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Posted by on in Alun Rees

“Nobody loves us, everyday hates us, think I’ll go and eat worms. “

Sometimes listening to discussions between dentists at my speaking events, or reading the opinions voiced online at various forums I have to wonder about the dental mind-set. There seems to be a dominant attitude that if there’s a way of seeing the worst in things they will.

It is understandable for dentists to feel unloved, let’s face it we’re hardly the most popular of professions. Very few others, even in medicine, routinely carry out potentially painful procedures in such a sensitive area with the patient supine and their airway exposed - rubber dam or not.

Dentistry can be an irritant both physically and financially; nobody leaps out of bed in the morning saying, “Excellent! Dentist today! I do hope they find something challenging to test their ability so I can lie there for an hour or two and then pay for the privilege.”

No wonder that more and more dentists choose to spend as much time as they can on such minimally invasive treatments as whitening and “short term orthodontics”. No drills, no needles and a result that the patient can see is a definite improvement, what’s not to like?

Perhaps social media has made things worse. Reading some of the “I’m more miserable than you, my life is worse than yours” Facebook postings recently has made me wonder if previous generations were more resilient or perhaps were better prepared for a lifetime of dealing with, “I hate these places” as a new patient’s open gambit.

In the pre-internet days the only place for dentists to share their misery was the local post-grad or BDA meetings. There the young bucks (yes, usually male) boasted about their gross whilst their more senior colleagues complained about anything and everything from the new practice down the road (unless the principal was present) to the price of alginate.

I recently I asked a group at a meeting to share what advice they would give to young dentists. Top of the list were “emigrate", “go part time” and “don’t be afraid to leave". This does point to a pretty low state of morale.

Everybody else thinks they know about Dentistry. Politicians, medics and now venture capitalists all believe that there are simple ways to “sort out dentistry”. The result is usually a few corners cut that are perceived as unnecessary by bean counters. So far few, if any, have succeeded in improving clinical care.

Add to the mix the dramatic reduction of dentists who have “skin in the game”. By this I mean the fall in partners and owners from 45% to 17% in general practice. This drift is taking us towards a situation where, in NHS practice anyway, associates are one court case away from being classed as employees. It also has a knock on effect on morale. If you have little or no say in the way your (work)life is being run and you feel like a cog in a machine then it does make it hard to feel valued.

I do wonder if the profession does enough to help itself.

As individuals dentists are often insular and divided, unlike medics we are not taught to be part of a bigger team, and are unable to see the greater good. Writing in “The Advance of the Dental Profession - A Centenary History of the British Dental Association”, N.David Richards noted that in the mid-nineteenth century there was a large group of “dentists” who attracted patients by blatant advertising. He also stated that, “at that time the vast majority of dental surgeons practised exclusively for their own individual and financial interests”.

One hundred and seventy years on I see some similarities. The dramatic increase in marketing and the insularity of many dentists come to mind. The rise in dentist-initiated referrals to the GDC says little good about those involved.

The profession has been played by government over the past dozen years where limited contracts have seen practices willing to join in a race to the bottom by undercutting their colleagues. There is little unity it seems except in complaining. The mantra of non-BDA members is “what has the BDA ever done for me?” Sadly there are too few willing (or able) to join in and serve, rather waiting on the sidelines for the benefits for which the members pay. The BDA has many faults and, by virtue of the inherent conservatism of its membership, tends to serve the late majority rather than be led by the early adopters.

Dentistry is a profession that is full of intelligent, flexible and adaptable people who are skilled at carrying out procedures that influence patients’ quality of life. They work well to deadlines and can make instant decisions (usually correctly).

