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What would you suggest? asks Alun Rees


A couple of months ago I stopped part way through a presentation and asked what words of advice the audience of dentists, of varying ages and experiences with the vast majority over 40, would give to a group of 25 - 30 year old dental graduates.

I have been mulling over their responses and the subsequent post-meeting discussions since then and sharing them whenever I can.

“Emigrate” was the first shout out. When I asked why, there were a number of answers, which set the tone for the mix of the realistic, but slightly miserabilist attitude, which can tend to dominate groups of dentists. “Because this country doesn’t appreciate dentistry, nobody values what we do, it’s better elsewhere”. This attitude harks back to my last post for GDPUK, “Nobody loves us every body hates us” and I believe that dentists should come to terms with the fact that people do like their dentist but don’t enjoy dentistry.

Next response was, “Say No”. On exploration this was the heartfelt plea to be left alone to do the very best for their patients. Constant interference from government bodies and the imposition of repeated layers of untried, untested and mostly unnecessary compliance have done little or nothing to improve the condition of patient care.

There was a feeling that dentistry had been caught napping about many of the changes and that the British Dental Association could and should have been more proactive in defence. (This was not a BDA section meeting). I teased this out a little more and the mood was that the BDA should lead, rather than react to change, that they should be the early adopters instead of worrying about the laggards.

“Go Part Time,” said an associate who shared how she had just reduced her working week to 3 days. My suggestion that all dentists especially practice owners should work no more than 4 clinical days a week (preferably less) was greeted with a certain amount of suspicion - no change there. Often I find that many dentists have such a “high maintenance” lifestyle because they can borrow highly that when they do want to consider reducing their hours they are so wedded to a treadmill of their own construction that it is hard to slow down.

The words of advice started to get more measured then and the group were clearly focussing on the target group rather than their own discomfort.

“Continue with Post Graduate training.” The awareness that in many areas therapists are replacing associates, who had not developed their skills and training beyond BDS, is leading to a growing realisation that you must bring something unique or special to the party. I do meet associates who cannot see the wall ahead of them and still believe that a few local meetings a year is all they need to stay current.

“Choose the right practice.” Said with some emotion by one dentist who shared some familiar stories of promises made and not kept by several principals with whom he had worked. The nods in the room showed that was a common experience.

“Get the balance right.” Bearing in mind that the subject of my talk was the causes and signs of burnout it was no wonder that this was in delegates’ minds. Unfortunately for too many it seems that balance is something that has to be restored in their lives after a problem or two rather than being established as a matter of course.

“Good financial advice, ASAP” This contributor was keen to encourage all young dentists to start planning for their financial future sooner rather than later. Their experience it turned out had been of needing to stay working rather than wanting to because they were not going to be as well off in retirement as they had believed.

“Look after yourself, physically and mentally.” In every group where I speak, especially about the topic mentioned above, someone comes and speaks to me at the end and shares their experiences of breakdown in some shape or form. This was no exception, except there were three of them who had not taken care and suffered from the consequences. The sometimes macho culture of (UK) dentistry can certainly take its toll with life altering consequences in some cases.

“Don’t be afraid to leave.” The world of dentistry is split into two groups it appears, those who have no idea of the value that they can to deliver to the world away from the dental chair and those who have walked away and been successful. The former camp may have self-esteem problems in my opinion and possibly never thought themselves good at dentistry in the first place. It could be that having aimed at dentistry from the age of 15 or 16 they can’t comprehend a life away from it.

“Choose your company wisely.” I thought this was particularly good advice, unfortunately the Internet is full of bad stories about “things” that have happened to dentists. If you are so inclined you can spend hours wallowing in websites, Facebook groups and bulletin boards where individuals try to out do each other with either misery or boasting about their success. All these of course are exaggerated and do little or nothing to help. If the old adage, “you are the sum of the people you spend your time with” is true, and I believe it is, then be selective and stay away from doom mongers and atmosphere hoovers who celebrate misery.

Finally came this gem:

“Don’t listen to old gits who tell you how good things used to be.” This was the view of the people who were really enjoying their lives in dentistry, who had control of their own destiny and could see opportunities in the future. They knew that there have been, and would, always be challenges and that was the way that life is. The “old gits” are the same people who moaned about the 1990 contract, the move to wearing gloves, and changing burs between patients. They were probably the ones who in their day missed vulcanite (look it up), daily “gas” sessions and the inevitability of full dentures. They were the gang who were suspicious that dental hygienists would take the bread from their mouth, believed that the relaxation of advertising was the death knell of professionalism and said that they would never get rid of their upright chairs.

There’s a lot of wisdom in dental audiences, it’s a shame it isn’t shared in dental schools.

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Recent Comments
Paul Hellyer

Shame about your last sentence

Having spent 6 years teaching undergrads in an outreach centre recently and speaking and teaching and publishing about stress in d... Read More
Thursday, 31 May 2018 12:11
Alun Rees

Thanks Paul

Thanks for taking the time to comment Paul. I frequently deal with the fallout from the consequences of stress in dentistry, my pr... Read More
Thursday, 31 May 2018 13:23
Paul Hellyer

Old gits

I think one thing which would help would be more of the old gits being willing to Mentor new graduates, after DF1. One of the com... Read More
Thursday, 31 May 2018 14:19
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I think I’ll go and eat worms

I think I’ll go and eat worms

“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.



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David Chong Kwan

Right on my mood today

You are not wrong. Nils desperandum. Read More
Wednesday, 28 February 2018 10:24
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Why don’t dentists work privately?

Why don’t dentists work privately?

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?







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Just say NO!

Just say NO!

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.



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Is it time to review Vocational Training in UK dentistry?

