Walking in the air – the Kevin Lewis column

Kevin Lewis explains why NHS primary dental care has never been a particularly good fit within the rest of the NHS.

In an ever-changing world, one of the few enduring certainties of life is that the epic cartoon short movie The Snowman would be screened over the Christmas period – for no particular reason although I gather that Father Christmas got added somewhere between the book and the movie.

Astonishingly, it was first screened on Christmas Eve in 1982 – exactly 25 years ago – and was nominated for an Oscar the following year. I must be getting old, because I can well remember that my children were very young when it first appeared.

The Snowman captures a moment in time – an age of innocence when children remained children for longer, and when winters really were winters (the writer of The Snowman, Raymond Briggs, recounted that the idea came to him while walking across fields through deep snowdrifts in the harsh winter of the preceding year).

Two of the first Christmas cards I received last month were one from Australia, depicting a traditional snowy Christmas scene and secondly a sun-drenched ‘island paradise’ scene with palm trees, golden sand and azure sea – in an envelope bearing a Manchester postmark.

All that talk of climate change must be true then.

How many snowmen does the average British child get to build during their entire childhood these days?

Not nearly as many as their parents and grandparents did, that’s for sure. Perhaps I have unwittingly discovered a new form of measurement for global warming?

Change is all around us, of course, and 2007 was certainly a funny old year for dentistry.

In many ways it was defined by the letters that were sent and received during the year.

The moment of truth arrived for the first cohort of dental registrants who had failed to meet their CPD requirements, and they received an unwelcome letter from the GDC. The first erasures are imminent.

The first year of nGDS came to an end and the body bags started to be counted.
Most of the ‘in dispute’ NHS contracts were finally sorted out – although some remain in dispute even now.

More dentists had stayed in the NHS than the gloomiest of the pre-contract predictions, but the levels of activity were a different story.

Unfortunately, a happy ending did not seem likely because labs and dental traders alike were reporting a sharp drop in business.

Then Barry Cockcroft came to the rescue with his ‘single-use endo’ letter and the sale of endodontic reamers and files improved overnight.

Later in the year, a fair number of NHS dentists were sent the ‘clawback’ letters that they were hoping not to receive.

Some at least of the recipients replied with some helpful suggestions as to where the PCT might store their contracts.

A few even provided the Vaseline.

During the year, a surprising number of dentists received letters regarding removal (or contingent removal) from Performers Lists.

Towards the end of the year PCTs received the first draft of Noddy’s Guide to ‘De-Commissioning’ NHS dental services.

Let’s hope they are slow readers.

Some Hep-B-infected dentists received a letter that they had waited years for, as the new DoH guidelines made it possible for some of them to renew their dental career.

For many, sadly, it was too late because they had already been forced to start a new life outside dentistry.

But for others it was a welcome light at the end of a very long and depressing tunnel.

Those aspiring to enter dental school got a letter inviting them along for their mandatory Hep B, Hep C, TB and HIV tests.

In the old days we used to be invited to a welcome speech from the Dean, followed by a freshers’ party. How times have changed.

In a few years the entry requirements for dentistry will no longer be a string of ‘A’ levels but instead, a medical certificate and a clean driving licence (to allow you to get to somewhere the PCT will allow you to work).

Talking of freshers’ parties, 2007 was remarkable for having witnessed the birth of the first two new UK dental schools for four decades, as well as a plethora of new DCP schools.

Graduate entry, four-year (or even three-year) dental courses may well be the future – but the future will be yesterday before we know it.

In the days when we were closing rather than opening dental schools, the Inland Revenue used to be infamous for dispensing threatening ‘we know where you live’ letters to defaulting taxpayers, in the weeks running up to Christmas.

The season of goodwill and all that.

Now the Revenue seems to have taken on the job of ensuring that everyone knows where you live.

Not to mention your bank details, National Insurance number and inside leg measurement.

In The Snowman, the little boy sensibly followed his natural instincts and kept his dressing gown on as he flew to the North Pole.

Last autumn, Gordon Brown rashly abandoned the sartorial principles of a lifetime and delivered the ‘Mansion House’ speech in full City battledress of white full bowtie and shirt, and formal jacket – and very smart he looked, too – only to spend the next few weeks in sackcloth and ashes as one disaster after another crashed down upon his suddenly-troubled premiership.

A lesson learned, no doubt. Next time, stick to the dressing gown routine, Gord – you know it makes sense.

If Blair sometimes demonstrated Teflon-like characteristics, Brown has latterly been displaying more of the features of top quality, industrial strength fly paper.

The Snowman, rather like the NHS, was very much the product of its environment. It was shaped from readily available materials, but it was ill suited to survive anything other than the cold, icy environment in which it had been created.

In much the same way, the NHS was created out of massive need coupled with fierce political will, in the face of the harsh, cold wind of post-war austerity.

It, too, was fashioned out of what was available at the time (which wasn’t a lot) and it was envisaged as a public service, never designed to survive the fierce heat of a competitive, commercial healthcare environment.

You may remember that the little boy in the story is carried up into the night sky, clutching onto the snowman’s hand for dear life.

He looks down over fields and oceans, and on reaching the North Pole he meets (in the movie, if not the book) Father Christmas and parties with all the other snowmen.

It doesn’t seem to matter that the little boy is the only human amongst so many snowmen; his new-found snowman friend makes him feel safe, welcome and secure.

What a contrast with the snowman’s stumbling efforts, earlier in the story, to understand and adapt to the little boy’s natural habitat.

It is unfamiliar and we discover that a snowman can’t survive for long in the armchair by the fire.

The story ends with the snow melting overnight and the little boy wakes up, wondering if it had all been a dream.

Then he finds the scarf that Father Christmas had given him at the North Pole and realises that it really had happened after all.

But at the same moment he also realises that he is now back in the real world, the snowman’s day is over and he will need to make his way in the world without him.

The NHS snowman may still wish to be friendly, inclusive and benevolent but it needs to find a way to exist in the searing heat of the commercial world where the general dental practitioner is forced to reside.

The UK in 2008 is a very long way from the North Pole and little boys aren’t the same as they were in 1982, let alone 1948.

They no longer feel the need to be ‘holding very tight’ to the snowman’s hand – although they may still want to be friends.

But can there ever be a comfortable liaison between a benevolent public service, the need for fiscal effectiveness and the independent contractor competing in the open commercial market?

The truth is that NHS primary dental care has never been a particularly good fit with the rest of the NHS.

Let’s face it: we are different.

We have tried to exist within an NHS that has changed and changed again around our ears.

The GDS has endlessly tried to rediscover and morph itself, but what works for the rest of healthcare may not work for dentistry.

Is it really so terrible to acknowledge this?

NHS dentistry succeeded in 1948 because it initially delivered what the State wanted, what the public wanted, and what a significant proportion of the profession wanted (eventually).

The balance would never be as easy again because the needs of the various parties would never again be so well-aligned, nor so easy to meld with a single system.

Add the fourth dimension (the PCTs) and it soon becomes obvious that it is painfully difficult to keep all four parties happy at the same time.

UDAs are not, and can never be, the ‘golden bullet’ that fee-per-item was in 1948.

For those in the NHS, perhaps the greatest challenge and opportunity in the 15 months that remain between now and April 2009 is to find a place where both we and the snowman can live together, or accept that we need to live apart if we are both to survive.

I do hope that you were able to enjoy yourself with family and friends over the holiday period and, in the face of everything, you still managed to chill out – as the little boy said to the snowman.

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