Category Archives: Dentists

Dentists are self-employed, and have to purchase their PPE

NHSreality has commented on the Dental situation, and observed that some forms of heart disease after dental caries present very late. Other issues around dental health and hygeine, prevention and treatment are mostly forgotten by the people who are lucky enough to have good dental health. Since there is no NHS dentistry for many, who have to buy private care, they will not be surprised by the dental charges for PPE. We live in a real world,a nd there are “hard truths” that the public need to realise. Dentists are self-employed, and have to purchase their PPE…

Sir, Criticism is levelled at some private dentists for levying a charge to cover the increased costs of PPE (“Hard to swallow: the £40 PPE bill”, July 11). The reality is these costs have been imposed by the government, with a poor evidence base. Combined with the price of some PPE having risen by more than 1,000 per cent, there is no alternative but to pass on these costs to patients. NHS dentists are unable to recoup any PPE costs since the government contracts their fees at a fixed rate. The British Dental Association is lobbying for additional fees to cover PPE for NHS dentists; there is no such initiative for private dentists. Most practices are “mixed”, providing both NHS and private treatments: private income often subsidising NHS. If these conditions continue, many high street practices will close within the year.
Jason Smithson; Bertie Napier; Tif Qureshi; Luke Thorley; Simon Thackeray; Rahul Doshi; Dominic O’Hooley; Wayne Williams; Nav Khaira; Matt Perkins; Victoria Holden; Stephen Jacobs; Zaki Kanaan; Debbie McGovern, British Association of Private Dentistry

Times letters: Facemasks and restrictions on our liberty

Sir, Even though Britain has the third highest Covid-19 death toll, some so-called libertarians are outraged at the prospect of mandatory facemasks (“Wear mask in shops from July 24 or face a £100 fine”, July 14). Their arguments recall those parodied in a Times leader in 1854, when the public health pioneer Edwin Chadwick was forced to retire from the Board of Health: “We prefer to take our chance of cholera and the rest than be bullied into health . . . There is nothing a man so much hates as being cleaned against his will or having his floors swept, his walls whitewashed, his pet dungheaps cleared away or his thatch forced to give way to slate . . . It is a positive fact that many have died of a good washing.”
Sasha Simic

London N16

Sir, The psychological effect of facemasks has barely been discussed but is key. I cannot believe I am alone in feeling anxious at the prospect of wearing a mask in shops and being confronted by crowds of people doing the same. Masks change the nature of non-verbal communication. Lip-reading or seeing a smile are integral in daily interaction. The government wants people to flock back to the high street, but I fear that by taking away the freedom of choice over masks, the opposite will be achieved. A compromise would be to mandate their use only at busy times or in busier stores. One thing is for certain: mask-wearing should not become a permanent part of our lives.
Rob Mitchell

Sir, Not all facemasks are equal. Front-vented masks might protect the wearer but they project a plume of unfiltered exhalation. Many of these masks appear in video interviews without comment and are advertised widely as being more comfortable for the bespectacled user.
Peter Feilden
Box, Wilts

Sir, Now that facemasks are mandatory in shops and on public transport, they must be sold for a fair price. The two main chemists on my high street are charging in excess of £30 for 50 disposable face masks. It is not acceptable for companies to make huge profits out of the pandemic.
Tracy Ambidge
Esher, Surrey

Sir, While the debate goes on about the wearing of facemasks, what about compulsory application of hand sanitiser whenever one enters a shop. After a brief retail expedition last week the smell of various sanitisers mingling on my hands was so pungent that I could not bear to put them near my nose and had to scrub my hands on arrival at home. As a strategy to keep me from touching my face, it is remarkably effective.
Peter Sergeant
Loughborough, Leics

Sir, Sir Jeremy Blackham states (letter, July 13) that it is not possible to eat while wearing a mask. I would point out, as a regular traveller to the Middle East, that women who wear the niqab are well used to eating and drinking in public.
Peter Cartledge

Tetchill, Shropshire

Sir, I agree that it would be difficult to enjoy a drink or a meal while wearing a facemask. However, this could have the benefit of reducing my calorie intake. Perhaps the “facemask diet” could be the next slimming craze.
John Forde

Dementia cannot kill off any one UK Health Service if you exclude it, but understanding is essential to reconfigure..

