I have never met Richard Emms but I would like to shake his hand after reading his speech to the LDC Conference, UK Dentistry needs more people like Richard. I have no idea if I am “out of order” by publishing this here but as long as Richard has no complaint then I can’t say I really care. If you are involved in Dentistry in any way at all do take a few minutes to read & digest.
LDC Conference chairman, Richard Emms received a standing ovation after his speech to the pre-Conference dinner. He called for consistency from Primary Care Trusts and honesty from the Department of Health. He called on the chief dental officer for England, Barry Cockcroft to trust the profession. ‘If our patients trust us to do the right thing why can’t the department, I think we’ve earned it’, he said.
“Distinguished guests, ladies and gentlemen. It is a great honour to stand before you this evening and to welcome you to this, the pre-conference dinner of the 59th Annual Conference of Local Dental Committees.
There is a mixture of emotions as I stand here, firstly pride… I’m proud to be on my home patch, very proud of the fact that you have elected me chair of this important body, and proud to be the third member of North Yorkshire Local Dental Committee to address you in this role, and I’d like to crave your indulgence to take this opportunity to thank two of my predecessors as conference chairs Stuart Robson and John Renshaw for the support and encouragement they have given me over the years since I joined the LDC as a fresh faced young pup almost twenty years ago.
As I look down and see John and Stuart’s name on this chain of office, it’s quite a humbling experience to read the other illustrious names of those that have gone before and to consider the contribution they have made to the profession, and the leadership that they have given.
The overwhelming emotion this evening however, is one of nervousness as one realises the fact that the audience at conference is traditionally, shall we say opinionated, and not one that will readily stand any bullshitting!
In recent years this seems to have been coupled with a predeliction for the ancient sport of chairbaiting, a situation that leads me to the feeling so quaintly described by Sir Alex Ferguson as teams approach the business end of the football season as, “squeaky bum time”.
And yet, and yet, I do feel a little more secure in having home advantage, as it were, and safe in the knowledge that I have played this venue previously, though it was a slightly different gig.
I appeared on the stage behind me here a few years ago in the Ripon Amateur Operatic Society’s 2002 production of Sound of Music so if things do go all a bit pear shaped this evening and I experience a Robert Green moment, I can always fall back on an impromptu Karaoke evening of such sing- along favourites as “How do you solve a problem like a Warburton contract” and that classic made popular by the PCTs “16 going on 17 pounds a UDA”
When you look around this magnificent auditorium you wouldn’t guess that when I was treading the boards up there as the Nazi butler of Captain Von Trapp, the building was close to being condemned, (unlike the performance I hasten to add). After 100 years the place was facing wrack and ruin, it was no longer fit for purpose. The Grand Circle behind you was unsafe, the roof leaked, and the dressing rooms, which are below us, were a hard hat area. A situation that was OK for the men playing the German soldiers, but it was hell for the nuns! I think we were the last company to perform here before it was closed for repair and refurbishment. After much thought and planning and several millions of pounds of investment, it was reopened last year and I’m sure you’ll agree it’s pretty impressive.
Around the same time I was elected to serve on the newly constituted GDPC where we soon began discussing another edifice that many thought was coming to the end of its usefulness, namely the old NHS contract.
Aha I hear the more astute and perhaps more sober members of the audience murmuring, he’s using the successful rebuilding of this auditorium as a metaphor for the reconstruction of NHS dentistry.
Would that I could. For while we began to put the foundations down for the new system, the plans suddenly changed and we were left with a structure vastly different from the one that had been envisaged. I’m sure you will remember those early days, Darrin Robinson, who was then with the Dept, was giving roadshows likening the new PDS system to a football match where we could stand on the sidelines to watch the early enthusiasts playing the game until we felt it was so good that we too were ready to participate.
You can picture the scene, the sun was always shining, the skies were blue, the grass was green, jumpers for goalposts, marvellous. Sadly just as we were all getting ready to join in, the park-keeper came along and not only moved our jumpers but told us all that from now on we would be playing a very different game.
Suddenly everything changed.
