Category Archives: Dentists

A general practitioner is trying to follow the dentists into private practice – clients will initially be the retired rich, but eventually many more of us.

A general practitioner is trying to follow the dentists into private practice. NHSreality has warned that this was likely, and that when patients demand a choice from their ambulance – (private or public A&E?) that will herald the end of Aneurin Bevan’s dream. The perverse incentives in private care need to be exposed.. but even if we get an honest debate I think rationing by price and access may be acceptable in Bournemouth, but not away from the retired rich, and the tooth fairies… It will be interesting to see if Dorset tries to stop/discipline this Dr… watch this space. If it is allowed it will spread…

Laura Bennett reported in the Sun 14th Feb 2017: WANT TO SEE A DOC? THAT’LL BE £145 – GP warns general practice ‘on brink of collapse’ as he launches private service in NHS surgery – Patients can cough up to see a doc or pay £40 for a phone chat – Dr Tim Alder ( Poole Road Medical Practice – Bournemouth ) has launched a new private service at his NHS surgery so patients can pay to skip the four-week wait for an appointment

AN NHS GP surgery has told patients they can skip waiting lists to see their doctor – if they cough up £145.

The surgery has launched a private service – operated by exactly the same NHS doctors – to run alongside its NHS services.

But patients have to fork out £40 for a 10-minute phone consultation, £80 for a 20 minute face-to-face appointment and £145 for a 40-minute consultation.

Dr Tim Alder warned general practice was on “the brink of collapse” and “heading for privatisation” as he decided to launch the controversial Dorset Private GP Service at Poole Road Medical Centre in Bournemouth, Dorset.
NHS patients at the surgery have to wait four weeks for a seven-minute appointment with one of the practice’s four doctors if they are not eligible for its same-day walk-in service.
But critics have slated the move as a “kick in the teeth” for the NHS and patients, claiming it creates a two-tier health system and goes against the principle of reducing inequalities in healthcare.

Dr Alder said increasing demand, a recruitment crisis and lack of funding as well as private provider Virgin Care taking over practices across the country meant the new service was the only way to safeguard the surgery’s future.

He said: “The Government is not trying to save general practice and now it is on the brink of collapse. But when it’s gone, they’ll realise how good we have been at blocking access to the hospitals. By then, it will be too late.
“We have to try something different now to make ourselves stronger in anticipation NHS primary care will be even worse.
“The worry is that Virgin Care, who are already buying up practices, are going to come in and would then just take us over.
“I suppose we’d rather be in charge of our own destiny.”

A humanitarian crisis – and the goodwill of staff has disappeared. When will the public ask for private A&E?

Many A&Es are failing now. As delays, standards, and staffing gets worse, more and more demand will come for private A&E and ambulances.

The risks of private care… overstated?

When will private hospitals begin to offer alternative A&E option?” NHS worse in Wales”. Close the doors!

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Why were doctors treated differently to dentists? Perverse…

The English Health service has changed it’s mind. Doctors working part time may avoid public declarations of non-NHS / locum income. If this ruling had been enforced it would have to apply to Dentists, Lucum Nurses and Physiotherapists, Consultants etc. (Possibly even politicians!) But the other jurisdictions may choose to be different…. Readers should remember this is a market controlled entirely by government. Undercapacity and under resourcing are political rationing choices made over decades. Failing with a cap on pay is punishment for poor manpower planning…..

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Chris Smyth reports in The Times 10th Feb 2017: Doctors win right to keep non-NHS income private

On October 4th he reported: Doctors split over NHS ‘loyalty’ plans

But earlier, on September 20th he reported: Doctors told to reveal all income from private work

On Jan 26th 2017The Times reported: GP plan to charge for weekend appointments

Jan 4th: Locums defy NHS pay curbs to take home £300,000 a year

July 9th 2016: Locum paid nearly £500k despite curb on agency costs

 

The Training of doctors…. unfortunately it is too late to recover in even the 5 years promised by government… Decommissioning of operations

A Times leading article alludes (correctly) that undergraduates are less value to the state than graduates who enter medical school. But Zawad Iqbal in “Doctors’ training needs streamlining before it’s too late” does highlight the problem of declining standards, and lowest common denominator medicine. The problem with the new GMC suggestion is that too low a standard may be deemed acceptable in order for us to have enough doctors in the short term. The fact that NHSreality would never have chosen to start from here is omitted. Long term rationing of medical school places, as well as too many undergraduates and too few graduates is to blame. A ten year program of capacity management may be undermined if we admit too many overseas doctors suddenly.. On the other hand, if the bar is set high enough… OK, I forget, nurses can do the job of a GP can’t they? NHSreality feels it is already too late, and it’s going to get worse… (Katie Gibbons reports from Kent: NHS operations postponed to save cash). Decommissioning is going to get worse still.

