From post-war veteran to post-millennium provider: a brief history of general dental practice from 1950-2021 in eight job advertisements.

The British Dental Journal has been the go-to place for jobseekers in general dental practice for many years. Using a selected sample of these advertisements from each decade from 1950 to the present, a brief history of general dental practice is described, from the post-war development of the NHS to the dental performer status 70 years later. The paper highlights some of the changes in practice over time and shows the continuing commitment of dental practitioners to the business of dentistry.

Introduction

General dental practice is a commercial venture,[1] provided largely by independent practitioners, investing their own capital resources in the premises and equipment to support the services offered. In the nineteenth and early twentieth century, most practices were single-handed, with perhaps an apprentice or assistant to help out and to learn.[2],[3] In the decade following the introduction of the NHS in the UK in 1948, an increase in patient demand led practitioners to expand their numbers of surgeries to keep up with need for treatment. Vacancies for dentists to work in these surgeries would have been offered by word of mouth through a small number of specialist agencies and probably most frequently via classified advertisements placed in the British Dental Journal (BDJ).

The job roles advertised in the BDJ, in addition to salaried and academic positions, included assistants, associates and partnerships. An assistant implied being a salaried dentist within a practice. An associate implied being self-employed within the practice and being remunerated by a percentage of the fees earned. Partnerships involved becoming legally part of the ownership of the practice and a long-term commitment to a practice.

Research using job advertisements has been used previously to track changes in the employment market over time[4] and to analyse the skill requirements.[5] Advertisements for jobs usually contain information about the workplace, information about the role to be filled and the skills required to fulfil it. They thus represent a window into the world of work of any particular profession, trade or craft.

Multiple changes have been made to the NHS arrangements for the provision of dentistry since the introduction of a free-at-point-of-need service in 1948. For instance, patient charges were introduced in 1951, elements of capitation and patient registration in 1990 and a target-driven, cash-limited contract in 2006. Previous studies have shown that dental practitioners adapt to their work to changes in remuneration[6] and contract arrangements.[7]

Following multiple readings of classified job advertisements from four editions of the BDJ (March and September) decennially from 1950 onwards, one advertisement from the 'associates' and 'assistants' vacancies was selected as 'typical' of each decade. Commonly, these were among the longest of each edition, yielding greater amounts of information than the much more frequent, shorter advertisements. Changes and developments in general dental practice, from the perspective of the practice owners, are highlighted and discussed.

Eight advertisements

3 March 1950

'An opportunity will occur in the spring or early summer for a young progressive dental surgeon to join a practice run by an ex Royal Naval Volunteer Reserve practitioner in a small coastal town. Assistantship with or without view. Treatment mainly good class conservation. Scope for advanced procedures, inlays, crowns etc. Modern, beautifully equipped surgeries. Efficient staff, practice well-organised. Applicant must possess the necessary professional and social attributes. High initial salary. Furnished or unfurnished accommodation available away from the practice'.

By 1950, the NHS in the UK had been established for two years. Initially, dentistry was provided free of charge and due to a backlog of unmet dental need, a 'tsunami of demand' was created and millions of dentures provided in the first nine months of the service.[8] In total, 70 practice vacancies were advertised in this edition of the BDJ but very few mentioned the NHS as the motivation for the vacancies.

The echoes of war were still present here and the practitioner felt their wartime service was of relevance to the applicants. Rationing was still in place and housing for returning soldiers, sailors and members of the air force with baby boom families was scarce, so accommodation was offered as an incentive to apply. Yet there was forward-thinking with the clinical opportunities of advanced procedures, such as crowns and inlays and unspecified modern equipment. Good organisation and efficient staff would have been added bonuses. A view to partnership was offered, along with a substantial salary. The necessary 'professional attributes' hint at searching for a colleague with high ethical standards of honesty and decency.

However, there is a sense of harking back in the request for the 'the necessary social attributes', searching for that sense of professional standing in society, with perhaps the necessity to join the local golf club and always wear a jacket and the regimental tie. It was a male-dominated profession.

15 March 1960

'Experienced dental surgeon required end of April as principal assistant in good class practice 20 miles from London. Two part-time assistants also employed. Four surgeries with modern equipment and airotors. Fully trained chairside assistants and own laboratory. Furnished flat with garage goes with the appointment. Remuneration on salary and commission or on commission basis only, if preferred. High standards of treatment required'.

Patient charges for NHS dental treatment were introduced in 1951 but did not appear to reduce the demand for access. By 1960, presumably on the grounds of cost saving, dentists began to form multi-surgery practices (in this case, with four) and some sort of hierarchy of assistantship. Here, a principal assistant was required, ahead in some unspecified way, of the two part-time assistants already recruited. Although other advertisers of the period were happy with 'newly qualified men', this one sought an experienced operator, capable of high standards of treatment.

