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Introduction: The changing face of dental practice
Whoever desires constant success must change his conduct with the times.
The latter part of the twentieth century saw far-reaching changes in the economies of most westernised countries. Such modern economies are based more and more on the production and consumption of increasingly differentiated goods and services. Few sectors have escaped this shift in emphasis and that includes the practice of dentistry. For many years the vast majority of dental procedures performed in the UK were done so under the National Health Service (NHS) umbrella, with treatment costs heavily subsidised by the government. There wasn’t too much choice in the kind of treatments being offered to patients, and even less choice in the way that this treatment was provided. Most patients received their dental care in converted residential properties and the treatment itself, if we are honest with ourselves, usually centred on a mixture of amalgams in posterior teeth, composites (or more likely silicate cements) in anteriors, extractions, a quick scale and polish (with little thought to any long-term management of the patient’s periodontal condition), metal-based full crowns, partial dentures, perhaps conventional bridgework and at the end of the road … traditional full dentures. The relationship between dentist and patient was paternalistic at best, with patients usually having little say in what treatment was provided – ‘they aren’t really paying for it so why should they have a say?’ was an attitude prevalent at the time. Going ‘private’ was an option taken up by a very small percentage of the public and usually only by those people living in the most affluent regions of the country.
While some cynics might argue that in many practices up and down the country this scenario has hardly altered, there is no doubt that times are changing. Treatment options have increased dramatically and the approach to care is now aimed more towards prevention than mere repair and is increasingly patient-driven rather than entirely dentist-directed, with a greater emphasis on elective dentistry in the form of whitening, tooth-coloured fillings, laminate veneers, implants, and so on. Since the events of the 1980s and early 1990s many dentists have opted out of the NHS and are now providing dental care that is financed independently. New corporate players, with a more retail-oriented outlook, have sensed an opportunity and have entered the market with considerable financial backing from a variety of financial backers. This introductory chapter looks at these various trends and explores how they have shaped, and continue to shape, the profession. The concurrence of these trends has created an environment in which an ever-increasing number of ‘savvy’ dentists are able to run extremely successful practices while at the same time providing the sort of care and work environment that could only have been dreamt of even a short while back.
The changing role of the dentist
Fundamental advances in oral healthcare have resulted in a far greater emphasis on scientific, evidence-based treatments. Take, for example, the recently adopted National Institute for Health and Care Excellence guidelines on the use of antibiotic cover in dentistry. These turned conventional wisdom on its head and have seen the almost total elimination of the once ubiquitous prophylactic antibiotic cover in UK dental practice.1 Research has done much to clarify the biological and behavioural mechanisms involved in oral health and the prevention of disease – primarily dental caries and periodontal disease. Successive Adult Dental Health Surveys have shown that the oral health of UK adults has improved significantly over recent decades. For example, the proportion of adults in England with visible coronal caries has fallen from 46% in 1998 to 28% in 2009 while the proportion of edentulous adults in England has fallen from 28% in 1978 to 6% in 2009.2 Nowadays, people are rendered edentulous at a rate that is almost too small to measure. Many millions have been converted from recurring emergency extractions to regular check-ups. In short, a massive number of people now enjoy the benefits of good dental health.
With this reduction in gross disease, in a more dentally aware population, a larger proportion of a dentist’s work is now elective in nature, dealing with matters of poor appearance and impaired function rather than the simple alleviation of pain. Greater emphasis is also being placed upon evidence-based dentistry. In tandem with these changes, technological developments in areas such as dental materials, pharmacology and treatment modalities have resulted in a much wider range of treatment options. Most of these procedures are much more technique-sensitive than their predecessors – for example, consider placing an implant compared with providing a partial denture, or inserting a posterior composite as opposed to an amalgam. Because of this added complexity these techniques demand a coordinated team approach if they are to be successful – ‘team’ meaning not only the dentist and his or her chair-side assistant but also hygienists and technical support, even front-desk staff have an important role to play by helping us to communicate better with patients as well understanding and even modifying their expectations.
All of these changes have a number of important implications for the way we work. While ever higher standards of clinical practice are required of the dentist and other members of the dental team, clinical practice will increasingly centre on prevention, control and self-care strategies based on knowledge of general health and the lifestyle of individual patients – for example, counselling patients to wear mouthguards while playing sports. Such preventive-oriented approaches towards care usually require a fundamental shift in the patient’s behaviour and the modern dentist (together with his or her staff) is therefore called upon to be more aware of, and more sensitive to, issues concerning patient compliance and motivation.
