Category Archives: Dentists

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.

Image result for decommissioning cartoon

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.

Image result for decommissioning cartoon

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.

Untrained in differential diagnosis, efficient investigation requests, etc. etc. – so asked to step in without liability insurance cover….

The Nuffield Trust report, Reshaping the workforce to deliver the care patients need , is written for the “employers”. The response from the BMA (for doctors) and the Patients Association (For patients) shows the initial thoughts of the professionals. It will be interesting to hear the response from the Insurance Companies that cover the doctors and nurses. They will anticipate more claims, and premiums will inevitably reflect this. Nurses are untrained in differential diagnosis, efficient investigation requests, etc. etc.  – so they are now asked to step in and probably without liability insurance cover…. Physiotherapists are efficient at musculoskeletal complaints and the experienced will recognise the “red flags” when cancer presents as (e.g) back pain, but expect delay and missed diagnosis. Demand for private health care may well rise, and a two tier system result. As NHSreality predicted (Dentistry now outside the Health Services for most of the nation ) General Practice could follow and become.. “two tier”.

 Sophie Castle-Clarke opines in The Guardian 17th May 2016: Reshaping the NHS workforce for the 21st century 

…Expanding the skills of the non-medical workforce presents big organisational challenges and will not be easy in the current financial context. Reshaping the NHS workforce also carries risks. Evidence shows that without carefully redesigning how different staff work together, new and extended roles like these could increase patient demand, thereby costing money rather than saving it….

and in The Times Chris Smyth reports: Nurses will be trained to cover junior doctors’ jobs

Thousands of nurses will be trained to fill in for doctors under plans to deal with chronic staff shortages.

Patients will be given drugs and tests by senior nurses, who will also be expected to take decisions on treatment usually made by junior doctors.

Details of the plan came the day before a deadline for a resolution of negotiations on a new contract for junior doctors. Tens of thousands refused to work even in A&E departments on two days last month in the first all-out strike in the NHS, and further strikes have been threatened.

Every hospital and many GP surgeries will be encouraged to develop advanced practice nurses under a blueprint drawn up for NHS Employers, the organisation that oversees staffing across the health service, to deal with a lack of junior doctors……

Katherine Murphy, chief executive of the Patients’ Association, said: “These proposals will not solve the shortage of skilled doctors and nurses across the health service.”

Mark Porter, chairman of the British Medical Association council, said that the plans were a sensible short-term solution, but added: “This should not be done at the expense of good quality training for doctors or, indeed, doctors themselves.”

50,000 short – not £millions but staff….

Covert rationing of places in training for Medics, Nurses and others has come home to roost. It is too late for this next decade. We need to plan for the next one, and to avoid the same continuing mistakes.

The times reports today 5th Feb 2016 the end of Chris Smyth’s article on “ditching reforms” ….

The NHS has failed to plan its workforce effectively ( Productivity in NHS hospitals ), with a shortfall of 50,000 clinical staff, the National Audit Office has warned. A report from the spending watchdog also said government plans to cap agency staff rates to get soaring temp costs under control, were unlikely to work.

Sophie Borland for the Mail reports: Report warns the NHS is short of 50,000 doctors, nurses and other staff – written by Lord Carter, a Labour Peer, this is critical of manpower planning, but who was in office 15 years ago, when the missing staff should have been offered places at Medical Schools? Labour. The FT – Carter report paints grim picture of NHS –

Getwestlondon reports 7th Jan 2016:West London NHS trusts facing up to 30% nursing staff shortage

Stroud Life14 Jan 2016 Staff shortage forces NHS chiefs to close Stroud Hospital department

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…


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



50,137 NHS staff on £100,000 or more

This recent report from the Taxpayers’ Alliance highlights the growing cost of  the corporate structure in the NHS , the problem is if we cut Consultant pay they will simply go elsewhere. Chief executives and their minions however don’t seem to achieve anything regardless of what re-numeration they receive as they are constrained by the political policy and budgetary constraints of the day  often far outside their scope of influence.

'With all the cash we earn it's surprising we don't have any WAGS!'

‘With all the cash we earn it’s surprising we don’t have any WAGS!’

Here is the article in full from the Taxpayers’ Alliance website


The TaxPayers’ Alliance November 10, 2015 6:00 AM

In it’s second release as part of the Public Sector Rich List series, the TaxPayers’ Alliance today reveals the full scale of senior pay in the NHS. We detail the GPs, dentists and senior managers in receipt of bumper pay deals, with a full regional survey of all those whose remuneration exceeds £100,000.

Nobody disagrees with paying doctors and nurses well for doing good, difficult jobs. But the NHS Rich List makes clear that management in failing hospitals are still picking up handsome pay deals at taxpayers’ expense.


Between 1999 and 2008, NHS spending increased in real terms by an average of 6.3 per cent per year. However, given impending demographic challenges and the fact that the kind of budget increases of the 2000s are simply not feasible, productivity will have to increase and pay will have to be restrained. A 2010 report from the National Audit Office found that:

“Over the last ten years, there has been significant real growth in the resources going into the NHS, most of it funding higher staff pay and increases in headcount. The evidence shows that productivity in the same period has gone down, particularly in hospitals.”

The key findings of this research are that in 2013-14:

  • There were at least 50,137 employees of NHS organisations and General Practitioners who received total remuneration in excess of £100,000 including:
    • 37,034 employees of NHS trusts and Clinical Commissioning Groups
    • 10,735 General Medical Practitioners in England and Wales
    • 1,794 General Dental Practitioners
    • 534 employees of NHS quangos
    • 40 employees of ambulance trusts
  • 1,757 received more than £200,000, 203 more than £300,000, 60 more than £400,000 and 8 more than £500,000
  • 2,381 were employed by NHS trusts and Clinical Commissioning Groups in non-clinical roles:
    • 472 received more than £150,000
    • 124 received more that £200,000
    • 23 received more than £250,000
  • The highest paid people in the NHS were 5 General Dental Practitioners whose earnings totalled more than £3.45 million – £690,572 each on average
  • The highest paid person at an NHS Trust was Mary Burrow, Chief Executive of Betsi Cadwaladr University Local Health Board who received £454,404

Jonathan Isaby, Chief Executive of the TaxPayers’ Alliance, said:

“No one begrudges paying doctors and nurses well for the tough jobs that they do, but it’s galling to see bosses at failing hospitals continuing to rake in the cash. It’s an insult to taxpayers, but it’s even worse for the patients who have suffered because of mismanagement, and worse. The rewards-for-failure culture is rife in the NHS and it must be stamped out as a matter of urgency.”

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