It seems to very many young dentists that the future is becoming bleaker. Many of us feel very worried but are limited in how we ought to address this rapidly declining situation. Al Hassan made the case very well for us in his article 'Defensive dentistry and the young dentist – this isn't what we signed up for'.1 Many senior colleagues, like Martin Kelleher,2 have also sounded the alarm and stoutly defended threats to our profession including challenging that increasingly menacing organisation called the General Dental Council (GDC) and the diktats of near totalitarian control by the state with its brutal and corrupting NHS UDA system.

The BDA Young Dentist Committee has highlighted the repercussions of the current problems and the threats that increasingly confront newer dentists. In October 2017, they published an online statement indicating that 53% of young dentists intend leaving the NHS within the next five years.3 The BDJ published an article indicating the difficulties in recruiting general dental practitioners.4 The current picture appears gloomy, and the general mood is it's not going to get better any time soon for us. Indeed, if this continues, short-sighted policy makers who currently hold the puppet strings will struggle to find any decent or appropriate NHS dentistry being done in the future.

The General Dental Council and ever helpful opportunistic lawyers

Al Hassan has indicated young dentists are now unfortunately forced to practice 'defensive dentistry'.1 This form of dentistry is being provided to patients for the benefit of dentists, not by dentists for the benefit of the patient. This is due in large part to the ever-increasing fear of a complaint to some 'authority' or some avaricious legal beagle. Many treatments which could often be carried out by young practitioners are routinely being referred on to more experienced clinicians, or to secondary care services, for fear of litigation. Sadly, this approach is sometimes to the detriment of patients. The GDC has rather perversely created the current threatening environment where many younger dentists find it difficult to adhere to their first commandment which is 'to put patients' interests first'.

Confidence is gained not only through experience, but also through having appropriate support. For a younger dentist, this takes many forms and is often gained from helpful discussions with more experienced colleagues such as some dental principals, or in hospitals from some senior staff members and some consultants. Wider support is also gained from professional bodies and indemnifying organisations. Regrettably, the GDC cannot be categorised as one such supporting professional body. Their mission statement informs us that they are 'regulating the dental team'. Compare this to the more helpful approach used by the language of GMC which prides itself on 'working with doctors'.

Let us highlight one of the many anomalies. It seems odd that the GDC will find fault with clinical notes documentation when one is undertaking root canal treatment unless it records in great detail the diagnosis, the LA used, the method of tooth isolation, the method of determining working length and all the tiniest of details of the endodontic instrumentation and techniques used. That demand means super-fastidious recording resulting in clinical notes for what should be a routine procedure taking almost as much time as undertaking said procedure. Conversely, clinical notes for a bimaxillary osteotomy can be written on one side of A4 (with diagrams), and apparently hold its own under scrutiny by the GMC.

It appears that the allegedly independent, but paid for, 'experts' (aka bloodhounds) who are advising the GDC will scent out the slightest weakness and not cease until they have backed one into a corner. The person advising the GDC to pull the trigger on your professional career and reputation may well be some occasionally wet fingered, ivory-towered academic, probably more versed in astronomical photometry than in the daily problems posed to dental practitioners working on rightfully demanding patients in the average primary care practice. Suddenly it seems foolish for young dentists not to provide 'defensive dentistry'.

Transformation in education and delivery of care

Recently, Peter Ward, Chief Executive of the BDA, published an eye-opening article highlighting the future intentions of Higher Education England (HEE) to transform the delivery of dental care in this country.5 The concept of a common point of entry into dental school for shared undergraduate courses is alarming. The skillset required to be an autonomous dentist – or to be a leader of a dental team and of the profession – is completely different to the skills required by an auxiliary, albeit highly valued, member of the dental team. The educational and intellectual requirements to get in to dental school are strenuous and the uniquely essential skills to become a dentist are nurtured and developed from the very first year of the 5-year undergraduate training programme. What compelling scientific evidence has been advanced to support this new 'pick it up anyway you like as you go along' model? The silence is deafening.

