Written evidence submitted by the Faculty of General Dental Practice (UK) (GDC0092)

1.              Introduction

1.1              The FGDP(UK) welcomes this accountability hearing with the General Dental (GDC). Scrutiny of the governance and decision-making at the GDC is timely given the frustration from within the profession concerning the performance of the GDC as the dental regulator, and the potential consequences for the delivery of patient care. Concerns have also been raised by the profession, stakeholders and in Parliament1, that the approach being taken by the GDC is inconsistent with that taken by other healthcare regulators.

1.2              These concerns have emerged in the wake of the Professional Standards Authority (PSA) report into the investigation into the GDC (February 2013)2, which highlighted deficiencies in the GDC’s efficiency and effectiveness, and the PSA annual performance review report for 2013/143, which found that the GDC had failed to meet eight standards of good regulation, six in its fitness to practise function and two in its registration function.

1.3              The FGDP(UK) is alarmed at the apparent lack of confidence that the profession currently has in the GDC and the potential for this to have a deleterious effect on patient care. We believe that there are several issues that have given rise to this situation, as detailed in our comments below.

1.4              It is essential that the GDC, like all regulators, is transparent, proportionate and fair in its dealings with the profession. This must include a commitment to ensure that all processes are conducted in a way that is unimpeachable and facilitates full engagement by the profession and stakeholders. We believe that this is not the case at present.

1.5              As one of the UK’s largest dental membership organisations, and the largest of the UK dental faculties, this is an issue that impacts on all of our members. It also has ramifications across the whole profession and, importantly, risks having a negative impact on the very patients that the GDC is tasked with protecting.

1.6              The FGDP(UK) is concerned with any issues that may have a negative impact on the delivery of good patient care, the standards of patient care, a desire to improve skills and knowledge through professional development, and a commitment to the profession by registrants. It is our understanding that there is a current perception within the profession of the GDC’s focus being ‘against the profession’, rather than ‘for patients’. We believe that this, along with the concerns identified by the PSA and highlighted in Parliament, should act as a catalyst for the GDC to reflect on its governance and processes, and urgently seek to make any necessary changes, while communicating this to the profession and stakeholders.

1.7              The Care Quality Commission has stated its view that people using dental services are less likely to experience poor care than in other areas of health and social care that fall under its regulatory responsibilities. As result, it proposes to focus inspections on those services that are seen as ‘cause for concern’. This view of dental care appears to be inconsistent with the significant rise in FtP cases that we have seen in recent years, and we would call on the Health Select Committee to probe further into why this might be the case.

2.              Annual retention fee, judicial review, and fitness to practise processes

2.1              Much of the current discontent with the dental regulator has arisen out of the GDC’s decision to raise the annual retention fee (ARF) for dentists by 55% (initially proposed as a 64% rise). It is universally accepted, and acknowledged by the GDC itself, that this is a significant increase. Indeed many, including Dr Daniel Poulter MP1, believe that there is a dearth of compelling evidence to justify such an unprecedented rise.

2.2              In his judgment on the BDA-led judicial review into the consultation process that preceded the ARF increase, Mr Justice Cranston stated that the GDC failed to follow its own processes and did not consult appropriately before taking the decision to raise the ARF. In summary, the consultation was judged to be unlawful. Notwithstanding the fact that Mr Cranston ruled that the ARF increase may nevertheless remain, the FGDP(UK) urged the GDC  to review its decision to raise the ARF to its current level. The 55% increase for dentists has remained in place.

2.3              We, like others, have made clear our disappointment in the GDC’s public statements concerning the outcome of the judicial review of 18 December 20144, which we consider have perpetuated a dismissive approach and one that does not recognise the disillusion among the profession. There can be no doubt that there exists an almost complete impasse between the profession and the GDC at present, and we have called on the GDC to take major steps to rebuild trust from within the profession.

2.4              The FGDP(UK) would assert that the discontent with the GDC does not simply lie in the issues brought to the fore by the judicial review. Rather, it would appear that this has evolved as a result of an unsatisfactory and overloaded fitness to practise (FtP) process. The FGDP(UK) considers that there exists a palpable fear of FtP from within the profession, which may precipitate a reluctance to treat patients with even moderately complex care needs. This, in turn, would reduce the range and level of skills within the profession, and it cultivates a working environment where judgment may be clouded by a concern of falling foul of inappropriate or vexatious complaints. Patients can only suffer as a result.

