Dentistry is tough, I have written that phrase as an opening to several pieces in the past. Things haven’t got any easier, in fact quite the opposite. There is a crisis of confidence in many young, and not so young, dentists.
April 1st 2035. On her 40th birthday Alice was taking stock of her career and professional life. Her initial dislike of working as a dentist for GleamDent had mellowed, she was still there, and life was good. The dental arm of a European health corporate had treated her well and she had responded by being a good employee. Her early days of ersatz self-employment had been swept away in John McDonnell’s first coalition budget.
The job had privileges including free health care, crèche and kindergarten facilities at work for her two children and six weeks paid holiday a year. In addition the profit sharing scheme allowed all employees to purchase shares in the company and provided bonuses related to personal performance and length of service.
The deep economic depression in the wake of the exit from the EU had a profound effect. Many universities failed financially and tertiary education was re-structured. Vocational degrees were reimagined and medicine, veterinary science and dentistry became graduate entry, usually via the new modular medical science degree.
Teaching in dentistry took place through an apprentice like system at one of the four English dental schools each of which was associated with a corporate body. Students, or dental cadets, were taught theory “in block” and practiced in outreach clinics. The cadets received their education, accommodation and a stipend in return for their commitment to the career structure for 10 years after graduation.
Experiments with on-line delivery of all teaching at undergrad and postgrad levels had failed when it was seen that isolation and lack of personal contact contributed to mental health problems. Psychometric assessments became as important as practical evaluations before prospective students were admitted to the course.
The financial crash led to the creation of a new National Health Care system, run mostly by large groups and funded by clear and compulsory insurance cover. All practices were effectively privatised and during the last decade the, quaint, old style of practice based in converted houses had nearly disappeared. They were replaced either by stand alone new builds in office blocks or, more often, in “Hurley centres” alongside medical colleagues with the onus fixed on “putting the mouth back in the body”.
Some of Alice’s friends were exceptions. These “Artisan Dentists” had solitary practices where they worked with only a nurse and some even did their own laboratory work. Alice herself had relied on digital technology for all her restorative work for a dozen years.
These Artisan outliers were not able to sign up to any of the main health insurers and depended upon on direct payments from patients. Like many of her colleagues Alice had been suspicious of their approach but after spending a few hours with an old friend had found the personal attitude interesting but not attractive.
Every GleamDent treatment pod was well equipped. Magnification was standard, the lighting excellent and state of the art patient distraction systems, long proved to be essential to obtain relaxation and co-operation were a huge improvement on local anaesthetic alone.
In the early days Alice, like many others, was uncomfortable to find that direct feeds from her loupes, in-surgery cameras and monitors meant that all clinical and non-clinical procedures were recorded. Feedback from the sensors measuring Blood Pressure, pulse and cranial activity, of dentist and patient was also monitored. It was easier to defend the increasingly rare allegations of poor treatment, and operator quality could be assessed and constructive feedback given. Plus, reflective practice in such a practical subject was easier when one could see one’s own work and reactions.
Since 2030 much of the adversarial legal system had been taken over by Artificial Intelligence, this removed the need for involvement of the discredited General Dental Council.
Vaccinations against caries and aggressive forms of periodontal disease plus genetic intervention had resulted in 95% of people being bacterial disease free, with ideal jaw and teeth relationships.
However there was a TSL (tooth surface loss) “epidemic”, due to people living on a 90% plant and fruit based diet. The consequences were that many people needed extensive reconstructions during their lifetime. These were mostly performed, like implants and orthodontics, by dental robots, using computerised treatment plans and 4-D printer generated restorations.
Alice found that these cases fulfilling and challenging. The rest of the time she spent supervising via the in-surgery monitors and mentoring junior colleagues whether they are therapists, dentists or students.
Would she choose dentistry for her children? She already had, thus earning herself a share of the GleamDent finder’s bursary.
One of the main tenets of Professor Onora O’Neill’s arguments around the theme of trust is that we must aim to have more trust in the trustworthy but not in the untrustworthy. She says, “I aim positively to try not to trust the untrustworthy.”
Which brings around the questions. Who can you trust? Who do you trust? And then by extension, Who can trust you? Who does trust you?
All of us exist in different circles. At the centre is the Circle of Control. Sometimes when I talk to dentists and their teams they say that they feel they have little control over their lives, I can understand those feelings but they are not correct. We have control on where our focus is from moment to moment. We choose and can control our reactions to events and to others. We control where and how we spend our time and energy. We control how we turn up every day. We also control how trustworthy we are.
The next circle is The Circle of Influence. In here are the things that concern you and that you are able to Influence. When we look at this closely many of the things that cause us concern are beyond our control and influence.
