Simon Thackeray

Some blunt dental views from Yorkshire

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Simon Thackeray

Simon Thackeray

Simon has been a GDP since qualifying in 1991, initially in the NHS, and since 2005 in private practice in Nottinghamshire. He is a critic of the increasing and often unnecessary bureaucracy surrounding dental practice. As a practice owner and Yorkshireman having to deal with this, Simon has a tendency to direct and forthright comment, especially when it gets in the way of true patient care.
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Once again the new patient charges have been announced for the NHS, and once again they have gone up far more than the amount dentists will get for their UDA’s. The third consecutive inflation-busting rise in patient charges means that an ever increasing number of dentists will find themselves as unpaid tax collectors for the government, with the added pleasure of having to continue to practice in a hostile environment where the threat of litigation and GDC involvement is ever present.

So what will it actually take for dentists to wake up and smell the coffee? Patients are paying an increasing amount for their care, and as they do so, direct their annoyance as ever to the dentists. Its unlikely that they will understand or accept the explanation given that the charges are in effect a taxation, as they are too closely linked to the provision of a service.

Why do many of the dental practices seem to forget that they are in truth independent contractors within the NHS, and as such only have to refuse to contract to the NHS in order to retake a degree of control of their own future once again? It can’t be that working within an NHS contract is too easy; we increasingly hear of the demands on the practitioner’s time to fulfil the contract requirements. This time of year is full of comments on social media about the increased flurry of activity in order to hit the UDA’s targets once again or suffer claw-back.

By raising the patient charges, the government is contributing less and less each year to the cost of dental provision. The population of the UK isn’t reducing, and the cost of providing dentistry isn’t either. But for less and less contribution the government is still dictating the terms of the contract, and dentists continue to accept it.

Will it actually take the government to raise the patient charge to £30 for an exam (whilst still paying £25 for the UDA) for dentists to realise that they would be better off just charging the patient £30 and sticking two fingers up at the government? Or is it the NHS pension that people are holding out for? Or the continued chance to pay an associate £10 per UDA when they are really getting £30?

Practice owners (and particularly the bigger practices and corporates) definitely have the whip hand here. I can remember the times when associates were few and far between. It appears that the reverse is now true in many areas of the UK (particularly in metropolitan areas), which allows the principal to reduce the unit price of a UDA paid to an associate. An increase in patient charges will likely bring a drop in the number of patients visiting practices, and in one fell stroke this will reduce the PCR, and reduce the chances of the UDA targets being met, and therefore a claw-back occurring. I know of many associates that are made liable for the gross amount of any claw-back due to their individual underperformance (rather than the net amount they have been paid per UDA). Add this to the NHS pension of the principal that is effectively enhanced by paying a smaller percentage of the UDA value, this hardly puts the principal under any immediate pressure to withdraw from the NHS system they are still aligned with. However, I suggest that it is now causing a much greater ‘Us and Them’ situation with associates than ever before.

So why is it ok to make money out of the associates and not charge the patients a decent amount for their care? Whilst a business has a duty to its shareholders and owners to keep its costs low, with the introduction of the minimum wage this means they don’t tend to be propping up their bottom line by charging their staff for the privilege. They tend to charge their customers for it with the increase in the charge for the product.

Unless you happen to be in a fixed price system…so the only way money can be made (let’s forget upselling to patients using the NHS as a way to get them in the practice for now) is by reducing the costs of the workforce and investment in the business. However the government expect more and more for less and less (look at the next round of orthodontic commissioning that is going on) and it becomes impossible to square the circle unless someone actually pays for it. That certainly isn’t going to be the government.

Given that some patients will not be able to afford the hike in charges does not mean that many others would not pay for a decent service if they had to. Surely having fewer patients (but of the sort that don’t sue and complain) that are being charged a fair amount for the service provided, with no third party dictating targets has to be better for the stress levels of both dentists and patients under their care?

Will it take associates to actually walk away from the profession and retrain? With the current environment of stress due to the GDC, threat of litigation, and the real time reduction in associate income, then this has never been more possible than it is now. And that will lead to a reverse in the associate market again, especially if the (currently unknown) effect of Brexit results in European dentists returning to their home countries – and who wouldn’t if it meant avoiding the GDC and Litigation!

So what will it take for the profession to see the light? That we need to realise the government would still wish to control us if they only contributed £1 in every £100 charged and only then will we react? Or do we need to remember that everyone who owns a practice is a private practitioner already and they should just tell the government:

‘No More’.