Keeping ‘up to date’ with all these changes makes dental education a vital and continuing process, demanding more commitment from the dental practitioner than in the past, when the pace of change was much slower and when many a dentist would seemingly pass from graduation to retirement virtually without ever learning anything new. In 2002, in recognition of this need for dentists to stay up to date, the General Dental Council (GDC) implemented its programme of compulsory continuing professional development (CPD), with CPD defined as:
study, training, courses, seminars, reading and other activities undertaken by a dentist, which could reasonably be expected to advance his or her professional development as a dentist.3
The advent of compulsory core subjects in 2007 further strengthened this approach. Successful dentists know all too well that keeping meaningfully up to date is a must, not something to which they pay mere lip-service and they will therefore devote time, energy and resources to do so. They will also encourage, even insist, all their staff do the same and indeed in 2008 the GDC made CPD compulsory for all dental care professionals.
Given the rapid changes in the way dental care is being delivered, CPD should also embrace not only ‘hard’ treatment modalities, but also ‘softer’ interpersonal and behavioural aspects of dental care as well as a knowledge of business management methods which helps to blend all these disparate parts together to produce a successful dental practice. In 2008 the GDC issued Guidance on Principles of Management Responsibility offering direction for those dental professionals with management responsibility.4 It is widely accepted that most graduating dentists sadly do not possess the requisite knowledge and skills to become competent practice principals and little seems to have changed in this regard since the publication in 1999 of one British Dental Association (BDA) survey looking into the views of over 1000 young dentists (that is those qualifying after 1987) who, while feeling well-prepared for general practice in most clinical aspects, considered themselves ill-prepared in areas such as staff management, business and finance.5 The dentist’s role is clearly changing and the modern professional has so much more to contend with than counterparts, say, 20 or 30 years earlier. This was clearly articulated in a letter published in the British Dental Journal in the spring of 2013, in which the author, a retiring dentist, rather cynically observed:
Forty years ago my job description was dental surgeon; today my job title is performer and provider of primary dental care for the local PCT [primary care trust], lead in child protection, lead for cross-infection control, radiological protection supervisor, health and safety supervisor, fire warden, lead for information governance, lead for staff training, and environmental cleaning operative.6
Perhaps fortunate then for the writer of that letter that he is retiring, as there lurks on the horizon a further sea change in the shape of revalidation. The publication in 2007 of the government’s White Paper Trust, Assurance and Safety7 proposed that all health regulators are required to develop a system of revalidation. Accordingly, the GDC has been working for some time towards a system in which a dentist is obligated to prove that he or she is fit to stay on the Dentists Register.8 Compulsory CPD can now be seen as a first step of a far wider process in which the onus is on the dentist to demonstrate not only that he or she has undertaken some postgraduate courses but also that he or she complies with the standards set by the GDC throughout his or her professional life. It is proposed that revalidation will encompass four domains: (1) clinical, (2) professionalism, (3) management or leadership and (4) communication. At the time of writing it is not clear how dentists in different sectors, such as academia, will be assessed. Not surprisingly, a number in the profession view this whole exercise as yet another set of disproportionate, onerous, bureaucratic impositions, as one frustrated contributor to an online discussion group noted:9
Another idea that sounds good on paper, but in reality is not necessary. Surely revalidation shouldn’t apply to anyone with a clear record with no complaints? What big problem do we have in dentistry that revalidation will fix. Revalidation is very likely to degenerate into yet another box ticking exercise, instantly increasing expenses to patients and dentistry providers, and reducing access to dental care. We’re already being revalidated and regulated and nickel and dimed to death.
The difficulty is that revalidation will happen. Forward-thinking dentists will not wait to be told to keep up to date and abreast of all relevant developments in their profession. Unfortunately, such developments and shifts in philosophy are often slow to be adopted by the majority of dentists, but those who have embraced this new paradigm of care are reaping the rewards in terms of increased satisfaction – not only their own but also that of their staff and, crucially, their patients. A number of dentists have seized upon the opportunities presented by entering specific niches within the profession – for example, in areas such as orthodontics and implants. This, unsurprisingly, has created a backlash from specialists in these fields who feel undermined and fear a lowering of clinical standards.
Patient satisfaction is, as we will see, one of the ultimate goals for any successful practice. For it to happen, the practice principal must see himself as more than just a dentist, he must also be a visionary. Dreams don’t usually come true by accident. Success in any walk of life is more likely to happen if you can envisage that success and then plan for it to happen. Key features of this planning process include a clearly articulated personal and professional mission statement coupled with specific goals covering every aspect of one’s life – financial, business, family, social, physical, intellectual and spiritual.
Greater emphasis on a team approach to provision of dental care
Successful dental practices show clear evidence of effective leadership and the creation of a working culture that is compatible with the practice owner’s core vision. Almost without exception, all successful dental practices possess a keen, motivated, highly-trained, well-rewarded, empowered and harmonious staff, which has traditionally comprised receptionists, back-room staff, dental nurses, hygienists and, of course, dentists, but which increasingly includes practice managers and treatment coordinators, among others. It is a key management task to see that such a team is established.