Is it time to review Vocational Training in UK dentistry?

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?


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Recent Comments
Ian Gordon

Let's rescue what we have

Alun. Excellent article. I have been involved with VT since 1990 , as a Trainer 13 time , as a VT Advisor for 7 years and now as ... Read More
Thursday, 13 April 2017 09:18
Alun Rees


Hi Ian Thanks for taking the time to respond. I think we're in agreement about most things. The problems that you describe are par... Read More
Friday, 14 April 2017 07:13
Ian Gordon

In defence of Corporates!

Thanks Alun. You are of course right that not all Corporates/groups are the same - but from time I have spent with CEOs and CDs of... Read More
Friday, 14 April 2017 08:13
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Fake News and La La Land

Fake News and La La Land

“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.

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7233 Hits

Body Odour in the Workplace

Body Odour in the Workplace

If your best friend won’t tell you what do you do? A different problem.

“I’m feeling a little bit under the weather”. Another vague absence. Karen was good team member, a hard worker and, with the exception of a couple of days a month, punctual and reliable. The principal and the practice manager didn’t know what to do; they had tried the usual approaches mixing concern and compassion but had got nowhere.

A recent survey of 10,000 office workers has found that most one-off sickies are due to hangovers with “just hating the job” coming in second. Neither was the case with Karen, she never drank and clearly enjoyed her career.

“Alun, I wonder could you do her appraisal when you’re next visiting the practice? We’re struggling with what to do about her absences.” Sometimes a different face, voice or ear will bring results. This time was a success and I was able to get to the heart of Karen’s problem. I found her to be a sensitive soul, caring and concerned but in the horns of a dilemma.

The practice consisted of six surgeries with one principal, four full and part-time associates and part-time three hygienists. They operated an egalitarian system where, in order to ensure their were no opportunities for favourites or cliques, the nurses moved around on what appeared to be a fairly complicated rota. This way they worked with associates, principal, hygienists, did their turn in the LDU and had a share of being a “float”.

It turned out that Karen’s absences always coincided with her being due to work with Pam, one of the associates. Pam was experienced, had worked in a variety of practices, hospital departments and had also had a spell working in the community. It was acknowledged she could be a bit brusque with both patients and nurses, but her work was good, she ran to time and grossed well. She was recently divorced, had no children and lived alone.

I managed to get to the heart of things when I met Karen. She was under the impression that the visiting Business Coach was there to see her for some sort of disciplinary matter but I soon disabused her of this and she relaxed. We proceeded with her appraisal, which went well, and having gained her confidence I introduced the matter of her absences. She eventually shared with me the fact that Pam suffered from what used to be labelled as “B.O.” - in other words she was smelly. All the nurses were aware of it but for some reason Karen was particularly sensitive and had needed to run to the toilet to be sick the last time that she worked with Pam. She had now got herself into a real state in case the same thing happened again. She had started to believe that she was the one with the problem and hence the absences.

When I asked the principal and the practice manager they both admitted to having noticed Pam’s odour but had presumed that it was a rare event. Bromhidrosis or body odour, is a common phenomenon in post-pubertal individuals and can rarely become pathologic if it interferes with the life of the individual concerned.

So far, so good we had a diagnosis, but how to treat the problem?

As I was there, and Pam was there that day, it was felt that there would be less of an embarrassment if I were to broach the subject with her. Fine I thought, the client is always right and I have to earn my corn. It wasn’t something that I had done before and I am all for new experiences, if it went badly then I would get the blame and could walk away for another three months.

We met after work and I gave myself 15 minutes to achieve the objectives which were, to point out to Pam as subtly but effectively that there had been comments, to find out if she realised that there might be a problem and then work out a way to deal with it.

Her reaction, thankfully, was not one of denial or to attempt to blame someone for “sneaking” on her. She was horrified and visibly upset. It turned out that she had rather “let herself go” (her words) following her divorce and some days it was all she could do to drag herself out of bed and often didn’t get round to showering or bathing. She wore a tunic at work but wore it over clothes and we agreed that a change to scrubs might help. Most, but not all, of the clinicians wore them and as they were laundered by the practice it removed any home washing. An easier conversation than I feared with, hopefully, a positive result.

When I checked in with the practice owner during our regular coaching calls Pam had obviously had a bit of an awakening. The odour problem had gone and she had taken ownership of the problem by taking the time to ask each nurse at the start of her next session with them to please tell her if there was any recurrence.

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5757 Hits

CDO shows her true colours

CDO shows her true colours

I wrote a piece for Dentistry magazine earlier this year about the new Chief Dental Officer who at the time was busy on a “fact-finding” tour of her new territory. Sara Hurley’s tour was without doubt planned as a charm offensive, featuring smiling photographs with some of the movers and shakers of British dentistry. When she made an appearance at the BDA conference in Manchester her ad-lib question and answer session on the BDA stand was very successful and she came across as personable, reasonable and eloquent. “Good”, I thought, “here’s someone who wants to make friends”.

After more than a decade of her successor, Barry Cockcroft, who could not be described as any one of personable, reasonable or eloquent she seemed a breath of fresh air. But, let’s face it, the bar wasn’t set very high.

In my article I reminisced about CDOs I had encountered, I would not claim to have known any of them. I encountered Brian Mouatt when I was doing the MGDS pre-exam course just after the Conservative government announced a new dental contract, which was intended to “sort out NHS dentistry for good”.

He gave a talk on the new contract and promised that he would answer our concerns when he had finished. However having completed his prepared address he muttered something about having a previous engagement and headed for the door, our angry comments and questions ringing in his ear.

I only knew Margaret Seward because she was married to my first boss, Professor Gordon Seward, she was in post for two years and presumably wasn’t able to leave much of a mark on things, people I have met who worked with her spoke highly of her.

