The results from the latest NHS Confidence Monitor survey revealed deep levels of unhappiness among NHS dentists and anxiety about complaints and litigation across both private and NHS sectors. Despite being anxious in this area, the private dentists who responded reported feeling much happier about every element of their work compared to when they were in the NHS.
Given the rather dark picture of the NHS painted by the 400 plus dentists from both sectors who responded to the survey, Practice Plan gathered a panel of professionals together for a discussion about the results. While the debate was too wide-ranging to share in full here, we have presented the panel’s debate around the future of dentistry in terms of training, skill mixing and the preparedness of the next generation of dentists to enter practice.
Nigel Jones, Sales and Marketing Director of Practice Plan, hosted the panel whose members included industry experts from the profession – Eddie Crouch, David Houston, Simon Thackeray, Dhru Shah and Paul Worskett – as well as representatives of the up-and-coming generation of dentists – Petros Mylonas and Jasmine Lobo.
Nigel Jones (NJ): Visiting practices as I do, I can see that dentistry is an amazing job – there aren’t many jobs where you can completely transform people’s lives. But it feels like there’s a big gap between the enthusiasm of young graduates entering the profession, and the negativity we’re hearing from parts of the profession, including this survey – and the BDA’s research that highlighted the number of people planning to leave the profession. What do you see happening with younger dentists?
David Houston (DH): So many younger dentists whom I meet or interview for posts appear to be so concerned about their initial career prospects that they will almost immediately take the first job offer they receive. Their greatest concern is “will I have a job” rather than “what type of job will I be accepting”. Since by definition, they are younger and less experienced candidates they rate as less attractive applicants to a prospective private sector principal. Thus, it almost becomes the default outcome that the NHS is the starting point for their practising career.
Some thrive in their FD year because of their personality and confidence in conversing with patients. But the undergraduate curriculum does not seem to prepare young colleagues for practising in the way it once did.
Simon Thackeray (ST): Dentistry has never really had a defined career pathway, although traditionally most people have taken the route of qualifying and then buying a practice. It is a profession that is always evolving, so this traditional route – however loose it may be at the moment – probably isn’t suited to the way people practise today, or how they will in the future. So, we need to look at the pathway and how we can change it to support those entering the profession today.
NJ: Given that, what do you make of the figure from the Confidence Monitor survey that 81% of NHS dentists don’t feel they can provide the level of care they want to?
Dhru Shah (DS): As a specialist, it takes me 90 minutes to do a consultation to the level of care that I am satisfied with. If you are setting your own fees, then that is fine. However, within the NHS you cannot set your own fees and you are not remunerated for time spent, just activity completed, and this is what creates the challenge in providing the level of care you would like to. Having a third party (the NHS) setting the fees is one of the drivers behind this issue, and I think dentistry is a fairly unique profession in terms of operating this type of business model.
People who graduated before me probably did more than I did at dental school, and I probably did more than those graduating now. But there’s another factor here, which is that social media has turned the internet effectively into a 24-hour global conference where students can watch amazing dentistry being performed. They may then aspire to that same level, but realise that they can’t achieve that higher level within the NHS. So younger graduates might be more attracted to private practice earlier because they see it as a way to control what they do daily.
Petros Mylonas (PM): That’s a good point. When I switched from the NHS to the private sector a few years ago it was about control – how much time I spend with patients, how I get remunerated. I have more freedom, and, so far, I’ve not had a complaint because I can talk to my patients. Everyone I know who has had an issue with patient complaints, it has been down to communication problems or issues.
ST: At the time we graduated there was a culture of expanding your skills by ‘having a go’. If Christian Barnard was practising heart surgery now and governed by the GDC he never would have done the first heart transplant.
We have to have an environment where people can move forward, and the person at the beginning of their career should not be judged by the same standard as the person mid-way through. That’s like using A-level algebra as a standard to judge everyone’s maths and then asking a toddler why they can’t do it. That’s not to be derogatory, but if you’re at the beginning of your career you won’t necessarily be able to do the same things as someone far more experienced, but you’ll be held to the same standard. There’s no recognition of that within the NHS.
DS: There’s a course starting in Liverpool next year which is for dentists and therapists training on the same course.
ST: If you suddenly have a course that supplies lots of therapists – which there’s nothing wrong with – but no dentists, how do you suddenly manage the sector’s manpower requirements?
Eddie Crouch (EC): If you think about the prototypes – originally there was a big move towards skill mix, but when the evaluation report comes out in a few months I think you will see a shift away from this.
Paul Worskett (PW): We’ve operated skill mix since 2011 and we’ve built it up and we’re still learning from it, but it’s incredibly complex. In the old days the patient saw the dentist for everything. Now, the dentist will prescribe treatment on the care pathway, but you might also have an oral health educator giving prevention advice, a therapist doing some perio treatment and simple restorations and the dentist doing more advanced work. But what if the patient cancels an appointment somewhere along that pathway? It can very easily fall apart. And trying to restructure appointments in a series, when your appointment book is already full for months is another problem altogether.
ST: We’re the only country that trains graduates to work within a system rather than do dentistry. They might have an awareness of more complex treatment, and an ability to do them, and some might have the courage to try and do them, despite litigation and the GDC – but fundamentally we train them to be NHS dentists, which is a distinct difference.
Jasmine Lobo (JL): That’s how I feel. I’m able to talk about some treatment options but some patients will have heard of options that I just won’t be able to talk about because I have no basis, I haven’t had a single lecture on it. I have to say that they will need to ask someone else or that I need to ask my supervisor, but it would be so much better if I could just talk about what’s available for them.
ST: The problem is as soon as you graduate you’ve immediately fallen foul of the Montgomery ruling, because how can you assess the material risk to the patient to consent them to have treatment if you don’t know all the various treatments available? We’re sending them out unprepared. In these highly litigious times it’s like covering them in dog food and sticking them into the den of hungry lions and expecting them not to get eaten.
NJ: On that vivid picture we’ll have to close for the moment. Thank you to everyone for taking part.
A lot more debate took place between the panel including the issues of contract reform and the prototypes, leadership within the profession, GDC standards and the appeal of practice ownership to young dentists. Practice Plan will be sharing more of the debate over the coming months through further articles as well as blogs and podcasts with panel members.