2.5              Furthermore, the GDC’s decision to make such an unprecedented increase in the ARF level at this point in time appears to be incongruous with the proposals to amend the GDC’s FtP processes via the Section 60 order, currently pending approval from the Government. The GDC states that among the consequences of the proposed changes to its FtP procedures is to have a more expedient and cost efficient process. The FGDP(UK) questions, therefore, the need to increase the fee by this magnitude in light of the potential for forthcoming cost savings.

2.6              Importantly, the alarming increase in the number of FtP cases has been a trend of which the GDC has been aware for several years. Indeed, as far back as February 2010, the GDC was reporting that ‘The volumes of fitness to practise cases have increased substantially over the last number of years’5,6, reiterated by the GDC in the launch of its consultation on its fitness to practice processes in November 2014, where it states a 110% increase in the number of complaints about GDC registrants since 2010. This would lead us to question why the GDC has not taken steps to both a) review the FtP process or b) make more gradual annual increases in the ARF prior to the decision taken in 2014. The ARF rate had not been increased for four years before October 2014. Ultimately, however, we question the reasons behind the considerable increase in FtP cases and also the length of time that the GDC currently takes for these to be resolved.

2.7              It would appear that some of the issues described above are as a result of an out-dated statutory framework. The FGDP(UK) understands that this is scheduled for review, although there is a suggestion that this may not take place until 2017 due to the pressure on Parliamentary time. Given the widespread concerns, it would seem necessary to expedite this review.

2.8              In addition to the concerns with GDC’s performance during 2013/4 highlighted in the PSA annual performance review report3, we would add our own concerns around the standards of practice against which dentists are judged and consequences in terms of inappropriate cases being escalated to FtP proceedings. Dentistry has a broad range of standards and guidelines that are referred to by expert witnesses as part of any FtP process, including those published by the FGDP(UK). We are concerned that many among these set out a level of practise that may be widely considered as ‘ideal’ or ‘aspirational’, as opposed to acceptable and meeting basic regulatory compliance. We have a great deal of concern around the way in which standards within dentistry are being interpreted within the context of an FtP process, and that this may be leading to inappropriate assessment of a registrant’s competencies.

2.9              Furthermore, there are indications that the FtP process itself, and the length of the process, is having a significant negative effect on the morale and general health and wellbeing of the profession. We are concerned that good dentists may be driven out of the profession, either as a direct result of inequitable FtP process or through a fear of such a process, and that this will impact on patient care and the oral health of the population. This may be perceived as unduly alarmist. However, the real and palpable fear within the profession of being caught in disproportionate and unfair FtP proceedings must not be understated, nor the potential for the detrimental effect on patient care. We would ask that the Health Select Committee is cognisant of this significant and unprecedented situation in its deliberations.

2.10              It is essential that the FGDP(UK) ensures probity of our published standards guidance, and that they serve to support improved practice in a way that is proportionate and best serves patient protection, while having the confidence of the profession. We have raised our concern regarding standards of practise with the GDC, and we are currently seeking clarity on the way that the standards are being applied.

2.11              We believe that it is both overdue and urgent for the GDC to commit to improving and speeding up the FtP process and to implement any changes with expedience. This will demand constructive engagement with the profession, stakeholders and Government to support the development of an FtP system in dentistry that protects patients while being proportionate and fair to the profession. We would call on the Government to urge the GDC to define a timeline of changes to be made in light of the PSA report, the judicial review and Section 60 order, including a commitment to review and report after a defined period of time.

2.12              Crucially, the GDC must ensure that it demonstrates to the profession its recognition that the regulation of dental care involves clinical judgement and widely differing circumstances from patient to patient. This must be reflected in the standards against which the profession is measured as a result of patient complaints, rather than be dictated by basic consumeristic factors.

3.              Patient complaints handling

3.1              It is essential that GDC acts in the best interests of patient protection. This includes having in place robust processes to ensure that registrants delivering care that compromises the safety of patients are brought to account and, if necessary, de-registered.

3.2              It is our view that the majority of dentists are seeking to deliver good quality care and provide a service that places the patient’s best interests at it centre. Good patient care frequently requires difficult clinical judgments, particularly where the patient has complex care needs and outcomes cannot easily be predicted. Of those considered to be among the most skilled and experienced within the profession, including Fellows of our own organisation, many will refer to cases where treatment has not resulted in the outcome desired, despite the practitioner having made clinical decisions that they considered to be appropriate.