The other CDO I met was of course the previously mentioned Dr Cockcroft who was the highly visible mouthpiece for the iniquitous UDA system and became the exception after a line of low profile CDOs.

In view of Dr Hurley’s ease with people and obviously understanding the need for good PR I was surprised to hear that the new CDO had been far too busy to answer questions on Channel 4 in the wake of their damning reports on UK dentistry. If an NHS dentist was similarly booked solid for 6 months it would be mismanagement.

There was something that kept nagging at me and that was the somewhat cynical conclusion we reached after Brian Mouatt’s sudden departure. The CDO is a civil servant and is there to do the government’s bidding. The current incumbent has spent her professional life in the services reaching a high rank, she knows all about chain of command and is used to taking orders.

Her announcement this week at an NHS Expo (whatever that may be) that, “Going to the dentist every six months is unnecessary,” as the Daily Telegraph reported it, only undermines the position of Dentistry.  The other statements attributed to her are more “austerity” fuelled DoH propaganda.

"You don't see your GP every six months so why would you see your dentist?” Dr Hurley said. Well, Sara that is because NHS medicine is an illness driven system that is reactive and gives only lip service to prevention.

“If you go to have your car MOT, and he says, come back in six months, do you blindly adhere to that advice?” Actually Sarah if I’m driving one and a half tons of complicated machinery that I want to be safe yes I do. What does the army do about recalling tanks for servicing at the correct intervals? I would suggest that if you do them “blindly” someone could find themselves being disciplined.

She was joined on the platform by Roy Lilley who described dentistry as  “a rich man’s hobby” as a regular reader of Mr Lilley I know him to be anti-medic, and by extension dentist, who thinks that every ill in medicine can be cured with a “cuppa builder’s and a hobnob”. He criticised improved surroundings for dentistry, perhaps a return to upright chairs, woodchip wallpaper and lino; with queues on the stairs for gas sessions - would this suit him?

It has taken dentistry half a century to get the message across that regular attenders have fewer problems, stay healthier and actually prefer the reassurance. The good practices already tailor their recalls to suit patients and have been doing it for decades. Your statement is irresponsible and only fuels any criticism and scepticism of dentistry. You knew that your words would make headlines and that you were undermining the hard won confidence that most general practitioners face. However as you have never been a GDP how can you possibly understand what that really means?

It would appear that after a year in post gaining the fragile confidence of dentists, the directive has come down to the CDO, “get rid of your camouflage tunic, put on your hard hat and Kevlar, come out into the open and start gunning down your colleagues. That’s what we pay you for, not popularity - oh and Sara don’t forget there may well be a gong in it for you”.

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8033 Hits

What will happen to associates?

What will happen to associates?

Nils Bohr was a Danish hero who received the Nobel Prize for Physics in 1922. The national brewer, Carlsberg, built Bohr a house. The home was next door to the brewery and allegedly had a direct feed from it, he fathered six children thus providing an early inspiration for the Carlsberg “refreshing the parts” adverts.

He once said, “Prediction is very difficult especially when it’s about the future.” Difficult or not I’m going to look at the future for young dentists in (general) Dental Practice.

It would be wrong to stare into the crystal ball without a quick glance over my shoulder. A sage told me in 1988 that in the future in the UK, “There will be NHS clinics and Private Practices”. With hindsight I’m surprised it took so long to get to where we are now.

Post Brexit, one big hitter remaining in-post is the Health Secretary Jeremy Hunt. There is still no money. The UK doesn’t care what Europe thinks of it, I know, but sometimes you hear the truth. A medic on Irish radio this week said, “The Tories don't like the NHS and Jeremy Hunt is doing his best to dismantle the basic principles of it”. In dentistry many of those basic principles are long gone and the remaining ones are being eroded as we watch.

No more money for education either. University fees and associated living costs are on the rise. Without free movement across borders in the future, university incomes from overseas may fall and UK student fees must rise accordingly. Dentistry is one of the most expensive courses to run, why not make the fees reflect those costs? Dentistry may well become the domain of the privileged, whose parents can afford to subsidise their offspring or arrange the loans for them.

With the recent relaxation of University status perhaps “a large corporate” could create or take over one or more of the Dental Schools to provide cadetships. The armed services have done this for many years. Five undergraduate years in receipt of a bursary and the tuition fees paid. The opportunity for vacation work/internships getting experience of all sorts at flagship practices and the indoctrination / assimilation becomes complete. Post-qualification you commit to, say, 10 years of service or have to repay their investment.

It is possible with this model that corporate dentistry can provide the closest thing to a career structure in general practice, something that the NHS has failed to do and significantly prevented private practice from doing.

The status of NHS associates does not bear close examination. In England and Wales there are fixed targets. Countrywide, associates do not provide their own equipment, are not directly responsible for marketing, wages, materials and so on and by any stretch of the imagination cannot retain the privilege of being self employed for much longer.

A quick flick of the pen by someone senior at HMRC would convert the status of associates to salaried employees. This might be welcomed by many dentists, young and old, especially those who have responsibility for childcare or who have spouses or partners who are in reasonably rewarded jobs.

Time and attitudes have changed and full ownership or traditional partnerships aren’t for everyone. The baby boomers who qualified before compulsory VT/FD and are now the (predominantly) male/pale/stale retiring on the proceeds of the corporate cash which many once derided. They may well be the last of their species.

Many young dentists look at the price of practices, the bureaucracy and the day to day pressure of practice ownership and decide that is not for them. The NHS has evolved into “turn up, get your UDAs, keep your nose clean from the GDC & CQC and go home”. Sounds like a job to me - not a vocation. The millennials are, allegedly, not keen on being tied to one particular practice.