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In a letter to The Times 3rd Feb 2017 Prof Derrick Wilmot of Sheffield writes: on DOCTORS’ TRAINING..

Sir, A medical licensing assessment for doctors is long overdue (“Doctors face tough new test on basic skills”, Feb 1). There is a similar situation for dentists. A third of the dentists entered each year on the General Dental Council’s register qualified at an overseas university. UK graduates are not tested by a common examination but by the individual university dental schools, which do try, mostly with success, to maintain sufficient quality and commonality. Many of the overseas new dentists entering the UK come from EU countries and cannot be tested. Brexit is the ideal opportunity to introduce a new robust common assessment for all doctors and dentists registering in the UK.

Recent years have seen a frightening increase in medical and dental litigation. Evidence for an association is weak but if a basic clinical education is lacking problems surely lie ahead both for the practitioner and, more worryingly, for the patient.

Emeritus Professor Derrick Willmot of Sheffield University, and past dean, Faculty of Dental Surgery, Royal College of Surgeons: Doctors’ training needs streamlining before it’s too late

The news that thousands of newly qualified doctors aren’t confident enough to perform basic tasks such as taking blood is a real canary in the coal mine moment — a warning sign that the way we teach doctors urgently needs to change.

Part of the problem is that the basic structure of medical training hasn’t changed in more than a hundred years. The General Medical Council sets the standards for undergraduate medical education and supervises the training and education of students. But the content and length of a medical degree varies widely, depending on which institution you attend, and the different medical schools are allowed to set their own criteria for licensing doctors.

There is no common standard to practise in the UK. Doctors from the European Union can work here if they’ve passed relevant exams in their own country. Doctors from other parts of the world are given a separate test, resulting in a confusing system with no overall benchmark.

So it’s a relief that medical regulators now want to introduce a standard test. But that’s still some years away and frankly it’s not enough. We should seize the opportunity to conduct a bigger and more wholesale review of how we train our doctors and whether these decades-old methods are up to scratch.

What doctors needed to know ten years ago is often a world away from what they need to know today. Basic science and clinical science remain the core modules on medical courses but healthcare delivery is becoming ever more important. As well as introducing a common approach to basics such as taking blood samples and performing lumbar punctures, areas such as data analysis, IT skills and interpersonal ability must play a bigger role in medical training.

One of the biggest opportunities being missed is in postgraduate medical education. This is because postgraduate training falls under the NHS rather than a university or medical school. Our doctors need to keep learning new skills if they’re going to give their increasingly well-informed patients the best treatments. The doctor of the future will not necessarily carry a stethoscope around his or her neck but will more likely be one of a specialist team working alongside health technicians, pharmacists and nurses.

Rather than introduce a new standard test for doctors after they have qualified, they and their patients would be better served if medical schools standardised the courses they begin at 18.

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Dentists are overwhelmed. Patients and politicians are in denial. Rheumatic fever may follow… “The NHS dental service is broken”

Up to the 18th century Rheumatic Fever and Rheumatic Heart disease were a significant killer. Dental prevention, allied to better diet, fluoride in the water (or tablets) and teeth cleaning has reduced this awful killer to a minimum. The current failing dental service could facilitate recurrence. Failure to implement a policy on sugar and sugary drinks, denial of the need to ration, and a “head in the sand” approach to the potential effect of poor dental health on poor people……… Looks like we will have to wait at least 2 years to get a new contract, and with too few dentists (rationing of places) the omens do not look good.The NHS dental service is broken

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Ollie Jupes in The Guardian 12th Jan 2017 reports: The NHS dental service is broken – and its rotten payment system is to blame – A rise in hospital tooth extractions for children in England and Wales is alarming. But this is just one symptom of the growing crisis in NHS dentistry

lmost as soon as I stepped into dental school in the mid-1980s, an enthusiastic and wild-eyed child dental health lecturer thrust a Venn diagram in my face. Few who are not professional mathematicians can say that a Venn diagram shaped and guided the whole of their working life, but this one did. The equation the three intersecting circles in this particular diagram represented was this:

Plaque + Tooth + Sugar = Decay

On Tuesday, the Local Government Association (LGA) released figures showing that in 2015-16, there were more than 40,000 hospital operations to remove teeth in children and teenagers in England and Wales. This represented a 10.7% rise in such procedures since 2012-13 and in the period from 2012 to 2016, the cost of funding these surgical operations has been estimated at £129m.