Image credit - Pascal under CC licence - not modified.


©Simon Thackeray, GDPUK Ltd, 2018
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There have been many episodes I’m sure we all know about where a colleague has done something that has been their eventual professional downfall. Examples like the well publicised cases of Joyce Trail and Desmond D’Mello are a demonstration of how a professional has destroyed their own career and reputation through their actions, whether it be an illegal act, or a dangerous one.

But none is more worrying then the Case of Bawa-Garba. I am sure you are all aware of this, but if not, very briefly this involved a junior paediatrician being charged and found guilty of gross negligence manslaughter due to the tragic death of one of her patients whilst under her care. However, what is unusual about this sentence is that it was not only a very short one, but also suspended; something that very rarely happens in a case like this. As is then the usual route of action, the doctor was referred to the GMC for the associated disciplinary hearing that comes with a conviction. The tribunal found that her fitness to practice was impaired, but allowed her to stay on the register. However, the GMC appealed this decision, and she was subsequently struck off by the High Court last week. Interestingly, an interim orders committee of the GMC suspended the doctor initially, which was overturned on appeal by the high court who ruled that even a serious criminal charge did not always mean that suspension was necessary or appropriate to protect the public.

As someone with a conviction for manslaughter, then one could always argue that a professional actually should not be allowed to practice their art on the public again, but there is case law that supports the more subjective approach that was taken in this case initially. But this case (without going into even more detail) is as much, if not more, of an indictment of the systematic failings of leadership and organisation inherent in the environment Dr Bawa-Garba was working in. That the tribunal found no impairment was significant, as the doctor had engaged in insight, and had placed her reflections on the tragic event on her e-portfolio.

And that is the problem.

By honestly reflecting on the events and committing them to the permanent record of her E-Portfolio, this allowed the GMC to use this reflection against Dr Bawa-Garba, and subsequently was part of the case that was successful against her. In effect, by complying with the requirements of the GMC, she has committed professional suicide by recording her reflections as required. It is fine to record ones reflections to show insight, but to then have them used against you is surely unfair. You would have to trust the regulator implicitly when committing your reflections to a permanent record, and the actions taken by the GMC will have served to destroy any trust that our medical colleagues would have had in their regulator. Given that the GMC has always seemed to be to be a more considered and pragmatic regulator than the GDC of late, then once can only wonder just what manner of jeopardy we will have to place ourselves under as a result of this ruling.

In one fell swoop, the GMC have removed the chance for professionals to show they have learnt from their mistakes and develop in a no (or low) blame environment (as indeed occurs in the aviation industry) and installed a culture of fear that I think even the GDC at its worst a couple of years ago would have struggled to create so effectively. However, with the new GDC rules on CPD and reflective analysis requirements that we now have, is there anyone amongst you that thinks that the same couldn’t possibly happen to dentists? Once a regulator has set a precedent, it is likely that they will all act in the same manner.

I suspect the GMC realise there will be a problem with personal reflection now, and given the release of a blog by the GMC on this issue at the weekend, this might be seen to confirm it. The amount of internet noise coming from the medical profession over this matter is significantly higher than anything we have been able to generate, and as a result one must hope that there is a higher likelihood of something significant developing over the next few weeks and months as a result of this case, something which hopefully will roll down to the GDC as well. Even Jeremy Hunt has raised concerns about this case and its unintended consequences.

Once cannot forget the tragedy of the death of a child in the case, but there has to be consideration of the bigger picture of how a ruling such as this will now probably affect the analysis of mistakes in healthcare that are needed to protect the public.  Furthermore, unless the use of reflective writing is somehow protected, the use against us of our own insightful learning could be our eventual downfall.


Image credit - James Cridland  under CC licence -  modified.

©Simon Thackeray, GDPUK Ltd, 2018
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We’re all members of a cult. Whether we like it or not, since mankind first appeared on earth, there has been a need for the majority of humans to flock together in some form or another. Whether it was for protection by strength of numbers, or to increase the genetic variety of a group, the formation of cults, tribes or groups has always been something that the human race has experienced.

I’m not talking here about race-related groupings of human, because that is something far more fundamental. That is all about the genetics that make you part of one race or another, and there is precious little you can actually do about the genes you were born with.

What I’m thinking about here is the tribal nature that makes you support one football team over another, or a different political party to someone else. Religion may also be part of this, but I am going to steer well clear of that for obvious reasons. However what is apparent is that most of these tribes and cults  are based on the shared values and belief structures that the members of the cult have.