3.3              The FGDP(UK) has significant concern over the way in which complaints are handled, and the consequences for increased FtP cases, as discussed above. Our members, and indeed Board members, as well as others in the profession, report cases where complaints relate to outcomes that are outwith the control or clinical judgment of the practitioner. Likewise, it appears that some complaints are difficult to substantiate, or may be considered vexatious. In many cases, professionals, and indeed Sir Paul Beresford MP in the GDC Parliamentary adjournment debate  on 9 December 20141, speak of cases where the complaint refers to an issue that can be remediated quickly and easily at a local level, without the necessity for escalation to the GDC.

3.4              We have made clear to the GDC our firm belief that a robust mechanism is needed to manage complaints in a proportionate and expedient manner at a local level, through so-called ‘consensual disposal’. We would highlight previous mechanisms for local resolution that were at one time mediated by the Local Dental Committees, in liaison with the practitioner and the complainant. A similar mechanism exists at present with the Dental Complaints Service (DCS), which works to resolve complaints made about private dental care.

3.5              The DCS is largely considered to be working effectively in the way in which it seeks to resolve disputes and manage complaints made by patients against dental professionals. We would echo this view, while pointing to the lack of such a system with regard to complaints following care delivered via the NHS system. We have also raised concerns with both the GDC and the DCS that, although an ‘arm’s length’ body of the GDC, it is essential for the DCS to continue to act independently from the GDC so that the emphasis remains on resolution rather than referral to the GDC’s FtP process. We believe that this is not only in the best interests of the practitioner, but also of patients, who are often seeking apology and possibly financial redress, as well as a resolution of any clinical issue, rather than a desire to take their complaint through an officious and lengthy FtP process.

3.6              We would welcome the opportunity to work with the GDC to help determine a suitable system for local resolution of complaints, and we would urge the Government to act similarly. Such a system would support expectations of most patients, help to support speedy resolution, and avoid expensive and lengthy processes that damage the profession and foster a culture of fear among registrants.

4.              GDC accounting and costs of regulating the dental profession

4.1              The key point of contention for Mr Justice Cranston in his judgment on the judicial review4, and the basis of his finding that the consultation had been unlawful, was that the GDC failed to provide the necessary evidence to explain how FtP complaints translated into an increased number of hearings and therefore higher costs. In our view, this is a serious issue. Taken together with the GDC’s reluctance to share its KPMG-commissioned review of the assumptions underlying the proposal to raise the ARF, and the its failure to act in a perfunctory and timely manner to address the growing trend in FtP cases at an earlier stage, we believe this accountability hearing should challenge the accounting and budgeting processes at the GDC.

4.2              There is general consensus that the size of the ARF increase is beyond what might be reasonably expected, and far exceeds the expectation of Government from regulators when setting fees1. The judicial review pointed to problems within the management and administration at the GDC4, which was also reported by the PSA in June 20143.

4.3              Furthermore, the significant rise in the ARF has been introduced at a time when changes are pending approval in Parliament that may offset some of the cost increases that the GDC states has led to the rise. In our view, this gives rise to serious questions concerning a lack of transparency regarding accounting and budgeting processes at the GDC.

4.4              The FGDP(UK), in a press statement in response to the outcome of the judicial review, made clear our view that the GDC should review its decision to raise the ARF to its current level7. Furthermore, we believe that the GDC should commit to reducing the ARF in light of any cost savings as a consequence of changes to the Section 60 Order, and for this to be subject to external audit.

4.5              At the present time, there are nearly 40,000 dentists and around 65,000 dental care professionals (DCPs) who are registered with the GDC. Following a consultation in April 2014, the GDC decided to increase the ARF fee in line with the costs associated with regulating each main group of registrant (dentist or dental care professional (DCP)). However, the numbers of registrants at the present time total around 40,000 dentists and 65,000 DCPs, with respective ARF levels of £890 and £116. This not only reflects the differences in the cost of regulating each group, but appears fair and equitable given the average earnings of DCPs when compared with dentists. However, we believe that the Government needs to give consideration to the costs involved in regulating both groups of professionals, particularly given that the total number of registrants is small in comparison with other regulated healthcare professions, and to what degree the dentist registrants may be subsidising the registration of DCPs. 

5.              GDC approach to the profession

5.1              The FGDP(UK) is concerned that the GDC must establish a more considered and positive engagement with the profession, or it risks precipitating further serious erosion in confidence, which may result in driving good dentists out of the profession. This, of course, would have a negative impact on the very patients that the GDC wishes to protect.

5.2              We would hold that an organisation strengthens its standing by showing that it has both heard and understood concerns where they exist, and is able to demonstrate humility and set out actions for remedy where it has been proved to have acted without due diligence. We would question the GDC’s tone of engagement with the profession and stakeholders with respect to the ARF consultation process and outcome of the judicial review, and whether this is indicative of a cultural malaise within the organisation; the detail within the PSA’s June 2014 performance review2 might point to this worrying conclusion.

