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Of course British dentists can talk about money too, and often do. But sometimes money appears as an unmentioned signpost in the background. No one talks about it, but everyone instinctively follows the way it points. And somehow, subtly, it begins to take over the agenda. As a clinical academic, I am not protected from this pressure. Nor are my colleagues in hospital, specialist and general practice.

Academics and money

Financial pressures have increased in academia over the last two or three decades. Nowadays, promotion depends far more on how much money you can bring into the institution. Research grants are obviously one aspect of this, but there are many other ways in which the pressure is manifest. Research assessment ratings mean that publications are needed to maintain institutional income. If the referees agree to publication, what does it matter later that people find faults in it? Certainly, some papers are rejected. Some bad ones get published, all the same.

Occasionally, a good paper is rejected for the wrong reasons, although this is harder to find out about. One which I know about (and had nothing to do with) may have had covert financial reasons involved in its rejection. A well-designed trial showed no clinical advantage in a particular expensive treatment; the paper was offered to a journal, some of whose editorial board had been involved in developing the treatment. The main reason offered for rejection was the small numbers in the study, though the journal in question has published other studies of a similar size both before and afterwards.

Academics are also subject to financial pressure in teaching activities – more students receive less attention, more overseas students are accepted for the sake of their fees, and the teaching contact hours may increase.

Fiscally-motivated harm to hospital practice

Hospital colleagues have seen enough of financial pressures in the NHS systems introduced in 1991. The academics have had a lesser, though proportionately wasteful, exposure; referring practitioners have had all manner of unnecessary administrative chores forced on them; and patients have had treatment needlessly delayed or interrupted because they simply lived in the wrong town, on the wrong street or even the wrong side of it. Predictable consequences (mentioned at the outset and subsequently by many people, including myself) were simply ignored.

One particularly bad aspect has been the extra-contractual referral (ECR), apparently to bother us no longer from April 1999. This was an intrinsically unmanageable contrivance of politicians who cared principally for cash limits and had no understanding of the complex systems of treatment in various specialties. It imposed much unnecessary work on large numbers of highly trained personnel.

For the sake of countless small fees, salaried consultants and other staff had to try to justify normal methods of treatment to purchasing authorities who had the money, but of course, no understanding of the work. Not only that, but ludicrous events occurred when purchasing authorities moved from block contracts to ECRs, as a result of which patients who were in a course of treatment had their next appointment cancelled until the authority had decided whether it could pay, and those on a waiting list were placed in suspension.

In addition, the providers (hospitals) had to keep a sharp eye on whether the block contract purchasers (health authorities) were running out of money: if this happened, patients had treatment delayed until the next financial year (unless the authority changed to ECRs, when treatment might not be approved at all). And all this created an enormous mountain of frustration and administrative expense. Money in fact was wasted, goodwill was reduced, suspicion increased and trust was damaged.

The cost of dealing with ECRs and many other encumbrances was hidden in the salaries bill. Our friends in the USA looked aghast as we replaced some of the best aspects of the NHS with the worst aspects of the health scene over there, which is dominated by the question of who is going to pay! At the end of the day, is the NHS fairer and better because of the so-called reforms like ECRs? Surely it is better to have waiting lists based on the need of patients, rather than their postcode.

Conflicting interests

The pressure on colleagues in their own practices was exemplified recently by one of the multitude of advertisements which arrives each week in mailings to dentists. It was made very easy. All the dentist had to do was to recommend a particular expensive product and give the patient an order form with the practice address on it. If the patient bought the product the dentist would receive a commission (over 15 %) paid directly from the company.

Whom is the dentist serving – the patient, the company or self? Professionals are in a privileged position – their essential work is advice. The patient trusts them and accords their recommendations a distinctive status. There comes a point when the legitimate promotion of a product by a company can spill over into manipulation. Some would label it prostitution for a dentist to recommend products purely for financial gain.

Others might say there was no real conflict of interest – the product is going to help the patient, and the commission is incidental only. Indeed? How many takers would there be if patients knew how much the 'incidental' commission was? A similar doubt arises over questionable or fringe products whose marketers try to coax dentists into promotion. For instance, a thousand patients buying certain 'food supplements' at the 'recommended retail price may add £50,000 to the annual profits of a practice.

Legitimate recommendation of a product is part of a professional's duty of advice. In selling some essential products which may be otherwise hard to obtain, a practice may reasonably pass on the retailing costs so incurred. Nevertheless, if you wish your patient to use something as a part of treatment, it is good to have no financial interest in it.

Trust – the signpost in the foreground

There is often a conflict of interest between trust and money. This is not new. However, in the professional's relationship with a client or patient, if trust is lost, nothing remains, not even the money.

It is right to talk of dentistry as a business, but the basic commodity is advice. If the academic spreads half-truths for the sake of financial gain, the road may lead on towards outright fraud. If the hospital dentist gives up the fight against the irrational aspects of bureaucracy and the patient is neglected as a result, that is an abdication of professional responsibility. If the specialist or general practitioner exploits the patient in hidden ways, that is a betrayal of trust. Any dentist may undermine trust in all these ways.

These matters have a habit of coming to light unexpectedly. The press revels in showing up those in positions of trust. Well-known persons who cheat their spouses by adultery always attract attention, and the net effect is to weaken the practice of trust by other people. Cheating clients is also newsworthy.

We all need to look hard at our own motives. It is not wrong to seek appropriate financial reward for our work. But where the relationship of trust is damaged, we shall lose other people's respect, and eventually perhaps our own.