“Where is he going with this blog?” I can hear you all thinking. This is not one of my normal types of observational commentary on the state of dentistry where I’m having a go at some (dis)organisation or system in dentistry.

Or is it?

Because it actually is exactly the same as usual in that I’m pointing out something that I believe is fundamentally inherent to the problems that we are experiencing in the profession at the moment.

Cults and tribes are collections of people who flock together under one belief structure. The profession of dentistry is such a tribe. We all share the same skill set fundamentally, and are working together to provide the same goal of health for our patients.

But within a tribe are often sub-tribes and cults. These are the things that seem to me to be dividing the profession in more ways than one and can often cause problems. When we look internally we see the infighting between some of the orthodontists and those providing GDP orthodontics. You can guarantee a lengthy ‘discussion’; when some of the more evangelical on both sides come out to discuss their views on this subject. The same is true of the two cults of private and NHS dentistry.

It is actually possible to be a member of different cults at the same time, and cross over seamlessly from one to another depending on the situation. You might find yourself agreeing with someone from another cult one minute, and then vehemently arguing the next.

When your strongly held values and belief structure is in disagreement with someone else’s equally strongly held views then conflict is almost inevitable. Only the control of the emotional aspects of these differences is what prevents the breakdown of the relationship between these two sides. Some people are able to control it more than others and agree to disagree, but many others are not.

Dentistry is absolutely full of cults.

More so than I think it has ever been before. I personally think the rise of social media and the ease with which one like-minded individual can find others who are from the came cult has been at least partially to blame.

The problems arise when the cults cause not only infighting in the profession, but also are responsible for the perception of the profession to the public (who I’ll just take as one big tribe at the moment).

Within the profession we have the cult of the Key Opinion Leader, some of whom seem to have opinions based on their parallel membership of the financially motivated cult, and who can pay them the most. Then we have the Celebrity dentist cult, often admitting to no personal or clinical failings and who may have sprung from anonymity in record time, with fawning acolytes who can see no fault in their heros. Given the following of some of these two groups, I’m actually waiting to read in the BDA news that 600 cult members have all drunk copious quantities of Hypo in a mass attempt to align their teeth. Ok, maybe that’s a bit far, but what will usually happen is the acolytes will be the ones who get left in the lurch either with the GDC or with a load of obsolete materials when the Guru-esque leader moves onto the next best thing since the last best thing.

There is the huge cult of the NHS dentist, who can often see no way out of the cult, but stay because they are also members of the ‘I’m alright Jack, my pension’s great’ cult or the ‘We cant go private where we are’ cult. There is also the sinister ‘Gamers’ cult, where you’re a member but don’t admit to it, either because you don’t want to, or because you don’t realise you are.

I could go on and on with this but I think I’ve made my point.

I’ve probably managed to alienate a huge chunk of my readers now with those analogies (perhaps it would have been more sensible writing a blog on the various religions after all !) because I’m sure you now will find yourself both agreeing and disagreeing with me and become annoyed at me in some way.

The point I’m making is that the values and beliefs that we have developed place us firmly in pigeonholes and groups in such a way that someone else can make an observation that can start a conflict if you don’t like it. I’ve done precisely that in the previous paragraphs.

But the above is all a myth based on your belief structure, which can be changed if you really want it to. Do you want to be a member of the cult of materialistic egotistical, self-promoters? Fine, do that, but then don’t be shocked when others take issue with that.

Until we have the unification of the profession behind one overriding cult then we will always be divided. Since these cults are nothing to do with our genetics but only down to our beliefs, it is all an entirely fictional situation that causes the problem; a brainwashing due to our desire to hold onto our beliefs and opinions.

We need to not become a profession against itself especially as we have enough external factors affecting us already. Unity and a sense of purpose is more important now that it ever has been.



Image credit - Legominifig under CC licence - not modified.









©Simon Thackeray, GDPUK Ltd
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No one can deny that modern technology has been a revelation in recent years. The use of it to improve diagnostic yields in radiography, to allow mainstream imaging in practice of aspects of dental tissues that we couldn’t previously visualise the same way  can only benefit our patients. Computerisation of dental notes and management systems, (whilst restricted in the choice of manufacturers) have probably improved the efficiency of most dental practices far beyond that of the old paper systems. Digital marketing tools, online presence through websites and blogs, and social media are all here to stay, and have driven the profile of the profession upwards. All in all, I think most of us would agree, technology has been largely a good thing for the profession

But one thing that I am REALLY struggling with that has come about as a result of this type of technology is the increase in Referral Portals for NHS referrals. On the face of it is would seem to be a streamlining of the process needed to refer into secondary care, and reduce the costs and problems with paper referrals. Entering the data via a computer linked to the patient database and directly into the referral systems would seem on the face of it far more efficient that writing a letter and posting it.

