Kevin Lewis explains why recent seismic events in Westminster have been overshadowing subtle changes happening behind the scenes.
When somebody finally writes the book describing the events in British politics over the last few months, it’s going to be a struggle to decide whether it belongs on the ‘fiction’ or ‘non-fiction’ shelves.
While it’s true that you just couldn’t make it up, on this occasion, you don’t need to.
How appropriate, then, that a Commons vote on the ban on fracking for Shale Gas Bill, should unwittingly have triggered a day of such seismic shock and far-reaching aftershocks – but of course, the rumblings underfoot had started long before that.
You can probably imagine my nervousness when trying to write a meaningful column on UK dentistry in the face of all this carnage – especially given that a week or two passes between me writing it and anyone reading it.
In that time, you can change not just a cabinet or two but an entire furniture warehouse: the only three constants in Downing Street these days are Larry the cat, removal vans and journalists.
But I am concerned that some really important issues for dentistry will get buried or overshadowed by all the machinations surrounding the headline events.
A previous secretary of state for health famously delivered a promise that patients would be able to see their (medical) GP within a certain number of days. A momentary sighting in an adjacent aisle at Tescos didn’t count.
This target has since moved more times than the occupants of Downing Street and it was expanded to include telephone appointments as well as face-to-face consultations.
The Covid-19 pandemic helped to justify that, but this new ‘delivery channel’ (note how quickly I’m picking up the jargon) is now ‘baked-in’ (there I go again).
Identity crisis
Then came the more fundamental question of whether one’s healthcare need was being dealt with at an appropriate pay grade given the ever-expanding menu of proxies for seeing your (actual) medical GP. And very good they are too, mostly.
Most of us would much rather see a live nurse practitioner, practice nurse, clinical assistant (or whatever), than be told that there aren’t any GPs on duty today and somebody will call us to make an alternative booking.
Are the GPs themselves still in Tescos, one wonders, or perhaps fully occupied writing death certificates, given that since July 2022, pharmacists, physiotherapists, registered nurses and occupational therapists (but not dentists, interestingly enough) can all legally certify fit (AKA ‘sick’) notes for patients who require them.
I’m not sure that ‘seeing your GP’ or even the subtly distinct ‘getting an appointment with your GP’ is quite the same as chatting on the phone with someone who once worked in the same building as your GP. Call me old fashioned.
The government’s plan to make much greater use of dental therapists to secure the continued delivery of primary care dentistry follows the same strategic direction.
It was at one stage the worst kept secret in dentistry, but is now the subject of an information blitz and charm offensive.
Earlier in my career, I was a vice president of the British Association of Dental Therapists, and I have long been a fan.
But it’s not difficult to detect that the penny has dropped at Westminster that thousands of dentists who have been driven away from the NHS will not be returning.
A way, therefore, needs to be found to obfuscate and mitigate the political fallout from that fact.
Descriptions
The Dentists Act specifically protects the use of the titles of ‘dentist’ and ‘dental surgeon’ and similarly reserves the formally recognised titles of the various categories of DCP, for those who are registered by the GDC in the relevant categories.
Strange as it may seem, there is no specific formal protection of titles such as ‘orthodontist’, because technically and legally speaking there is no such thing as an ‘orthodontist’, even though the GDC maintains a specialist list for orthodontics.
Instead, you are (or are not) included on the specialist list for orthodontics held by the GDC, and the same applies to the other 12 specialties that are recognised by the GDC.
You can only call yourself a specialist if you are on a specialist list.
Then things get even murkier because there is no recognised specialty or specialist list for implant dentistry or ‘implantology’ and it is not unusual to encounter dentists describing themselves as ‘implantologists’.
This is about as meaningful as calling yourself a ‘fillingologist’, but some people believe that it bestows some kind of virtual status, authority and recognition upon their exploits. ‘Exploits’ and ‘exploitation’ being the operative words in some cases.
But before and during 2022, the GDC has been working quietly behind the scenes with COPDEND and the specialty advisory committees (SACs) to tidy up the anomalies regarding access to the monospecialty lists (eg perio, endo, prostho) within the canopy of restorative dentistry, and to revise the specialty curricula more generally.
The original aim to put new ones into place by September 2022 has been deferred to September 2023, so watch this space. Closely.
Meanwhile, the master plans to solve the staffing crisis in many parts of healthcare (including NHS dentistry) and social care, in hospitality and the leisure industry, in agriculture and the food chain and elsewhere, all relied heavily upon immigration and the swift relaxation of the rules on immigration and on any restrictions/barriers to those new arrivals joining the UK workforce and where necessary being granted fast-tracked ‘equivalence’ in any qualification/registration terms.
And this brought the (then) home secretary onto a collision course with several cabinet colleagues as well as the (then) PM because the (then) home secretary was outspokenly committed to the 2019 conservative manifesto and its promise to get a firmer grip on immigration and to reduce net immigration.
Whatever your view, it was clearly not destined to end well. And it didn’t.
Gatekeepers
But the emerging big picture is that GDPs are increasingly seen as the awkward squad.
Right now, they are also the primary gatekeepers to NHS dentistry, controlling the feeding chain, referring upwards to secondary (specialist) care and downwards to therapists, hygienists, dental nurses and the other groups of trained and registered DCPs.
But they also control the increasingly important third referral channel – to themselves, but in the private sector.
The timing of the rapid re-positioning of dental therapists in the primary dental care firmament is not accidental and we are likely to see a lot more blurring of the edges of the scope of practice debate in the years ahead, just as we have seen in primary care medicine.
Whether you view this as a threat or an opportunity is for you to decide, but it’s not going away.
Alongside this, we should be keeping one eye on the burgeoning ménage à trois of the corporates, the GDC and the government because the corporates are viewed as a means of disempowering the awkward squad.
Migrating towards the best option
But have lessons from history been learned? The UK has, in theory, about 44,000 registered dentists but still only 5,000 registered dental therapists. Many of the former don’t currently work in the UK at all, and many more don’t work in the NHS at all.
Similarly, a significant proportion of the therapists work exclusively or largely as dental hygienists, supplementing the 8,700 registered hygienists – but doing more private work than ever before.
Canada, Australia, New Zealand and scores of other countries have well-developed training and career progression pathways for dental therapists, oral health therapists and dental hygienists.
We have some excellent training here too, and (through the College of General Dentistry) are on the cusp of matching that with world-leading career pathways for all DCPs as well as for dentists working in primary care.
But most people tend to migrate towards the best option(s) available to them, and when they have worked hard to achieve a professional qualification, who could blame them?
The recent strike of junior barristers working at the criminal bar may have surprised many, given the general perception that barristers are hardly likely to be clogging up the queues at food banks.
But the reality is that many of them are doing just that, in between working at government-controlled legal aid rates well below the minimum wage for the hours they work.
So, it’s true that money talks, but crime doesn’t pay.
Everyone has a tipping point at which they need a serious re-think. And barristers – like NHS dentists and politicians – seem to have reached it.
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