What is it with change – we’ve just been through an election campaign where two of the parties’ slogans, not surprisingly perhaps, focussed on change. Its true that we are not happy with things the way things are and that something needs to be done, but why do we have to have so much change, so quickly and so all consuming. The only constant seems to be keep changing.
Confession time. I’m a bit of a traditionalist; I’m comfortable with the familiar and quite like the status quo. I like old fashioned musicals, test cricket and the fact they still sing Abide with Me at the cup final. There’s a line in that hymn which seems appropriate for dentists at this time and in the situation in which we find ourselves, ‘Change and decay in all around I see”
Was it always so, – did we ever face such changes in our working lives in such a short period of time. I suppose it’s inevitable that at these sorts of events one looks back before looking forward.
When I qualified in the early eighties the only acronyms required were MOD, ELA and RCT plus the occasional, not politically correct, tongue in cheek ones that suggested perhaps that a condition was “normal for norfolk”. Any jargon we used was purely clinical, Mandibular, maxillary, extraction, oro-antral fistula.
In the new NHS it’s so much more complicated. If you wish to open a practice you contact the PCT with an EOI. They will then give you a PQQ before an ITT where you can consider the KPIs and the QOF after which, if you are successful, you will need to register with the CQC. One needs to look at the dashboard and check the metrics, observe the traffic light system and allocate to Red Amber or Green.
If you want advice, it’s a toss up whether you call the BDA or the RAC. We seem to be talking a different language these days where just like Humpty Dumpty in Alice in Wonderland words can mean anything they choose them to mean.
How can all practices have an average value? By its very definition some must be better and some must be worse. I must have treated thousands of patients but I don’t think I’ve ever seen an average patient; I’ve certainly never seen one and only provided the average of 1.4 restorations. To criticise a practice for not having an average return is about as sensible as castigating a PCT for not having all their workers of average intelligence.
Ask any clinician about quality and you will get a range of answers but I guess some would include the margins on a crown, the longevity of a restoration, or the radiographic appearance of a completed root filling.
What you wouldn’t hear amongst the answers would be the number of new patients seen, the presence of a swanky NHS logo or the percentage re-attending within nine months.
And at what point did nine become a magic number. How can only one interval from NICE Recall Guidelines be taken, Recall Guidelines remember, and then that be misinterpreted and the meaning changed and re-attendance pattern used as a measure of quality. I’m sorry, that’s not quality, that’s rationing.
And its not just recall intervals. We seem to have entered a world that wants to measure everything. We forget that very often the things that can be counted don’t count and the things that do count can’t be counted.
Real quality is any number of timeless classics, reassuring the patient, continuity of care, time spent in communication, a willingness to go the extra mile. Which box do I tick for that data set? We are facing a steady erosion of what we have traditionally recognised as professional responsibility, “doing the right thing when nobody is watching” as Susie Sanderson quoted at last years conference. An erosion of the discernment that our professional education and experience has brought us. Most practices that are not achieving their UDAs are not doing so because they are slacking but because they ARE being professional and, despite the system, are trying to do what’s best for their patients.
I qualified at the end of the paternalistic era, the era of doctor knows best and patients were expected to have done to them what the dentist felt was best for them. We moved through to the phase, quite rightly, of agreeing options with the patient and listening to their wishes.
It’s a great privilege to metaphorically take a patient by the hand (CRB and ISA checks permitting of course) and lead them through an agreed treatment plan, and it’s why patients stay with us because they trust us to inform them and to do the right thing.
But that’s going, its been replaced with a ‘PCT knows best’ mentality with their hard enforcement of clinical data sets without the knowledge of the circumstances of the patient sat in the chair in front of us. Where there is a greater concern with structures and process than care. We heard just a few days ago that there’s to be a public enquiry into last year’s tragic events in Mid-Staffordshire when the quest for target achievement became paramount and patient care suffered.
I think it’s Goodhart’s law that states that when a measure becomes a target it ceases to become a measure. So, in the target driven NHS, its starting to get somewhat soul destroying, and I’ve lost count of the number of colleagues who have said to me that they are glad that they are at the end of their careers and not at the beginning.