The introduction of the airotor in the 1950s, enabling rapid removal of tooth structure, warranted a specific mention as a part of the modern equipment in place. The continuing demand for restorative treatment is indicated by the presence of the practice's own laboratory on-site. The importance of support staff to the recruiter was clear and instead of being simply 'efficient' as in 1950, here there are fully trained chairside assistants.

Incentives to join the practice included a flat with a garage. Car ownership doubled during the 1960s[9] and there was an expectation that the appointed person would earn sufficient income to maintain a vehicle on the road. Dentistry was seen to offer a financially rewarding career. Income from the practice was offered either on salary and commission or commission only, beginning a move away from the more traditional salaried assistantship models.

3 March 1970

'Young principal in West Midlands seeks associate or assistant in ultra-modern practice. Exclusive use of two surgeries, fully equipped for low seated dentistry and aided by two charming assistants. Here is dentistry without tears for both patient and operator. The practice is situated near open countryside with excellent outdoor amenities and yet close to Birmingham'.

The importance of support staff was again emphasised, but moving away from efficiency and training to character, the nurses here are described as charming, which may highlight the beginnings of the importance of the relational aspects of teamwork within a practice. Low seat dentistry, with the patient in the supine position and the operator and nurse seated, in conjunction with airotors with water coolant, demonstrates development of more comfortable working practices and certainly made a dental nurse - charming or not - essential for aspiration and support. The availability and exclusive use of two surgeries indicated a high volume of work was expected to be produced, yet the promise was for no tears and a consequent happy working environment. This and the closeness of open countryside and outdoor amenities appears to show a young principal concerned for the mental health of their potential hardworking recruit.

The position of associate became more prevalent around this time, indicating a further move away from the salaried position of the employed assistant to a percentage-based financial arrangement of the self-employed associate. In this arrangement, the principal deducted a fixed percentage from the associate's gross income to cover expenses and thus the more work the associate produced, both sides of the arrangement gained financially: the pressure from one or both parties to produce a high volume of work increased.

March 4 1980

'Help! Overflowing appointment book, colleague welcomed to join purpose-built, two-surgery practice overlooking the South Downs. Entire building recently refurbished and re-equipped. Established 15 years with good proportion of private work, some intravenous (IV) work and part-time hygienist. Full- or part-time or whatever basis mutually agreed but with some degree of permanency in mind'.

The healthy nature of dental practice as a business enterprise continued through the 1970s, with this practitioner having invested in an entire refurbishment and re-equipment project and, having too much work, sought a colleague to help out. Since establishment of the practice in 1965, growing demand under the NHS fee-per-item system increased the workload for general practitioners and expansion of facilities was one way of coping with this. There appears to be an element of desperation for 'help!' in the flexibility of terms being offered. Whether the view over the South Downs is sufficient additional attraction is unclear.

The availability of private work was mentioned as an incentive to join the practice. While this would have still been fee-per-item, the practitioner would have been able to set their own fee, rather than being committed to the rigid set fees of the NHS. Decreasing dependence on the fixed-fee NHS was seen as another way of reducing the pressures of the NHS treadmill. During the 1970s, IV sedation, offered privately as an adjunct to NHS restorative fees, became a popular mode of delivery of dental care.

The presence of a hygienist in the practice here, however, shows the trend of increasing emphasis on prevention; the benefit of fluoride in toothpastes and being topically applied becoming evident during the 1970s.

8 September 1990

'The opportunity has arisen for an associate to take over a full list from a colleague of five years who is now moving north. The overriding factor is quality not quantity with the ability to be caring and sympathetic with patients. We have a purpose-built practice with five surgeries, our own laboratory and established for 30 years. The two partners have a special interest in oral surgery and orthodontics and the successful applicant will have the opportunity to further their knowledge in these fields if so desired. Newly qualified would be welcome. Remuneration by agreement'.

By 1990, the BDJ had over 300 advertisements for general practice jobs per issue. A more mobile dental workforce was appearing, with vacancies advertised to take over existing lists becoming increasingly common. The stability of this practice would be seen as a positive attribute. The previous incumbent was in post for five years and was passing on a full list of patients. The practice was purpose-built and established since 1960.

Although a laboratory was still seen as an asset to be stressed, the clinical emphasis was not on the high turnover of previous years but on a more patient-centred, caring approach. This is another example of a practice set-up, presumably as a squat practice, in the 1960s, grown through the heyday of the NHS fee-per-item practice. But change is afoot. Specialisms began developing, with partners interested in orthodontics and oral surgery. Training started to be offered to any applicant who might be interested in learning from them. The drive for postgraduate education and continuing professional development began.