In 2015-16 the admission target, for English dental schools only, was 809, presuming a 10% drop out rate and excluding overseas students there will be another 700 new dentists joining the ranks of the profession year on year. Of these about two-thirds will be female. At present the profession’s mix is 50-50 but it’s a fact that women work less than men over the course of a career, men don’t have babies and predominantly childcare duties fall to mothers not fathers.

This trend started with medicine and has had a profound effect both in   general and hospital practice. Interestingly the sex-mix pendulum has swung back in some medical schools.

One reaction with medical GPs is the change in status in response to the difficulty in recruiting partners by expanding the number of salaried doctors.  The government sees this as easier to control and privatise. Those GPs in favour of becoming salaried has now reached nearly 30%, nowhere near a majority but significant numbers are beginning to think the unthinkable.

In my last piece for GDPUK I wrote, “Meanwhile many quiet, thoughtful young dentists are taking a long view and working at their skills.” They are realising that to escape the mire of the NHS demands a commitment to growing themselves and that the sacrifices don’t stop with a BDS. In fact the years of serious dedication are just starting.

So the future, NHS clinics run by a handful of large corporates with salaried dentists and therapists, and private practices where an M.Sc is the starting point for consideration.

Your choice.

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5404 Hits

The Great Dental Bubble

The Great Dental Bubble

Once upon a time someone started to blow a bubble.

All Pixar films have a simple story structure which can be summed up as:

“…Once Upon a Time…

Every Day…

One Day…

Because of that…

Because of that…

Until Finally….”

So if Pixar did the story of recent Dentistry, here’s the movie storyline.

Once upon a time nearly every new dentist went and worked as an associate in General Dental Practice with an NHS contract.

Every day, 5 days a week, they worked for 8 hours and had an hour for lunch. Some of them were better than others and some were worse. Some were faster than others and some were slower. The faster they worked the more they earned. Every month encouragement came from the practice owners, “get your backside in the air and get your gross up”. Every dentist in every practice did the same thing - they repaired broken and diseased teeth. Some liked to spend half a day a week making dentures or braces or using a scalpel - but that was just a diversion from drill’n’fill.

At the end of the month the owner let the associates keep half of what they had earned. This was often a lot of money for a young, newly qualified person. Their friends from university who had studied medicine, accountancy and the law couldn’t understand how dentists could justify the amounts they earned when they were so young and inexperienced and were envious. Secretly many young (and old) dentists agreed, but they couldn’t bring themselves to suggest a change. These were the golden years, there was lots of disease, plenty of patients and the Prime Minister’s purse was bottomless. In fact there were too many patients so in some places people queued to have their teeth out or tried to do it themselves, or so the TV said.

One Day the Prime Minister, Mr Blair, an ex-lawyer, said, “This is not good enough, something must be done”, and he decided that market forces must be applied. But firstly he made the NHS the National Religion and everybody must be an acolyte, for to speak against the NHS was sacrilege. Then he applied the rule of supply and demand, so he opened up lots of new dental schools where intelligent young people could become noviciate monks and nuns of the NHS. Although the words “private” and “dentistry” were considered blasphemy “private” and “university” were compulsory so the novice dentists were made to pay for the privilege of half a decade of confrontation and humiliation. Saint Tony also sent messengers out to all corners of Europe welcoming dentists to England and Wales where the NHS was the envy of the world and the dental streets were paved with gold.

Next his Grand Vizier, HenHouse and his Lord High Chancellor, Broon, said that the purse was closed, there would be no more money, each dentist must make do with what they had last year and the year before that.

Because of that even the fastest of new dentists were not able to get their backsides in the air and the slow ones earned the same as the fast ones. The practice bosses saw that where there had been queues of patients there were now queues of new dentists who had to repay their loans and were competing to work in the NHS churches. Some of these bosses saw this as an opportunity and competed to see who could pay the least. Some were allowed to keep a quarter or a third of what they earned. In his retirement villa St Laurence de Lando looked down, smiled broadly and said, “I told you so”.

Because of that lots of young dentists said, “We must buy our own businesses. We shall become dental entrepreneurs, what ever that is.” So they hocked the family silver, mortgaged their future earnings and sold their soul to the NHS (praise be its name), and in the subsequent sales frenzy this let St Laurence’s contemporaries buy much bigger villas on golf courses than they had ever dreamed possible. “We are the bosses now” trumpeted the new owners, “we shall buy lots of practices and screw down those associates who were not clever dental entrepreneurs like us. Then we shall sell out at the top of the market and make a shedload of cash.”

Meanwhile many quiet, thoughtful young dentists took a long view and worked at their skills. They saw that in the long term the religion would be exposed for the sham that it was and patients would choose between private practices with personal service and Nash clinics where they chose a number and waited their turn for the announcement, “dental cubicle number thirteen please.”

Until finally, one day the bubble burst, NHS dentistry was handed over, lock stock and barrel, to Tesco and many churches became empty shells, a testament to a great failed experiment.



Image credit - Isabelle Acatauassú Alves Almeida  under CC licence - not modified.

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Recent Comments
Keith Hayes

What about the wicked Witch?

I like the fairy story Alun, but please can we have a happy ending where dental professionals are able to put patients first and s... Read More
Thursday, 09 June 2016 09:50
Alun Rees

What about the wicked Witch?

Well the witch is dead, but that doesn't mean the threat has gone. It's only a fairy story Keith - real life is not like that at... Read More
Thursday, 09 June 2016 10:25
Gordon Pate

a nice fairy tale

very accurate depiction but sadly most of the flock still believe the nhs religion to be the one true religion and too many of its... Read More
Thursday, 09 June 2016 11:00
6424 Hits

Yes Minister, No Dentistry

Yes Minister, No Dentistry

The new Minister was being briefed by the new Permanent secretary, Lady Arabella Sternchin.


