Select Committee on Health Minutes of Evidence

Memorandum by Mr Clive Bosley (D 34)


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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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