Lester Ellman, who needs no introduction to UK dentists, asks if colleagues today are pulling together and maintaining the high ideals of our noble profession. There are pressures on practitioners that had not been thought of years ago - how are we coping?

I recently attended a family wedding overseas and one of the other guests was the 94 year old grandfather of the bride whose wife had sadly died a few months earlier. At various times during the period the family was together the old man broke down for a few moments as he reflected on the absence of his life’s companion with whom he had shared some 68 years. They had travelled life’s bumpy road together and like most people had experienced the good times and the bad but as he recovered his composure he kept repeating how good it was that we were all together. Somehow this mantra eased his pain: gave him comfort – enabled him to face the ordeal with some composure. I suppose he was in pain but was making the best of a difficult situation.

In some ways that is the position of dentists in England and Wales today. We didn’t ask for the present contract; it was thrust upon us. Though there were things wrong with the old one, they didn’t warrant the wholesale destruction of the system. But the profession has done its best to comfort itself with similar thoughts that ‘we’re all in it together’.

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Most of us are tied into the system because we have to earn our living from the practice of dentistry. And many are devoted believers in the concept that the NHS should be the first port of call for healthcare needs – including dentistry.

Because of these things the profession at large is able to be disadvantaged by a government which recognises the position and is unscrupulous enough to exploit it.

We are locked in unless we can escape.

On July 5^th 2008 the NHS will be 60 years old. Happy Birthday NHS!

It is worth reflecting on what has happened in dentistry in the intervening three score years.

In 1948 the dentistry which was available was fairly limited but the initial mad rush by the public to avail itself of this new free service was for sets of full dentures.

I would not like you to get the idea that there was no dentistry prior to 1948 as many organisations ran schemes to foot the dental bills in exactly the same way that they dealt with the medical bills. Many of these schemes were provided through employers deducting money from their staff at source to ensure that cover was in place. Trade unions and many self help groups provided insurance cover through weekly collections of funds to offset doctors and dentists bills. The dentists worked to agreed fee scales rather as they did in the Item of Service days of the NHS. But there were still some who had no cover and who did not seek care.

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Many years ago when I worked in a long established practice in Glasgow we discovered a fee tariff from 1933 which had been issued by the local insurance schemes who worked in concert to cover their subscribers’ treatment. At that time an extraction was 5 shillings which is equivalent to 25p and each additional extraction was charged at the same rate. This was a substantial fee for the time considering that in 1965 the NHS fee was less than double that amount.

So, when Nye Bevan opened Park Hospital in Manchester to signal the start of the NHS, the treatment availability moved from local schemes into the National Arena. Uniformity was expected of the service for all patients regardless of their ability to pay.

It was just a short time before the first fee cut and not too long before the introduction of charges for treatment. Both of these processes have gone on incessantly throughout the 60 years but what has been lost is the uniformity of treatment sacrificed to grant local control to PCTs who did not want it and to whom it is another burden as they struggle with the concepts of ordinary commissioning let alone ‘World Class Commissioning’.

We are trained to look after the oral health of our patients and this, rightly, has taken precedence over all other considerations. When we swore a version of the Hippocratic Oath on qualifying, the avowed aim was to provide healthcare without regard to personal gain. Now, obviously, we cannot afford to work without pay but, nevertheless the primary consideration should be the welfare of the patient. This aspect has been discarded by the DoH who seem to have concentrated on creating a limited budget and conditions capable of controlling dentists.

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Part of our problem is that our ethics are instilled in us throughout training and the skills we are taught do not deal with the business aspects of practice. Were we just in it for the money, we too might be blockading Whitehall to create havoc for our cause.

Yet, we have always combined the provision of healthcare and the running of a practice to provide the best care for our patients. We have managed that delicate balance of commercial necessities against patient care with the skill of a tightrope walker -, swaying at times but never losing sight of the end point of maximising the benefits to our patients and rarely, if ever, falling off the rope.

With the introduction of UDA targets and financial penalties for failure the necessity for understanding the commercial aspects of practice is greater than ever before. Previously, if there was a shortage of funds it was fairly easy for a practitioner to increase his earnings by working longer or harder or both, secure in the knowledge that payment would follow. With the new contract there is no way to earn more by working harder as the cash is capped.

Given the systemic changes to our terms and conditions it would seem right to introduce the undergraduate to the uncouth commercial side of general practice. In many cases graduates, too, would benefit from additional training in this area but we remain resistant to this idea, adhering still to the precepts of a bygone era that we are healthcare workers not business people. The introduction of the cash limited contract thrusts control firmly into government agency hands: it is no longer in the control of NHS dentists. Some Deans of Dental schools believe their task is to educate their students in the arts and science of dentistry in its purest form. Worthy though this is, to send them out so ill equipped for practice life is a great disservice.

What a confused and tragic degradation of high ideals. Nye Bevan would be spitting feathers if he knew.

“ We think caged

birds sing,

when indeed

they cry.” John Webster 1612 ‘The White Devil’

Lester Ellman June 08

15 years 10 months

Literate Lester tells a good tale

You all moaned for so long about the old item of fees system that it is no wonder this peculiar new contract was imposed .
If you'd just kept on working ethically [and if the DPB had really tried to catch out those who abused the system and left the honest ones alone ] and if GDPs had not been represented by people whose main income was private practice everyone would stil be content . :'( :) :D >:( :( :o 8) :P :-\ :'( :)

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