It is so obvious that in a compassionate society we need to reconfigure the health services, and the social services. The perverse incentive to allocate all  possible conditions  to be classified as  social is so great. Fully funding the “Health Service” means that we don’t have enough money for the Social Service, which is means tested, but for which nobody prepares.

We could initiate laws that forced preparation, but they would be evaded.  Dementia cannot kill off any UK Health Service if you exclude it, but understanding is essential to reconfigure..  With a 40% rise predicted over the next 10 years, Belfast has led the way in this round of comment. But it will be quickly forgotten, as denial, especially by politicians, who will also suffer, becomes the norm, and the media move on again. If the odds are 30:1 we need to cover it..

The Alzheimers Society Jan 12th 2020: The Dementia Time Bomb

Victoria Ohara on 9th June in the Belfast Telegraph: Warning of dementia ‘time bomb’ as 60,000 people in Northern Ireland to suffer by 2051

James Ashworth in the Express says that the number of cases will double by 2050

The percentage of people suffering from dementia in Britain is set to increase from 1.6% to 2.7% by 2050, according to a report by Alzheimer Europe which reviewed 16 population studies

Giles Sheldrick reports 21st June in the Express: “Dementia crisis as £26bn “time bomb” threatens to sink the NHS. (As if it is not sicking already)

40% rise in Dementia cases in 10 years leads to “time bomb”. The Mail. 21st June.

A changing opportunity for the four UK health services.. Solution: avoiding paternalism, for rationing, and for financial probity.

Social care and the impact

of the pandemic – If social care and health care are to be funded the same way, then we can combine them.

Honest and pragmatic solutions to Social Care are ignored – by all parties. ( And the media )

The risks associated with not haveing a dentist and dental care…

There are large long term risks to the population, particularly the poorest and children of lowest social groups, in not having dental care. The prediction from some dentists is that the higher rate of caries from neglect will lead to an epidemic of Rheumatic Heart Disease in 20-30 years. But then, which party or politician will care about the votes of these people in 30 years’ time? The wait for a Dentist is only part of the problem: now we have longer waits for cancer treatments and that will hit voters! Unfortunately it wont hit MPs as they will go privately, and have access to all the central London facilities, and even if they stay in the EHS, they retain choice. We have rationed dental training, and now we are rationing dentists. In most overt rationing systems those at most need would get subsidised treatment, but most British trained dentists are working in the affluent areas, and privately.

Fiona McRae reports 12th June in the Times: Dentist closures leave thousands without access to NHS treatment

One of the country’s most densely populated cities does not have a single dentist able to take on NHS patients.

Up to 20,000 residents of Portsmouth will be without a dentist when a chain of practices closes its doors next month.

With no surgeries accepting new adult NHS patients, the nearest practices are in Gosport, which is a ferry-ride away, or Havant, a half-hour drive away, according to the NHS website.

The British Dental Association (BDA) said that “years of underfunding and failed contracts have taken their toll”, leaving practices struggling to recruit staff, and communities from Devon to Cumbria having difficulty getting access to dental care.

Research by the BDA highlighted 13 towns and cities where no dental practices were registering new adult patients, including Plymouth and Barrow-in-Furness.

It also calculated that more than a million new patients had tried and failed to find a surgery last year.

Colosseum Dental Group, which is owned by an investment company based in Switzerland, is closing three practices in Portsmouth next month. Estimates of the number of patients affected vary. Local sources have put the figure at 20,000 but NHS England suggested that it would be closer to 9,000.

Colosseum Dental blamed the closures on “longstanding and ongoing challenges in dentist recruitment”.