“Good morning Minister.”

“Good morning Arabella - it is OK for me to call you Arabella I hope? “


“Quite acceptable Minister.”

“Good I didn’t want to get off on the wrong foot. I heard that old Humphrey could be a stickler for protocol.”


“I never worked directly with him, Minister, so I was never more than ‘my dear girl’.”

“Well that’s all clear then. Now as we’re both new boys, what are we going to do to get rid of the dentists Arabella?”


“Ah yes, I have done some research.”

“Splendid. Burning the midnight oil what?”


“No Minister. Burning out interns. It seems that one your predecessors thought they had things sorted out a decade ago.”

“What was the intention?”


“Well they imposed a new contract that was so ridiculous, so half baked and so poor for all parties that no-one with any common sense would sign it.”

“What happened?”


“The dentists signed it. They ignored advice and signed in their droves. Now the doctors, as Mr Hunt is finding, love a fight, the BMA is a nasty opponent and of course people like doctors. We presumed that as it was so obvious the dentists would lose their clinical freedom and wouldn’t be able to do clever work they would say no and head for private practice. But no such luck.”

“That was 10 years ago though Arabella, haven’t we tried anything since?”


“We got this chap Cockcroft to tell everybody that everything was wonderful.”

“Oh yes I met him once - the shifty one who can’t look you in the eye?”


“That’s him. Well in spite of the fact that nobody ever believed a word he said, indeed quite the opposite, they all opted for to jam today instead of no bread tomorrow.”

“Didn’t we try anything else?”


“Yes we opted for ‘death by acronyms’, the civil servants’ foolproof fallback.”

“What did we use?”


“First there was something called HTM01 oh something, it was all to do with cross infection. We put it about that dental practices were death traps and full of all sorts of bugs. We backed it up with lecture tours by a couple of burned out bug counters and some research work by the manufacturers of some extraordinary things called washer disinfectors. They were really souped up dishwashers but had the lifespan of a mayfly. Did no end of good for our German chums who sold them and made the fang farriers pay for servicing. Fact finding trips to the Black Forest all round!”

“I remember that. What else?”


“Then we thought we would trial the CQC on them - totally inappropriate for their industry of course but it helped us prepare for the real targets, the GPs. We made them pay for our mistakes too - what a naive bunch these are.”

“Didn’t they smell a rat?”


“Sadly not at all, in fact they kept coming back for more. A bit like dental Oliver Twists, “give us more UDAs”, they said.” Then a stroke of genius, they sent Bill Moyes to the GDC.”

“What madman Moyes? He’s not still at large is he?”


“Oh yes indeed Minister and he’s on our side now.”

“So let me get this straight, the original plan was to freeze them out of the NHS, into the good old private sector. How would we placate the voters, you know the Daily Mail reading “we support the NHS” brigade? They vote for us you know.”


“Privatisation minister.”

“Shhhh! Keep your voice down. How?”


“You remember the Carlyle group?”

“What the chaps who sell guns and ammo? They’re so bad even the Yanks don’t like them. How did that work?”


“We arranged for lots of little practices to be bought by Carlyle.”

“Goodness that’s cunning - what did the dentists do?”


“Some of them especially those growing long in the tooth - if you’ll excuse the pun - hated these “corporates” with a vengeance, but they hated the CQC, GDC and so on even more.”

“That doesn’t sound too good.”


“Bear with me Minister.”

“Chance would be a fine thing.”


“Cheeky. It seemed that once these upright, responsible members of the profession saw the colour of Carlyle’s cash they couldn’t wait to trouser the money, roll over, mutter “what principles?" and head for the golf course to blow their lump sums on Rory McIlroy clubs and Audi estates”.

“Gosh - I wondered where old Keith the teeth went. He was my constituency’s BDA rep and a right royal pain in the posterior.

So where are we now?”


“It has proved such a success that the first thing on your desk - once we get rid of this Brexit thing of course - is to consider the idea that we let the Carlyle conglomerate have the whole dental, err, shooting match. It will stop us having to pretend to deal with that dreadful Armstrong man from the BDA, apparently everyone preferred Martin as he knew how to make a decent G&T but this fellow just drinks pints of real ale and keeps nipping out for fag breaks and, by the look of him, the odd pie or two.”

“Isn’t that a bit drastic?”


“Not at all if the Mancs can manage health care, then Dentistry is just nickel and dime stuff as the cousins would say.”

“Just like that?”


“Indeed, Brexit may be a fly in the ointment, however.”

“How so?”


“Keeping these dental sweat shops, sorry surgeries, manned depends upon foreigners who can’t find work in their own lands. At the moment they can get work here easier than our own graduates.”

“Is that fair?”


“What’s fair got to with it? When was a dentist ever fair with you?”

“Sorry Arabella, do continue.”


“Our graduates are so in debt, what with £45k of tuition fees and much the same in beer loans that they are starting to undercut Johnny dental foreigner.”

“Maggie would be proud.”


“Indeed Minister. But it doesn’t stop there. We have plans for the private dentists too.”

“What now?”


“The Dutch control the fees that these cruel b****** can charge so we plan to do that and also to introduce a compulsory insurance plan to match the fees. We started talking to Wesleyan and Simply Health a couple of years ago and they have been very active and are readying themselves.”

“Goodness you have been busy.”


“That’s just the start minister. Your next meeting this morning is with Nigel my colleague from education. We intend to liberate the dental schools from University control. It’s something that we have been working on for a decade - it was Blair who originally got the ball rolling.”

