Teeth at risk

In 1999 I did a short stint as CEO of the South Australian Community Housing Authority, while the agency’s future was being reviewed. The previous CEO had left under a bit of a cloud, so a ‘steady hand’ was needed for six months or so. It was fun, and the mission to deliver housing for low-income people certainly fitted my values, but a bigger challenge came along sooner that I expected.

Another CEO had fallen out with his Board of Directors and resigned, but this time the conservative Liberal Party government was talking about winding up an icon of progressive healthcare, the South Australian Dental Service—known to all as SADS. Private dentists had long argued that they could do all the dental work for school-age children and poor people with improved subsidies, and that there was no need for salaried dentists to be employed as public servants. The Australian Dental Association, really the private dentists’ lobby group, had the ear of the Health Minister. The end of SADS was nearly fait accompli, when the Human Services Department Chief Executive persuaded her Minister that installing a ‘trouble-shooter’ CEO for 12 months was worth a try. My name was put forward, and that nearly scuttled things, because the Health Minister and I had a chequered history, dating back to my role in closing a mental hospital.

A Liberal party elder statesman was sent to see me, to suss me out. He was extremely blunt, telling me that he agreed with the private dentists, and that I’d have a hard job convincing him that ‘a pack of chardonnay socialist public servants’ could do a better job than private enterprise. He looked at my CV, we talked for quite a while, and he decided that it was worth a try, as long as he became a Board member, ‘to keep an eye on you’, and that I undertook to (a) get the budget back into balance within six months and (b) ‘Get the Australian Dental Association and that pain in the arse Professor of Dentistry from Adelaide University to both stop bothering the Minister and Premier with a string of complaints about SADS.’ I do like a clear brief, and I said I’d take on the job.

The Chair of the Board, a recent government appointment, was a private dentist, but he shared with me early on that he had real doubts about winding up SADS, because his best guess was that there was no way his colleagues could do the amount of dentistry required for the same cost. In other words, privatising this public service would most likely cost taxpayers more. But I knew from several politically sensitive previous jobs that the facts are weak in the face of ideology and party platforms, so this was going to be about really good information at my fingertips, a quick return to budget discipline and building solid relationships with the main complainers.

The honeymoon period in any change leadership job is extremely valuable, and I tried not to waste it. I shook a lot of hands, talked to many meetings of staff, and called up briefing papers on every topic that seemed related to SADS losing so much political capital that it had nearly been closed down. The Board, at least half of them Liberal Party stalwarts, several thriving on their role of disseminating damaging stories about SADS, were my first target for spreading the love. I had one-on-one meetings with all of them within the first couple of weeks. It was quickly obvious that a balanced budget would give me some breathing room to assemble more good news about SADS’ value, so that became the top priority.

It took several heated management meetings, and complete re-jigging of financial reporting, to clarify that we were heading for a deficit of about $2.5 million by the end of the financial year, less than nine months away. With a total annual spend of $35 million, most tied up in salaries and essential dental supplies, this was a scary assignment. Not one of my senior colleagues thought it could be done. But we did it, over six weeks of analysis, debate and difficult decisions. Workloads were increased, periods between scheduled dental check-ups were extended, stock-piling of dental supplies was refined to ‘just in time’, capital works projects were deferred or spread over more years, vacancies in non-essential areas were left unfilled, leases were re-negotiated and more dentistry was farmed out to private dentists willing to accept our low rates. No patient was going to miss out on urgent care, we sacked nobody, but we were going to break even. The Board were satisfied, and we had the temporary reprieve we needed to start working towards a better future.

I think my management team surprised themselves with this achievement. What they didn’t know was that I was amazed. This was the most serious bit of cost-cutting I had ever attempted, by far, and my confident demeanour in the first few weeks was more about hope than certainty. Patient, detailed, sometimes gruelling dissection of every spending line gradually yielded up a clear path to survival. It was exhilarating. We had come up with an austerity budget that hurt nobody.

While all this was underway, I was getting to know the ‘stakeholders’ of dentistry, or oral health as it was becoming known. The Australian Dental Association, which had a fearsome reputation as a lobby group, was quite easy to win over. My predecessor had stayed right away from them, but I asked for their help on several matters, especially finding dentists who would take on some of our work at our rates. They did this quickly and graciously, and seemed to thrive on being asked at last. Together with the Professor of Dentistry mentioned above, we worked out a scheme for private country dentists to provide placements for final year dental students. This had been on the back-burner for years, and country people were being denied the extra services that these young trainees delivered under supervision. It was so easy to arrange, and now the Board had the first of the good news stories that I thought might save SADS. The Liberal Party elder statesman, whose constituency was in the country, was delighted. The SADS whisperers in the corridors of power were starting to say the right things.