Finally the outer circle is the Circle of Concern. In here lie all the things that concern you in your work and life, including health, family, finances, the general economy and so on. Everything inside the circle matters to you, everything outside the circle is of no concern to you.
The lesson around the circles is to “Focus on what you can control and don’t waste energy on the things that you cannot.” To take a topical theme, it is very unlikely that any of us can control the outcome of the UK’s proposed Brexit deal - yet many are losing sleep, getting anxious, losing friends and letting it dominate their thinking.
To return to trust. Dentists often say they feel they have lost trust in successive governments, in the GDC and, increasingly, their colleagues. They will often give me evidence of things that have happened where their trust has been “betrayed” by an associate, a principal or an employee. When a patient makes a complaint we feel our trust has been betrayed in some shape or form and it hurts, of course it does.
Often when we analyse the situation we find that the relationship had not been founded on trust, that there was not complete transparency between the parties. In the past when deference was given to professionals there occurred “blind trust” which now, quite rightly, plays little role in our lives.
Unfortunately too many of our relationships have to be with the slab like nature of organisations, where trust is replaced by unintelligent accountability. This is based on managerial concepts of controlling performance by setting targets for individuals and institutions. Success, or not, is measured by whether targets are attained.
For the majority of dental team members, gaining trust with patients and each other is built in gradual stages. The speed depends upon the individuals involved. Bud Ham described the stages involved as a five-step process, Acquaintance, Rapport, Mutual Acceptance, Mutual Respect and Intimacy. The requirements for each stage are “Others’ Conscious Attention, “Friendliness”, “Shared History”, “Disclosed Beliefs” but for the final stage we need to take the risk of sharing “Secrets”.
Most teaching on good communication is “sales based” and stops at “Rapport”. I think it’s only just starting and would suggest that if our relationships are to be trustworthy they must, as Bud says, get closer to the Risk of Intimacy; emotional, mental or spiritual intimacy.
To return to Trust and to wrap things up.
I'm sure I'll take you with pleasure!" the Queen said. "Two pence a week, and jam every other day."
"Well, I don't want any to-day, at any rate."
"You couldn't have it if you did want it," the Queen said. "The rule is, jam to-morrow and jam yesterday – but never jam to-day."
"I don't understand you," said Alice. "It's dreadfully confusing!
Poor Alice, life had seemed much simpler when she graduated BDS, two years ago. A sunny summer passed living on her parents’ credit card visiting her friends from university. But the confusion had already started.
Alice was qualified and fully GDC registered so could work privately. She must wait 8 weeks until September to start her FD job post. She kept hearing about the shortage of NHS dentists but this was the “system”.
Her FD year went well, learning new skills with a supportive trainer, and then she failed to get either of the associate jobs in “mixed” practices for which she had been interviewed. The successful candidates were people who called themselves “Cosmetic Dentists” with portfolios of perfect photographs of composite restorations and who boasted about how many Invisalign cases they had done.
Soon, she was back living at home to start her first “proper” job; working in Mr Jackson’s practice where she had done her work experience from school. Mr Jackson didn’t own it any more and it wasn’t quite the same, being part of the “GleamDent” chain where everyone wore identical, shapeless “scrubs”. It didn’t seem as friendly as she remembered.
Her interview had been OK, although they didn’t seem keen on her charity work and hobbies nor did she didn’t get to meet any of the other dentists. The practice manager, “Queenie” as everyone called her, seemed a bit brusque and insisted on her signing her employee contract before she left the building, although she was sure they had told her on her FD course days that wasn’t best practice. Queenie said that was what GleamDent did and it was a standard “BDA” contract, so it should be OK.
The confusion continued. When she was eventually paid, four weeks after the month end, she hadn’t earned as much as expected. There were so many deductions! Laboratory work she understood, but laundry bills for those awful scrubs? She had made a couple of private crowns for an old friend using a different impression material, so she must pay 100% of the material cost as it was a “non-standard” GleamDent product. Hadn’t she read the employee manual listing what was acceptable and what was optional? Well no, she hadn’t because it wasn’t available.
CPD provision and certification was available in-house, at a cost. £100 for someone from GleamDent HQ to recite Prof Welbury’s child safeguarding manual, seemed a bit steep.
She did at least have a GleamDent online mentor and coach. He worked at a practice 150 miles away had seemed encouraging when they first met via Skype, “the first five years are the worst!” he had joked, she presumed it was a joke. She hadn’t been told that she would have to pay him too.
Alice had been a diligent student and enjoyed statistics but “practice KPIs” were a mystery all of their own. She received daily, weekly, monthly and quarterly reports, which usually arrived in the early hours of the morning. Queenie expected her to have read and understood them by the time of the next team morning huddle, or “The naming and shaming session” as the other associates called it.