The demand for treatment remained high and other advertisements mentioned being ready for the imminent arrival of a new NHS contract, introducing registration of patients and an element of capitation. Vocational training was becoming established but it was still possible as a new graduate to go directly into general practice from university.

9 September 2000

'Full-time experienced associate required to join our established practice. We have a well-developed independent and NHS patient base. Comprehensive facilities include full clinical computer system, newly equipped surgeries, orthopantomography (OPG), referral unit for surgical dentistry and sedation/implants with restorative training. Qualified management team and specialist trained dedicated nursing staff'.

The term 'independent' was coined to indicate independence from the NHS, rather than the previously common term 'private'. In essence, all practices are 'private' in that they contract independently to the NHS. The move away from solely NHS practice to mixed NHS/independent practice gathered pace, driven in part by a government fee cut in the early 1990s, with the popularity of capitation schemes, such as Denplan, growing rapidly. Long establishment and new equipment continued to be a major feature of enticements to apply for the post.

Computerisation started to become popular; here, the clinical system implies that appointments were still managed in the traditional paper appointment diary. New equipment included OPG and treatments extended to implants, along with continuing interest in sedation. This practice offered a specialist referral unit for such surgical work, evidence again that specialisation was on the increase.

The increasing importance of a team of staff to run a successful dental practice is highlighted by the specialist-trained and dedicated nursing staff. 'Charming' nurses are long gone, as are the days a dentist, nurse and possibly a receptionist would cash up and pay the wages every Friday. The increasing complexity of managing a modern business operation with specialised staff, different systems of fee collection and incoming referrals was recognised by the need for a qualified management team.

11 September 2010

'Associate required. Established list of private and Denplan patients + small amount NHS. Six surgeries. British Dental Association (BDA) Good Practice. Vocational training. Fully computerised. Digital x-ray OPG. Central sterilisation, orthodontics and implants. Therapist/hygienist and oral health educator. Friendly supportive staff. Performer number required. Immediate start. Would suit experienced practitioner wanting to locate to a beautiful part of the country'.

A new, target-based NHS contract introduced in 2006 continued to drive the move away from reliance on the NHS for financial survival. However, vocational training was now compulsory for all new graduates and practices offering had to have a NHS contract. Increasing regulation, including the need for central sterilisation facilities, increased the running costs of practices. External endorsements, such as the BDA Good Practice and other similar schemes, assumed a greater importance in gaining public trust in the profession or validation of hardworking performers.

Dental practitioners were divided into providers (the holder of a contract with the NHS) and performers (frequently associates, contracted to the provider to perform a certain numbers of units of dental activity [UDA] per year). Activity and performance ruled the NHS working life.

The drive to remain up-to-date with modern equipment also continued with full computerisation, including digital radiography. The clinical scope of general practice provision, alongside the use of specialists, increased, as did the increased use of additionally skilled dental care professionals. The description of the character of the staff as supportive underlines the team aspects of the provision of oral care in the twenty-first century.

28 May 2021

'A great opportunity is a terrible thing to waste! Why not check up on this fantastic chance to join a very established dental practice? If you are looking for job satisfaction within a friendly, forward-looking practice with a long-established and loyal patient base, we tick all the boxes. We offer the security of an easily obtainable UDA level (6,000 or pro rata at up to £12, depending on experience) plus the benefit of an additional private income 60:40 currently matching and often exceeding our NHS earnings! All aided by a fabulous back-up team of friendly and experienced nurses and smile advisers. Our purpose-built, re-fitted and air-conditioned three-surgery practice is fully computerised, has a large private car park and is on a prime site only five minutes from the city centre. If you already have a performer number, we look forward to hearing from you! Don't miss this!'

The COVID-19 pandemic of 2020 and consequent lockdown decimated dental services for some months but with strict infection controls of aerosol generating procedures and vast amounts of personal protective equipment, practices began to return to a limited 'new normal' in mid-2021. Very few vacancies were advertised in the 2021 paper edition of the BDJ but the resilience of dental practitioners to overcome this adversity and enthusiasm to return is shown in this advertisement. Loyal patients are a feature to attract applicants which is of relevance given the core 6,000 UDA target. The possibility of doubling the £72,000 on offer from the NHS with 40% of the income from private work would have been an additional incentive to apply.

Re-fitting implies recent investment in the practice and with computerisation, air conditioning and car parking, all the benefits a modern dentist needs to work hard and perform were available, plus, of course, friendly and experienced nurses. Unlike many previous years, there is no mention of clinical facilities such as digital radiography, IV or technical back-up. What seems more important here is the forward-looking presence of a smile adviser. In addition to provision of restorative care, the ability for practitioners to make smiles and to whiten and straighten teeth is an essential marketing tool for today's dental practices.

