The blame game

AccusationsKevin Lewis uses the BDIA’s warnings over buying cheap dental equipment to warn the NHS about continuing to drive down UDA values.

My heart sank when I saw the front page headline in The Times a few weeks ago, which read ‘Blundering doctors get protection from blame’. On closer inspection, however, it turns out that not all of the medics in question will need to have been ‘blundering’ in order to escape criticism and disciplinary action. It is quite sufficient for them to have made a minor human error like a lapse in concentration (perhaps when overworked and exhausted).

The article had been prompted by Jeremy Hunt’s contribution to the Patient Safety Global Action Summit 2016, held in London over two days in early March, with some genuinely high profile attendees. Speaking at the summit, Jeremy Hunt set out several new initiatives including the setting up of an independent Healthcare Safety Investigation Branch, and as part of this (as from April 2018) expert medical examiners, who will independently review and confirm the cause of all deaths arising from healthcare incidents. The plan is to introduce legislation that will give local hospital investigators the powers to offer ‘immunity’ to those who hold up their hand and admit errors that might otherwise have gone unattributed and/or undiscovered. If you are getting a sense of deja-vu, this could be because something along the same lines was originally recommended by The Shipman Inquiry, and subsequently by Robert Francis QC in his watershed report following the tragic events of mid Staffs.

Jeremy Hunt explained: ‘A huge amount of progress has been made in improving our safety culture following the tragic events at mid-Staffs but to deliver a safer NHS for patients, seven days a week, we need to unshackle ourselves from a quick-fix blame culture and acknowledge that sometimes bad mistakes can be made by good people.

‘It is a scandal that every week there are potentially 150 avoidable deaths in our hospitals and it is up to us all to make the need for whistleblowing and secrecy a thing of the past as we reform the NHS and its values and move from blaming to learning.’

What is not to like about unshackling ourselves from a quick-fix blame culture? Unveil your shackle-cutter Jeremy. But let us pause for a moment to consider that bit about a safer NHS seven days a week. Like all well-manicured political soundbites it sounds great (as always) but merits a little closer inspection. It is well recognised, for starters, that human factors and system factors conspire to make healthcare riskier when delivered by less skilled and less experienced teams and especially those who are strangers, working in unfamiliar environments with unfamiliar systems and processes.

It turns out that NHS Trusts appear to have breached the pay cap on agency nurses in excess of 60,000 times in little more than a year, so desperate have they been to the plug the gaps of what are fast becoming chronic, continuing shortages of skilled staff. These shortages are particularly acute in the evenings, overnight and weekends and public holidays, but they are in danger of becoming a designed-in feature of the NHS system, which would sit at odds with all the other aspirations, however desirable they are.

The Royal College of Nursing is turning up the heat, pointing to ‘an over-reliance on short-term staffing’ and this has of course also been a recurring theme underpinning the dispute between the government and the junior doctors. It is reported that some individual trusts are having to drive a horse and cart through the agency and locum pay caps on what is almost a routine basis – hundreds of times a week. These caps were introduced after the government was roundly criticised last autumn after revelations that more than £3 billion of precious NHS resources had been spent on agency staff in the 2014/2015 year alone.


One of the welcome themes of the Patient Safety Global Action Summit is a public recognition that when things go wrong in healthcare, there is too little focus on system-wide and process-related issues, and perhaps too great a readiness to embark upon witch hunts in order to point the finger of blame at erring healthcare professionals. OMG – please tell me I am not imagining this.

On reading a little further I discovered that the immunity is not quite as open-ended and unqualified as it seems at first blush. Apparently the GMC and other regulators could investigate any information that reached them directly and independently, even if relating to precisely the same events for which ‘immunity’ had been granted in an internal NHS investigation.

But looking upstream can provide both root cause and mitigation for the imperfect acts and omissions of humans. A decision to invest huge amounts of NHS money to recruit unknown staff to work nightshifts in hospitals where they are strangers to both their working colleagues and to the patients they are treating, is not one that anyone in his (or her) right mind would wish to take. The consequence of that decision might be felt not only by an unfortunate patient or two, but also by the healthcare professional(s) who try their best in an imperfect environment and yet are all too often left to pick up the pieces and the blame – after they have been hung out to dry by a system that has learned how to deflect blame and managers who run for cover.

But upstream from those managers are other decisions taken by people even further from the coalface – high level decisions about public spending, NHS funding, training, staffing, targets and priorities and a whole load of other issues. Amongst them, questions like why it is that so many NHS training places consultant positions remain unfilled. Dentistry is plagued by this resourcing drought every bit as much as medicine, but the impact cascades through the system like a stack of dominoes.

Zero hours contracts

Another ‘upstream’ problem that has a lot to answer for is the commissioning of NHS dentistry at obscenely inadequate UDA values. Those responsible will no doubt see these bargain basement contracts as a triumphant demonstration of their strategic prowess and negotiating skills, but it doesn’t feel much like a triumph when a young dentist attempts multi-visit band two courses of treatment for barely £10 in their pocket for the whole course of treatment.

