What's my motivation here?

There is a story told about the late Sir Lawrence Olivier, when co-starring in a West End show with a leading Hollywood actor. The American actor, a successful student of method acting, was having difficulty getting into role. After several unsuccessful attempts at a particular scene, the star held up the cast and production while he roamed about the stage muttering 'what's my motivation here?'. Sir Larry put up with this for a while and then approached him. “Look, your motivation here is you're being paid ten times as much as the rest of us. And my motivation is just to get through the bloody thing!”

A new book by Julian le Grand, professor of health policy at the LSE, is titled 'Motivation, Agency & Public Policy: of knights & knaves, pawns & queens'. In it, le Grand, who is just beginning a secondment to the Downing Street policy unit, develops a theme that he came up with some years ago. He argues that the history of social welfare over the past 55 years can be partly explained by the change from treating professionals as 'knights' (who could do no wrong) to 'knaves' (who are not to be trusted). Le Grand takes his concept of 'knave' from David Hume, the 18th century philosopher, who argued that only bureaucracies designed for 'knaves', ie, proofed against the incompetent, inefficient and corrupt, could possibly be effective.

Le Grand cites the medical profession to elaborate his thesis: for the first decades of the NHS, doctors were all-powerful 'knights' of the service, whose moral and scientific authority was beyond challenge. Today, the combined effects of consumerism, market reforms, and the end of deference; as well as medical mistakes, scandals, and arrogance, has resulted in the medical profession losing its mythical status. Doctors are now treated more like the 'knaves' of Hume's bureaucracy. Moreover, as the professions lose power, so patients cease to become 'pawns', passively waiting to be ordered about, and take on the characteristics of 'queens', with the power and independence to move at will.

How much of this thesis is relevant to dentistry? Here the situation is less clear-cut, but le Grand's ideas may strike a cord. The system of NHS dental fees, sensible in 1948 when large-scale intervention was required, rapidly fell out of favour with a profession who felt as if they were not to be trusted to practise good-quality dentistry without a rigorous system of checking and payment by results. Dentists, in le Grand's terminology, were 'knaves'. The idea that dentists might, as a matter of professional ethics, naturally engage in therapeutic relationships, thus became unthinkable, first to Whitehall bureaucrats and then to the profession itself. Mistrust bred mistrust.

....nobody but a fool would say that the future is certain or that an NHS dental service is secure.

Now that old system is going, many dentists find it difficult to believe that the future could be better. Perhaps for a year or two, they say, but then all will revert to type. Those who talk about a new model based on trust are called naïve, fools. 'Remember 1990!' is the cry. Certainly nobody but a fool would say that the future is certain or that an NHS dental service is secure.

When looking at proposals for change, it is often instructive for partners, like the American actor, to ask: 'what is my motivation here?' If the Department of Health has finally begun to see dentists as more 'knight' than 'knave', is it because they have finally realised that a profession that can control its own destiny will not stay in an NHS that misuses it, when it has an alternative. For the profession, and certainly for the BDA, the motivation is that every dentist — NHS, private or mixed practice — should be able to deliver good quality care, to have a rewarding professional experience, and to be properly remunerated.

The new proposals at least give dentists with NHS contracts the chance to do this. While this may not give dentists the 'knightly' status once accorded to the doctors, in today's world of patient partnerships thankfully, that is not an option. Yet if dentistry can take its place within modern primary NHS care, with an equal right to resources and an equal voice in planning services, we have to give it a go. Not knight or knave, but good, modern oral healthcare for all.

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Wylie, I. What's my motivation here?. Br Dent J 195, 616 (2003). https://doi.org/10.1038/sj.bdj.4810776

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