Kevin Lewis: 'Enough is enough'

Discussing the state of NHS dentistry, Kevin Lewis ponders the relative merits of too much, too little, and things we are told too often.

Fifty years ago, the Japanese engineering and manufacturing boom was at its height in many industries and the revolutionary ‘just in time’ (JIT) production and supply chain concept made famous by Toyota was gaining traction.

Prior to that, many companies and shops held what would now be considered ludicrously high stock levels close to the point of sale. Designed to build in a capacity sufficient to absorb sudden wide surges in demand, some dubbed this the ‘just in case’ (JIC) approach, but it consumed a lot of resource one way and another.

Fast forward to the modern-day economy and the landscape has changed profoundly. But the questions still arise of when enough is enough, what qualifies as being too much or too little, how you avoid it and what you can or should do about it.

The immigration debate became a key factor in the recent UK election both directly (fuelling the emergence of the Reform Party as a serious player and disruptor) and indirectly – especially in workforce discussions relating to the health, social care, agriculture and hospitality sectors, but in many others too.

If you need people to do an important job and the domestic workforce is unavailable or unwilling (at the price on offer, or at all), you have an acute problem that can only be fixed in a small number of ways and probably never quickly enough.

Similarly, the COVID inquiry is regularly raising questions about the wisdom of overcapacity or under-capacity at various stages, demonstrating that perhaps only Goldilocks is able to declare it ‘just right’.

Hey presto

Lord Darzi’s ‘Independent investigation of the NHS in England’ was interesting enough, but its significance has been somewhat overstated and overplayed.

It rather insults the intelligence of the UK population, and all those working in and around the NHS, that anyone – not even a highly respected national clinical treasure like Lord Darzi – could carry out or credibly ‘lead’ a comprehensive review of arguably the largest and most complex organisation (and by some distance the biggest employer) in England, carefully review all the evidence, reach properly informed and considered conclusions and produce a report and recommendations – all within the space of a few weeks and supposedly from scratch, on top of a day job as a busy working clinician.

The ‘Blue Peter’ conclusion is that this report is one he made earlier, or more precisely that most of it was prepared by others many months earlier and his Lordship kindly sprinkled his fairy dust over it and lent his name and credibility to it.

But genuinely independent it most certainly ain’t: Lord Darzi was appointed a Labour life peer in 2007 and served as a Labour parliamentary under-secretary of state for health in Gordon Brown’s government until Labour lost the 2010 election.

Some time later (in 2019 during Labour’s anti-semitism turmoils under Corbyn), he chose to formally de-affiliate himself and became an independent peer but ‘optics’ aside, his strong political DNA is a matter of record.

He was a natural choice to be commissioned by the incoming secretary of state Wes Streeting to carry out this ‘quick and dirty’ review which, almost by magic, came to the same conclusion as in every other government department: things are much, much worse than anyone ever realised or could have guessed at, everyone is very shocked and surprised and almost all of the problems can be traced back to the day after the previous Labour government (of which he was a part) left office in 2010.

This kind of timescale recurs throughout the report and many of the conclusions are familiar from Lord Darzi’s previous commentaries on the NHS over many years.

Dire warnings

Having said this, many similar reports have been written at similar times of crisis over the 75 or so years since the inception of the NHS, with equally dire warnings and damning conclusions.

This one, at least, does not cast the NHS in England as an irredeemable basket case, but the report’s quasi-political provenance is laid bare by what it is and is not prepared to criticise, blame or suggest as possible solutions or ways forward. It is relentlessly ‘on message’ in support of the incoming government and its stated aims, priorities, ‘red lines’ and timeline.

But any clinician who works in an NHS hospital, or who understands the internal workings of the NHS behemoth, or who has experienced the dysfunction of NHS management, will raise at least one eyebrow at the statement that: ‘Some have suggested that this is primarily a failure of NHS management. They are wrong.’

The NHS is in crisis but there is no suggestion here that the quality of NHS management needs any improvement, nor that the performance of NHS managers should be regulated in the same way and just as proactively and robustly as the performance of clinicians.

