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The contrast to my own lifetime experience, dedicated to the National Health Service, was considerable. He was committed to the improvement of aesthetics and had developed techniques and materials that enabled him to restore teeth to an appearance indistinguishable from the natural tooth whether viewed by natural, ultra-violet or polarised light. His three-surgery unit located near ski slopes close to the Italian/Swiss border accommodates visiting specialists. On my first day there an oral surgeon was busy dealing with impacted teeth and other surgical problems referred both from within the practice and from other practices. His is a truly integrated practice providing a broad spectrum of expertise with perfection as the target.

The practice also has a seminar room with full lecture facilities. My second and third days there were spent in the company of dentists from as far afield as Sweden, Poland and the USA. We were presented with a superb collection of photographs of some work done in the practice complemented by a description of the techniques used. The sessions were completed by a video of the complete treatment of a case.

Quantity versus quality

In Italy I have experienced the achievements possible within private practice. Has the UK devotion to the NHS held back the achievements of practice? Has the quantity of treatment been more important than the quality?

1948 was the start of the National Health Service. The BDA advised its members not to join, the conditions were not considered to be right. Coincidentally I commenced clinical training. Our phantom head course and the first six months of clinical practice used treadle engines. The techniques, materials and sterilization were unbelievably archaic by today's standards. However I trained and qualified when the public and profession were dedicated to the newly founded NHS. As newly qualified practitioners we had no experience of private practice.

Food for thought

In 1951 I lost control of my career to the War Office. In due course I was posted to military hospitals in Austria. Behind me I had left food rationing, utility clothing and furniture. Here, as a member of an army of occupation, I found food in quantity and of a quality that I hadn't experienced since 1939. Clothing was fashionable, furniture elaborate and unrationed. Perhaps the controlled egalitarian society at home was unequal to the task? Could a demand led decentralised system lead to better results?

By the time I completed my National Service the NHS had unleashed an enormous pent up demand for treatment which the profession was attempting to deal with. The fee scale was reasonably fair to start with but because of the very long hours and high productivity of the profession the total Government spend exceeded the Treasury's willingness to fund. Successive cuts to the fee scale were made and the 'treadmill' started. This was not a well chosen time to start a new practice. Dentists worked hard to earn sufficient to pay their bills and to pay the tax on last year's earnings, which were based on punitive rates. The harder they worked the greater next year's tax bill became and the lower the fee scale. Unbelievable as it may seem today some tax rates exceeded 100%. The concern of the profession in Britain was more towards survival than research into improvements in technique. But improvements came with tungsten carbide burs, then diamond burs and high speed air turbines. These all increased productivity and exacerbated the problem of the treadmill. However the British public still had great expectations of the NHS and did not have the disposable income that made private treatment available to them. Could the opportunities for private practice overseas, then available, have been better alternatives?

Despite the difficulties my practice expanded rapidly. I was, at this stage, offered the opportunity of taking over a prestigious private practice but my partner opposed the proposal. Should I have insisted? Instead we committed ourselves to the NHS.

Professional dissension

The profession was very unhappy. Some like myself became active in the BDA whilst others supported alternative associations. This was unfortunate as it split the profession making it easier for the Government to divide and conquer. Unfortunately the Treasury was interested only in reducing costs and the Pilkington Commission introduced the concept of the 'average dentist' whose target net earnings were to be set by a 'Review Body'. The 'Dental Rates Study Group' had to identify the productivity of the average dentist and what his average expenses would be in order to produce a scale of fees. Inevitably the dentist with above average expenses or lower than average productivity lost out whilst those with below average expenses and above average productivity were better rewarded. The patient and the NHS could only expect an average level of service from an average dentist using average materials and average laboratories of average cost. Regrettably the pursuit of excellence was made almost impossible by this commitment to the average, an averaging down not an averaging up. Fortunately there were opportunities worldwide for the development of dental techniques and the NHS could not prevent the forward march of dental progress.

