Back to the future

Lord Byron said, 'The best prophet of the future is the past'.

Stephen Tidman's compilation of UK dentistry's past is a case in point.¹ His meticulous cataloguing of the journey over the last century should be compulsory reading for anyone interested in improving quality and access to dentistry. For policy makers, it will help them to avoid preventable misadventures. For the profession's negotiators it will help them spot the bear traps. For pure historians, it tells a fascinating story of societal change and the integration of dentistry into public healthcare.

He begins the story in 1920 when the world was in the grips of contagion and the global economy was in turmoil. Civil strife was in abundance and megalomaniac national leaders strutted on their journey to international conflict. He takes us through to 2020 when ... well what can I say? The levers of change acting upon dentistry during that time were diverse. Scientific understanding and technological advances moulded the clinical specialty and brought about near-miraculous developments, treatments and cures. The deployment of epidemiology and preventive health campaigns influenced disease patterns. Organisation of the profession itself forms a vital element of the story.

The emergence of the single biggest influencer of UK dentistry - the NHS, was born in turmoil and has remained in states of varying turbulence. Successive governments have struggled with the classic management tensions of quality, quantity and cost. This has led to legislation, regulation and continuing conflict between service commissioners and those at the sharp end.

The message to dentists and to the public is actually that "we know it's not working and we know why it's not working, but it's just not a priority".

Stephen's granular analysis of legislation is interspersed with descriptions of what the profession was thinking and 'what happened next'. So, there should be nothing new under the sun for current planners.

At the time of writing, it is pretty clear that the current approaches to commissioning dentistry in all corners of the UK are fundamentally broken. This truth against such a background of intelligence is more damning than failure borne of ignorance. The message to dentists and to the public is actually that 'we know it's not working and we know why it's not working, but it's just not a priority'. This indifference is evidenced in three ways. Firstly, there is a management aphorism which says 'if you can't measure it, you can't manage it'. There is no published data that accurately reports what the NHS pays general dental practice dentists. If you look at the statistics in the Doctors and Dentists Review Body (DDRB) report, you will see that whereas figures for salaried doctors and dentists pay come from published pay scales, GDS pay figures come from the HMRC annual survey. As legitimate as that survey is, it does not stratify sources of income. Instead, it reports total incomes of anyone who describes themselves as a GDS dentist. The fact that increasingly those individuals derive substantially more of their income from other sources is not taken into account. It is this total figure which is used as a comparator and reference point. This material overstatement of NHS dental incomes means that the true picture remains invisible. Its use as a comparator with other NHS healthcare professionals is unhelpful.

Secondly, the issue of the costs of running a dental practice has been totally neglected for a long time. Whereas there was once a detailed analysis of operating overheads built into dental settlements, for the last 20 years it has been progressively demolished. The most recent attempts by UK governments to nod to expenses was laughably inept. In Wales, the expenses were assessed as exactly the same percentage as the pay award. In Scotland, it was assessed as something less, and in England, an abstract multiplier was applied. None assessed the economic reality of the costs of providing dental care. It is therefore unsurprising that NHS dentistry is becoming unviable.

The final evidence of the broken system is the continuation of a contracting system in England that was brutally imposed in 2006, was widely condemned by ministers in 2010 and yet still exists in 2023. With no serious effort or commitment to reform, one can only assume that the status quo is satisfactory for the UK government. If there is any doubt about the truth of this inactivity, I would commend the most recent report of the House of Commons Health and Social Care Committee which observes inter alia: '...It is frustrating to have to return to recommendations made by our predecessor Committee fifteen years ago that still haven't been implemented…' These strands are merely the current bones of contention. Reading the excellent timeline reveals that there have been others. I would urge the contemporary custodians of the profession to learn from what has gone before.