Representatives of the British Dental Association, the Faculty of Dental Surgery of the Royal College of Surgeons and the LGA were quick to (quite rightly) reinforce their calls for the speedy introduction of the “sugar tax” on soft drinks and for the government to support public health campaigns to remind parents of the importance of their child’s oral health. While these are critically important and valid calls for action, I don’t believe they give the whole picture of why hospital child extractions are rising. I think my hypothesis is best summed up in another Venn diagram. I would add a fourth circle.

Plaque + Tooth + Sugar + Absent Dentistry = Child Hospital Extractions

I’m not talking about a lack of availability of NHS dentists – everyone in England and Wales has the right to be allocated an NHS dentist by their local NHS area team. Rather, it is as a result of the deficiency of appropriate care at ground level in the General Dental Service (GDS).

Up to 2005, dentists working in general NHS practice were paid a fee-per-item of treatment they provided. While many felt that this system was seriously underfunded, it sort-of worked. Treatment was carried out, and dentists were paid for providing it. Significantly, in that same year, the National Audit Office said in its document Reforming NHS Dentistry: “Oral health in England is improving generally, with oral health in 12-year-olds the best in Europe.”

One year later, a new system was introduced into the GDS that was probably created by a James Bond villain: “No, Mr Bond, I expect you to die – but not before financially ruining you and taking the shirt off your back and, dammit, your boxer shorts.” Hospital extractions have increased ever since. The new dental payment system meant that dentists, no matter how they tried, could rarely hit the targets set for them in order to maintain their average income. Not hitting targets results in a dentist receiving clawback – where the local area NHS team sends a metaphorical “heavy” around to take their money back.

All general dental practitioners (GDPs) who wanted to stay in the NHS were forced to enter into this deal. The current system is based on units of dental activity (UDAs) and a dentist is contracted to complete a specified number of UDAs per year. In essence, a dentist carrying out a course of treatment involving one filling will earn exactly the same fee as if that patient required a dozen fillings and hours were needed to provide the treatment. The government imposed the new system in 2006 (it was condemned by a parliamentary health select committee in 2008 as “unfit for purpose”), claiming that the new system would give dentists freedom to focus more on prevention than active intervention. It did nothing of the sort.

Deciduous (baby) teeth have thin coatings of enamel and caries (decay) can rip through the teeth very quickly if oral conditions – either diet or cleaning – aren’t right, if the patient fails to attend appointments, or if a child is difficult to examine adequately because they are fractious. And even if you do have cooperation from a child, treatment often takes twice as long as for an adult.

What we currently have is a failing dental service where clinicians are having to be too focused on targets to spend adequate time on giving individual prevention advice, are overwhelmed by sheer patient numbers and are constantly banging their heads against parental brick walls. I once had a patient spread out a picnic with cookies and soft drinks in my surgery for her children while she had her check-up. Very quickly, teeth become grossly decayed, infected and require the drastic measure of general anaesthesia and extraction. It’s thanks to this new payment system that dentistry has now joined the NHS crisis.

Childhood obesity: a plan for action – Publications – GOV.UK

 

Open Wide – The system for dental care is letting patients down. Regulatory gaps need filling and dentists seem to agree..

Dentistry pay dividends in poor societies. The incidence of dental decay is related to that of heart disease and severe untreated caries is a cardiac risk. This was known by the Victorians but recently seems to have been forgotten. The Perverse Incentives in the dental contracts have all led to perverse behaviours. Why cannot the assessment be separated form the treatment, as in Medicine where a GP refers to a surgeon? A recent Times leader explains and is reproduced below.