Whatever the KPIs said, Alice felt as if nothing could improve. She couldn’t grasp why patient’s late cancellation of hygienist appointments could be her fault or why she was then expected to make a contribution to the hygienist’s wages.
Twelve months later and the promised “loads of private patients” was rarely more than a trickle of challenging full denture cases. Alice was the last to arrive and got the highest needs NHS patients, she had trouble making her UDA targets and was now facing subsidising any practice clawback. “Your problem”, said Queenie during one of her little “pep-talks,” is that you care too much. You spend too long with the patients; the chatting and consent should be done by “TCO Jackie”, the treatment coordinator. “You must learn how to become a more effective operator, you’ll never be a success unless you cut corners. How do you think Dr King, (the founder of GleamDent) made his money?”
Alice remembered a line from her FD Information Handbook, warning about social media blurring the boundary between public and professional life. She hadn’t realised that there could be a similar blurring between ethical and less ethical behaviour.
It all seemed dreadfully confusing.
The phrase “Existential Crisis” has been used a lot recently. In an individual it is defined as, “a moment at which one questions if their life has meaning, purpose or value”. Often it occurs at a point of depression or negative speculations on ones purpose in life.
Extrapolate that to a country and you have UK 2019 where political leaders in both government and opposition seem to have lost their perspective on many things, not least the word beginning “Brex”.
Dentistry like much of healthcare, is no exception. There are many dentists examining themselves and their motivations, trying to make sense of the direction they thought they were heading and the reality. Are these individuals really symptoms of a far bigger crisis or crossroads within the profession? And is it limited to the UK?
Examine the traditional career pathway. Dental student, FD, perhaps a little hospital work then an associateship or three, find a place that suits you and either buy into a partnership or buy a practice of your own. The financial pressures of ownership led to a focus on the reality of running a tight ship making the years of relative sufficiency and comfortable associateship feel like a dream. It all seems so simple.
With hindsight 2006 was a far greater watershed than we could have imagined. Fixed contracts have brought associates to the verge of employed status. Scarcity of contracts has led to massive inflation of their value. Most agree that the contract remains bad for everyone involved excepting those who hold the purse strings and make the rules. Yet there are no shortage of takers.
Looking at it from more than a decade and a half, the one outstanding thing was the independence of practitioners. Even those who chose to be “career” associates (including those who worked part time with family commitments) had stability with their own contracts and patients. The DoH write the rules, they wanted control and they have taken it.
Add to the mix the onus on universities to produce graduates to work in the NHS as opposed to being safe to provide care under any arrangement. The change in emphasis appears small, but is significant.
The fall out from Shipman has brought about a broad brush approach to the need for compliance, adding yet another contribution to the erosion of morale. The Care Quality Commission was never suited to Dentistry and remains a poor fit. Yet the tank trundles ever onward, distracting and crushing dental teams under its tracks.
There has been a growth of larger practices and the pervasive influence of corporates, some, not all, with a culture of command and control management which puts the investors’ interests above those of the patients and workforce. New graduates, taken in by piecrust promises and unable to find other posts are discovering that there is no line on a spreadsheet for empathy and care.
The commoditisation of orthodontics, led by the Align corporation, far from increasing individual skills is leading to an A.I. world. How many steps away are we from photographs taken with an app on an iPhone transmitted to a central hub for diagnosis, treatment planning and subsequent appliance delivery direct to the consumer. Why bother with those pesky dentists with their expectations and sense of entitlement?
Diagnosis of disease will be done more accurately using computers, treatments that can’t be carried out by robots will be performed by Dental Therapists. The headlong rush to being “Dental Beauticians” opens the market to many. Just because something has always been safe and controlled doesn’t mean that it will remain so. Remember coal, steel and newspaper typesetters.
In their book “The Future of the Professions”, Richard and Daniel Susskind predict the decline of today's professions and introduces the people and systems that will replace them. In an internet-enhanced society, we will neither need nor want doctors, teachers, accountants, architects, the clergy, consultants, lawyers, and many others, to work as they did in the 20th century.
The authors challenge the 'grand bargain' - the arrangement that grants various monopolies to today's professionals. They argue that our current professions are antiquated, opaque and no longer affordable, and that the expertise of their best is enjoyed only by a few.
Perhaps we should all embrace Dentistry’s Existential Crisis and plan for our futures.
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.
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.
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.
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”.
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.
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…
Because of that…
Because of that…
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.
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.”
“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.”
“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.”
“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.”
“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.”
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.
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.”
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.
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.