So why do I have an issue with it? This sort of advanced technology is right up my street normally. However, because of the way these systems seem to be implemented, I can see potential problems for registrants falling foul of the GDC Standards when they are forced to use them. The GDC standards that I personally think relate to this type of system are :


Standard 1.7 – Put patients interests first before your own or those of any colleague, business or ORGANISATION – these systems tend to be imposed unilateral decisions that don’t seem to have any guarantee that they are better for the patient (or indeed tested fully).

Standard 4.2.6 - If a patient allows you to share information about them, you should ensure that anyone you share it with understands that it is confidential – How does a faceless system with no identification of who receives the data comply with this standard?

Standard 6.3 – Delegate and refer appropriately and effectively. However, someone else often choses where the patient goes and who they see, with the clinician often having no idea of the degree of expertise that clinician actually has. Referrals are even rejected if often irrelevant (but required) tickboxes are not filled in.

Standard 6.1.5 – You must ensure that all patients are fully informed of the names and roles of the dental professionals involved in their care - How does a portal allow us to do this? Do we give all our patients Bill Gates’ name as its done on a PC?

Standard 6.3.1 - You can delegate the responsibility for a task but not the accountability. This means that, although you can ask someone to carry out a task for you, you could still be held accountable if something goes wrong. You should only delegate or refer to another member of the team if you are confident that they have been trained and are both competent and indemnified to do what you are asking.

For me this is the big problem. This alone is where the entire concept falls down unless we are indemnified for the errors of the system. What if this is a life changing referral such as a tumour? You are going to be ultimately responsible as you have to make the referral, and you can guarantee the powers that be who thought it was a good idea to impose the portal will NOT indemnify you against the failure of the referral in some way, nor will the GDC.  If the referral is rejected because of some missing tickbox that is largely irrelevant to the immediate urgency but required because some software engineer hasn’t allowed any flexibility in implementation then I personally cant see how this should ever be the responsibility of the clinician. The fact I might for example omit the patients GP because I’m more interested in the speed of the referral is a pedantic bureaucratic issue and not one of patient care.

I can’t comprehend how we as a profession have allowed this type of loss of control of patient care to creep into our referral systems. I am fairly sure there are practices that are on referral pathways that our patients will be allocated to that many of us would not be happy for them being treated in. Part of being a professional means that you take on the ultimate responsibility for the care of a patient, and the GDC standards means that includes ensuring they are referred to an appropriate colleague. Unless every single one of these referrals is triaged by a clinician then there will be mistakes made. And this pre-assumes the system actually works like it should…..

I have had the misfortune recently of being forced onto a pilot in my local area of just one of these systems. Due to the obviously more knowledgeable people in charge of procurement in my area, they foisted a system onto practitioners without actually discussing anything with them first. To say I experienced problems was an understatement, and I know many others did too (despite the LAT saying the response to their questionnaires about it was overwhelmingly favourable – presumably because the portal lost as many bad responses as it did referrals). To be quite honest, I would have been better served learning how to send smoke signal referrals rather than use the system that was imposed. I did some research into the actual system and found that it had been dropped by at least one area as it was unsatisfactory, and another region have accepted that the same system isn’t good, but it’s the best they’ve seen. Hardly a glowing endorsement is it?

For example, in the 2 months I used it, we experienced a plethora of problems. I don’t think it is particularly useful to have to spend over TWO HOURS trying to upload a Periapical radiograph, knowing that if it wasn’t sent the referral would have been rejected. This was a compressed file of just 103kb. I don’t think it is particularly helpful to have half the tick boxes missing for medical histories, or dropdowns that you can’t fill in because they are incorrectly populated. A spell check that allows only the incorrect spelling of a drug is also pretty useless. It’s not useful that the system doesn’t tell you if the referral has gone correctly, or instead forever been lost in the ether of the internet. It’s not professional to have no idea who you have just referred the patient to or who is going to read the information. Not particularly useful if your patient who doesn’t have an email address (like many of my elderly patients) can’t even be referred at all as the system refuses to accept the referral without their email address. It also falls foul of my data security policy of allowing an unknown (to me) commercial third party installing software onto my system (which is massively firewalled both by hardware and software – which would appear to more than can be said for the NHS system if the recent Cryptolocker problem is anything to go by).