The need for a team approach to dentistry received considerable attention throughout the 1990s, primarily in the various reports published by the likes of the Nuffield Foundation10 and the GDC.11 Generally speaking, there has been a move away from small, often single-handed, practices with minimal support staff, in favour of larger group practices with a corresponding emphasis on the ‘team’ approach to care. In addition to the advantages a larger team can bring in terms of the range and flexibility of services that can be offered to patients, expanded practices are better placed to take advantage of economies of scale, as both fixed and non-fixed costs can be spread over more dentists and surgeries. From the description we have given here thus far, it may seem that this trend is entirely one-way, an assumption that would, however, be misleading. A number of dentists have ‘downsized’ from larger practices (with one or more associates) back to single-handed practices, albeit with a strong emphasis on quality of care provided by a small team of dedicated staff. It appears that for some dentists the task of finding associates who share the same vision of dental practice proves to be just too difficult in a climate characterised by a shortage of dentists, or more pertinently a shortage of dentists they would want to have working in their practice. One dentist expressed this view thus:*
The second best day in your working life is when you take on an associate … the best day is when they leave.
Ten years ago, when the first edition of this book was published, we discussed the perceived and actual shortage of dentists in the UK. This is less of an issue now and as a result there is a significant and continued reduction in associate remuneration. This is partly a result of there being more dentists in the marketplace and partly because, from a business standpoint, practice owners simply cannot justify the high percentages previously being paid.
While the rate of change towards a more integrated team approach is first and foremost a commercial response to the need for higher levels of care and service being demanded by the public, it is also widely appreciated in the profession that there is a need to clarify and enhance the roles played by all types of dental ancillary staff. The Dental Auxiliaries Review Group, which was set up by the GDC to explore the future role of ancillary dental staff, published its report in May 1998 and concluded that ‘dental care in the next century will be provided by a multi-skilled team comprising members of the dental profession and professions complementary to dentistry, all led by a dentist’.12 It was anticipated there would be new classes of operating auxiliaries who would carry out the more routine aspects of dentistry as part of teams directed by a dentist, probably one per team, whose role it would be to do the treatment planning and the more sophisticated aspects of dentistry. This gained further momentum in 2008 when the GDC introduced mandatory registration for all dental care professionals, dental nurses, dental technicians, clinical dental technicians, hygienists, therapists and orthodontic therapists. At the time of writing, over 63 000 dental care professionals are registered with the GDC. There is, however, one potential fly in the proverbial ointment with the announcement by the GDC in March of 2013 that it would remove its barrier to direct access for some dental care professionals. In the past, every member of the dental team had to work on the prescription of a dentist. This meant that patients had to be seen by a dentist before being treated by any other member of the dental team. This latest move represents a complete volte-face by the GDC and clearly contradicts earlier GDC initiatives (as discussed earlier). It appears to have arisen through pressure from the Office of Fair Trading and is being vehemently opposed by the BDA, whose view was very clearly stated in a statement released on the date the decision was announced:
This is a misguided decision that fails to consider best practice in essential continuity of care, patient choice and cost-effectiveness, and weakens teamworking in dentistry which is demonstrated to be in patients’ best interests. Dental hygienists and therapists are highly-valued and competent members of the dental team, but they do not undertake the full training that dentists do and on their own are not able to provide the holistic, comprehensive care that patients need and expect. Our fear is that this could lead to health problems being missed in patients who choose to access hygiene and therapy appointments directly.13
It remains to be seen exactly what effect this move will have on the dental marketplace, but at first sight it does appear to undo all the effort put into promoting the concept of the dentist-led team, which focuses on the need for patients to see a dentist first for a comprehensive oral health assessment and treatment plan.
Thinking of patients as consumers is something of a double-edged sword. On the one hand, dentistry, along with all the other healthcare services, is finding its clientele to be more demanding in terms of the expected range and quality of services, as well as the availability of information about those services. Increasingly, people want more say about their health and health services and are demanding the best care for themselves and their families, together with greater choice in that care. The profession should not see this as being a negative development. On the contrary, it is a plus for the profession to have patients who don’t look on themselves as passive recipients of care and who instead demand a greater involvement in the process of care. The fact too that patients are paying a much larger percentage of the total treatment cost than in the past has clearly had an effect, in that they expect to know much more about what exactly they are receiving for their money. Patients are also more likely to express their dissatisfaction whenever they are unhappy with any aspect of the service provided and this has led to a far more litigious environment than at any time in the past. Indeed, one of the most noticeable trends over the past two decades has been a dramatic increase in the number of patient complaints against dentists. It is debatable whether this is because of a moral decline in the profession, or because modern dentistry is so much more complicated nowadays that more things can go wrong or possibly because the public are more inclined to complain in these modern times. The truth is likely to contain elements of all three of these. What is undeniable is that in recent years there has been a staggering growth in the number of disciplinary cases being heard by the GDC. In response, in 2005, the GDC published Standards for Practice14 effectively a road-map detailing the responsibilities of a dental profession. This was updated in 2013 and appeared as the subtly re-named Standards for the Dental Team15 featuring the following nine key principles.