In her research in the 1980s Helen Finch concluded that the majority of people don’t like dentists as a profession but do like their own dentist. Instead of running scared of those who tell us that the sky has fallen in, we ought to embrace the respect that has been hard gained and exploit it. No, the GDC, CQC won’t do it, the DoH won’t do it, the BDA tries but can’t do it, the only people who can do it are individual dentists and their teams. It’s time that all dentists celebrated what they do, shared the fact that they are far more than the hackneyed drill & fill merchants and started to actively convert their patients one by one to the benefit of good dental health.

If not decide how you want to eat your worms.



©Alun Rees, GDPUK Ltd, 2018
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Posted by on in Alun Rees

This piece is not aimed at those people who work in salaried posts without a choice of materials, staff, equipment or patients. I believe they do great work in spite of the system. It is focussed on the self employed, those who have made the choice to hitch their wagon to the NHS and who now frequently find themselves with a dilemma of conscience.

The National Health Service, once “the envy of the world” is effectively broken. Starved of investment and degraded by political interference the morale of staff from cleaners to consultants is at an all time low.

The budget cannot stretch to include high quality dentistry so we have the ideal political option, control the fees, tax the recipients and squeeze the providers.

For more than five decades dentistry and dentists were perceived as the awkward squad and outsiders because they retained their independence and dealt with cash. After fifty five years the unthinkable happened, they were effectively neutralised, hobbled and brought firmly into the NHS tent. Limited contracts placed a cap on earnings. The new contract brought a system that measured activity but did not reward it and has ground down the nearly universal entrepreneurial spirit that had existed. No matter how hard you work you will never earn any more from practicing NHS dentistry only by profiting from other’s labours.

These controlled contracts have had their value eroded by inflation, post crash austerity and three successive governments determined to break another profession. Yet, counter-intuitively, the price paid for the exchange of contracts has increased out of all proportion.

Dentists complain, with justification, that their clinical freedom has been undermined, there is no reward for prevention and the fees paid are still linked to random measures taken a dozen years ago.

So why do dentists put up with it? Behind closed doors everyone  agrees that it is difficult, if not impossible, to maintain standards in the face of increasing bureaucracy, the imposition of disproportionate compliance and the threat of big brother GDC. Yet if a dentist dares to say to a patient that they cannot carry out a treatment to a satisfactory standard on the NHS and they could do it better if they charged a fee that is proportionate to the time, skill and materials required they can be pilloried for bringing the profession into disrepute.

The NHS is the elephant in the room of far too many discussions.

As a “retired” dentist (i.e. no longer on the register) and, running the risk of never being asked to be an after dinner speaker at a GDC bunfight (their loss, I’m quite a good turn), I’ll say it. In many cases if you want the full range of choices, materials, techniques and options of treatment to ensure that someone can deliver their best for you then you will have to pay that someone to treat you privately.

If you want dental care without the clinician needing to compromise, then you have to pay and not have the relationship controlled by a third party.

In my own practice I reduced my reliance on NHS funding in 1993 in the wake of a 7% gross fee cut, I had large borrowings but was fed up of being told how I should treat my patients, I wanted something that was better for them and better for me.

For much of the past 40 plus years NHS dentistry has avoided looking itself in the eyes, owning up and speaking the truth. The hamster wheel rotated ever faster until it became so compromised and patched up that it eventually ran out of spares and ground to a halt.

The majority of people seem to believe that the current situation is unsustainable and it cannot carry on much longer. Don’t think that the people who issue the contracts are going to change anything. They hold the cards, they are the ones who say jump and unfortunately a great many dentists default response is, “how high?”.

To return to the original question, why don’t dentists work privately?

In my experience the reasons fall into two main over lapping categories, fear and comfort.


There’s a fear of failure, they think that their patients will not pay them, they fear that the patients will all run away to the practice down the road. They fear that they will not make any money, they quote anecdotes of people who have tried to leave and gone broke.

They are frightened they do not have the skills to perform dentistry to the best of their ability. That’s valid in the short term only, ask anyone who has escaped and they will tell you it takes several years to fully escape from the “make do and mend / just enough is good enough” approach encouraged and fostered by the stifling NHS contract.

