about all the available treatment options, both NHS and private, and then they can make an informed choice.

‘Partly that comes from the perception of patients who see themselves as NHS or private and feel that if they go to a private practice they can’t have NHS treatment. I think we need to be clear that the NHS door is still open to them.’

The panel also discussed how this fear of meeting such standards is impacting the younger generation of professionals and is potentially a contributing factor, along with a lack of confidence in their ability upon leaving dental school, in why many of them are leaving the NHS, and dentistry as a whole, early on in their careers.

Ros Keeton, from the BDA Benevolent Fund, said, ‘The CDO does not appear to be worried about young dentists leaving the profession at all. At an event I was at recently, Sara Hurley said she thought it was perfectly acceptable for us to train people only for them to work just one or two days a week and then leave altogether.

‘But the reality is that is absolutely the wrong thing to do. We’re bringing talented young people into this profession, spending a vast amount of money training them, but we’re not hanging onto them and that’s a desperate waste.’

Eddie added, ‘When I first qualified I wasn’t capable of doing some treatments, but I learned because, with the patient’s consent, I had a go. In those days we didn’t do vocational training, our first day of practice was being thrown in at the deep end, and you made mistakes. But somehow society was tolerant of that and people didn’t seek to gain financial advantage from it.

‘Society is very different now and we’re not going to be able to change that. But, what we can do is try to make changes to the regulator and the way that indemnity providers actually fight back against cases that really shouldn’t be anywhere near the GDC or compensation.’

This changing nature in the way young new dentists first begin practising today compared to in the 1980s or 1990s resonated with many on the panel. David said many of his foundation dentists arrive highly motivated but also unskilled and inexperienced, and carrying out their first surgical work in his practice not as part of their curriculum.

Joe questioned whether, with this change in society, it should fall to the GDC to have more of a hand in ensuring that dentists leave foundation training feeling confident enough to perform treatments and knowing what to expect.

He said, ‘If the GDC are meant to be overseeing the curriculum of the dental school so that dentists are competent when they qualify, why aren’t they facing up to their responsibilities and acknowledging it’s not being done to a high enough standard? They’re quite happy to take the £890 from newly qualified dentists and get them onto the register and then throw them to the wolves the first time they step out of line.’

The recruitment and retention of dentists isn’t just an issue for the newly qualified. Many on the panel pointed out that experienced dentists are also planning to leave both the NHS and the profession as a whole – creating a scenario described by David Houston, the Joint Principal of the Houston Group – a four-site group of mixed practices, as ‘losing quality at both ends’.

David said, ‘There are so many principals selling up because they’ve become disillusioned and they don’t want to put up with the regulation and administration any more. What they really want is to do dentistry. So, they sell to someone who allows them to have a two or three-year career extension before retirement, if they wish, which takes all the stress from their shoulders and allows them to just be a dentist. Many become associates, but not for long, so we’re losing confidence at both ends because people who are doing their very best work later in their career and should be celebrated, are actually leaving.

‘We need to give these people something to aim for. We need to allow them to develop and flourish right through to the end of their careers, not to feel probed so much by authorities so that even when they’re so close to the end they feel they have to give up because they have no energy left. The system has to support them.’

Simon added, ‘One of the issues there is the GDC and the massive fear culture they have generated. You could remove the NHS from the equation, that’s just a system that sits on top of everything, but fear of the GDC and litigation goes across the whole of dentistry.

‘There is a fear culture that either the GDC has decided we should have in order to know our place, or it has occurred because of the system that’s been put in place. Either way, as soon as we can get rid of this fear of losing your career over some spurious or stupid mistake or difference of opinion, you will take the shackles off dentistry – you’ll get younger practitioners who are prepared to push themselves appropriately, and you’ll get older practitioners who aren’t going to sell out because of the regulation. This is where the fundamental changes need to happen in order to get some morale back in the profession and have NHS practitioners who don’t feel quite so scared.’

As ever, there is so much more that was said in a wide-ranging discussion of the issues affecting both NHS and private dentists. Over the coming months, Practice Plan will be sharing more of the debate as well as the discussion from a second panel held with younger members of the profession.

The panel’s debate stemmed from the results of the sixth NHS Confidence Monitor survey which was filled in by 495 private and NHS dentists over the summer of 2018. Some of the key statistics revealed included:

  • 86% of dentists don’t see themselves operating within the NHS in five years’ time
  • 85% of NHS dentists found it difficult or very difficult to balance professionalism with the highest standards of excellence while working within the NHS
  • 89% of NHS dentists and 37% of private dentists are anxious about the risk of complaints
  • 80% of NHS dentists and 49% of private dentists are anxious about their ability to meet standards set by the GDC
  • 82% of NHS dentists are unhappy about the level of care they can provide to patients.

To see the full survey results, visit: www.nhsdentistryinsights.co.uk

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