Written evidence submitted by General Dental Council (DTY0091)

About the GDC

The General Dental Council (GDC) is the UK-wide statutory professional regulator of over 115,000 members of the dental team, including over 43,000 dentists and 71,000 dental care professionals (DCPs). In England we regulate around 34,000 dentists and 65,000 DCPs.  

An individual must be registered with the GDC to practise dentistry in the UK. Unlike other health professional regulators, we register the whole professional team, across the four nations of the UK, including dental nurses, clinical dental technicians, dental hygienists, dental technicians, dental therapists, orthodontic therapists and dentists.  

Our primary objective is to protect the public, and in doing so to:  

• Protect, promote and maintain the health, safety, and well-being of the public. 
• Promote and maintain public confidence in the professions regulated. 
• Promote and maintain proper professional standards and conduct for members of those professions.  

All patients should be confident that the treatment they receive is provided by a dental professional who is properly trained, qualified, and meets our standards. To achieve this, we register qualified dental professionals, set standards for the dental team, investigate complaints about dental professionals' fitness to practise, and work to ensure the quality of dental education.

We welcome the opportunity to respond to this inquiry, with an appreciation that systems promoting equitable access to dental services have a positive impact on patient safety and public confidence in the dental profession. 

We support collaborative efforts across the sector to address the complex multi-faceted challenges around NHS dental access and continue to undertake regulatory work within our remit which could contribute to dental access improvements.

How we have responded to this inquiry

The GDC has no role in relation to the commissioning or provision of NHS services and therefore we have not addressed all the Committee’s questions directly. Nevertheless,  the statutory model of professional regulation we operate does have important implications for the issues the Committee is concerned with, which we address under three main headings:

• Maintaining the safety of the public through registration of the dental professional workforce
• Securing the effectiveness of dental services by supporting dental professionals to use the full scope of their professional practice
• Ensuring that the education and training of dental professionals provides an effective preparation for working life.

We have also provided summary finding from our research on the impact of COVID-19 on dentistry.

The number of dental professionals registered with the GDC has grown slowly but steadily in recent years, with no apparent change in the pattern resulting from the pandemic. The total number of dental professionals does not, however, provide a complete picture of the available dental workforce, still less does it give any direct indication of NHS capacity. This is because dental professionals can choose to reduce the total number of hours they work and can also choose to reduce the proportion of time they spend on NHS work. There is evidence of both of these effects, though neither can be quantified precisely. There are also workforce pressures from the continuing backlog of treatment which could not be provided during the pandemic, though that effect should diminish over time.

Any future workforce strategy will therefore need to address how best to retain current dental professionals in NHS practice as well as how best to encourage a flow of new entrants to the professional registers, including from outside the UK. Without the former, the latter can be of only limited effectiveness. We support the broader coordinated efforts required to encourage both UK and international registrants to enter, and then remain in, the NHS workforce – for example, training programmes and processes to enable the allocation of NHS performer numbers to internationally qualified dentists, training incentives for dental professionals, and NHS dental contract reform.

The dental workforce and international registration

With widespread NHS workforce shortages, there has been growing sectoral interest in international recruitment and the GDC’s routes to registration for internationally qualified dental professionals. Whilst responding to the changing system context and endeavouring to minimise barriers to workforce supply, it is essential that we continue to operate clear, fair and effective registration processes for internationally qualified dental professionals, which safeguard the high standards expected of all registrants. We cannot compromise those standards.

Current legislation governing the registration of internationally-qualified dental professionals is cumbersome and over-prescriptive. We welcome the legislative changes which have very recently been approved by Parliament, which we expect to come into force in the near future.[1] The impact of the greater flexibility allowed by the new legislation will not be immediate, not least because some provisions do not take effect until 12 months after the coming into force date, which itself has not yet been set.

Internationally qualified dental professionals, particularly dentists, make an essential and significant contribution to UK dentistry. In recent years more than a third of newly registered dentists have qualified overseas. There are currently two primary routes to international registration, one for European qualifications, the other for the rest of the world.

European qualification route

Dental professionals – in common with other healthcare professionals – with qualifications from EU member states continue to be entitled to register to practise in the UK.[2] This has been and continues to be the larger of the two main international registration routes. The application process is relatively straightforward because UK legislation continues to mandate the recognition of European qualifications as being of an equivalent standard to UK qualifications. The GDC has no power to make any individual assessment of the knowledge and skills of an applicant who holds such a qualification.

The Secretary of State is required to review these arrangements in the first half of this year and to publish a report with his conclusions by the end of June 2023.

Overseas registration route

Our enabling legislation requires the GDC to satisfy itself that applicants from the rest of the world individually have skills and knowledge at the standard we require of UK-qualified registrants. Holding a dental qualification is a necessary, but not sufficient condition.

For dentists, the primary means of assessment is the Overseas Registration Examination (ORE). Currently the ORE is subject to practical and legal constraints which make it difficult to adapt capacity to meet changing demand for places. It includes tests of practical skills which require specialist equipment and supervision to conduct and although the GDC is responsible for the ORE, it must be delivered by a UK dental school. Those constraints will be eased once the new legislative changes come fully into effect and we expect to consult on new arrangements to increase the capacity of the ORE later this year.

For dental care professionals there is no requirement to sit an exam, but applicants must provide evidence of their individual knowledge and skills which is assessed by the GDC. The GDC is not able to make a direct assessment of clinical skills, as it does for dentists.

Future approaches to international registration

The amended legislation will make it possible to address the limitations of the current system. Our immediate priority will be to improve the operation of the ORE, though the impact of this will be limited until mid-2024 because of transitional provisions in the new legislation.