Scratch the surface of a lot of these excuses and there often emerges problems with self esteem. They worry that they will be rejected, their patients will effectively say “We don’t love you any more”. They think that they are just not good enough human beings. 

What I also see are people who have skills which are not valued by their paymasters, presuming that they will not be valued by their patients, they say, “They don’t want good dentistry”. This is one small step away from, “they don’t care about themselves, why should I care for them?”


“People will often not make changes until the pain of not making a change exceeds that of making the change.”

The so-called comfort zone has to become pretty uncomfortable to force many to leave it. There is a line on the Pink Floyd track “Time” which runs, “Hanging on in quiet desperation, it’s the English way” for English substitute NHS.

The head in the sand is easier, the hope that Mick Armstrong, Sara Hurley et al will deliver a change, the nirvana contract. Then we will all return to the “golden age” of UK dentistry which you never actually experienced but older people have told you about. Wake up, it’s Jeremy Hunt who has got control and he doesn’t care about you.

There’s the money, let’s not forget, in spite of falling incomes for associates it seems that principals are surviving. With every year they are that little bit closer to claiming the NHS pension, but with every year of added stress they are less likely to enjoy a full life with the pension.

We must also consider the increased value of the practice, the market has peaked and the corporates are growing shy. It would only take a small government bill to remove the exclusivity of the contract and bang goes the bubble.

Final comfort excuse, “I support the NHS”. Really? Really??

I will often ask wavering clients to ask themselves, “Is this what you signed up for? Is this what you saw yourself doing when you left university? Is this what you want to be doing in 10/20/30 years time?”


If the answer to any of these questions is “No” then the next ask is, “When are you going to change?”.


So - why don’t dentists work privately?







©Alun Rees, GDPUK Ltd, 2017.
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Posted by on in Alun Rees

Just say no.


I deal with more and more dentists who are close to or have reached burn out one of the causes of problems is of their own making, it’s their inability to say, “No”.

The temptation in any transaction is to say yes. In the hurly burly of the semi-organised practice where the pressures on our time are made worse by a lack of clear guidelines that facilitates people to say, “no” on our behalf we can always be under pressure to answer in the affirmative.

The NHS is constantly telling their professionals that they should be doing more, that activity is the key to everything, (hell they even called the measurement system units of dental activity) and that to turn someone away is wrong, implying that it’s also unprofessional.

Yet we know that to squeeze a quart into a pint pot leads to wastage, a mess and someone having to clean up later. Here we have one of the paradoxes of the NHS, pile high sell cheap and put in long hours but woe betide you if quality should drop.

One extreme of this is in NHS practices with large numbers of high-needs patients who are not motivated enough to attend regularly but who expect to be seen at short notice. Often it seems they expect a better service than they would get from their GMP.

Time is like land, they aren’t making any more of it so use it wisely. It can be a good servant but a hard master.

Many of us have had the pleasure and pain of starting “a book” from scratch. I did it first for somebody and then twice for myself, possibly a definition of business masochism. In those circumstances faced with an empty diary, a phone that rings sporadically, debts and a growing sense of self-doubt, the knee-jerk response to every call is to get the patient in as quickly as possible, it smacks of desperation but who cares?

By the time I did it for the third time I had learned a tip from the restaurant business and gave a “false” date of opening. When the phone rang we implied that I was booked for a fortnight ahead. Emergencies excepted, obviously. The demand levels rose and within two months I was booked a fortnight ahead.

Unfortunately that sense of urgency, of fearing failure and wanting to oblige may lead to subservience and can prevent the dental business from maturing. The result can be a manic, uncontrolled version of Dental “ER” where the appointment book is full of unprofitable sessions.

