A Midsummer Night’s Dream

Kevin Lewis questions why we are continuing with the UDA system when there are other ways to deliver quality dentistry.

Not quite midsummer when you come to read this, I accept, but it was when I wrote it. Bear with me.

‘I have had a most rare vision. I have had a dream, past the wit of man to say what dream it was. Man is but an ass if he go about t’expound this dream.’

You may or may not recognise these words as those spoken by the character Nick Bottom, a village weaver in Shakespeare’s classic play whose title has been lent to this column. The whole point of the character is that he is totally self-absorbed and convinced of his own importance, and full of grotesquely grandiose ideas – yet has no appreciation of how incompetent and ridiculous he really is. Everybody else can see it, but he can’t. We have all had dealings with plenty of people like him, I am sure.

Puck, on the other hand, is busy, clever and endearingly naughty. This is made easier by the fact that Puck is a fairy, whereas Bottom is of course stuck with the handicap of being a human. It is the mischievous Puck who temporarily transforms Bottom’s head into that of an ass, thereby emphasising Bottom’s pomposity and foolishness. And yes, I know what you are thinking. If only…

Perverse incentives

Everybody knows that the UDA system is dreadful for dentists, we will get no public sympathy for that. But the system is also dreadful for patients in ways that are less obvious, and only now is the full scale of that dreadfulness starting to emerge.

It is almost 25 years since Sir Kenneth Bloomfield coined the term ‘perverse incentives’ when describing the dreadfulness of a previous system and yet the inbuilt incentives of the current system are every bit as bad and arguably a lot worse. If the public were to realise the harsh truth it would have more chance of becoming an agenda item. Unfortunately the story that the media would love the most is the suggestion that it is the fault of rich and greedy dentists and their ethics if they respond to those perverse incentives in ways that harm patients. And if dentists are seen to be doing this out of commercial self-interest, the media would have another field day. The Government can point to the fact that dentists are contractually obliged to offer everybody just about everything they need. And then express its disappointment and shake its disbelieving head and argue that it is hardly the fault of the system if dentists abuse it.

NHS dentists have long been accustomed to the expectation that they will do things for nothing and/or that they will always do the right thing for their patients, whether they are paid for it or not. Unlike the first round of Wimbledon, dentists don’t get paid £45k for stepping briskly onto the court and then limping in pain. Nor, unlike politicians, can they claim expenses for accommodation they are not using. NHS dentists are doubly fortunate in being able to spend an obscene proportion of their time on activity that attracts no fee whatsoever and if as a result of giving away so much of their time and profitability they also fall short of achieving their overall activity targets, they can hand back a significant part of any money that they have been paid. Who else can claim that?

England’s chief dental officer, Sara Hurley, fessed up that the clawbacks from dental contracts in England alone may well have soared to £95 million, and none of this remains in dentistry. She, I am sure, could put £95 million to good use elsewhere in dentistry rather than waving it goodbye. If I was the CDO I would be pretty angry and frustrated with the system that has allowed it to happen on her watch.

A most rare vision

If we could leave it to the fairies to work their magic, I sometimes wonder if they would apply disappearing lotion to NHS dentistry. Many believe that it has ceased to be a force for good, and for many fee-paying patients it’s an illusion anyway as the state contributes little or nothing towards the cost of their treatment. There is a growing view that it is also actively undermining the standards of care and inhibiting professional development. Yet dentistry existed and thrived long before the NHS was created and even had its own regulator for more than a quarter century before the NHS arrived into dentistry. Is it so much of a dream to imagine UK dentistry without it? Or a slimmed-down ‘core’ NHS service sitting within a comprehensive private service owned, operated and controlled by dentists, perhaps?

‘I know a bank where the wild thyme blows,

Where oxlips and the nodding violet grows,

Quite over-canopied with luscious woodbine,

With sweet musk-roses and with eglantine.’

Sounds too good to be true doesn’t it? That elusive flower-decked bank may well be the private sector in one form or another, but that is up to you. Even eglantine has sharp thorns to impale the unwary, because this is the real world. The real world, not the artificial, constructed parallel universe of UDA-land. Any of the above scenarios would be very different to individual dentists being fearful of leaving the NHS when others around them are staying signed up to it – and is there not a compelling honesty in telling the public that moving to a core NHS dental offering is a necessary part of making the NHS books balance? Frankly, it has become much easier to convince people there are fairies at the bottom of their garden, than to convince them of any merits in the UDA system. For many, it is more a question of recovering some independence and self-respect, autonomy and options.

Today’s young graduates emerge from dental school carrying massive student debt, as highly trained and highly qualified dental surgeons. And yet their reward is that they cannot even choose where in the country they will live and work, and in the blink of an eye they discover that they are disempowered ‘performers’ manacled to a system that is known to have been broken for over a decade. It is demoralising in all senses of the word, but primarily morale-sapping and a tragic waste of a precious resource and in case we haven’t realised, it’s a shabby abdication of our collective responsibility for the future of UK dentistry.

Sometimes you need to be able to rise above all the graft, pain, noise and nonsense to see things as they really are. And be honest with ourselves and with our patients how ridiculous it all is, rather than continuing to be a party to rationalising or justifying it in some way. As one fairy said to another in A Midsummer Night’s Dream,

‘Lord, what fools these mortals be.’

You may or may not believe in fairies, but maybe we are all too close to the action to realise how we look to others.

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