We are also beginning longer-term work to design, develop and implement more effective and efficient routes to registration that are scalable, sustainable, and above all robust in their assessment of an applicants’ ability to practise safely so that the public is protected. Our focus will be on improved approaches to the assessment of individuals, as that provides the greatest assurance that our standards are being met and are being consistently applied. We may also consider recognition arrangements with dental education providers in other countries where we can be satisfied that both the content of courses and the standards required of students are consistent with those we set for UK-qualified registrants.

Supporting the effectiveness of the whole dental team

All members of the dental team contribute to providing high quality oral healthcare. There have been organisational barriers to some dental professionals using the full range of their skills, particularly in NHS settings and we welcome recent initiatives to address these issues. Doing so not only provides broader opportunities and improved job satisfaction for dental professionals, but also enables the optimisation of skills mix in dental teams resulting in more effective use of dental service capacity.

The GDC plays an important part in this through our responsibility for defining the scope of practice for each of the dental professional groups and for regulating which groups can provide treatment to patients independently (known as ‘direct access’).

Scope of Practice

The GDC’s Scope of Practice guidance sets out the skills and abilities in the scope of each of the seven dental professional registrant groups. Within each professional group, scope of practice will vary between individuals, and may change over the course of an individual’s career, based on their training, experience and continuing professional development. Professionals should only carry out tasks which they are trained, competent and indemnified to deliver.

We are in the process of reviewing and updating the format and content of this guidance to improve its clarity. We want to make clear that the Scope of Practice guidance should not be seen as a list of tasks that can be done by any individual registered in that specific professional category. Rather, a judgement about whether a task falls into an individual’s scope of practice is based on the training, competence, and indemnity of that person, as well as the professional title under which they are registered. We will launch a formal consultation on the updated guidance in February 2023 and expect to publish the final version towards the end of the year

Direct Access

The GDC’s Direct Access guidance explains when certain dental care professionals can provide care to patients without prescription by a dentist. Under direct access, patients can be seen by certain dental care professionals, including dental therapists and dental hygienists, without having to see a dentist first. 

In practice, however, various system factors may prevent dental professionals utilising their full scope of practice or working under appropriate direct access arrangements. For example:

• Dental professionals may face difficulties accessing training to develop additional skills.
• Medicines regulations mean that therapists and hygienists must rely on Patient Specific Directions (PSD) or Patient Group Directions (PGD) to administer prescription-only medicines to patients. This includes local anaesthetics which are commonly required for different dental treatments. There may be challenges accessing PSDs and PGDs which cause delays to care.
• There is a lack of stakeholder awareness around what treatments different dental professionals can safely provide to patients and how dental practice business models can be designed to support skills mix.
• In the NHS context specifically – there is a lack of clarity around NHS remuneration mechanisms for dental care professionals who do not have performer numbers but are delivering care under the NHS contract.

We are actively supporting initiatives across the dental sector which help registrants to overcome such barriers and to work to their full scope of practice.

Education and training for the dental workforce

High quality education and training is the essential foundation of safe and effective dental care. It ensures that dental professionals have the skills and confidence to meet their patients’ needs, address wider population health requirements, and adapt to new models of care. Education and training can also contribute to workforce satisfaction and influence dental professionals’ decisions about where to work.

The GDC has a statutory role in quality assuring dental education and training programmes which lead to a registrable qualification, as well as those which lead to dentists’ inclusion on a specialist list. We do not have a specific statutory role for overseeing education and training other than that leading to registration or joining a specialist list, though we do require all dental professionals to undertake continuous professional development.

We are currently in the process of reviewing and updating our guidance which contains the learning outcomes that individuals must be able to demonstrate by the end of their pre-registration education or training. The learning outcomes we expect UK education and training programmes to deliver are also reflected in the assessments we use to establish whether an individual trained overseas should be admitted to the dental registers. We recently consulted on our proposals, which include expectations around behaviours alongside the learning outcomes. and take account of the fact that professionals will be working in an increasingly complex environment and need to understand and manage the impact of wider contextual factors on patient safety and their own performance and wellbeing. This work aligns with a recommendation in the Professional Standards Authority’s ‘Safer care for all’ report that regulators should identify opportunities to equip practitioners to deal with future challenges in how care is delivered.

More broadly, we recognise that dental education and training programmes – at both pre-registration and specialty training level – will need to evolve to meet changing patient and workforce needs. We will continue to work with dental education and training providers and other stakeholders to ensure that programme developments fulfil regulatory requirements and meet our standards for education.

Relevant findings from our research

We started research in August 2020 to better understand the scale and nature of the impacts of the COVID-19 pandemic on dental professionals and the public. Our latest of COVID-19 research was undertaken in the last quarter of 2021. Whilst it covered both private and NHS dental care provision, certain findings may still be relevant to aspects of this inquiry and are summarised in the table below.

This research has informed our work around education and professionalism, as well as wider policy development relating to changes and innovation in dental care delivery. We have shared our research findings with stakeholders for collaboration purposes.

The results of ongoing projects in our wider programme of research may also be applicable to this inquiry. These projects are anticipated to complete over the course of 2023, with reports to be published on the GDC website:

• Research with the public, to understand patient and public perspectives on dental care provision in the context of pandemic recovery and other aftershocks, such as the recent financial crisis.
• An evaluation of GDC’s Enhanced Continuing Professional Development scheme, which includes exploring the impact of current system shocks and CPD needs going forward.
• Research with early career registrants (five years on the register or less), investigating registrant perspectives on Preparing for Practice, which includes reflectively exploring how the pandemic affected registrant experiences of education and training.

Jan 2023