Mesio-angular impactions

‘Whose bright idea was this?’ is sadly a question that one hears with depressing regularity in dental circles these days. And it tends to be asked with a somewhat different emphasis than when it was first used. Its easy to imagine the rush as Humphrey Davy and Thomas Edison lurched to take the credit for electric light. But, in dentistry, it is more like the AGM of The Magic Circle, such is the propensity of the responsible parties to disappear without trace as soon as the full horror of the implications of their ‘bright ideas’ comes to light – if you will excuse the pun.

Since Jimmy Carter embedded the approach in the US, politicians and legislators in many parts of the world (including the UK) have been obliged to carry out a Regulatory Impact Assessment (RIA) as part of the process of introducing new legislation. These days, the prefix ‘Regulatory’ is generally dispensed with since actual regulations are the least of our problems such has been the proliferation of other forms of governance and direction from on high. Some Impact Assessments (IAs) undertaken since then have been famously wide of the mark or economical with reality, but the principle remains an excellent one that should be adopted more widely than is usually the case.
Perversely, it has become the norm to undertake health impact assessments when seeking to design and implement projects, policies and plans, but before you get too excited, it is the health of patients and the public at large that is the concern of these HIAs, rather than the impact upon the health and wellbeing of healthcare providers.

Pause for thought
Most of the problems stem from an alarming disconnect between the architects of policies and those who end up being the victims of them, or the people having to make them work. This can arise from just not understanding the possible consequences, or from being so preoccupied with other objectives that you never give them much thought. Sometimes, the people concerned know exactly what the impact will be, but choose not to let it concern them.
The GDC came within a few microns of several spectacular own goals over issues that included the ‘call me doctor’ debacle, its original guidance on non-surgical cosmetic treatment and some of its pronouncements regarding bleaching/tooth whitening. The fancy footwork in relation to the shortened graduate entry dental degree programmes is ongoing but still embarrassing. And fancy though it might have been after the gaffe came to light, it is still more reminiscent of Les Dawson and the Collyhurst Cloggers than of Riverdance. What we are suffering even now on the Fitness to Practise front is the legacy of some ill-considered decisions made a few years ago, but who has felt the brunt of the impact? Twice over, too, because registrants get hit in the midriff by the consequences and, again, in the pocket by the ARF that is needed to pay for it all. At least there are signs that the Fitness to Practise supertanker is starting to turn around, and not before time.
The adverse impact of the 2006 NHS contract in England and Wales has been so profound, in so many different ways, that even the most pessimistic observers could never have foreseen how much long-term damage it would leave in its wake. The present clamour surrounding the proposed NHS reforms and the new medical GP contract, and the government’s determination to push through with these changes in the face of all this opposition, should leave us in no doubt that IAs have much less of an impact on politicians and legislators than they do on the people that will be affected. Civil servants have learnt how to manipulate the process in order to talk down the negative impact of anything that the government of the day is determined to do anyway.

No flies on us?
The introduction of CQC into primary dental care in England, at what seemed like the worst possible moment – at least until an even worse one followed it – provided a real education in the IA process. Nobody could have been in any doubt that the impact was going to be huge, but it is always possible to argue that it is a price worth paying, especially when the worst of the impact is likely to be upon soft targets and when you can run a public interest argument on the benefits side of the equation. I am not suggesting there have been no benefits at all, because I am convinced that there have in the wider sense. But the question that needs to be asked is whether the scale of the original problem and the scale of the potential benefits, is proportional to the burden it has placed on the affected parties. The secondary questions to ask when imposing change are whether the timing is right, what other things are impacting upon the same people at the same time, and whether it makes sense when viewed alongside other things that might need to be done. In the case of CQC, I would love to have been a fly on the wall when it was decided to prioritise primary dental care over primary medical care, and when it was decided that the two-year delay for the medical GP practices was inconsequential compared to the horrors that needed fixing in all those dreadful dental practices. At least we can be sure that if there are any flies left on the walls of primary dental care practices, someone from CQC will have counted them by now. Meanwhile, the flies on the walls of medical GP practices can relax for a while. What seems to be missing, time after time, is a rational and informed assessment not of the immediate impact of a change in the law, rules, regulations, guidance and all the other ‘stuff’ that comes our way, but of the secondary implications and longer term consequences and the effect that the change might have on attitudes, behaviour and morale. Because CQC took time, energy and money away from practice owners, it less obviously took time, energy and money out of patient care at the same time. But much more profoundly it was a tipping point, when many felt that enough was enough.

Blind date
At this time of year, more than 1,000 new graduates are about to start their first job in Foundation Training (or VT, if you haven’t been following past episodes of this story). You might have thought that the end of FT/VT for one-year cohort of recent graduates would naturally coincide with the start of FT/VT for the next year. Obviously, that would make perfect sense as it would cause chaos if different deaneries started and finished their FT/VT programmes at different times. Or if practice owners/trainers suddenly found themselves with an empty surgery for a month. Or if, in a year from now, hundreds of FD1s exited their FT/VT year a month after everyone else and found that all the best associateship jobs had been snapped up. You have probably already guessed what I am about to tell you – a significant number of VT/FT schemes will now start and finish in September, not August. You might also have thought that an impact assessment was a prerequisite for a far-reaching decision like this, but there you would be wrong.

A year ago, National Recruitment and central ‘sight unseen’ allocation of FD/VT places went live across the country so new graduates ended up with trainers they had never met in practices they had never seen, and practice owners entrusted their patients and practice goodwill to their new employees who they had not chosen. So sanitised were the CVs, and so stripped of any meaningful information, that nobody had given a thought to what would happen if a left-handed graduate was placed in a surgery that would only be possible for a right-handed dentist to work in. With handpieces, cables, instruments and materials being dragged from one side of the surgery to the other and dentists, patients and nurses coping with the fallout – so to speak – it gives a whole new meaning to impact assessment.
Sometimes, UK dentistry really does seem like a classic case of the blind leading the blind, leading the blind – a situation where impacts will never be far away.

Kevin Lewis is renowned for his vibrant and influential writing, where he imparts his unique insight into UK dentistry. In his 20 years in full-time general practice, Kevin developed special interests in preventive dentistry and practice management.
He has been involved with Dental Protection since 1989, initially on the board of directors, then as dento-legal advisor, before being appointed dental director in 1998. Kevin is  also a popular speaker, lecturing on a variety of issues at many different events worldwide.
He has contributed to two CD training programmes on infection control, and a BDA A12 Advice Sheet. In 2003, he became a member of the Council of the Medical Protection Society.


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