One Colosseum Dental patient, who did not wish to be named, said: “I received a letter saying that I would be provided with ongoing care at another surgery but when I contacted them I was told all they could do was put me on a waiting list. They said Colosseum had made a ‘business decision’ to shut the three surgeries and the staff had been made redundant.”

Stephen Morgan, Labour MP for Portsmouth South, said that poorer members of the community would be worst hit.

“The news that three dental practices in Portsmouth are set to close is deeply concerning,” he said. “How will poorer families pay for the additional transport costs? How will single parents get the time off work to travel the extra distance? What will the additional environmental cost be for our city, which is already plagued by air pollution? The government needs to answer these questions.”

He added that the situation raised questions over the use of private organisations to run public services.

Mick Armstrong, the BDA’s chairman, said: “We are seeing practices struggling to remain sustainable as vacancies go unfilled and over a million patients are unable to secure an appointment. NHS dentistry remains the Cinderella service and this is the latest evidence that its future can no longer be guaranteed.”

A spokesman for NHS England South East said: “There are more than 20 dental practices open in the Portsmouth area and patients at nine in ten dental surgeries will not be affected by these changes, while support is being offered for people to find alternative care where it is needed.”


More than a million new patients were turned away by NHS dentists last year, on top of 700,000 who could not get an appointment with their usual surgery.

Some patients have spent years hunting for a dentist, others have given up and even pulled out their own teeth.

Changes to how dentists are paid, introduced in 2006, are at the root of many of the problems.

Dentists went from being paid per treatment to being paid for a target amount of work each year under the new contract. They are now paid as much for doing ten fillings as for one.

Those who hit their quota early in the year have no incentive to do more NHS work because they will not be paid any more for it. Those who can’t make their targets face financial penalties.

NHS dentistry gets funding for only half the population, and the profession is struggling to recruit and retain staff.

Three quarters of practices had trouble filling dentist vacancies last year and six out of ten dentists say that they plan to leave the profession or cut back on their NHS work in the next five  years.

Agonising delays for cancer treatment for the Scots

Endometriosis patients have to go overseas

Update 18th June 2019: BBC News 17th June – MP calls NHS summit on Portsmouth dentist closures

DENTIST CLOSURES 13th June The Times

Sir, The reasons that there are such problems over access to NHS dentistry are multifactorial (“Dentist closures leave thousands without access to NHS treatment”, Jun 12). Dentists are faced with working in a target-driven system: if a practice misses targets it is faced with financial clawback and the threat of contract termination. Dentists are paid the same amount if a patient needs one filling or five fillings and two root canal treatments, so the incentive of taking on high-needs patients is zero, as it could mean potential bankruptcy. Costs have risen hugely since 2006, with only small yearly increases in funding for NHS care. Care Quality Commission regulations and General Dental Council guidelines heap pressure on clinicians, meaning more paperwork and less time with patients. Dental litigation is increasing, so the fear of being sued means spending more time writing notes in case of a claim. A new contract was promised years ago but dentists are still left in the dark regarding the future.
Dr Mike O’Reilly

Prestbury Dental Practice, Cheshire

‘… and as the Minister in charge I can assure the public there is no shortage of NHS dentists.’

Can the NHS be saved? Only with different local and global thinking, and changing the “rules of the game”.

All of us in the caring professions know the answer to this question, and indeed that there is no “N”HS any longer. The Guardian knows the answer….. Iain Robertson Steel, a retired medical director acknowledges the problem (But suggests no answer/solutions), but on 26th April  in the Western Telegraph I suggested a “fourth option” for people in Pembrokeshire.  This last is only for local needs, and a letter suggesting a global rethinking was in the Western Mail 25th Jan 2018 is at the bottom of this post. What can save the 4 health services is not clever reorganisations, but an honest debate on overt rationing, and making it clear to everyone what is not available free, for them. ( Changing the rules of the game )

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Can the NHS be saved? The Guardian – Dennis Campbell – 

…the Guardian’s health policy editor Denis Campbell spent a day in King’s College hospital in London. He found staff and patients who are devoted to the NHS but who can also clearly see what is needed in order to sustain the service for future generations.