The other major change proposed by HEE will allow dental care professionals (DCPs) to provide ever more treatments currently only provided by dentists. However, in their very finite, politically driven wisdom, HEE have made a small concession in allowing only dentists to diagnose and manage acute conditions. That's nice of them. Apparently, many more DCPs can and will be allowed to provide independent dental treatment after undertaking relevant, successive modular courses but rather curiously, in spite of that, they still cannot diagnose. That's an interesting approach, if sadly, an intellectually bankrupt one, or one devoid of the slightest inkling of common sense. This political and financially driven half-baked proposal demonstrates that policy-dictators do not understand the subtleties and interdependencies of sub-specialties that a dentist must appreciate to deliver the most appropriate care for their patients.

Clearly, the primary concern for HEE and other government stooges is not the quality of care provided to patients, but rather to reduce costs while giving the illusion that all the relevant dentistry is being delivered by a 'dental professional', irrespective of whether that be a hygienist, therapist, dentist or GDC registered specialist. Doing that should allow the political spin doctors to claim that 'more patients than ever have been able to access an NHS dental professional' regardless of what happened at, or after, that 'contact'. Did the patient have the correct, or most effective treatment, by the most appropriate 'dental professional'? Does it matter to HEE or the other government lackeys? Not really, if it is only the numbers of 'contacts' that the civil serpents [sic] wish to measure for their political masters. Is that not a clever and cunning wheeze to portray a discredited NHS dental system to be in rude health? Text your answer, please.

The obvious aim of all this HEE conspiracy is a dilution of the dental profession. Aukett has already alluded to a loss of autonomy in dentistry,6 and with these new and insidious changes being proposed, our profession will be greatly devalued among the wider professional community. This affects none more than the young and recently qualified dentist, and provides yet another reason to leave NHS dentistry as soon as possible for some more caring rational and professional system. As if we needed another one.

The UDA system

Within primary care NHS dentistry, three parties are present in every consultation and treatment session: the dentist (supported by their team), the patient and lurking in the bushes, the overbearing influence of the government. The forced implementation of the 'new' contract and the introduction of the multiply flawed UDA system in 2006 only served to benefit one member of this threesome: the government. By no means is anyone suggesting that finance is not an issue for some GDPs, but it is not the only one. How could anyone have thought that a system which does not remunerate preventive dentistry, or the provision of appropriate endodontics or periodontal care or decent dentures be a good idea?

Recently qualified dentists enter the workplace wanting to provide the best treatment for all their patients. How naive and idealistic we were, and maybe are. Besieged young NHS primary care practitioners need to juggle overbooked diaries and sub-optimal dental materials while patients complain about their 'extortionate' band-2 UDA fee and the latest no-win-no-fee dental lawyer licks their lips while waiting for the results of their advertising in freebie papers and on popular radio-stations. It should come as no surprise, therefore, that nearly half of young NHS dentists see their future as being in some sort of private practice where they at least they should get enough time to get to know the patients well enough before trying to treat them appropriately.3

Going forward?

This article has highlighted some of the factors resulting in a sub-optimal environment for young dentists to thrive and grow. Things must change. So, what does this 'promised land' look like? It's a place where the GDC recognise the pressures young dentists face on the front line. It's a situation where NHS dentists, do not have to, in effect, do the rationing on behalf of some less than truthful government agents in the provision of dental care for patients. It's where good, safe, sound dentistry can be provided without the fear of persecution. It's ultimately an environment where the patient, the dentist and the government are working towards the same goal, rather than just paying lip service to it.

There is a lot to be grateful for as a young dentist. This is a great profession as Ofori-Attah7 demonstrates very well. We are a motivated, intelligent, caring workforce, which is well able to advance the provision of care of dentistry for this generation. However, if changes aren't made soon, the NHS risks having a whole generation of disaffected young dentists and from that outcome, sadly, nobody wins.