Dentists, and the dental therapists, hygienists, prosthetists and assistants who work with them, were an entirely new type of colleague for me. Their world was very narrow, focused on the number of ‘teeth at risk’—I kid you not, that was how they measured demand. Most of them had gone directly from high school into the teeth business, and it showed. Except for the specialist dentists, including orthodontists, endodontists, maxillo-facial surgeons and others, most were very shy outside of the oral health world, a bit defensive around medical doctors, and convinced that nobody else could understand their work. Although many were long-serving senior people, they had minimal networks in the bureaucracy and politics of government, which helps explain how they had failed to see the dangers I was brought in to deal with.

The dental therapists were an unusual lot in several ways. They had mostly been recruited about fifteen years before, in a scheme to bring dentistry to all primary school children at an affordable cost to the taxpayer. They were trained to a level where they could do inspection and cleaning of all teeth, and extractions and fillings on milk teeth in younger children. Along with fluoridation of water, the School Dental Scheme was credited with giving South Australian children the equal-lowest rate (along with Norway) of tooth decay in the world. Private dentists were apoplectic about this threat to their monopoly at the time, and they fought successfully against any further recruitment. They were still making scurrilous remarks about the incompetence of therapists when I came along.

The other unusual thing, besides this one cohort all being women and about the same age; 35 to 40 when I knew them; was that they all seemed to be very good-looking. Two of them had been ‘Miss South Australia’ around the time they came into the scheme. I found out later that one of my predecessors had managed the whole selection process, which was swamped with applicants, and he had used his power to fill his working world with beautiful women. I can only wonder how many talented people, men and women, might have come into that scheme if they’d had the chance.

And, like most of their oral health colleagues, all of them had perfect teeth. Before this job, I had never really noticed teeth much, although I was self-conscious that mine were a bit battered and small. Within a few months of being in SADS I was planning my own major upgrade, at considerable cost. Sitting in meetings where everybody had a Hollywood smile does that to you. A friend of mine was/is a very successful private dentist, and he had been telling me for some time that the up-front cost was trivial compared to a lifetime of comfortable eating and a confident smile. Now I was ready. He said ‘If you bought a new car, within a few months you would have forgotten how much it cost—it will be the same with this.’ I had the feeling it wasn’t my new car we were talking about, and I did see him in a brand-new Mercedes convertible soon afterwards. I probably paid for the leather seats.

Over the next year, SADS became the poster-child of the health system in many ways; reducing waiting lists, working pretty much harmoniously with private dentistry and their professional association, and, most importantly, not blowing its budget. We were given extra funding to reduce country waiting lists, and we delivered all of that through private dentists. I involved all of the staff who wanted to participate in a strategic planning process; focusing the priorities for the next few years. It was very satisfying, particularly as I watched jaded people start to get excited about their work.

A few remained grumpily uninvolved. There was a Professor of Dental Surgery who told me to ‘Keep out of my way unless you want me to withdraw my services.’ He ran a clinic in the Dental Hospital. People were told they had a morning appointment or an afternoon appointment. This meant waiting for hours, often to be told to come back tomorrow. I challenged him about it, and he said ‘These people would just be sitting at home watching daytime TV—they’re better off here.’ I stayed in his face until he compromised and divided the day into four sessions. I hate those attitudes to people doing it tough, and luckily he wasn’t typical of most SADS professionals.

With a new strategic plan, a budget that we all knew could work, and a supportive board, we had managed to get fully on-side with the Liberal Party-led Government, just in time to see them get kicked out of government in an election that brought Labor back into power. I found it ironic that this whole change-management process would most likely never have happened if Labor had been running things all along, but they were delighted to give us a small budget increase and take all the credit for saving the public dental service. All’s well that ends well, etc.

My tenure as CEO was short-lived. The new Minister of Health said to me privately that ‘We might use you for some other projects we have in mind.’ I wouldn’t have minded staying with SADS a bit longer, to see the new plan unfold, but it wasn’t to be. The nation’s best dental administrator, who was running the Victorian equivalent of SADS, wanted to come home, and he took over from me shortly after that chat with the Minister. My next ‘trouble-shooter CEO’ job was great, but I have some very happy memories from the time I ran the dental services.

For the first time in my life, most days I had felt fairly confident that I knew what I was doing; that the processes I was leading, and the understandings I could call on to back my judgements were generally about right. I’d learned to be patient, and to be a better listener, and it was working. And I still have those new teeth. As my dentist friend said at the time, ‘Only the best for the boss of SADS’.

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