We have written to the General Dental Council to outline concerns about the way in which the NHS contract impacts on the delivery of oral health care to patients.
The letter is below:
Dear Dr Moyes,
Many thanks for the invitation to attend the launch of the General Dental Council’s strategy on Tuesday 26th January; it was a very interesting event. I was pleased to hear so many eloquent speakers with a commitment to ensuring proportionate and effective regulation in the dental and wider health sector and the willingness to listen more sympathetically to problems besetting the profession.
I was especially pleased to see the importance that the panel and audience placed on quality and even love in regulation; it is certainly an integral part of care and so cannot be absent from those who regulate the caring professions. If a profession is not supported and allowed to be professional; that is, if we feel persecuted rather than supported by our regulator, then services will necessarily suffer. At the moment, as was made clear by other delegates, less experienced colleagues are now afraid to provide the full range of treatments for which they are trained as they fear litigation and a disproportionate reaction from regulators. If this state of affairs is allowed to continue, oral health in the country will suffer and that is an outcome which is absolutely unacceptable.
I was disappointed not to receive an answer to my question which, simply put, is: will the General Dental Council take more cognisance of, and indeed an active interest in, the NHS arrangements under which the majority of dentists, especially newly qualified dentists, operate?
Much of the frustration that the profession currently feels towards the GDC comes from the disconnection between the apparent ‘gold standard’ expectations of the regulator compared to the ‘tin plated’ budget the NHS expects practitioners to work with. The mismatch in expectation is something that needs to be resolved urgently. We realise this is a difficult area for the regulators but none the less it must be addressed for the sake of both public safety and professional standards. Obvious areas of risk lie in periodontics and endodontics which in either case have effectively no funding allocated to them and, as mentioned at the meeting, practitioners providing those treatments feel as they are doing so just for love. Just this week we were informed of a 12 year old root treatment which was found to be less than gold standard with a substantial settlement awarded after litigation. Why carry out a long winded root treatment when the tooth can be extracted for a similar fee and a much lower risk of repercussions?
What is most disheartening is that there is nothing in the dental contract pilots and prototypes that suggests that a reformed NHS contract will do anything to alleviate this problem. This will inevitably store up a time bomb of problems in terms of fitness to practise and litigation issues in the future which we all ignore at our peril.
Additionally, the contract prototypes will use an automated care pathway and algorithm which determines care based on the information gathered by the clinician. Such a system risks undermining the role of a professional regulator as it is in danger of eroding clinical judgement, especially if clinicians are not supported by their regulator to override an automated system when their experience and clinical judgement makes them feel such action is appropriate. I feel the setting of recall intervals for patients is particularly relevant here.
The best way for the General Dental Council to fulfil its function of “protecting patients” is to first and foremost protect the ability of dentists to act as autonomous and respected clinicians by assessing the contractual and environmental drivers that constrain how professionals are able to deliver care. If professional clinical autonomy is reduced then professionals’ accountability must reduce with it. Without accountability, how are we to ensure patients are safe?
The Strategy commits the GDC to working closely with the NHS. However, this commitment appears to only reference complaints. I would welcome a clear commitment from the Council, that they will work with the NHS to ensure that the clinical limitations and perverse drivers within NHS contractual arrangements are removed.
I would welcome the opportunity to discuss these and other issues with you. Indeed, we within the LDCs would all welcome your engagement in this important discussion.
Vice-Chair, Federation of London Local Dental Committees
The GDC has now replied and invited comments from LDCs within The Federation about the pressures that the NHS dental system places on professionals.
The reply is below:
Dear Mr Patsias,
Thank you for your letter of 18 February following your attendance at the GDC’s strategy launch and debate on 26 January. Thank you also for your kind words about the event; I am very pleased to hear that you found it interesting, and I will pass on your feedback to the speakers. I am also pleased that it came across as a demonstration of an increased willingness to listen: that is very much how it was intended. I hope that the profession and other interested parties will see a lot more of that going forwards than has perhaps been the perception in the immediate past while we have been getting to grips with serious challenges relating to fitness to practise processes.
I believe that no suitably qualified professional acting with current expertise within their scope of practice, who understands fully and takes seriously his or her obligations to patients, should be in any fear of the regulator. The standards and guidance that we publish are largely at the level of principle and leave a wide margin of appreciation for professionals to decide how to deliver them. Moreover, the incidence of fitness to practice complaints to the GDC is very modest. Roughly 30m adults in England and Wales claim to attend their dentist at least once per year, but only 3000 (0.01%) lodge a complaint with us, and roughly half of these are dismissed at the triage stage.
It is certainly the case that a number of bodies are involved in specifying, regulating and inspecting the practice of dental care. However, in this respect the dental profession is no different to other parts of the healthcare system.
In the English hospital sector, for example, the CQC sets quality standards (advised by NICE) and inspects services, NHS England or clinical care commissioning groups negotiate contracts and assess performance against the provisions of the contract, Monitor and NHS England structure the tariff and set price levels, Monitor sets the competition rules and polices compliance, Monitor regulates the financial viability and governance of Foundation Trusts, the GMC and NMC regulate the professionals. And this is against a backdrop of professional advice provided by the Royal Colleges.
This list is simply the main bodies. There are several others I could mention, but I think I have made my point.
And we need to bear in mind that the GDC operates within a legal framework that determines the extent of our remit. We have no role in negotiating the contract or representing professionals in discussions about the tariffs for NHS work.
I think a case could be argued for the GDC to take appropriate steps to understand the combined pressures under which the profession operates and, importantly, what might be the impact on patients, and to draw any concerns to the attention of the parties who negotiate the contract. However, that is not currently seen as any part of our role, and, even if it were, I do not think we currently have the expertise or resources to make a useful contribution. Nonetheless I would be interested if you and your colleagues were to share with us specific examples or evidence of your concerns.
In the meantime, we are working very hard with our partners across the dental regulatory system, within the context of the CQC-led Regulation of Dental Services Programme Board, to bring some additional clarity to roles and responsibilities and to join up our activities better. I can confirm that this work, of which NHS England is a key partner, extends beyond complaints to encompass the interplay of different regulatory and compliance systems more widely. You will have heard John Milne of the CQC talking about this at the seminar and in case it’s helpful, here is a link to the relevant material https://www.cqc.org.uk/content/future-dental-service-regulation
It’s also why we are keen to build a much better dialogue with the profession itself so we improve the way that we regulate and the way we contribute to the wider system of regulation in the interests of patients. We see local dental committees as providing a key foundation for that dialogue, we and Council staff are actively seeking opportunities to engage. If you consider it would be helpful for us to continue this debate directly with members of the profession in your area, we are very willing to do so.