A long-term plan designed to secure the future of NHS England has been delayed once again by Brexit. But as Britain’s health service heads into its annual winter beds crisis, the Guardian’s Denis Campbell visits King’s College hospital in London to find out what staff and patients need for the future – and how much it will cost. 

“The Welsh NHS and social care is a shambles and no longer sustainable or fit for purpose.” Dr Iain Robertson Steel in the Western Telegraph 7th December.

Health service needs to be remodelled Western Mail 25th January 2018

From the perspective of west Wales there is no British health service.

I do not have access or choice to anywhere outside my own rural trust (Hywel Dda) unless the service needed is not available here. Even a second opinion has to be within the same trust.

There are four, and possibly five health services if Manchester is included. The WHO has said it will no longer report on an “NHS”.

The lack of choice, the covert rationing, and the unequal access to tertiary centres, primary care, and palliative care threaten to bring on civil unrest.

A Welsh mutual of three million people cannot offer the same quality of healthcare as one of 60 million. Even if the Welsh Government has tax-raising powers, there are not enough taxable earners to rise above the decline.

We seem to have forgotten the power and improved health outcomes in large mutuals. Since the UK’s health service has to be refashioned, now seems a good time to unify again, and re-establish the same rights across the country.

Increasing taxation to pour more into a holed bucket should not appeal to most taxpayers.

We need a new health insurance system (the original NHS was insurance based) and the caring professions will remain cynical until what replaces “in place of fear”, avoids bringing it back.

Dr Roger Burns


Pembrokeshire GP urges a “fourth option”. Western Telegraph 26th April 2018

The finances are in such a mess, that local post code and unexpected rationing is everywhere… The “Rules of the game” need to be changed…..

Changing the rules of the game

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In Wales they really can waste money: £68m unveiled for health and care hubs

BBC News reports 6th December: £68m unveiled for health and care hubs

The profession will not see this as positive. It marks the beginning of the end for self employed GPS. It is probably a waste of money, and it is part of the direction of travel, where fewer and fewer people have access to the expertise needed when they are ill. Differential diagnosis, risk analysis and safety netting are all part of a Drs training, and in the case of GPs, living with uncertainty so that good gatekeeping ensures minimal waste. These GP “Geese” who laid those golden eggs are not here now….

But it may be attractive to part time GPS with families often married to other doctors.

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ITV News 6th December covers the initial reaction of the profession: Plans for 19 new health and care centres…..

…Dr Charlotte Jones, chair of the BMA’s General Practitioners Committee says she’s concerned about the lack of involvement of local clinicians:

Whilst we welcome improving access to services closer to people’s homes, it’s difficult to assess the impact this will have without knowing the intricacies of how it will work. It’s concerning to us that the initial reaction from LMC members suggests that they haven’t been involved in the design of the scheme.

It’s vital that local clinicians, who understand the needs of the local community, are involved in service design to ensure that patients receive the services they deserve.

As part of the work to improve access to local services, investment is desperately needed to ensure the GP estate is fit for purpose. Robust premises strategies must be developed, with the full involvement of LMCs. – Dr Charlotte Jones, Chair GPC Wales

Dr Ian Lewis reports 26th November in Walesonline another money spend, mostly from charitable fund raising, which will cut out the GP. By deskilling the GP how does society gain? This is the opposite of utilitarianism. (Greatest good for the smallest number) and brings back the suggestion of the Court Report in the 1970s#; A child health centre in West Wales could be created 20 years after it was proposed – The venture has been in the pipeline for almost 20 years and is estimated to be worth £2.5million