Discussion

Advertisements for jobs in the BDJ are a shop window for practice owners. They do not show the views of any other dentists. The voices of academics, educationalists, public health professionals, community dentists, corporate bodies and associates/assistants are not represented here. However, the advertisements do clearly show what practice owners think is important about their practices and how these change (or not) over time. Without practice owners being willing to set-up and manage the business of dentistry, general dental practice would not exist.

The importance of the facilities within the practice are a clear, common thread over the decades. 'Equipment' is a word common to many, in particular, modern equipment. The technical changes in dental hardware can be mapped over time, from the introduction of airotors and low seat dentistry, to IV, OPGs, central sterilisation, full computerisation and digital records. These changes also represent the continuing investment practitioners make into their businesses. Many advertisements describe 'recent refitting' and 'newly equipped'. While this might be a marketing ploy to attract applicants, the importance which practice owners place on investing in their businesses cannot be overemphasised. If practitioners aren't willing or able to invest in keeping up-to-date with developments, then dentists in the UK would still be offering little more than basic, pain-relieving dentistry.

Equally important is the provision of support staff, from nurses variously described as charming, experienced, qualified, friendly, supportive and dedicated, they too require the investment of time and money to be developed into a safe and efficient team. The introduction of additional qualifications for nurses and the use of hygienists and therapists sees the focus move away from clinical provision entirely by the dentally qualified and onto other dental care professionals, to increasing the possibility of the delegation of care. The increasing importance of specialisation, postgraduate education and qualification for dentists is apparent too, all of which come at a cost to the practitioner.

With changes in regulation, practice ownership is now possible by non-dentally qualified personnel. The same provisos as above still apply though; that oral care is largely only possible with the involvement of those willing to invest their own money into the business of dentistry.

Financial reward for the applicant of the advertised posts is also a common theme over the decades. From the offer of a high initial salary in 1950 though salary and commission, percentage payments and capitation systems, to mixed NHS and private income, practice owners assume that remuneration is of major importance to the applicants. In any percentage-based system of remuneration, the practice owner also gains from the throughput of the associate and other advertisements stress the need for the applicant to be 'keen', 'efficient', 'hardworking' and 'conscientious'. In addition to financial incentives to apply, indirect incentives have included accommodation, garage/parking and closeness to other amenities, such as the South Downs or a city centre. In earlier years, permanency with the offer of 'a view' to partnership or the request for a long-term commitment appear common. In later years, a more fluid market develops and the opportunity to settle down in one place seems to be less of an incentive. If this lack of desire to settle in one place is an increasing feature of the dental workforce, then potentially, the baseline of business-owning practitioners may be weakened, as fewer are willing to make long-term financial commitments.

Mental health of dental care professionals has assumed a high profile in the past few years but previous advertisements may indicate that practice owners have been aware of the problem for some time. In 1970, the advertiser was providing dentistry 'without tears', near open countryside and with access to excellent outdoor amenities, indicating an early interest in the non-dental life and health of any incoming dentist.

Previous studies of job advertisements have focused on the attributes and qualifications which applicants need to have[5] in order to verify that educational establishments are teaching the skills needed in the real world of work. Advertisements for assistants and associates do not seem to demand too much of the clinical skills of the applicants. Roles for either the 'experienced' or 'newly qualified' are on offer. 'The ability to be caring and sympathetic with patients' and 'the necessary professional…attributes' appear to be the limit requested in these advertisements. 'Ethical' is a frequent pre-requisite in other advertisements over the years and the continuing need for the teaching of these soft skills at undergraduate level is apparent. In the last two decades, the unteachable necessity of a performer number is the only essential requirement.

Conclusion

Clearly, this paper is not a scientific study of job advertisements in the BDJ. It is entirely possible that with a rigorous content analysis of advertisements, a different - or at least, a more nuanced - story could be told. It is also possible that in the last two decades, both the influence of alternative methods of job seeking (online agencies and social media, for instance) and the increasing corporatisation of dental practice have decreased the influence of the BDJ as an advertising medium for general dental practice. However, what these chosen advertisements show are resilient professionals, rising to the challenges of changing rules and regulations; a profession with committed practice owners who want to keep up-to-date with techniques, workforce developments and equipment; and professionals motivated by the business of dentistry and the need to make a profit. What is missing from the history told here is that there is hardly any mention of oral or dental health. What is needed in the future, if the small business model is to continue to be the basis of dental care, is a way forward which allows the combination of income generation for investment, alongside the provision of integrated, holistic oral care and treatment for all.