Memorandum by Mr Clive Bosley (D 34)
INTRODUCTION
The witness is 58 years old and has practised
as a General Dental Practitioner in London and Oxfordshire since
qualifying form UCH in 1967. From 1967 to 1992 he practised entirely
within the NHS since then he has considerably reduced his NHS
commitment. He has served/is serving on all local NHS and BDA
committees and centrally on the Advisory Board of the RCS England
which became the Faculty of General Dental Practice. He has carried
out disciplinary work for the NHS and Denplan. He is a member
of Oxford's premier Dental Peer Review Group. During the 70's
and the 80's the witness became disturbed that NHS practice became
increasingly geared to embrace the lowest common denominator driving
down standards. Finding this, in turn, increasingly unacceptable
the witness converted his practice to one in which he felt more
at ease. As a counsellor of many practitioners he is aware that
this is a common situation. The fee cut of 1992, helped focus
his intentions. The witness's personal income remains approximately
that recommended by The Doctors and Dentists Review Body. His
witness is given as a practising dentist with his finger on the
pulse of professional opinion.
MODERNISING NHS DENTISTRY—IMPLEMENTING
THE NHS PLAN
Any consideration of Dentistry is to be welcomed
as generally the profession considers itself to have been increasingly
sidelined.
I consider that the strategy will not bring
about a reconciliation between dentists and the NHS as it fails
to address the fundamental problem. The GDS is a fees based system
which is grossly underfunded, the policy of adding bounties to
certain practitioners emphasises the inadequacy of the fees system
which still applies to the majority of practitioners. The fees
system was condemned by Tattersall in the 1960s and by many learned
commissions since. Mrs Bottomley declared it "discredited"
in 1992.
In the year 1998-99 the "inadequate"
fees system was funded by a government spend of £1,079 million
to which patients added £442 million in charges. The additional
annual spend through this strategy of £120 million reduced
to £6,000 per practitioner and to £3 per patient it
is unlikely to make the earth move. This additional funding is
for 18 months only.
Keeping a usable mouthful of teeth for life
and let us not forget that life now means 90 years is not an easy
task. Imagine being given a brand new motor car at 18 years and
being told to make it last for as long as you wished to drive.
The simile with a dentition is valid. Moving on in the same vein
imagine that HMG had set up The National Car Repair Service in
1948. The NCRPS would by now show the same problems as the GDS.
The garages would be full and overworked. The Chancellor would
be raging at the cost and some of the public would deliberately
abuse their vehicles as "the NCRPS will put it right".
Test the proposed strategy with these similes.
MANPOWER
There is an acute and increasing manpower shortage.
In the UK we have some 3,000 patients per GDP the rest of Europe
and the USA some 1,200 per practitioner. There are sufficient
Hygienists in the UK for each dentist to use one for half a day
per week. We need hands, qualified hands, fast.
HOURS OF
WORK
The witness, like most of his colleagues works
nearly 40 hours per week wetfingered in the mouth. Administration
takes an additional 10 hours a week. Unverifiable Continuing Professional
Development some three hours per week and verifiable CPD at least
10 hours per month. He is on 24 hour call via a radiopager every
weekday for his patients and every fifth weekend is on 24 hour
call for himself and another four practitioners. Every week therefore
he is on call, or at work, continuously for 120 hours and every
fourth week does a continual shift of 336 hours. He now takes
six weeks leave per year. Until 1992 he took up to two weeks holiday
and worked longer hours.
QUALITY ISSUES
The Strategy document comments disparagingly
on Private or Independent dental practice. There is no justification
for this. It is a scandal that the public are led to believe that
the NHS is a gold standard yardstick. It is a curate's egg, good
in parts. The witness perceives that the exigencies of NHS funding
are deviating UK practice from international norms. The General
Dental Council has done sterling work over the years in maintaining
standards of training and education but has failed in one respect.
It has failed to confront the DOH with the cumulative dumbing
down that the system imposes. The strategy does nothing to remedy
this year on year decline.
In the past a dentist possibly could skate on
the thin ice of practice and if he fell through expect some sympathy
for the circumstances in which he worked. All invasive practitioners
now are expected never to make a mistake. A system which demands
an enormous output of invasive treatment is incompatible with
a working environment conducive to avoiding errors. Would we visit
our doctors if they were obliged to rummage our bodies physically
in order to obtain the funds for their premises, staff and salaries?
I think not. The strategy does nothing to amend this deplorable
state of affairs. Therefore dentists understandably must remove
themselves from the system in which they face an ethical dilemma.
It is they themselves, not the system, which is put on trial.
To finish—manpower is for me the key issue.
We need more dentists and auxiliaries. To get them, and retain
them, the profession needs to offer attractive working conditions.
A thousand times a year I am told "I couldn't do your job
. . ." The stresses of performing invasive work on fellow
beings should not be compounded by a system which has lost sight
of any rationale.
The profession has no difficulty with maintaining
and increasing standards of clinical or business practice nor
with CPD or clinical Governance (although CG is perceived as perhaps
another route by which professionals can be obliged to modify
their treatments on grounds of cost or expediency, which is not
always good dentistry). Significant funds will be needed.
EMERGENCY COVER/OUT
OF HOURS
SERVICE
These duties have been funded by redistribution
of existing funds within the dentistry pot. As a result the service
provided is ad hoc and very variable. Manpower and funding
are again the key factors to bring about improvement.
SIX MONTHLY
DENTAL/ORAL
EXAMINATION
The witness observes that in his practice some
patients need re-examination quarterly, some half yearly, some
longer, but rarely longer than one year. One is monitoring a continually
changing situation and can find oneself blamed if a lesion becomes
large. There is in today's litigious society no sense in a prescriptive
change.
THE FUTURE
Either, continue the current system properly
funded or re-jig the whole system. Important considerations are;
that the service is affordable to the nation and is providing
the means for dentistry appropriate for the 21st century. As dental
caries and periodontal (gum) disease are eminently preventable
the system needs to involve all patients in the payment so that
minds are focussed on preventing and avoiding disease rather than
wallowing in treatment because it is "free".
February 2001
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