Kevin Lewis: examining the NHS dental recovery plan

We may already be unwilling participants in the latest of a long line of historic workforce miscalculations, Kevin Lewis discovers. But are the clues in the past, the present or the future?

Aficionados of Star Wars will no doubt shudder at my shameless purloining of the timeless adios made famous by Obi-Wan Kenobi. But there is method in my apparent madness.

A long time ago, in a galaxy far, far away there was a country called the United Kingdom. At the time the first Star Wars movie was released (1977) there were 20,000 dentists registered to work in the kingdom. Great minds of unfathomable depth on the dark side decided that this was far too many, so a master plan was devised to start closing three of the 16 undergraduate dental schools in existence at that time, and that hatchet job took place during the 1980s. Not long after the third of these schools (Edinburgh) held its final graduation party in the early 1990s, the great minds on the dark side decided that someone in a parallel galaxy must have miscalculated, and we needed more dentists after all.

Workforce master plans

So, another master plan was devised, which involved the opening of three new dental schools on remote planets called Preston, Plymouth and Aberdeen. Once humankind had spent four years on these distant planets, the great minds postulated, they would want to stay there and set up new civilisations, solving the longstanding problem of the uneven geographic distribution of UK dentists and ensuring that everyone would have access to NHS dentistry, no matter where they lived. If you are already thinking that you know how this bedtime story ends, hold that thought for a moment.

Workforce planning is well known to be an imprecise science, and in healthcare there are so many moving parts to factor in that one wonders why anyone ever bothers. Whatever you come up with will almost certainly be proved wrong, but not necessarily for the reasons one might have expected (but clearly didn’t). The only mystery for outside observers is the striking tendency for each generation of great minds to re-discover and recycle flawed assumptions and failed strategies from previous master plans announced by the dark side in response to some previous crisis or another.

Payback and fairness

Every genius workforce plan since the beginning of time has proved to be glaringly wide of the mark and I have no reason to believe that the latest NHS incarnation will be any different. The dental recovery plan has been widely criticised (including in this column) but it wasn’t all bonkers. An ‘OMG’ moment for dentists who graduated pre-2000 and remembered how things used to be was the stark statement that one in three dentists with a registered address in England currently do no NHS work at all in England. The scale of that statistic is eclipsed only by the political reaction to it.

For example: ‘The taxpayer makes a significant investment in the education and training of dentists in England. It is fair that the public expects this investment to be reflected in access for patients to NHS dentistry.’ Coupled with this: ‘We recognise that a significant proportion of dental graduates are likely to live and work near their dental school after graduation. Therefore, we wish to undertake this expansion (of dental school places) in a way that is targeted to improve provision in areas of the country where it is most needed.’

‘Unfit for purpose’

Against the political background of the growing number of ‘dental deserts’, the references to the geographically targeted ‘allocation’ of dental undergraduate places and (no doubt) foundation training places too, is understandable but potentially troubling. The dental deserts in England have not been caused by dentists – they are the direct result of government policy, the ghastly UDA system and the lack of belief that any government, of any political complexion, has the courage and appetite to reform and re-finance NHS dentistry on a scale sufficient to attract and retain dentists again. Forcing them to work in a system that is known to be broken and unfit for purpose is not a long-term solution and the government should be considering fairness to them, as well as to taxpayers.

This begs the question of whether school leavers choose and apply for a university degree course in dentistry – accepting the inevitability of all the significant student debt involved – in order to graduate as a dentist, or simply to become compliant cannon-fodder within the NHS workforce in a part of the country to be dictated by the NHS. No other comparable university graduates have to suffer this fate.

Thirty years have passed since the publication of the Nuffield Report into the education and training of personnel auxiliary to dentistry, and 25 years since the extended and sometimes heated debate prompted by the influential DARG (Dental Auxiliaries Review Group) report. But time stands still, it seems, because many of the ideas in the latest NHS workforce plan and the workforce-related proposals in the dental recovery plan are hauntingly familiar from those two reports dating from all those years ago.

Optical illusion

Modern-day politicians clearly subscribe to the ‘if it looks like a duck, walks like a duck, quacks like a duck…. (etc)’ school of thinking because whenever a highly trained but socially important (and politically sensitive) workforce is disaffected, demoralised and/or in short supply, the go-to response is to create an alternative workforce that can be wheeled in to replace or be passed off as the one that has gone AWOL (or something resembling it). The tactic also works when the original workforce is flexing its muscles and/or threatening to go AWOL, as a ploy to concentrate their minds and reduce their bargaining power, while maintaining the illusion for public perception purposes that nothing much has changed.

Even the workforce numbers can be airbrushed to obfuscate the reality. Consider for a moment the police community support officers (and their subtly misleading uniforms), the teaching support assistants and learning support assistants in classrooms, the battalions of physician associates, GP assistants, nurse practitioners, first contact practitioners, advanced clinical practitioners, clinical assistants, treatment co-ordinators, trainee nursing associates and other exotic flowers blooming in the garden of your local medical GP practice.

‘Use the Force’

No surprise then that the latest master plan includes cryptic, heavily coded clues that we can expect much of the same. For example: ‘Enabling dental care professionals (DCPs) to work to their full scope of practice would improve access to NHS dental care for patients and allow dentists to focus on delivering more complex care, which only they can provide. However, there needs to be a shift in mindset to change the current ways of working. To encourage this culture change, we have published guidance clarifying how skill mix in NHS practice can be used within existing regulations.’

When Obi-Wan Kenobi famously urged Luke Skywalker to ‘use the Force’, I am not sure this is what he had in mind. It is insulting and disingenuous in the extreme to suggest that what disaffected NHS dentists have needed through the past 18 painful years since UDAs became the latest instrument of torture is ‘a shift in mindset’ and/or a ‘culture change’. Unless, of course, the shift in mindset includes an improved sense of optimism for the future, trust, mental health and wellbeing, and a belief that their skills are genuinely recognised and valued in their own right, and not simply as a means of taking some of the public (electoral) and media heat off the government.

L’espoir qui tue

The culture change is easier to understand; the government is relying on the presumption that an alternative workforce will be less scarred by history, excited by the recognition of their importance and the lure of upskilling, and more easily deceived by vague promises of an idyllic and fulfilled future. In short, a culture of hope rather than despair.

It was John Cleese who (as the tortured headmaster in Clockwise) said: ‘It’s not the despair, Laura. I can take the despair. It’s the hope I can’t stand.’ Borrowed from an earlier French usage: ‘C’est l’espoir qui tue’ (literally, it’s the hope that kills you) this should surely be the strapline for the past 75-plus years of NHS dentistry. During these decades, workforce planners have lived in hope (but alas, in vain).

Successive governments of all hues have lived in hope. Generations of dentists have lived in hope, and above all, patients have lived in hope. But any genuine hope for the future needs to have its roots firmly secured in all the lessons from the past – and that’s where the current plan comes unstuck.

Kevin Lewis: A New Hope? Examining the NHS dental recovery plan