Kevin Lewis – an exercise in recycling

Kevin Lewis discusses recycling ideas in dentistry

Kevin Lewis discovers that, in NHS dentistry, new ideas and new solutions appear to be in very short supply.

The government’s green credentials may be in a state of flux – especially after its better-than-expected outcome in the recent Uxbridge and Ruislip by-election – and Labour is clearly bristling at the one that got away and reflecting upon the electoral impact of the London mayor’s ULEZ ambitions. But in dentistry, the recycling agenda appears to be alive and well.

The House of Commons Health Committee’s report on the crisis in NHS dentistry was published in mid-July. One of its most striking (and revealing) observations was this: ‘It is frustrating to have to return to recommendations made by our predecessor committee 15 years ago that still haven’t been implemented.’

That earlier Health Committee had reported in 2008, a couple of years into the ill-fated, UDA-based contract. The clairvoyants who comprised that committee had even then correctly anticipated ‘trouble ahead’ in terms of the recruitment and retention of NHS dentists. They could hardly have guessed just how much trouble.

‘Yet another crisis in NHS dentistry’

Going back a further 15 years, it is almost exactly 30 years ago that an even earlier Health Committee was discussing yet another crisis in NHS dentistry. On that occasion, in the wake of the 1990 contract reforms and the government’s clumsy responses in 1991 and 1992 after concluding that the profession was doing far too well – or at least much better than intended.

The profession had overwhelmingly voted against those reforms, just as it had done when NHS dentistry was first introduced in 1948. The key difference in 1992/3 was that many in the profession felt by that stage that they been let down once too often and they sailed off into the private sector, mostly never to return.

In 1948, practitioners still believed that commercially they couldn’t afford not to be in the (then free of charge) NHS, in the face of almost unlimited demand and post-war austerity. By 1993, a new generation of dentists was battle scarred, less trusting, older and a lot wiser.

In its 1993 report the (then) Health Committee commented that: ‘The present system of remuneration for dentists seems to have an inherent leaning towards instability which threatens to undermine the commitment of dental practitioners to the NHS.’

Also, that: ‘The productivity incentives in the current system exert pressure on the quality of care.’

‘We have made the improbable and impossible work’

Through one set of reforms after another, the profession has traditionally rolled up its sleeves, applied a bit of creative thinking and real-world ‘nous’, and made it work. We all know the line about people who fail to learn the lessons of history being doomed to repeat it, but in UK dentistry, we are turning this into something of an art form. The truth is that we have made the improbable and impossible work far too often, and far too well.

About 20 years ago, Tony Blair famously promised that everyone who wanted to see an NHS dentist would be able to do so. This was mighty clever wordcrafting at the time because it shifted the focus away from actual need to demand and patient empowerment and choice (then very much in vogue). It was therefore subtly different to the aspiration recently voiced by Neil O’Brien (Parliamentary Under-Secretary of State for Primary Care and Public Health) in his evidence to the Health Committee: ‘We do want everyone who needs one to be able to access an NHS dentist.’

Naughty and NICE

Shortly afterwards, the new Labour government released its NHS Plan, the National Institute for Health and Care Excellence (NICE) and other healthcare agencies saw the light of day. In 2002, dentistry’s own Options for Change document (Options) was published. The original NICE Guidelines on Dental Recall Intervals (2004) conveniently challenged the time-honoured ‘six-monthly checkup’ tradition (‘four-monthly checkup’ in the case of children – a legacy of the NHS fee-per-item payment system).

But in the absence of any credible, robust evidence to support the much longer intervals recommended by NICE, they were viewed with deep suspicion as a convenient ruse to solve the dental access crisis prevalent at that time by keeping largely healthy patients out of dentists waiting rooms and thereby freeing up dental capacity.

How interesting, then, that the 2023 Health Committee reaches for the same NICE guidelines to flag up ‘available’ NHS dental capacity, calling upon NHS England to more rigorously police those defaulters who appear to be seeing their patients more regularly. I wonder whose idea that was?

Options for Change

A reflective BDJ article at the time (2003) explained that Options ‘has been described as perhaps the most radical and ground-breaking opportunity for NHS dentistry to finally move forward after prolonged periods of stagnation and disharmony. The Options agenda has the potential to bring in a new style of NHS practice for dentistry, providing a way to finally get off the current “treadmill” and to develop new NHS dental services where prevention is a priority and providing high quality dental treatment, tailored to the long-term needs of the 21st-century patient, is the driving aim.

‘However, the difficulties on all sides of leaving behind decades of disputes and overcoming real access, workforce and funding issues must not be underestimated or dismissed.’

Options dangled the carrot of a better working life for NHS dentists, more time with patients, a reduced focus on output and volume and a greater emphasis on prevention and quality. Also, a new focus on patient experience and choice (and the active encouragement of NHS/private mixing, a bit ironic given the recent events in the Williams v GDC furore), a greater use of skill mix, more flexible and locally sensitive commissioning based on need, and addressing health inequalities.

‘It was all illusory’

The only thing not to like about it was that it was all illusory. Somehow, all that early promise ended up with the ghastly 2006 dental contract, which in many respects achieved precisely the opposite of the laudable aims listed above. As things turned out, devolution had (in 1999) already come to rescue of dentists in Scotland and Northern Ireland, who thereby dodged the destructive bullet of the 2006 contract that was imposed upon dentists in England and Wales.

Jimmy Steele produced his excellent report in 2009 when things were already starting to go horribly wrong again, and again, there was a lot to like about it – but sadly, what dentists and the public want and need is not something that successive governments appear to have an appetite to pay for.

We don’t need any more reports to tell us that.

Encore une fois

If you place yourself in a dark corner somewhere, and read the latest report of the Health Committee line by line, there is something hauntingly familiar about the analysis and recommendations. I had to check that I wasn’t reading the 1993 report or Options for Change by mistake.

Yes, by common agreement we have (yet) another crisis on our hands, and many of the wonderful things that we would all love to see happen are just as alluring today as they were at the time of the post-mortems on all the previous dental contract crises. But if we keep coming up with the same high aspirations and empty promises, the consequences will be as depressingly familiar as on all the previous occasions.

‘These are not sustainable solutions’

With one slight exception, I think. This time, one detects a whiff of genuine, unadulterated desperation. Once you start talking about locking new graduates into working in an NHS system that older, more experienced dentists have abandoned as being unfit for human consumption (let alone purpose), and detrimental to their financial, general and mental health and wellbeing, that is what desperation looks and smells like.

The shortsightedness of anyone thinking that overseas-trained dentists will find that same flawed system irresistible on anything beyond a very short-term basis is beyond me. These are not sustainable solutions.

Do you really want to penalise home-grown dental graduates and/or treat them less favourably than new arrivals who trained elsewhere? That would do wonders for university applications for many degree courses on offer to school-leavers and those with other first degrees – but not for applications to study dentistry. The Health Committee reports that this ‘tie-in’ suggestion came from NHS England, which is predictable while at the same time beggaring belief and betraying a paucity of ideas and ambition.

The NHS Dental Recovery Plan may have been released in the interval between me writing this column and its publication. If so, may I wish those of you who read it a speedy and pleasant recovery over the remainder of the summer.