Kevin Lewis – square pegs, round holes and other conundrums

Kevin lewis NHSAs conversations concerning NHS dentistry continue to reverberate, Kevin Lewis offers up his own take on the unfolding crisis.

Albert Einstein wasn’t a dentist, as far as I am aware. We will never know for sure whether or not he ever made that much-quoted observation that the definition of insanity is doing the same thing over and over again, and expecting different results.  

This insightful quote has been attributed to him so often over the past century. It would seem almost disrespectful to strip him of the credit at this late stage.

A couple of months ago, I gave a cautious welcome to the incoming Health Minister with responsibility for dentistry, Maria Caulfield.

I also referred to NHS dentistry as having reached a tipping point. It’s edging ever-closer to a precipice beyond which a credible, meaningful service could not exist. Primarily, because it depends upon having (and retaining) a huge number of dentists. Dentists that are ready, willing and able to deliver a proper service.

Different challenges

Each of the four countries of the UK has its own challenges at the present moment. Each are seeking to manage them in different ways.

You know when you have got it wrong when you are continually deafened by a chorus of disapproval from the very people you need to be winning over.

And so it has proved in recent weeks, most particularly in England, but also across the rest of the UK.

In mid-January the Minister did not mince her words when referring to ‘the disastrous contract of 2006’. A Conservative parliamentary colleague agreed that it ‘is no longer fit for purpose’. Also, that it ‘holds dentistry away from the people who need it’.  

Across the UK the profession’s representatives are telling their respective governments that the pandemic has worsened an already-dire crisis and they need to act quickly and decisively.

NHS England clearly misinterpreted that exhortation, announcing quickly and decisively that the 100 practices who had been acting in the greater good by serving as the ‘prototypes’ to test alternative models of delivery to replace the lamentable UDA system, would be expected to return to standard UDA-based contracts as from April.

That will for most of them be a mighty shock to the system. The only ‘concession’ would be a 8% ‘funnel’ so that they could escape financial penalties if they achieve 90% of their contracted UDA level in their first year back on the treadmill.

The BDA described this as being ‘thrown under the bus’ by the government, perhaps only omitting to add the small detail that the bus is moving at the time in question.

Myths and fallacies

It is often said that you can’t fit a square peg into a round hole. And yet we all know that you can – if the peg is small enough and the hole is large enough.

Dentists have been that square peg in the round hole of NHS dentistry for most of the past 70+ years of its existence.  

At the best of times we are a rotten fit with the rest of the NHS. We are both regarded as such and treated as such.

We have muddled along reasonably well for short periods, but time and time again successive governments have felt the need to make the hole smaller and as a result, the peg got cramped for space and progressively squeezed.

That point has been reached again with NHS England cranking up the pressure on returning to pre-Covid activity levels in full knowledge of the many practical obstacles to achieving that.

They might as well just ask for the money back and forget about the activity. Perversely, for some practices it will make more sense to quietly accept the financial penalty, in order to avoid the even greater possible losses they might incur if they attempt to ‘churn through’ the additional activity required.  

Given the massive check up and treatment backlog, which was not of the profession’s making, there is a lot of Band 2 treatment out there waiting to be done and once the minimum Band 2 criteria had been achieved, everything else for that patient would attract extra costs without generating any additional revenue.

Be realistic

In Scotland and Northern Ireland a fee per item system survives (just about) and softens the pain of the rates being set so unrealistically low.

But expecting people to work for low rates is one thing. Expecting them to work for nothing at all (as in England and Wales) is crazier still. But doing this and expecting them to reach into their own pockets and subsidise a mountain of additional work takes it to a new level of lunacy. You can’t get more unrealistic than that.

The NHS itself reports that the number of dentists who carried out any level of NHS activity in fell by about 1,000  (roughly 4%) last year and continues to fall.

Meanwhile the GDC has reported – contrary to the expectations of many observers – a slight increase in the total UK number of registered dentists at the end of 2021, when compared to a year earlier.

The BDA’s own research indicates more than half of dentists currently working in the NHS are planning to reduce their NHS commitment and activity in the year ahead. I think there is clue nestling in there somewhere.

While the NHS wants its missing activity back for political reasons, the Treasury wants it for other reasons. 

Patient Charge Revenue (PCR) disappeared into a deep, dark hole during the pandemic. The Chancellor wants his missing £600m back from 2020-21, as well as an unquantified sum for the current fiscal year.

PCR is part of how the government funds NHS dentistry. Without its restoration, the squeeze will soon be applied yet again.

Knee-jerk reaction

Despite this, the government announced an extra £50m  available to commissioners in England, in order to secure additional activity from NHS dental practices outside normal contracted working hours.

But while any additional investment into dentistry must in principle be welcomed, this knee-jerk reaction to growing public and cross-party pressure has been dismissed as something of a political stunt and empty gesture. 

The extra money has to be spent by the end of next month. You can’t commission services from practices that aren’t there any more. Nor from practices that are already working long and punitive extra hours and scrambling to meet their existing targets. 

Nor can you get patients seen by the 1,000 dentists that have already left the NHS.

In all probability the money won’t all be spent. No doubt this fact will be used as a stick with which to beat the profession. As well as a headline to point to, whenever awkward access criticisms arise.

Little Bo Peep

Maria Caulfield, as I highlighted in my column welcoming her to office, has a daunting ministerial portfolio of which dentistry is only a very small part.

I don’t know how many hours she gets in a typical day. Although, she famously claims that in her spare time she ‘looks after some sheep’.  

We hope and trust that she is not referring here to her responsibilities for primary care dentistry.

But just in case she was, please feel welcome to sing along with the lyrics of this old nursery rhyme. It comes with an educational sting in its tail:


Little Bo Peep has lost her sheep

And doesn’t know where to find them.

Leave them alone and they’ll come home,

Bringing their tails behind them.


Little Bo peep fell fast asleep

And dreamt she heard them bleating,

But when she awoke, she found it a joke,

For they were all still fleeting.


Then up she took her little crook

Determined for to find them.

She found them indeed, but it made her heart bleed,

For they’d left the NHS behind them.


And as for the last line there, guilty as charged. Sorry about that.

It is true that many times in the past the profession has threatened a lot. However, in the end most dentists fell into line and got on with it.  I genuinely believe that this time around, something more is stirring.  

The government may well be foolish enough or sufficiently out of tune with rank-and-file dentistry to assume that it can hold its nerve in time-honoured fashion and expect normal service to resume.

On this occasion they might well encounter a very different result. I will leave you to decide whether it is the government or the profession that is showing signs of insanity.

Catch previous Kevin Lewis columns

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