We know from his previous reports that regulation is not the Darzi way. No doubt the relevant unions (UNISON and its partners MiP and FDA, representing healthcare managers and civil servants, including those within NHS England who commissioned and probably did much of the work for the report) will be grateful for that.

Glaring uncertainty

Predictably, Lord Darzi didn’t have much to say on NHS dentistry in England, but he did manage to sidestep the awkward reality that the ‘broken’ GDS contract is the one imposed upon the profession by the Blair Labour government in 2006.

What he did conclude is that: ‘There are enough dentists in England – just not enough dentists willing to do enough NHS work, which impacts provision for the poorest in society.’ And few would take great issue with that.

But the urgency of the current trawl of the universe for more dentists to come to work in the UK, and the frantic dismantling of any potential obstacles to that – with no strings as to their willingness to work in the NHS – suggests otherwise.

Perhaps enough is not enough after all? Or perhaps this is a switch from ‘JIT’ to ‘JIC’ thinking, or even a strategic masterstroke whereby flooding the market with extra dentists, coupled with two or three years of the strong and bitter-tasting medicine foreshadowed by the Prime Minister and chancellor for the budget in a few weeks’ time, might rinse household budgets and confidence, thin out a few appointment books and force some dentists to re-think their exodus from the NHS?

As discussed in my column last month, the proposed ‘tie-in’ to require graduates to meet a minimum (as yet unclear) commitment level to work in the NHS in England, in default of which they would need to repay £200k or thereabouts of alleged training costs, applies only to graduates from English dental schools/universities, not to graduates from Cardiff, Belfast, Glasgow, Dundee or Aberdeen.

Nor to graduates from anywhere else in the world (or other galaxies), it seems. So, it is hard to predict what the more granular impact (and unintended consequences) might be. Even the General Dental Council (GDC) has recognised that glaring uncertainty.

Broken and broke

The Darzi report points to the NHS’s ‘crumbling infrastructure’, and the lack of investment since – yes, you’ve guessed it – 2010.

No mention of the legacy left by the 2008 global financial crisis, no mention of the infamous Liam Byrne ‘I’m afraid there is no money’ letter he left in 2010 for his Tory/Lib Dem coalition successor, and most bizarrely the summary dismissal of the COVID pandemic as a minor inconvenience only made worse by the policy decisions made before, during and after it.

In fairness, his Darziship resisted the even-more-infamous and much funnier (but largely lost in the mists of time) riposte of the departing Tory chancellor Reginald Maudling, who in 1964 welcomed his Labour successor Jim Callaghan with: ‘Sorry to leave it in such a mess, old cock.’

Not for the first time, Darzi calls for the NHS and its systems and processes to be modernised, forcibly shifting them ‘from analogue to digital’ requiring a ‘major tilt towards technology, to unlock productivity’.

One part of the NHS that doesn’t suffer from a crumbling infrastructure or outdated facilities but instead demonstrates a very healthy appetite for technology (and productivity), and embracing the digital age, is of course primary care dentistry.

But that investment has been paid for by dental patients and practice owners, not by the state, and the 2006 dental contract which was in situ throughout Lord Darzi’s time in government has actively penalised investment in facilities.

Moreover, private dentistry has directly subsidised the opportunity for many NHS patients to benefit from all those modern facilities at no cost to the state. That uncomfortable reality is rarely acknowledged.

Tinkering must stop

Enough funding alone is not enough. But it’s a good start and Shawn Charlwood (General Dental Practice Committee chair) is right when he says that while the tinkering must stop and fundamental reform of the dental contract is essential, Wes Streeting and Stephen Kinnock’s funding ‘taps’ must be turned on alongside that reform, not left as a vague aspiration for the future if all goes well on the long road ahead.

Furthermore, since the new government has been prepared to throw staggering sums of money at millions of public sector workers in healthcare and beyond to resolve longstanding disputes, the issue of genuine pay (and operating costs) restoration for GDPs cannot now be swept aside.

What’s good for the geese must also be good for the gander, and given that dentists across the UK have had their pockets picked year on year ever since 2006 (and before) by successive governments, they have every right to take the view that this time, enough really is enough.

Kevin Lewis: ‘Enough is enough’