The NHS may take the view that there are huge benefits in finding providers that are willing to offer services at UDA rates, which after the deduction of practice overheads, pay nothing whatsoever for the time of the performers. Think of all the additional UDAs that can be commissioned with the money saved, for example. May I suggest that you don’t spend too much time thinking because you inevitably end up thinking about the quality of care that can be provided at a consistent loss – patient after patient, day after day, week on week and month on month. The commissioners in question are knowingly buying counterfeit services.

Talking about counterfeit services, there is an interesting parallel with all the recent noise from MHRA, Trading Standards and even the GDC, underlining the concerns voiced by the BDIA about dentists seeking cut-price dental products that are not what they purport to be. The argument goes that dentists must surely know that when they pay a fraction of the usual cost, they are not buying the genuine article.

I would argue that the same applies to the commissioners of dental services. They too must surely know that when they are paying a fraction of the true, reasonable cost they cannot in all conscience expect the same standard of care. But they do of course. And so does the GDC, and the law firms who bring negligence claims.

In both of these instances it is likely to be the dentist who gets the blame when things go wrong. And this allows the politicians the luxury of being able to promise members of the public a high quality service where just about everything is available, most things are possible and patients are consistently safe. So when Jeremy Hunt says that we are making ‘a huge amount of progress’ in delivering ‘a safer NHS for patients’, and are on the move ‘from blaming to learning’ I do hope he doesn’t mean that the NHS is learning how to drive down UDA values, having already learned who to blame when it all goes pear shaped. I admire and welcome his commitment to ‘unshackle ourselves from a quick-fix blame culture’ but the blame and compensation culture has become so deeply entrenched that I wonder if he fully appreciates the scale of his task?


  1. 1

    I am a UK graduate Dentist. I qualified from Kings College School of Medicine and Dentistry in 1991.
    I have worked in the UK and have completed my Vocational Training here after graduation.
    I wanted to make you aware of the situation that I now find myself in and ask if there is anything that can be done to expedite my return to work.
    After graduating I worked for the NHS for one year in Oxted, Surrey before going onto work in some Independent practices in Kent. After this time I travelled overseas and ended up working in Australia where I met my wife. I resided in Perth, Western Australia for the next twenty years working in private practice and have owned two private clinics in that time and employed many staff members.
    I returned to England in July 2015 for family reasons.
    Since that time I have been seeking work as a Dentist without success.
    The main reason for this lack of success that I can see is the impossible mountain of bureaucracy that I have encountered since my return.
    The reason I say this is as follows:
    1-An unreasonable list of rules and regulations required to obtain an NHS provider and performer number that would leave almost anybody tearing their hair out trying to satisfy. I can understand that some of these rules maybe required for foreign trained Dentists but to insist on them for UK graduates defies any logic. I do not wish to bore you with the list of requirements that I have been asked to satisfy but can do so upon request.
    2- The insistence of D1 use class regulations for Medical operations. I have not been able to source even one location in My area that falls into this use class since I have been back. There is a complete lack of this type of property. When I do find a location suitable to establish a Dental practice I am invariably told that it is not D1 and therefore I must apply for a change of use. For some unknown reason a change of use application takes at least three months to process and then at the end of this wait the decision can still be no. All of the landlords that I have spoken to are reluctant to enter into such a drawn out process and invariably end up letting their premises to other applicants that are seeking a similar use class to the existing one. This has happened to me on numerous occasions and is very frustrating. I do not understand why this insistence on D1 use class for medical operators? In my time in Australia no such regulation exists and everybody was able to function satisfactorily without it.
    3-Massive over regulation of the profession by multiple bodies: General Dental Council, Care Quality Commission, NHS, Health and Safety. In order to satisfy all the regulations that are required by these four bodies one would have to be Superman and quite frankly it is mission impossible to even attempt to do so. The regulations are an impossible burden on health care providers that are leaving us dismayed and seeking alternative careers or emigration.
    4-I have a wife and two children plus a mortgage to support and this impossible set of rules and regulations that has been created by people who are not Dentists beggars belief quite honestly. I am unable to earn an income from the profession in which I was trained and that is a sorry state of affairs.
    I recently met an Orthodontist. She has not been able to work for two years because of this mountain of nonsense that has been placed before her on her return to UK from Australia.
    I fail to understand why such regulations should be insisted upon for UK graduate Dentists.
    In my own case I have been working in Australia where the standard of Dentistry is far higher than the UK but I feel like I am being treated like I have been working on the moon.
    I am so frustrated about this and am contemplating returning to Australia where conditions for Dentists are far more friendly than they are here.
    It is really demoralizing to be in this situation after twenty five years as a Dentist. I have considerable experience in my work but I am being treated as though I had just graduated with no consideration taken for my position or experience.
    There is no one to talk to within the Dental profession or the NHS as everyone does not seem to care.
    Time for a career change.

  2. 2

    Dear Jason

    I am very sorry to hear of your plight and can quite understand your difficulties. My dental colleague and I discussed your situation and we wonder if we can offer you some assistance. We would be very happy for you to make contact to discuss this further if you so wish.

    We can be reached on our Practice number on 01202 871053.

    With best wishes,


    Dr Peter Mounce.

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