Just as there wont be enough Doctors, there won’t be enough care homes. There are many opinions, but NHSreality fears that Wales is pouring money into a number of buckets which have holes in them. There are just not enough trained people: GPs, Nurses, Physiotherapists, Psychologists, OTs, Psychotherapists, Radiologists, Anaesthetists, you name them…

Mark Smith reports in Walesonline 4th December: The Welsh care homes under threat for not meeting standards – Care homes in Wales are under threat of being suspended or de-registered

BBC News 21st September: NHS reform can cut costs, says local council leader

BBC News 4th December: Cash ‘ploughed into NHS’ preventing change, AMs warn

BBC News 5th December: Welsh Government ‘sticking plaster’ on health services

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We need to train a lot more dentists if “Sixty per cent of dentists ‘will quit NHS within five years’”

Interestingly the Times carries an advert in the middle of this article and guess what for: private medical insurance. (Choose Monkey for Affordable Private Health.) Its going to get worse and health inequalities will widen. We have prolonged under capacity and a contract that infuriates the dental surgeons. I have a possibility of a suggestion from a dentist – watch this space. In general, if you wish to control a profession – create overcapacity.

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The Times reports 2nd October 2017: Sixty per cent of dentists ‘will quit NHS within five years’

More than half of dentists plan to leave the NHS within the next five years, a survey has found.
A study by the British Dental Association (BDA) discovered that about 58 per cent wanted to move on, either to private work, overseas, into retirement or out of dentistry altogether. It also found that 53 per cent of young and newly qualified NHS dentists, aged under 35, intended on leaving.
Henrik Overgaard-Nielsen, chairman of the general dental practice committee of the BDA, called for government reforms to avoid a crisis. He said: “It is a tragedy that a decade of underfunding and failure to deliver meaningful reform now risk shutting off the pipeline of NHS dentists. Government has made NHS high street practice so unattractive the next generation are now looking to the exit.
“These young dentists are the backbone of the dental workforce, and losing them at the start of their careers raises existential questions about the future of the service. This is a crisis made in Westminster, and Westminster must respond.”
The survey was carried out in June and July of this year and 1,212 questionnaires were completed and returned. Forty two per cent of those young dentists planning on leaving said that they intended to focus on private practice instead.

Harman Chahal, chairman of the BDA’s young dentists committee, said he had decided to leave NHS practice in April. He said that young NHS dentists were “offered no reward for going above and beyond, just the constant threat of penalties for not hitting government targets”.
“We have a system that limits our ability to care for those who need us most, while forcing us to explain the mechanics of the payment system to patients who expect NHS care to be free at the point of use,” he said. “The dental contract has reduced our patients to a line in a spreadsheet.”

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New patients turned away by thousands of dentists – it is getting worse

Kate Gibbons reports in the Times 17th September 2017: New patients turned away by thousands of dentists

‘… and as the Minister in charge I can assure the public there is no shortage of NHS dentists.’

Thousands of dental practices are refusing to take on new patients as one couple came forward to say they had resorted to pulling out their own teeth.

Of the 2,500 NHS practices that give details about how to register online, almost half were not accepting new adult patients. The British Dental Association (BDA) said that the figures reflected “an emerging crisis” driven by ministers’ “principal interest in keeping costs down”.

Analysis by the BBC also found that 40 per cent of new child patients were being turned away from practices, despite tooth decay being the leading cause of hospital admissions among children.

Rebecca Brearey and Nick Oldroyd, an unemployed couple from Dewsbury, West Yorkshire, are among those who have not been able to gain access to dental care. They claim to have “ripped out” their own teeth to cope with the pain after being refused NHS treatment for four years.

“It got so bad that after taking a combination of paracetamol and alcohol I ripped my half-rotten teeth out,” Ms Brearey told the BBC. “I’ve literally begged to be taken on by an NHS dentist, but every time I’ve been turned away.”

“I’m on benefits and trying to get a job, and when someone sees my teeth they just think I’m another waster. I do believe if I could get some dental care I might be able to begin turning my life around.”

