Kevin Lewis – new year, same problems

It may be a time for contemplating the future, but Kevin Lewis suggests that we shouldn’t ignore the clues and problems from the past.

Welcome to mensis ianuarius, as they used to say in Rome – the month of January. The Romans used a 12-month lunar calendar but settled on the wizard wheeze of a ten-month year ending in December – as in ‘Septem’ (seven) through to ‘Decem’ (ten) – choosing to disregard the ‘bleak mid-winter’ and starting again in March when it started to warm up a bit. I wish I’d thought of that, but in fairness I was quite young at the time.

January was added later, as an afterthought – just like dentistry. It’s just over 100 years since the first substantive attempts to regulate UK dentistry. A loose system of voluntary registration with the General Medical Council (GMC) had operated since 1878 and those who were already practising dentistry in 1921 were grandparented onto the new register, but thereafter all new applicants needed to have an approved qualification.

The new Dental Board was regulating both the people who were practising dentistry, and/or carrying on the business of dentistry (ie, owning and operating dental practices), and also – for the first time – regulating what they were doing and how.

There was always a carve-out that preserved the right of medics to practise dentistry if they chose to, but otherwise it became illegal for any unregistered person or body corporate to practise dentistry, or to own/operate a practice. One of the statutory functions of the GDC was to enforce that – in the courts if necessary – which in turn begged the question of what was and was not ‘dentistry’.

The dental landscape

The old answer used to be ‘dentistry is what dentists do’ but dentists now do different things and the GDC faces the cleft stick of having to regulate dentists for doing new things that it knows little or nothing about, hesitating to pronounce something as being ‘dentistry’ if it can legally be done by non-dentists (or if it is a grey area), and thereby avoiding backing itself into the awkward corner of having to attempt to prosecute these non-dentists for the illegal practise of ‘dentistry’.

But that was then, and this is now. The landscape has since been transformed and the GDC is dealing with new and different manifestations of the same old problems.

Overseas-trained dentists are no longer the exception but have become a crucial part of the mix, especially for the delivery of NHS dentistry. The cavalry once came from Australia, New Zealand and South Africa, then from Europe, and now increasingly from the rest of the world (but especially the Indian sub-continent and other hotspots in Asia).

As academic entry thresholds for the UK dental schools have moved inexorably higher, a more recent and expanding stream is being seen in the shape of UK-born and educated students graduating abroad and then returning to work back home in the UK.

Corporates are no longer the exception either, partly because they may not be UK-owned and controlled but also because ‘dentistry’ itself is no longer limited to the things that are taught at dental school. Indeed, the alternative menu of ‘dentistry’ (sic.) is fast becoming the new mainstream that many patients are prepared to buy, many dentists can’t wait to do (privately) and a variety of new players want a slice of.

It’s where the market is, where the money is, and in case the GDC asks, it’s dentistry Jim – but not as we know it.

Smile Direct

Recent events have illustrated the scale of the problem. The collapse of Smile Direct Club last month has been foreshadowed for a while after several years of crisis in its ‘home’ US business, which prompted the company to look for new markets in the UK and more recently in Australia and Canada. The direct-to-public delivery of aligners, tooth whitening accessories, sports mouthguards and even anti-snoring devices has presented a range of new challenges for dental regulators in many parts of the world.

It underlines the urgent need to understand and tidy up corporate opportunism and teledentistry and workarounds like ‘virtual supervision’ – token and usually un-named dentists who act as ‘middlepersons’ to legitimise illegal dentistry by creating the illusion that a suitably experienced UK-registered dentist is on top of things. The only thing they are notionally on top of is the notepaper, except for the small detail that there isn’t any. The identity of these enabling dentists is deliberately obscure and doesn’t even appear on the websites of most of these companies.

Now that digital scans are widely used as an alternative to impressions, shopfronts can be (and have been) used as an incredibly cheap ‘front end’ without a single GDC registration or piece of dental equipment in sight. The GDC has fought a half-decent rearguard action by issuing guidance for UK registrants and information for the public, but fought shy of taking on the companies, their directors, or their front-end representatives.

The barefaced cheek of Smile Direct Club’s advice to (former) patients takes some digesting and many UK dentists have been erased for a lot less.

Play by the same rules

You are no longer a patient, your treatment and lifetime guarantee is hereby cancelled but if you have been paying us by direct debit don’t forget that you must keep up the payments in full until the total amount has been paid off. In the meanwhile find yourself a dentist (good luck with that) and pay them to pick up your treatment where we left off, even though all our marketing lured you in by persuading you that it was better, cheaper and easier to ‘cut out the middle man’ and deal direct with the aligner supplier. Not any more it isn’t.

The old adage ‘when in Rome…’ should extend to dentistry. If you want to work or operate a dental practice in the UK dental market, then play by the same rules as everyone else. Smile Direct thought it was smarter, but it turns out it wasn’t. If you want to do the work of a registered dentist, then train as a dentist. Not a compressed, fast-track form of shortcut dental training or ‘lift’ training, but the same robust training as any other undergraduate UK dental student must undertake.

If you want to do things that demand specialist knowledge and expertise, then undertake and complete specialist training or obtain a proper recognised qualification rather than attending Noddy’s Short Course in Brain Surgery, with visiting virtual professor Big Ears chipping in for an occasional session.

Mr Plod at the GDC should start taking postgraduation training and credentialing more seriously instead of abandoning the public to be misled into believing that those who ‘big themselves up’ and claim or imply special or specialist expertise are the real McCoy, when they have no such specialist training at all.

Much ado about Nuffield

The latest report from the Nuffield Trust, released a few days before Christmas, takes some digesting too and it was quickly picked up by the media across all formats.

It concluded that universally available NHS dentistry is all but lost given that neither of the main parties have shown the necessary appetite to resuscitate it before the vital signs started to disappear (along with the workforce).

The winner of this year’s General Election will be forced to concede, on their watch, that nothing that can be done now – not even a huge injection of money – has an ice cream’s chance in hell of rescuing the situation. Instead, the quandary is to find a sustainable and acceptable ‘new normal’.

As Nuffield shrewdly observes: ‘Policy makers need to work out which of a series of politically unpalatable choices they wish to make.’ Nuffield lands uncannily close to the view of the 1993 Health Select Committee (a targeted core service) and my own semi-recovery plan remains a hybrid of that, and a modified form of grant-in-aid or voucher scheme (which has worked pretty well for the opticians).

A year of optimism?

January takes its name from Janus, the Roman deity often pictured as having two faces looking in opposing directions. At this time of year I think we all do a bit of that: reflecting on the past and looking forward to what the future might hold.

Janus was the god of passage; of endings and beginnings, of opportunities and gateways and transition to better things and places. But after 60 years of successive governments failing to find an NHS dental system that they could effectively control, no political party can claim to be the saviour and protector of NHS dentistry.

After all it was Labour who dreamed up and imposed the 2006 UDA-based contract in England and Wales, following which Andy Burnham and then the incoming Tory/Lib Dem coalition turned a blind eye when its fundamental problems were first coming home to roost after the initial transition period.

More recently it has been a constantly revolving doorful of Conservative ministers who have all allowed the same ghastly and destructive status quo to continue – mostly because it delivers much greater government and treasury control than any alternative.

So be optimistic about the new year, by all means – but perhaps not about a new NHS contract that will be any better for dentists or their patients.