“You know Tony was a good man really, a shame he pretended to be a red and a bit too keen to press the button. But ethically one of us.”


“Instead of teaching the new dental apprentices in ivory towers they will go to urban silos or, as Peter Mandelson christened them, “outreach centres”. These will be run by Carlyle, using their new branding of “ToothSkool”, and the apprentices will learn on volunteer patients for the new three year course. The volunteers will get rewarded with beer vouchers and the children a sticky bun. We have no end of great people coming on board to sponsor these places. Coca-Cola, Tate & Lyle, Kraft Food, Tesco.”

“What fun….good lord Arabella there’s a seat in the Lords waiting for you if this works out.”


Yes Minister.



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7700 Hits

Pressure - what pressure?

Pressure - what pressure?

The news that the BDA is putting together a Research Project Advisory Group supporting research into the mental health and wellbeing of UK dentists might be greeted with suspicion in some quarters. Not in this one, anything that can look seriously at the causes of frustration, despair and burnout in dentistry must be supported.

Several years ago my accountant, who was married to a dentist’s daughter and had a dozen or so dental clients said to me, “I don’t know how you guys do it. If I have a problem I can close the file, go for a walk round the block and come back to it later in the day. Or I can go down the corridor and talk it through with someone. If you have one it’s right in front of you, living, breathing and, possibly, bleeding. You’ve probably got two more sitting waiting outside as well.”

I remember spending ages formulating this statement when I wrote my first report for a client:

“I need to make a couple of points about Dental Practice ownership. Firstly it can be a solitary place; being a medical professional has pressures upon it, having to make immediate decisions with patients that are awake and where you have a finite time to complete procedures produces even more pressure. Being the owner and main producer of a small business is lonely too.

Next; dentists, in common with a lot of “solopreneurs”, are notoriously poor leaders; they have problems separating management from leadership. They have difficulty in keeping themselves in a position where they are able to make decisions about their businesses in a dispassionate way.”

Mike Wise had taught me that it was OK to repeat the same stock phrases in different treatment plans so, as this applied to most of the reports, I have written it again and again. Firstly composed nearly a decade ago, the pressures have not diminished, indeed quite the opposite.

I accept that many of those obligations are by no means unique to dentistry, everyone who makes a living has to do it in a finite time to turn a profit. Even the biggest movie star, musician or sportsman has deadlines to hit. We all have to please someone at sometime. Human nature says you are a special case and begrudge anyone else’s right to be treated as such.

Dentistry is unique. Of course, in some ways, the business model may be similar to others. The need for systems, HR, financial controls, time management and dedication can be found in many other walks of life.

There’s one big exception. Dental clinicians have the use of sharp instruments with the potential to cause pain and inflict lasting damage. This carries a huge responsibility. It’s this last point, a major cause of stress, that the bean counters don’t grasp - and how could they? You have to be there to know that peculiar feeling of dread before exploring a hot pulp, the uncertainty of trying a perfect veneer or the sinking despair of fracturing a root in a phobic patient with limited opening.

Too many dentists don’t share their experiences, their uncertainties and concerns. Across the country attendances at many courses and BDA section meetings are down. One reason for this is the intrusion of “higher powers” to make CPD yet another exercise in box ticking of having turned up and fed the time in the approved core subjects. By extension, non-core subjects are seen to be less important.

Another reason is the courses, lectures and seminars are accessible on-line so that you can be solitary and get information at a time that suits you.

Often dentists view each other as competitors and are suspicious of others’ motives. I was recently given two separate opinions, “there’s no point in going to our local meetings because they are dominated by 1) the willie-waving early adopters who boast and lie about what they are doing and earning or 2) the patched elbow brigade who only moan about the CQC, GDC, BDA and are hanging on for their pensions.” Take your choice.

What is missed is the sharing of experiences, of being part of a community with mutual support. There’s nothing better than finding out that someone has had an even worse day than you.

Without that where does the frustration go? A fast drive home? Difficult on this crowded island. A fast cycle home? Good. Via the gym? Now you’re talking. What is all too frequent is a stop at the off licence and an evening shared between TV, laptop, iPad, smart phone and paperwork. Or goodnights made to children on the phone after your last patient and before you get on with the next bout of compliance.

Some people grow an outer skin so that the day to day doesn’t get to them, but in many this carapace resists any change and when it finally cracks the result can be catastrophic. The consequences of the pressure are physical and mental ill health, and a poorer quality of life than might have expected. So perhaps those expectations should be tempered or better still there should be training in how to handle the pressures. That has to start at undergraduate level.

Resilience is a word that is often bandied about but not properly understood, applied or taught and I’ll continue with it next month.


Image credit - Kevin Dooley under CC licence - not modified.

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7797 Hits

You don’t have to do this - letter to a wavering dentist.

You don’t have to do this - letter to a wavering dentist.

You don’t have to do this - a letter to a wavering dentist.

Is this really what you want to do? You don’t have to.

Many students have made their decisions to study dentistry at university in their mid-teens, an age when they are neither mature nor in possession of great insight.

Parents, family and teachers see dentistry as a well-remunerated, successful profession with a secure future. Well positioned on any socially acceptable list that makes it traditionally attractive to the children of immigrants. My mother, a migrant from Ireland was determined that both her children would have professions, her background, in nursing, favoured the medical. I became a dentist, my brother a doctor.

How many of us have the nerve to say that it’s not what they want? Many dentists are ill suited to a profession that makes extensive physical, mental and emotional demands on its members. I am not convinced that the undergraduate course prepares students for the rigours of general practice.