That’s a sad indictment on a system that, when it was being discussed back in 2004, was supposed to be good for patients, good for the department and good for dentists. It took a special skill to get it wrong on all counts. But what can we do –
We have a new coalition administration and I understand they want to focus on outcomes. Ok that’s fine, but it will require a deal of thought and work not only by GDPC but also by practitioners like those in this room, those who are at the tooth face, to come forward with suggestions so that appropriate outcomes can be determined and how they can best be evaluated.
And yes at the moment we have Steele with his recommendations on a new way of working, and it will be interesting to hear Jimmy again tomorrow, one year on, as to his take on the state of change, and I am sure that there will be strong opinions expressed from delegates on the direction of travel.
But is it enough, have we gone down the road we’d rather not journey, too far away from our practice independence toward micro management ever to return. Perhaps.
But its no good just moaning about it and throwing our hands up in despair. Some LDCs have not joined us this year as they feel that some of our meetings and conferences are pointless, we never change anything, and that it is just one big whinge fest. I’d like to hope that surely we could be more than that. Yes, things are now more locally and regionally focussed, and we are building a strong network of regional LDC groupings, but it is still centrally where the big decisions are made and it is only through national gatherings such as this that we can hope to influence policy.
In the film Network, Peter Finch plays a grizzled cynical anchorman in a US news station who eventually has had enough. He goes on air and announces to his audience that “I’m mad as hell and I’m not going to take it anymore” a mantra that is taken up by the viewing public.
Perhaps that’s what we need to do. We need to stop our whinge fest and say we’re mad as hell and we’re not going to take it anymore. We need to retake a hold on our professional lives and livelihoods and articulate our thoughts, and our concerns, to put forward our ideas for change because that surely is the function of this conference.
Where can we start. Flippantly, I could suggest at the very beginning. It may not be raindrops on roses or whiskers on kittens but perhaps I can share with you some of my favourite things!
How about some consistency from PCTs?
How can it be that using the same guidance, one PCT does one thing and another takes a contrary view? One willingly collecting LDC levies whilst another refuses. I’m all for local solutions, but for one PCT to say that practice transfers are not allowed whilst another encourages it is unfair, confusing for everyone and breeds uncertainty.
How about some honesty from the department? We might not like what you have to say but at least we would know where we stood.
· if you don’t like the idea of independent contractors – say so.
· if you want a service to be purely access driven – say so
· if you want limited treatments and a core service – say so
but please – don’t pretend to us or our patients that in the current climate you can provide all of the treatment, to all of the people, all of the time. That fools nobody.
And what about trust?When this place was a wreck and PDS was on the horizon, we were promised, don’t laugh, a high trust environment.The Chief Dental Officer believes we should have ‘earned autonomy’ in other words we should show that we can be trusted. Well I’m sorry Barry but we have been educated over many years to think, to diagnose and to treat on an individual basis. Yes we are mindful of the wider aspects of health care but our responsibility lies with the patient in front of us. Their needs and yes their demands are paramount.
If our patients trust us to do the right thing why can’t the department, I think we’ve earned it. So here we all are, gathered on the eve on conference. We come from the four corners of the country, from the North of Scotland, from Southern Cornwall, from East Anglia and from West Wales. We come to represent our constituents, their practices and their patients and it’s an opportunity to make known their feelings as to what is happening and to present our ideas for change, in a constructive fashion I hope, with knowledge and with passion. I hope we will have robust debate and by the close of conference have articulated not only the personal views of the delegates but of those we represent.
I started this evening with a theatrical allusion and I’d like to close with one. Towards the end of Howard Barker’s play Victory, which is set in the aftermath of the English Civil war and the restoration of the Monarchy, one of the characters has this line, he says; “You have nowhere to go to in the end but where you come from”
I hope that during the debates tomorrow you too will remember where you come from and what our purpose is. Enjoy the rest of the evening, I shall be able to now, and have a great conference. Thank You”
The Incisal Edge 