I met a colleague, Mary, at a local meeting once and asked her if she was going on holiday this year, her reply alarmed me, “Yes but I only ever take a week, if I have a fortnight there are so many patients to see with problems when I get back it’s just not worth it.” Shortly afterwards I needed to replace our receptionist for maternity leave and recruited an individual who had worked as a nurse and subsequently run reception for Mary. When her husband’s job relocated they had moved away for three months until he was promoted and re-relocated.

Within a week my appointment book was a war zone, every patient who with even the slightest problem and then summoned to be seen as soon as possible. Double booked, triple booked, lunchtimes, after closing, it was a nightmare. When I asked her what was happening to my beautifully crafted, session based and above all organised and optimised book, I was told Mary had said you had to see the patient at once, that patients were encouraged to ring whenever they wished and she would always see them, on that day.

Clearly there was a difference of philosophy and opinion, she had no hesitation in telling me that I was wrong and we agreed to part. Control was re-established and I fully understood why Mary had to take early retirement a couple of years later - burnt out by a bonfire of her own making.

Ideally the people answering the phone should only do that, but it’s not always possible or practical. They must be trained to ask the right questions and to have a manner that reassures and doesn’t alarm and that reflects your practice ethos.

Jack Welch the former CEO of GE wrote in his autobiography, “Saying no is incredibly liberating. Try it on anything and everything that is not part of your deliberately chosen work-life plan”

But it’s hard especially if you have built a system on saying yes.

The first step to change is to decide what you will and will not do. Then introduce boundaries which cannot be crossed. It’s not my place to tell you what they are in your case but common ones are working longer hours than feel comfortable, missing important family duties and giving your patients access to an “open book”.

The next is to decide when you work at your very best and concentrate on those times for your most challenging (or most rewarding) work.

Finally zone your appointment book and vary those zones from day to day through the week for flexibilty. I am not naive enough to suggest that you can avoid some early and late working but when and what must be under your control.

Delegate everything that you possibly can. Dentists should only do what only dentists can do.

I recently helped a principal who was close to breaking point, his private practice was so busy that he wasn’t able to take a holiday and was missing out on his family life. He had the tiger by the tail not daring to let go but losing the strength to hang on. It took a few hours of questions, of analysis of his business and some questioning to show that his beliefs were not really truths.

Once that was established, the tiger was slain he took a filleting knife to his schedule keeping what only he could do and delegating everything else, including some of his more straightforward implant cases. Sanity was established but more to the point he felt that he was in charge of his life rather than the other way round. He could see the choices, and was able to take them.

No is a wonderful word and might just save your health.



©Alun Rees, GDPUK Ltd 2017
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Posted by on in Alun Rees

I was not an outstanding student. I had a very full 5 years at Newcastle but was not famed for my exam grades. Past form being no guide to a cup final I passed my finals.

This was before vocational training, whether voluntary or compulsory. Most of my year headed into general practice within days of graduation and kept their heads down for the next 35 or more years. If they were spared.

Inspired by MASH the movie and dreading being stuck in one place I spent two and a half years as an oral surgery resident, dealing with inpatients, impacted 8s, smashed faces and bleeding sockets. I learnt skills that would help me through my clinical career and life, once you have had to cope with gunshot injuries and Le Fort III fractures not much phases you. I coped with warring consultants, departmental politics and green-gowned theatricals but not with primary FDS. General practice was next and, like everyone else, it was in at the deep end and sink or swim. I bobbed about keeping my head above water, unsure what I was doing for many years.

The hospital service had made me open books, read journals and attend regular study days. There were no such expectations in practice, indeed any day long courses were frowned upon, as you “would not be earning”. The limit to my being mentored in practice was a dressing down when I missed caries, “you could have earned another £X here”.

Post Graduate Education (later CPD) was dominated by what was put on at the local PG centre with Section 63 and BDA section meetings, plus the very occasional trip to London for a day at the RCS.

To cut a long story short, one evening with Philip Greene changed my life and I realised that I had to know more about perio. That’s where my CPD proper started and much of it was beyond “approved by the NHS”.