After 5 undergraduate years and now carrying a large student debt it takes a brave new graduate to dare admit to parents and family that they have studied the wrong subject. If you have a degree in humanities or pure sciences you are fortunate to be able to continue with your subject. Only with a “vocational” degree is the graduate able, and expected, to follow a career pathway.

Socially, turning away is akin to failing to show up at your own wedding. An individual might be secretly admired for admitting that they don’t feel the commitment needed for a happy marriage but it’s a brave dentist who says that they have done the wrong thing.

Turn things on their head, if you know in your heart of hearts that you are going to be unfulfilled and unhappy being a dentist isn’t it better to say so sooner rather than later? How many more miserable years can you tolerate? How much stress and heartache can you endure once you have admitted to yourself that you’re in the wrong place?

Far too many dentists have plodded on through degree, foundation training, associateship, partnership, marriage and children all carrying with them increasing financial pressures.

They thinking that this is the way that it has to be, that it will get better, easier, less of trial to get out of bed in the morning - next year. They live from holiday to holiday and get absolutely no fulfilment or satisfaction from the clinical work that they do or the people for whom they are supposed to care.

Often they succumb to the stressors. One of my contemporaries only accepted that he had a problem when he needed a quarter bottle of vodka to start work in the morning and was facing his third drink driving conviction.

I have attended funerals of successful and apparently happy dentists who have taken their own lives because they could only see one way out.

These problems are not unique to dentists and many people “live lives of quiet desperation” so I would encourage them to change also, if they can.

What else is possible?

The answer is anything that you want to be. There are ex-dentists who are successful architects, writers, lawyers, musicians and businessmen. I know of one former specialist orthodontist who now builds dry-stone walls (and will also teach you how to build them). The discipline of your training means that you are suited to re-train in many disciplines.

Let’s not forget those people who are stuck in a rut. NHS dentistry has never embraced excellence, though lots of good work is done in spite of the system. You will never perform at the highest level on the conveyor belt of UDAs or whatever imposed system of production is in vogue this year.

If you are having second thoughts then I suggest that you examine your reasons. If you feel that you aren’t right for a job that demands a high standard of manual dexterity in order to practice at its best then you should explore your options.

Darwin says that empathy is instinctive not learned, so if you are not a person-person will you be happy going against the grain and attempting to gain the trust of your patients day in day out for the next 30 years?

If you are doing it just for the money, you will probably be disappointed at the amount of further training, dedication to a career pathway and sheer hard work that it will take. You might get a better return on the invested time in some other field.

On the other hand if you stay and you choose to dedicate yourself to a unique discipline, then every day will give a new challenge. You have the opportunity to grow as the leader of a team in a niche where you help your patients not only to achieve and maintain an important element of their general health but also to have an enhanced sense of confidence, comfort and function.

If you want to be happier then say so, and do something. This isn’t a rehearsal, there is no second chance, no re-run, no “it’ll be all right on the night”. If you want to be better nobody can do it for you. If you need help ask those who have already done it, study excellence and embrace it.

Polonius said to his son:

“This above all: to thine own self be true,
And it must follow, as the night the day,
Thou canst not then be false to any man.”

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Recent comment in this post
Gaurav Vij

Great post....

Great post and sums it up succinctly. My experience is very few are cut out to be dentists. You are basically a surgeon in the cla... Read More
Saturday, 16 January 2016 07:20
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Davids and Goliaths of Dentistry

Davids and Goliaths of Dentistry

This post was stimulated by my re-reading Malcolm Gladwell’s book “David & Goliath”. In it he examines the underdog in several circumstances and how they have managed to overcome the odds to become victorious.

Initially I was looking to draw analogies between the “corporate” large and chain practices and the small, independent practice. My idea was to show that a good little ‘un can beat a big ‘un every time. The idea grew on me so I have expanded the remit.

Quite often when I listen to owners of small dental practices I am reminded of the children’s ‘swing song’ that starts, “Nobody loves us, everybody hates us, think I’ll go and eat worms”. Certainly when one looks at the plethora of legislation, political interference and change in consumer expectations one can understand this attitude. Yet it is those changes or rather the practices’ response to them that can make success more likely.

Let’s look at the David and Goliath of the title. David was smaller, poorly equipped and had no experience of battle. Goliath on the other hand was battle hardened and massive in terms of both physical size and equipment. But we know the result, one slingshot brought the giant to defeat.

Perhaps with these two protagonists we saw a hint of the first guerrilla war. History shows that a larger organisation doesn’t approve of small groups. Michael Collins and his flying columns had learned lessons from TE Lawrence (of Arabia) whose methods, although successful, were frowned upon by the British authorities.

The Davids of Dentistry are used to being the smaller person, indeed one of the reasons for successful small practices is that the owner will put in hours outside the “9 to 5” for repairs, maintenance and upkeep. These hours are never allocated in year end accounts. The successful Davids are light on their feet, flexible and adaptable, they know their terrain and where they can operate to best advantage.

The Goliaths have capital, resources and are “business savvy”, whatever that means. They can absorb wasted efforts, tolerate inefficiencies of staff and materials and, above all, can take a long view.

The negative for the Davids is that they can get stuck in a rut of reacting to circumstances and their campaigns are short term. Financial survival is usually at the top of their agenda meaning that they tend not to consider a long term strategy. In order to survive they need, in the words of Alastor Moody, constant vigilance, this becomes wearisome with time and contributes to their eventual burn out.

On the downside for Goliaths is their rigidity and lack of conventionality as their bean counter driven businesses seek to impose an external model onto a personal service. A surfeit of management levels and often unsympathetic HR practices mean that their teams operate at less than optimum efficiency.

