22 Sep 2020  •  Blog, NHS  •  9min read By  • Nigel Jones

Nishma Sharma: As dentists, we need to do the right thing

Nigel Jones talks to Nishma Sharma, a practising dentist and clinical advisor for NHS England and the Office of the Chief Dental Officer, about communication between governing bodies and dentists, the management of associates during COVID-19 and the silver linings for the profession…

Nigel: The lack, or slowness, of communication, from those in charge during this time has been a source of frustration for many dentists. As someone with a foot in both camps, both a dentist and someone who works in ‘the system’, how did you feel about that?

Nishma: My sole role at the office is to be the voice of the practitioner on the ground because there will be people working at decision-making levels around the table who have not done a UDA in their life and wouldn’t understand how much a band three is worth.

I feel like my purpose over the past few months has been to pass on what is happening on the ground. And my frustrations were well and truly known and felt!

It wasn’t a frustration with my colleagues at the Office sitting around postulating and not doing anything; it was that the hard work was being done, but it just wasn’t being cascaded through because of the way in which the system operates. I saw it first-hand, the frustrations and constraints the CDO had to work under, and it was horrible and that’s why other methods needed to be used, such as speaking to magazines, going online or using social media.

All I was concerned about was getting the communication out there about how we get back to work safely, and it was frustrating it was not getting through, but it was not for lack of trying.

Nigel: It sounds like this crisis brought into very sharp focus some of the limitations of the framework in which you’re having to operate. But what are some of the positives and silver linings of this very big cloud we’ve been living and working under?

Nishma: There are so many positives. One is that there was collaboration between these huge organisational beasts that govern the profession, so I hope this will be the end of siloed working.

Pre-COVID-19, a piece of policy would take nine months or a year to put into place; during lockdown we were whipping it out within weeks. When you’re focused, when you collaborate, when you know you have to do it, it can be done. It shows the power of people working together is much greater than people doing things in bits and duplicating efforts.

There is a whole world of dentistry outside of the four walls of drilling, filling, suction, repeat over and over again. There’s this whole political arena and I don’t think enough emphasis is placed on training dentists into knowing what that arena is and how it works.

It’s a game of chess, and if you don’t know the rules of the game, you don’t know what you’re playing, you’ll never be able to checkmate. And I do think it suits decision-makers that dentists are kept in the dark because that way you can be checkmated over and over again. You think you’re getting somewhere, but you’re not.

So, it’s time for the profession to engage, and there’s the silver lining. People now know who these organisational bodies are, who the CDO is, what the commissioners do and the difference between them all. It’s about educating yourself beyond clinical dentistry.

From the ashes rises the phoenix and I think we’ve finally got a voice. People have galvanised, started lobbying and it’s gained momentum – and that’s what we need. Private dentistry finally has a voice. I’ve always played with the idea of having a union of dental associates, but the acronym would be UDA…so maybe not!

I can’t praise enough the local dental networks and their chairs; they’re all acting like mini CCGs that are influencing local and regional policy, and they will just become stronger and more pertinent as time goes on, especially if we have local lockdowns.

And lastly, the country saw a world without dentistry and it was rubbish. We’re finally, as a profession, being noticed by our elected officials, the NHSE and most importantly, we’ve been noticed by patients – they value us again!

Nigel: I like your comment about the UDA, as in Union of Dental Associates! What’s your opinion on the way associates, and the wider practice team for that matter, have been handled and what should be happening?

Nishma: It’s a difficult one and, this is a purely personal opinion, it boils down to just aligning our moral compasses and doing the right thing.

We were all worried about the abatement figure, and I feel that NHSE have been very fair and reasonable in what they’ve given and they’re expecting in return a minimum of 20% activity, and that is measured by UDAs and other clinical indicators, like remote consultations. And that is on the proviso that the money they give is passed over to whoever it is owed to – your dental nurses, therapist, your staff, associates, etc. It couldn’t be clearer.

I think it’s unscrupulous and wrong that people will hold onto this money, with the fear that there might be a claw back or something might happen. I understand why people might think that; there’s a massive mistrust. But associates need to be treated fairly. We will get over this current situation and you will need your workforce. Just do the right thing.

If there is a declaration that you then need to sign to say I have handed over my 20%, I’ve paid my associates and all my staff correctly, you’re in a dilemma. What do you do? Do you do the right thing and just sign it happily and move on? Or do you sign it and you haven’t done that? And if there’s evidence to suggest you haven’t done that, what will the penalties be? A breach of contract, withholding of money? Does it become a probity issue? Fraud, where the penalties are significant? You just don’t want to fall down that trap. Don’t be what people think we are, be who we really are. Do the right thing.

There will be those practices who cannot pay because of the way their practice is structured and they have a tiny contract, etc. In that case there needs to be a frank discussion with your associates where you explain the situation that you may not be able to pay them fully at the moment as otherwise the practice would fold. Who in their right mind would say, ‘Yeah well, I still want my money?’

NHS England has invested and trusted in us as dentists to do the right thing. All it takes is a few bad apples to spoil the cart, and then it will be back to UDAs, and we just don’t want that. There is such an opportunity here if we behave the right way.

Nigel: What do you think that the future holds and how can the profession influence it both in terms of its input into the design of a new contractual framework, but also the way it behaves?

Nishma: I think the way forward for our profession is to engage as much as we can, and to do that we need to learn the rules of the game. Figure out who does what because that way you can have an intelligent debate and negotiation.

I also think when it comes to moving forward, I can’t say it enough; it is about behaviours. Just do what’s right by the patient within your own capabilities so that we can prove that capitation works. If we don’t, it does go back to the UDAs, which, as we know, is a completely broken system, incentivising bashing out widgets.

If a crown was clinically required and necessary six months ago, why isn’t it now? Why is there this drop all of a sudden if you’re able to carry out AGPs? If you are and you’ve got through your backlog of pain patients and incomplete treatments, there’s no reason why you can’t start seeing children and more routine or high-needs routine work.

We need to not try to play the system. We need to behave and do the right things. Where you can do it, do it, and we will reap the reward from that as we come to a reformed contract that works better for everyone.

I have faith in that system. I have faith that something will need to change because we can’t go back to what we were, but it’s a very real threat if the indicators show that we can’t be trusted or a few bad apples spoil the cart. We just need to work together on this.

Nigel: Thank you Nishma for a very interesting discussion. There’s always more to say, and I hope we can do it again soon!

Watch the full interview, where Nishma and Nigel further discuss more issues including a report on the resilience of mixed practices and timescales for a reformed contract post-COVID-19.

*This interview took place on August 19th.

Nigel was speaking to Nishma as part of our ‘Inside Out: NHS Dentistry Discussed’ series. Upcoming guests include John Renshaw and John Milne.

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