Dentistry now outside the Health Services for most of the nation

Getting to see a Health Service physio – like getting to see a health service dentist

Shropshire whistleblower dentist tells job tribunal of ‘witch hunt’

NHS losing billions to ‘fraud by doctors and dentists’

Dentists demand a deposit from NHS patients

The Times leader:

Trips to the dentist are unsettling enough already. That dentists are rushing patients out of the door in order to stack appointments high and maximise their income, as our investigation today reveals, is unlikely to calm anyone’s nerves.

Root canals, which save troublesome teeth, take twice as long as extractions but both procedures are worth three “units of dental activity” (UDA). Dentists are paid per UDA, so they are financially better off performing two extractions than one root canal. Some patients, therefore, end up losing teeth that they could have kept. Likewise, with a check-up counting as one UDA, some dentists are ploughing through their consultations to get through as many as possible.

The Department of Health needs to step in. A new sort of contract is clearly required to iron out perverse incentives. It could be modelled on the arrangement for GPs, who are paid according to the number of patients on their roster. The government should also consider capping the amount of appointments that dentists can heap into a day, to prevent such “conveyor-belt” dentistry. Regulators should also take responsibility for keeping dentists in check, not point the finger at each other.

Britain’s dental health could do with a check-up. More than 50,000 children have teeth removed each year, costing the NHS £20 million. The sugar tax proposed in George Osborne’s March budget will be a straightforward way of addressing both Britain’s obesity crisis and its dental problems. The new government must press ahead with the policy.

This may also help to level out the country’s staggering oral health inequalities. Unskilled workers are ten times likelier to be missing teeth than those in the professional class. The present regime for public dental health is clearly not working. It is time that legislators and regulators took a second bite at the apple.

Update 9th August 2016: Chris Smyth in the Times. The great dental rip-off

Thousands of teeth needlessly extracted as surgeries accused of putting profit before patients

Letters 9th Aug 2016:

Sir, The overwhelming majority of NHS dentists want to see the back of a contract that has failed patients and practitioners alike (“The great dental rip-off”, August 6). This article claims that dentists are putting profit before patients, when the reality is that this contract forces them to put government targets above all else. Either we hit our quotas, or we get penalised. Further, when we do more, we don’t get paid for it.

It’s a contract that rewards dentists for ticking boxes for treatment and repair, not for improving our patients’ oral health. It was meant to improve access to NHS dentistry and put prevention at the heart of the service, and it has failed. Sadly, the government seems unwilling to let go of activity targets. A watered-down version of this system won’t cut it. We need a contract that really puts prevention first.
Mick Armstrong
Chair, British Dental Association;
Henrik Overgaard-Nielsen
Chair, General dental practice committee, BDA

Sir, I am an NHS dentist and believe the current contract is the worst thing that has happened to NHS dentistry. Three UDAs [units of dental activity] are awarded for a course of treatment (including examination, x-rays, fillings, extractions and root canal), not for a single visit. A patient may need ten visits, and the payment will be the same as for one visit. Show me a builder who would build a ten-bedroom mansion for the same price as a one-bedroom flat. The majority of ethical NHS dentists struggle to provide good basic dentistry under the current system.
Mandy Hewitt
Ruddington, Nottingham

Sir, Dentists have been pleading with the government to change this system since it was imposed ten years ago.

This is why: the patient has a check-up, scale and polish, x-rays, preventive care and advice for one UDA (£25 on average). Once a treatment plan is agreed, the payment from the NHS to a dentist for all the treatment the patient needs to secure dental health, apart from crowns, is a further two UDAs: £50. Cost of two single-use rotary nickel titanium files for a root filling (essential): £20. Money remaining to cover all other costs: £30. Minimum time for a patient who requires a root filling: 40 minutes.

Each of my surgeries costs me about £94 an hour to run before I can make any profit.
Celia Burns

Wylde Green, Sutton Coldfield

Sir, Your report and editorial suggest that dentists can claim as many UDAs as they like. On the old system, dentists could earn more by carrying out more treatment, and the annual dental budget could only be estimated. The current contract was designed to allow a budget to be set in advance. Each dentist is contracted to carry out a certain number of UDAs a year. If a dentist exceeds the number of UDAs contracted to them they get no additional pay. If they fail to complete the contracted number, their fees are clawed back. The dentists have to tender for contracts each year. Whose fault is it if dentists are paid for a large number of UDAs?