The important thing for Davids has been to avoid the  temptation to take on the Goliaths at their own game and terrain because they will surely lose. With market changes it becomes more and more difficult in the post Shipman world for David to remain profitable. The battlefield has morphed too, the big armies of Goliath have taken a lot of the easy low ground of the NHS contracts and can use their clout and experience to bid for more.

Davids must choose their battles, battlegrounds and to time their campaigns with care. They need to learn not only from Goliaths’ mistakes but also from their successes and ensure that they are strong where their opponents are weak. In addition they must look at all the Davids in other professions and industries for inspiration.

Can Goliath learn? Of course he can. To my knowledge nobody has devised a franchise operation in Dentistry that reflects the unique elements of the profession, rewards the franchisee and gives them a sense of freedom. Not yet but with imagination it could work if done properly.

The pattern of post-war Britain has been about smaller companies being absorbed by larger ones. Is it possible for the independents to stay small and free of involvement? Perhaps the model for freedom is one of small managed groups of practices? Here much of the tiresome “grunt” work is centralised. It is this work that, in my experience, ultimately leads to owners losing their resilience, their final fatigue and despair. This sees with them reluctantly selling to a Goliath or to another increasingly cash-strapped David to perpetuate the battle. This group model leaves the clinicians and customer facing team members to do what they are good at with support coming from dedicated and probably off site back office.

All wars eventually end with talks and compromise. The challenge for the different Davids is to find someone with whom you can share a philosophy of business and agree a way forward to keep your places on the battlefield of dentistry. This way the strengths, efficiencies and independence of you Davids can be continued.


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Why isnt perio sexy?

Why isnt perio sexy?

Why isn’t Perio sexy?

My undergraduate years were spent in the old Dental School in Newcastle-upon-Tyne. During my five years I learned about dentures, amalgam, gold, porcelain and of course the use of forceps of all shapes and sizes.

I know there was a periodontology department, my tutor was a senior lecturer. The staff were perceived as a bit wet, uninspiring and dominated by the rest of the “cons” floor. Our restorative treatment plans always ended with the phrase “S&P”. There was a hygienist training school but our paths only crossed socially and the idea of integration was years away.

We had to do a “perio" case as a final year project, and mine was to be shared with another student. The patient was wore a chrome partial denture and “needed” a full mouth gingivectomy. My colleague did his half of the mouth, using whatever technique was fashionable then, reviewed her and re-appointed for my ministrations in a month. With gingivectomy knives all set I looked in her mouth, looked at the notes, looked back again and realised that I couldn’t tell the difference between the treated and untreated sides. Patient discharged and my case written up with the patient described as “non-compliant”. I passed - so that’s OK then.

Three years of oral surgery only added to my ignorance. Then the move into general practice, an NHS amalgam factory with a hygienist. One serving five dentists. The mystery deepened, what were these things called PGTs and why did they have to be booked at 11.45am? The answer, the appointment straddled midday so covered two sessions. My introduction to gaming.

I moved from practice to practice, some scale and polishes were bloodier than others, sometimes the blood oozing around the matrix band or the acetate strip was a nuisance. In 1985 I joined a practice where there was a newly qualified hygienist whose company I enjoyed, she explained that her role was primarily as a communicator. There was a glimmer of light at the end of the tunnel.

But then the practice was sold. The new regime sacked the two hygienists as being unprofitable and told the associates that they should be looking to do at least four crowns on every patient. I jumped ship - again. It seemed that everywhere I worked patients were treated as mouths on legs whose teeth were there for the benefit of the dental profession.

In December 1987, disillusioned by dentistry but searching for something, I rolled up at the Grand Hotel in Leicester for an evening course given by Phillip Greene. I met the WHO/CPITN probe.

A revelation! First move, order half a dozen CPITN probes. Second, explain to each and every patient what was going on, why it was important and what would happen next. Then a setback, the hygienist was sacked for having the temerity to tell the practice owner’s patients that they had gum disease. He explained it to me by saying that, “hygienists were mostly cosmetic really, a bit like hairdressers”.

For a decade I had drifted but was now a man possessed. I had a dream and a plan. I had been reactive, patients brought their diseases for me to treat. Time for a paradigm change, let’s make a presumption that people want to be healthy and to stay healthy.

The only solution was to start my own practice, so I did. It went well, so I started another 12 months later. In those days I used nurses to inform, to educate, to explain what the diseases were and how they could be controlled. No scaling until plaque control was good. I persuaded “the hygienist” to move to Gloucestershire to join me and for the next fifteen years we worked in adjacent surgeries sharing our patients.

I did the first BUOLD course in perio, I joined the BSP, I bought and read Jan Lindhe’s textbook.

The patients who had good plaque control had fewer problems, their endo treatments worked, they didn’t get recurrent caries, working on them was easier win/win.

We became a practice that listened and talked to our patients. When the time came to leave the NHS most understood why and stayed with us. When treatment options were explored the patients got it, there was already a relationship so we never had to worry about “selling”. Choices were offered, benefits outlined, costs explored and commitment gained, either then or further down the line.

All because everything was done on a basis of health.

Nearly 30 years on from my epiphany I talk to clients and find that many dentists are still driven by what they can do to patients rather than for them. Perio (along with paediatrics, prevention, pathology and public health) is still a Cinderella subject. Hygienists still work in cupboards.

Yet those practices that embrace health thrive, are profitable and happy.

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Recent Comments
Bruce Mayhew

Reply following your perio art...

Dear Alan I see your posting from time to time and often wonder if Dave Bridges was your hygienist,(because he was right up the sh... Read More
Tuesday, 17 November 2015 18:03
Alun Rees

Thanks Bruce

Hi Bruce Thanks for taking the time to comment. Although Dave Bridges and I practiced in the same city (Gloucester) we were not i... Read More
Tuesday, 17 November 2015 18:48
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