Kevin Lewis column
 

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Kevin Lewis column

 

Kevin Lewis column

Kevin Lewis looks back at past and present dentistry reforms and highlights the BDA’s crucial support along the way. . .

Once upon a time, there was this new Labour Government that had a vision for a completely new, revolutionary way to deliver healthcare in the UK. Not everyone thought it was a good idea, and the British Dental Association (BDA) made clear its opposition to the proposals and strongly advised its members to steer clear of the new contract that the Government was offering them.

A significant number of dentists heeded this advice but, after a lot of muscle flexing, the majority of dentists did not. Dentists simply made individual decisions based upon their own individual circumstances – and who could blame them? These circumstances varied according to the size, nature and location of the practice, the local competitors, and not least the stage in their career that the dentists in the practice were at. These were complex and weighty considerations.

During the three years that followed, many dentists did spectacularly well and were delighted with the decision they had made. Interestingly enough, some of them had given the contract a wide berth, while some had done precisely the reverse, seizing the contract with both hands. Yet both groups were smiling like Cheshire cats.

But it didn’t take long before the Government came to the conclusion that the contract was far too generous, and a number of significant changes were made. These changes ensured that dentists needed to work much harder, and to be much more productive, to earn the same money. The dentists who had refused to sign the contract smiled a knowing smile, and said ‘I told you so.’

But this was no fairy story. All this really happened – not in 2006, but in 1948. The story shares many similarities with the events of 1990-1992, but with striking differences. Firstly, it was of course a Conservative Government that introduced the new contract in 1990, at a time when it was already into its third term rather than in the first flush of reforming zeal. Secondly, the context could hardly have been more strikingly different.

In 1947/48, British dentistry was all private. By 1989/1990 it was mostly NHS. By 2005/2006 a mixed NHS/private economy was firmly established. Another significant factor was that the 1948 new contract arrived against a background of post-war austerity, whereas the 1990 contract came after a decade of unprecedented economic growth and prosperity. The outcome was, to an extent, a reflection of the moment in time.

Once upon a time, there was a national fee scale and narrative, and a ‘one size fits all’ national contract. The BDA’s role as the principal negotiator of the terms of the NHS contract was both central and crucial. They didn’t always get what they wanted – as Mick Jagger observed round about that time – but nobody was in any doubt that they were there at the table. But there was also far greater homogeneity in the congregation of dentists that the BDA was representing.

The BDA already had the significant challenge of representing the salaried dentists in the hospital and (community) primary dental care services, the defence forces, industrial dentists, the university teachers and researchers as well as practitioners.

The biggest single group was the practitioners, by some distance, but after the 1990 contract any cohesion within this group evaporated. Some went in one direction and some went in another.

Pay-as-you-go private dentistry, private capitation schemes, practice-based bespoke capitation schemes, the NHS and any combination of the above. Then came specialist lists and a further schism. Then even the NHS practitioners split into PDS and GDS before the PDS group split further into first, second and third wave PDS, Options for Change fieldsites and commissioning pilots, ‘early’ (i.e five minutes to midnight) PDS and eventually nPDS. The ‘base contract’ proved to be a mirage and nGDS was its surrogate with the DwSI as a simultaneous offspring.

This brief overview encapsulates the dilemma that the BDA has faced over the past decade or so. In one sense, understanding this helps to explain the difficulty the BDA had in maintaining a consistent and sustainable stance in relation to the unfolding NHS reforms. The profession was no longer a cohesive unit and even the reforms were a moving platform.

For the BDA, and for many in the higher ranks of it, the lessons of 1990-1992 live long in the memory. In adopting a posture that would delight one constituency of BDA members, it would run the risk of alienating or infuriating another. Nevertheless, it is still fiendishly difficult to be all things to all people, and ultimately nobody thanks you for it.

Another issue for the BDA is the demographics. The profession’s average age is younger than ever before, and the proportion of women higher than ever before. UK graduates now form very much the minority of all the people who join the Dentists Register each year. This will remain the case even after the current expansion of undergraduate places, assisted by the Peninsula and UCLAN-based dental schools this time next year, and even after we allow the four (in some cases) or five years that it will take for the first graduates to emerge.

Today’s new arrivals are mostly from Eastern Europe and they will be blissfully unaware of the historical role and dento-political context of the BDA. Meanwhile, for those of my generation, the BDA was, above all, the profession’s negotiator in all matters NHS and the source of much of our postgraduate education.

In those far-off days lecturers carried not a laptop or portable drive, but a safebreaker’s toolkit to disembowel any rogue projector that gobbled up one’s slides (happy days). There is a gradual wakening to the fact that this traditional raison d’etre of the BDA has now a raison d’avant ete. Local commissioning and the CPD explosion has seen to that.

We need only look across to other professions, or to other countries, to realise that we would be poorer without a vibrant BDA, a relevant BDA and a well-supported and inclusive BDA. Without it, we would find ourselves acutely exposed to any ‘divide and rule’ aggressor.

The BDA needs to be stronger than its component parts, not despite these ever-increasing differences but because of them. We should not assume from the massive changes that we have seen in recent years that there is no longer a role for the BDA. There is a role, albeit a different role than for DPA (formerly GDPA), the specialist societies, the Colleges and Faculties and an altered and fast-evolving role at that.

Bringing together these disparate groups and interests in British dentistry is a big enough job for anybody. Peter Ward has made a commendable start as the BDA’s chief executive, and there is a promising mix of talent and experience in evidence to advise and support him. It looks and feels like something is stirring.

 Posted on : Sun 17th - Sep - 2006

 

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