But having the system obviously ticks another box for those who confuse boxticking with patient care. By having a system that once again means all the responsibility still lies with the registrant even though they have no control of it is highly convenient for the powers that be. They get to have a load of committee meetings about the procurement, knowing full well that if and when it fails, and if and when patients suffer from it, it will be the clinicians who will get the blame for it. Having a system imposed from above without actually making sure it works is nothing new: lets face it the NHS hardly have a great track record in getting IT infrastructure correct out do they? Heaven help us if our friends at Capita get involved with implementing one of these systems; patients will probably end up with an 18 month wait instead of an 18 week wait. Still, at least losing patients in the system will make the waiting lists look good for the managers and they can get their bonuses for being so successful…..

So unless we get some form of indemnification from those who perpetually get to wash their hands of responsibility, I can’t see how we can use these portals and still adhere to our required standards. Please correct me if I’m wrong.


Image by Benjamin White

©Simon Thackeray, GDPUK Ltd, 2017
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No one can have missed the inexorable rise in the use of social media for virtually every kind of interaction we experience in the modern world. From a few users 10 years ago there would appear to be now virtually every corner of the globe unaffected by it (except for maybe some long lost Amazonian tribes – lucky them).

Dentistry has not been slow to embrace this revolution, and as a mechanism of disseminating information world wide, sharing new techniques, and even asking advice about a case, then it there is no doubt that is it hugely helpful. Accessing social media though our smartphones is perhaps the most common application of this media, and it is thought that phones are now become part of the way in which we experience life, and how we form our memories. Certainly, creating a virtual scrapbook on our social media persona that shares with other people is something that will help you look back on events perhaps differently to how you did in the past.

But I worry that some people don’t understand the dangers of social media enough. I’ve written about this before on this blog, and the majority of what I said then holds true now. But there now seem to be some people who take the whole social media thing to be a benchmark by which they should measure their own lives against. There is a relatively new Facebook group called ‘Mental Dental’ which was set up to help dentists with some of the challenging mental health issues that can occur in our profession. Personally as someone who has suffered mental health issues in the past, I think it’s a pretty crass title, but the ethos of the group is actually a pretty good one. Whilst much of the time it might be seen as a moaning forum, there are some quite worrying threads that appear from time to time, and it may be that having this type of forum is beneficial to those wanting to ask advice, or just offload anonymously.

However, one of the recent threads that drew my attention was a post about how a practitioner felt he or she was so unsuccessful when compared to all the other dentists who were posting their personal and professional successes all over social media. This concern was so great in this practitioners mind that they were considering leaving the profession because of it. There has always been a degree of ‘Keeping up with the Jones’s’ in all aspects of our lives, and until one becomes satisfied with themselves as a person, there might always be a tendency to search for success via the medium of materialistic gains. However, what struck me in this case was what appears to be the sheer despair this person was feeling, and all as a result of what some people post on social media.

Social media to this person had become the real world, and the posts of amazing composites, perfect implants, and then fast cars, and exotic holidays was seen as the absolute reality of other peoples lives. The superficiality of such posts is obvious to many, but not to others who may already be suffering from a change in their perception of the world due to the mental health issues that appear to be quite common in our profession. It might not be so easy to ignore these sorts of posts when someone is feeling depressed by the profession, and the damage that this can then do could potentially be quite serious.

There seems to be a lack of humility generally on social media that is behind these types of posts. Whilst it is everyone’s right to post what they want and when they want, certainly the ‘Look at Me aren’t I great’, or the so-called ‘Humble brag’ type of posts sometimes serve only to sometimes make other people feel negatively toward the poster, or more worryingly, negative towards themselves. There is no background to a social media post usually, so the context is completely lost. Does the poster EVER have a bad day? Do they Ever have things go wrong in Clinic? Have they ever worried about their Health/Finances etc.? Given the tone of many of the posts we see, the answer to all the above appears to be no.

It’s important then to keep in mind all that happens on social media is NOT necessarily true, and that we should look more deeply into posts like this. It is vitally important that we should all keep in touch with the real world around us.

Social media is here to stay, but it needs taking with a large pinch of salt at times.

©Simon Thackeray, GDPUK Ltd, 2017
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