Occlusion with Higson and the full BSOS year experience, with visiting speakers from the US opened my eyes wider. This coincided with my starting my first practice and nothing had prepared me for that! I found the people on the courses stimulating company who cared deeply for their patients, always looking for better ways to treat them. These people further opened my eyes to a philosophy of prevention. “What you need to remember, Alun, is that you don’t cure caries with a turbine” came as a shock, I was a dentist and I drilled teeth didn’t I?

BUOLD took me back into (mostly) university led teaching which was sometimes undergrad+ but led me to think about solutions. A week on the MGDS course made me remember how much I hated exams. Then came several years of tutelage and discipline of Mike Wise and eventually a spell with the Open University Business school MBA course that helped me to get to grips with my expanding and floundering business.

VT was a great idea but it came after my time. There was something to be said for my ad-hoc, buffet style of learning but I know I could have done it a lot better with a mentor. However VT / FD is facing major problems. Many good trainers have been forced out of a pile high / sell cheap system regretting the regular opportunity to pass on their skills and experiences but unable to square the commitment with the imposed system. The majority do not do it for the money, those who have done are left disappointed and their trainees disillusioned.

New graduates and young dentists face a changing world and it’s about time we looked to the future with a clean slate instead of reacting to the present. The department of health / NHS has responsibility for postgraduate training. The NHS is falling apart and has never taught dentists, dentists teach dentists. Is dental education really one of their priorities?

No other profession has such a poor career pathway. It’s not going to happen unless some enlightened and altruistic dentists make it happen. An independent VT system is an idea whose time has finally come. The last time it was mooted there was some enthusiastic support but the project was savagely crushed under the jackboots of Whitehall.

To take Covey’s axiom and start with the end in mind, what skills will a dentist require beyond 2030? How can these skills be learned? How can the very best be encouraged to deliver the very best care that they can and to properly lead skilled teams?

Here’s what I am starting to see in the switched-on practices. The principal has a set of values and standards that they share and instil in their associates. They help the associates to build a rolling personal development plan where, over a period of three years or so, they not only attend courses that will educate, enthuse and encourage them but also are able to put those new ideas and skills into practice. The idea is to provide a bedrock for their next 20 or more years and to imbue good habits. The associates earn reasonably well, possibly less than they would delivering UDAs but they work with great support staff, the pressures they will feel are the ones associated with doing a good job and they have no quotas to fill.

They routinely visit and observe specialists working and take part in routine, non-judgemental two-way appraisal / audit sessions. If they find that they want to pursue a further qualification they are encouraged. In addition they are shown the workings behind the practice so that they are able to understand how a successful dental business functions. Their communication and leadership skills are developed and enhanced.

How would it be if these Private trainees were able to rotate through say, 4 to 6 practices, over a three year period not unlike a registrar system and were expected to embark on a Masters degree during the latter part of their training?

There is an irony here in that the “corporates” would be better placed to provide such a system; there would be the opportunity to provide different practices for their trainees to work. Sadly they are mostly wedded to shareholder value, concentrating on servicing NHS commitments in an environment which does not encourage excellence - in spite of what they say.

So what’s going to scupper this?

•   Failure to ensure this is a win/win/win trainees/trainers/patients.

•   Egos.

•   Involvement of medical educationalists.

•   No long term plan.

•   No leadership.

•   Allowing the NHS within a hundred miles of this idea.

•   Not enough people with the vision to make it real.


Now who’s going to run with it and safeguard the future?


©Alun Rees, GDPUK Ltd 2017
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Posted by on in Alun Rees

“The NHS is safe in our hands. The elderly are safe in our hands. The sick are safe in our hands. The surgeons are safe in our hands. The nurses are safe in our hands. The doctors are safe in our hands. The dentists are safe in our hands.”

Margaret Thatcher, 1983.