However, to claim that the upper limit of patients is 30 per day is unrealistic. In the 1990s I used to work with three staffed surgeries and treated 70 to 80 patients a day. That would equate to more than 30,000 UDAs a year. On a four-day week, I hardly ever ran late.
William Eckhardt
Retired general dental practitioner
Haxey, S Yorks

Sir, In view of the “great dental rip-off”, will the cabinet secretary recommend that all dentists become economical with the tooth?
David lilley
Ashby de la Zouch, Leics

Whistleblowing in the US – helping to change the organisational culture? No comparison with state owned organisations.. Exit interviews better and less destructive..

Whistleblowing in the UK health services is akin to a jihadist setting off his own detonation. Initially it could change organisational culture, and if there is sufficient compensation it might be worth it (for some). Surely the answer lies in confidential, depersonalised and amalgamated “exit interviews”: much less destructive. Retiring doctors and nurses could all contribute – together as a year class. I think the result might surprise politicians for the classes of 2014, and 2015..

An interesting article in the Economist 5th December 2015 reports: The age of the whistleblower – Life is getting better for those who expose wrongdoing, but companies continue to fight back—often against their own interests but makes no reference to public companies such as Health Trusts or Education departments. Recent evidence from Sussex and Mid Staffs is not encouraging for Whistleblowers, and most are much worse off afterwards. Usually they have to leave their jobs. In Hospitals and in General Practice whistleblowers have to move area…

Whistleblowing.pdf (from the Economist) contains the graphic below. It would be interesting if there could be similar from the public sector. The Economist could do us all a great favour by ranking and publishing yearly..

Corporate crime - Whistleblowing Ranking

The same edition of the Economist exposes the difficulties Swiss employees in the food industry are having. Whistleblowing in Switzerland – Rough terrain – Two court cases illustrate the struggles of employees who allege wrongdoing

There has been a sea change in Wales as the BMA is openly advocating the honest language of overt rationing, and exit interviews for all staff. The exit interviews, if conducted by a third party (Patients association, Community Health Councils) could be a really useful way of avoiding the need for whistleblowing and career self-destruction…

terroristschool-vi

NHS whistleblowing ‘problems persist’ – Patients First has yet to demand open exit interviews

Whistleblowers are promised more protection and new jobs – trying to change a culture of fear. Trusts to commission “Exit Interviews”?

Mr Cameron has to instruct CEOs, Board members and Chairman to give exit interviews

 

 

A reminder in poetry: “I am a child of the NHS”

On the 60th Year of the NHS I read a poem “I am a child of the NHS”… Unfortunately I don’t have the author… Reader –  let me know..

I am a child of the NHS
And despite my complaints you cannot guess
How grateful I am for the service I get.
Sometimes I reflect on the media and press
Which are patently unable to cope with the stress
Of  projecting the truth to the Nation.
The whole concept
Of cradle to grave
Caring for the dying, the elderly, the depraved,
(of nothing to pay, and no duty to save)
For that rainy day or medical surprise
Is “in place of fear”; A fantastic idea.
Aneurin Bevan was the constructor/designer
But time and reality are mean destroyers
Budgets and acronyms abound
To confuse the public in getting around
The shape of a wonderful dream
Which is becoming a nightmare
Said our friend Anne today:
“you can go to hospital well (if you dare)
And come out smelling of MRSA”.
So what is bringing back the fear?
And to compound the rationing, beware
For now both Dental and Physio care
Are unavailable to most – were you aware
That those  words “commissioning” and “fund-holding”
Were parodies of the truth?
And hidden deep in the morass
Of a beurocracy this crass
Is absenteeism so perverse,
It is shamed by every organisation
In the whole Universe
A reflection of a system designed
For the assertive, with morale much worse.
Forget Equity, Forgive Access,  Remove Choice, Allow unfairness
Remain National, not regional,
Counter litigation paranoia with no-fault compensation (none can afford lawyers)
And save my NHS.
So who is the “gatekeeper” in this mess? Your GP,  would you guess.
(that person who does sustained, unpredictable, often imperative, multitasking, for individuals families or groups)

I am a child of the NHS
And, still, despite my complaints you cannot guess
How grateful I am for the service I get.

and it’s worse in wales..

NHS cuts back on IVF treatment due to cost pressures – The Mail 3rd November 2015