NHS England said that 95 per cent of people seeking a dental appointment were able to get one and 39 million treatments were carried out in England last year.

However, new figures from the NHS show that half of all adults and nearly 5 million children are not seeing a dentist regularly.

Henrik Overgaard-Nielsen, chairman of general dental practice at the BDA, said that the figures were a stark reminder that dentistry remained a “Cinderella service”. “Many dentists would love to do more NHS work, but the contract imposed on them penalises them when they don’t hit quotas and does not pay them when they do more.

“Despite years of promises we are no closer to a decisive break from a model that puts government targets ahead of patient need.”

Analysis of more than 7,000 dental practices in England that are listed on the NHS Choices website found that just over 2,500 had information about whether they were accepting new patients. Work to transfer ownership of NHS records to individual practices began in April, but some practices are still waiting for access to their profiles or learning how to update the system.

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.

Why were doctors treated differently to dentists? Perverse…

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

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

10% increase in vacancies. “Industrial scale” recruitment from overseas is a clear admission of recurrent cross party political failure.

Dentistry is important – for an important sub group…

Civil unrest will be inevitable… This is the future … “Super-surgeries with 50,000 patients” – take it or leave it..

‘Your insurance doesn’t cover acts of God, like age related illness and accidents.’


After failing to tax sugar – Doctors want warnings on sweets and chocolate to scare children off sugar…

Lets face it, it’s the same ignored and disenfranchised families in the Grenfell tower as the people who don’t get to the dentist. They are an important sub-group. The dental contract needs renewal, and dentists are altruistic enough to want a service that prevents both long term and short term complications. If the BDAs approaches have failed to make caries important (short term) then perhaps the emphasis on preventable heart valve disease (long term) will make government see sense. NHSreality still feels there are too many perverse incentives in a system where the surgeon is the same person as the assessor…

Chris Smyth of The Times reports 30th June 2017 on the BMA ARM conference: Doctors want warnings on sweets and chocolate to scare children off sugar

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Warnings on sweets and chocolates are needed to scare children off sugar and help to fight tooth decay and obesity, the British Medical Association has said. The labels could include pictures of rotten teeth and overweight children, although milder “traffic light” warnings may also be considered.
The BMA also wants free toothbrushes for children under five, and for schools to teach children about brushing their teeth to help cut the “shocking” number who need surgery.
A third of children are overweight or obese when they leave primary school and tooth decay is the most common reason for children to be admitted to hospital. The BMA said tougher action was needed after Theresa May dropped plans to curb promotion of junk food in a government obesity strategy last year.

Iain Kennedy of the BMA said 18,000 children under five had been admitted to hospitals in the past two years to have teeth removed, often under general anaesthetic. He said: “Doctors are calling on the government to help prevent further children from needing these operations by regulating food manufacturers to place warnings on sugary foods.”
Mick Armstrong, chairman of the British Dental Association, backed the plans, saying: “These simple steps could ease a huge burden being felt across the NHS. Political indifference has allowed a preventable disease to become the number one reason for hospital admissions among children.”

Graham MacGregor of Action on Sugar said: “We should have warning labels and they should show rotten teeth, people who are obese and amputated legs, because that’s the reality.”

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

The most common operation on children – dental extraction or clearance. At risk – a generation lost to good dental care

Five million children failed to see a dentist in past year..

How do politicians of all parties maintain that the NHS is free at the point of delivery? Dental care is certainly not..

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

Patients at risk as GPs face forced shutdown – will Primary Medical Care follow Dental Care into being covertly rationed?

Health Services (England) dentistry “for sale”.

Dentistry is important – for an important sub group…

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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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Dentistry is important – for an important sub group…

John Appleby in the BMJ opines on whether “Dentistry: should it be in the NHS at all?” (BMJ 2016;355:i5986 ) and comments “…continued inequalities in dental health (partly exacerbated by patient charges) suggest the NHS should perhaps be doing more—not less—to fulfil its fundamental mission on equal access for equal need.” So if dentistry is to be excluded for the majority it is still important for the NEETs. it could reasonably be rationed out of the local Health Service provision for those paying tax….