I remember thinking that when Margaret Thatcher said those words, written by speechwriter John O’Sullivan, that it was thoughtful of a politician to mention dentists. Thoughtful and unbelievable.

The use of the ‘Epistrophe’, the rhetorical tool of repeating of a word or phrase at the end of each sentence was used to echo Churchill’s ‘Anaphora’ of “We shall fight them etc”. Rhetoric has given way to the sound bite of, “The NHS is safe in our hands” which has always been Fake News or as my schoolteachers would have called it “Lies”.

The majority of politicians when given the opportunity have repeated the “safe hands” mantra. I wondered if it was a stock phrase they taught you at MP elocution school along with, “Hard working families” and "Education, education, education”.

“La-La Land” has been defined as “a euphoric dreamlike mental state detached from the harsher realities of life”. Few dentist fall into that category but I believe there are many who may hope: “To think that things that are completely impossible might happen, rather than understanding how things really are”.

A definition of madness is to do the same thing again and again hoping for a different result. Since Mrs Thatcher, governments of every hue have sought to undermine the dental profession by repeated assaults and insults both specific and general.

In the UK, like the majority of countries, most routine dentistry is provided by small businesses with the owners taking the financial risk of failure but also any profits from success. For years there was a 3-way set up, patient, dentist and NHS; the first paid the second the fees that were decided by the third that also set the rules. There was the possibility of competition, expansion and genuine entrepreneurship within the system. 2006 changed much of that.

The 2015 saw the Tories return to government free of their Lib-Dem coalition partners with talk of SMEs (Small and medium sized enterprises) being the “lifeblood of the economy”. Promises were made of more investment in super-fast broadband for entrepreneurs, a review of benefits for the self-employed and a trebling for the start-up loans programme.

A commitment was made by Prime Minister David Cameron (remember him?) to, “slash red tape” and to change employment laws to enable greater competition. One promise that was kept was for referendum, an excuse for any and all procrastination for the foreseeable future.

Cameron not only promised “the NHS is safe in our hands”, but also, “there will be no top down re-organisation” before letting Andrew Lansley set about things like a drunken bull manoeuvring a JCB in china shop.

The (genuine) news that the Inland Revenue’s “Make Tax Digital” (MTD) plans will mean all self employed individuals and small businesses having to make some form of tax return and payment on a quarterly basis hardly bodes well for dentists looking to reduce their costs. It will involve far more time and increase accountancy fees.

Changes in Business Rates will have a profound effect on many businesses, with London rates set to rise by 35.5% over the next two years. The fact is these changes should be made every 5 years but were delayed from 2015 so as not to interfere (i.e. prove unpopular) with the general election is further evidence of interference with the truth. Mrs May quickly promised help, then admitted there is no more money.

For years the GDC said that they could not make any changes and an act of parliament was required. This happened in late 2015, I am not sure that anyone has felt the benefits of “a more streamlined complaints system with timelier decisions, and with appropriate safeguards for both patients and dental professionals”.

Finally on the Fake News front that (new) NHS contract. As the BDA says, “The 2006 dental contract is not fit for purpose. It rewards dentists for hitting government targets for treatment and repair, not for improving their patients’ oral health.

In the 2010 general election, the opposition Conservative manifesto pledged a new dentistry contract. The coalition agreement – struck between the Conservatives and Liberal Democrats – pledged the contract would be introduced by the next election, in 2015.

In August 2016 Lord Prior said, “I believe that we expect the new contract to be introduced fully in 2018.”

And lawyer, John Grant ,wrote after yet another debate on the proposed contract.

At some point there will be a new contract, but at present no one knows at all what this is going to look like.

When it does come in the government – no matter which party is in power – is going to want an awful lot more from dentists and in return is going to pay significantly less.”

If you think things can only get better (see 1997) then you are not only living in La-La Land but still expecting it to win the Best Film Oscar.

©Alun Rees, GDPUK Ltd, 2017.
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