The view was often canvassed that the profession should limit its NHS commitment and develop alternative paymasters to the Government. However most of the profession were too committed to the treadmill to be able to break free and all our approaches to 'insurers' were met with the industry view that dental treatment was uninsurable at a cost acceptable to the public. Regrettably the time was not yet ripe for change.

Reorganisation of the NHS

A need was perceived to integrate the general practitioner, hospital and school services and 1971 saw the Government undertaking to reorganise the NHS. Since that time there has been continual change imposed upon the NHS. Arguably these changes have increased bureaucracy and decreased clinician morale. They have been more concerned with financial, administrative and political control than with the development of preventive measures and of new or improved treatments.

In 1974 I exchanged treatment planning for the individual patient for service planning for a million people. Very determined characters represented the hospital, school and general practice sectors and I learnt the hard way the extent to which individual 'fiefdoms' would be protected. Nevertheless I found it a very interesting and challenging time. However when the next unwelcome reorganisation came along I returned to general practice.

It took the 'Thatcher' approach to concentrate everyone's mind. The era of full mouth clearances and full dentures had passed. Pressure from both profession and public had widened the scope of the NHS. Aluminous porcelain had arrived and porcelain crowns were 'in'. The change from low technology to high technology treatments placed increasing pressures on the NHS budget and on the concept of the average.

The private alternative

'Thatcherism' preached self-sufficiency, disposable incomes were rising whilst the reputation of the NHS was falling. An increasing proportion of the population became willing and able to fund a level of service provision that was generally unavailable under the NHS. An increasing number of dentists were being forced by financial pressures to develop private practice. The adult private patient was becoming the norm, not the exception.

I believe that the Association did achieve a better dental service for the public, although this has never been recognized by the media, and a better deal for the profession although dentists have rarely recognized this. With hindsight the demise of the comprehensive free dental health service was inevitable. The original concept of Beveridge had been that the need for health care would cease if enough resources were given, that all illness and disease could be eradicated like smallpox.

Short-sighted politics

Today we appreciate that the more successful and advanced the health care the more resources are needed. The public recognises the best and rejects the average. Politicians have been too slow in recognising this. They have continued to make unsustainable promises to the public and the changes have taken place in a discordant way in confrontation with the profession. To assuage political dogma the Government early in this Parliamentary session reduced resources available to health care by removing tax relief from health insurance premiums thus constraining the development of non-NHS services. Despite the best efforts of the profession we have been unable to achieve an on-going comprehensive NHS dental service advantageous to both patients and profession whilst the Government continues to discourage the private sector which has been challenged as creating a two-tier service.

The controversial Welfare Reform and Pensions Bill of May 1999, which modifies the founding principles of the post-war welfare services in order to limit Government expenditure, lays to rest any lingering hopes of Government funding for a modernised, comprehensive and free at the 'point of need' dental health service. The introduction by Government of 'rationing' within the Health Service supports this view. The new equipment, materials and techniques that were on show at the BDA's Torquay Conference in May 1999 will only be affordable with 'new' money. The conference's theme, 'The Business of Dentistry', exemplifies the symbiosis between good dental practice and good financial provision.

Branding

The changes in the funding of dental services will not lead to a two-tier service but to a multi-tiered, multi-faceted service. Patients will now choose from a variety of ways of achieving dental health. As Tony Kravitz, Chairman of the GDSC, pointed out in the June 1999 issue of BDA News the 'entry of Boots and Specsavers into the dental market' opens up the possibility of 'branded' dental services including an NHS brand. Hopefully the NHS will continue to enable all the population to have access to professional services.

My visit to Italy became much more than an assessment of Italian dentistry. It made me reassess the value of my whole career and the choices I had taken. I was most impressed by the quality of what I saw in Italy. Visiting 'specialists' helped to achieve the integrated service envisaged in the 1974 reorganisation. The rewards of the highest standards of clinical practice became apparent and I wonder whether I should have spent more time developing clinical skills and creating my own integrated practice rather than devoting myself to the NHS. Had my commitment to the NHS given my patients, my family and myself the best I could achieve?

Perhaps my greatest regret is that I started as a student in 1945 and not in the year 2000 when there are such exciting opportunities ahead.