When the NHS opened for business in 1948 two of its biggest product lines quickly became the supply of spectacles and dentures. According to the British Dental Association, in the first nine months of the NHS, dentists provided over 33 million artificial teeth, 4.5 million extractions, and 4.5 million fillings. Dental surgeries were overwhelmed by the demand for treatment.1 Since then dentistry has moved on from drilling, filling, and extraction—but so too has the public’s dental demands. Are we approaching a point where it will become increasingly hard to justify tax funding for dentistry? Is the perfect smile a medical necessity worthy of public subsidy?

There is no doubt that the nation’s gnashers have improved tremendously over time. In 1968 a staggering 37% of the adult population of England and Wales had no teeth.2 A decade later, in England, this proportion had fallen to 28%, and by 2009 it was just 6%.3 Over the 30 years to 2009, the proportion of people with 21 or more teeth increased substantially; among people aged over 55, for example, it more than doubled from 30% to 63%.3

The improvement in the number and quality of people’s natural teeth reflects general improvements in living standards and diet, but also reductions in smoking, greater use of fluoride toothpaste, and the efforts of the dental profession. The number of dentists has increased—by 20% in the past decade—and they are doing more work, although this has flattened out over the past few years (fig 1).4


Fig 1 Numbers of dentists with NHS activity and courses of dental treatment relative to 2006-07 (value 100) in England for financial years 2006-07 to 2015-16 4

But although the epidemiological trends in dental health have been going in the right direction, we still have not only a substantial burden of dental disease but also considerable variation—across regions and socioeconomic conditions. The national 2013 children’s dental survey, for example, found that around one in seven children had severe or extensive tooth decay, or both.5 The factors associated with an increased risk of severe dental problems included living in Wales or Northern Ireland, eligibility for free school meals, only attending the dentist when they had tooth trouble, and the consumption of sugary drinks.5 Variation in line with levels of deprivation more generally is also evident in adults’ use of dental treatment. For example, figure 2 shows a positive observed relation (correlation coefficient +0.73) between deprivation and the rate of teeth extractions across local authority areas in England in 2015-16 and a negative relation of a similar magnitude between deprivation and fitting of crowns.6


Fig 2 Number of extractions and crowns per 100 courses of dental treatment in England by local authority based measure of socioeconomic deprivation for financial year 2015-16 (author’s calculations)6

One reason for the different direction of relations may be that in 2015-16 the patient charge for an extraction was £51.30 (€58; $64) compared with £222.50 for a crown. As the findings from the children’s survey indicate, variation in use of different types of dental treatment is influenced not only by lifestyle behaviours related to dental health but by the financial barriers to accessing dental care and how much patients are charged for a treatment.

For a health system based on the separation of treatment and ability to pay, the negative impact of dental charges—even substantially ameliorated by exclusions—is shocking. In 2009, for example, around a quarter of adults surveyed across England, Wales, and Northern Ireland said that their dental treatment had been influenced by cost. For those with very poor dental health this figure reached 50%.7 Nearly a fifth of people had delayed treatment because of cost, and a partially overlapping group of around one in seven said treatment had been both affected and delayed because of cost 7 (fig 3).


Fig 3 Influence of cost on choice and timing of dental treatment in England, Wales, Northern Ireland, 20097

Dentists may not have the same denture workload as they grappled with in the early days of the NHS (fig 4), but despite improvements in people’s general dental health, many people still require the services that dentists provide. And continued inequalities in dental health (partly exacerbated by patient charges) suggest the NHS should perhaps be doing more—not less—to fulfil its fundamental mission on equal access for equal need.


Fig 4 What do dentists do all day? Total number of clinical treatments for adults and children, England, 2015-16


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.