5.3              We also have concerns regarding the placing by the GDC of an advertisement in the magazine accompanying the Telegraph on Saturday in August 2014, urging patients to complain if not “completely satisfied” with their private dental care. This is because: a) It encouraged people to complain rather than to seek redress directly with the practice and/or local complaints processes;  b) The advert suggested that a complaint was appropriate should the patient not be ‘completely happy’, which may be perceived as support for complaints that are outwith the dentist’s quality of practise, and; c) The timing of this advertisement, and its cost (£5,500), was ill-judged in the extreme, appearing at the same time as the GDC proposed a significant rise (64%) is the ARF and in the wake of the PSA’s June 2014 critical report.

5.4              We believe that it is of paramount importance for the GDC at all times to act, and be seen to act, in accordance with the standards they set out for the profession, or it risks being perceived as lacking credibility. Constructive dialogue between the GDC and registrants is needed to avoid further deterioration in the relations between itself and the profession.

6.              Communication skills in complaints handling for newly qualified professionals

6.1              We have earlier referred to a palpable culture of fear within the profession and its likely consequences (2.4, 2.9, 3.6). We would also reference the General Medical Council’s internal review into the effects of FtP investigation on suicide among doctors8. While they pointed to pre-existing mental health issues and other factors that may have contributed to the deaths, they make a series of recommendations for GMC practice in the review, and we would urge the GDC to consider the value of some of these recommendations as part of its FtP process. These include:

1. Doctors under investigation should feel they are treated as ‘innocent until proven guilty’
2. Reduce the number of health examiners’ reports required for health assessments
3. Appoint a senior medical officer within the GMC to be responsible for overseeing health cases
4. Introduce case conferencing for all health and performance cases
5. Set out pre-qualification criteria for referrals from NHS providers and independent employers
6. Make emotional resilience training an integral part of the medical curriculum
7. Expose GMC investigation staff to frontline clinical practice
8. Develop a GMC employee training package to increase staff awareness of mental health issues.

6.2              Regulation per se does not protect patients and ensure good standards of care; this relies on compliance by the profession. A disillusioned and fearful workforce will not bring about the improvements in care quality and patient outcomes that we would all wish to see, and are central to the aims of the FGDP(UK).

6.3              For patient complaints to be handled effectively at the practice level, the practitioner will often need to be in possession of sophisticated communication skills to bring about swift and satisfactory resolution. We are concerned that a lack of experience and comprehensive training in skilled communication within the context of complaints may contribute to a climate of fear among newly qualified professionals, and leave them more vulnerable to FtP.

6.4              Clearly, there will be cases where a FtP process is appropriate and justified. However, we believe that the current issues within the profession provide an opportune time to review the training and local support given to young practitioners in handling complaints. The GDC conducted research in the summer of 2013 to identify risks in the transition to independent practice, and the FGDP(UK) contributed to this work. It would be helpful to review the findings of this research in the context of complaints handling.

6.5              The curriculum for dental foundation training (DFT) has recently been subject to consultation by the UK Committee of Postgraduate Dental Deans and Directors (COPDEND; June 20149) and is in the final stages of development. Unlike medicine, DFT provides the only gateway into the dental profession post undergraduate degree, and completion of DFT is not subject to formal assessment. The FGDP(UK) has long called for a summative assessment of competencies to mark completion of DFT. The MJDF qualification of the joint dental faculties (FGDP(UK) and FDS) at the Royal College of Surgeons of England represents an appropriate assessment for this purpose, and would provide a robust basis on which to ensure that practitioners moving into independent practice have the necessary underlying skills to develop a mature approach to complaints handling. We welcome support from the Government towards this aim.

7.              Towards continuing assurance in dentistry and a College of Dentistry

7.1              The GDC has for a number of years been engaged in a broad programme of evidence gathering and research as part of the development of a framework for continuing assurance (CA) in dentistry. The FGDP(UK) supports the aims of CA as a means of validating professional competence on an ongoing basis; this is necessary for standards of patient care to be maintained and to reassure the public. We will continue our involvement in this important work, and we would urge the Government to provide the necessary support to the GDC to ensure that this remains a priority within the future regulatory framework for dentistry.

7.2              The FGDP(UK) also strongly supports a move towards quality assurance (QA) of continuing professional development (CPD) within dentistry, and is contributing to work to develop a QA framework for CPD10.

7.3              The FGDP(UK) is firmly of the view that progress towards CA and QA of CPD would benefit from the formation of a College of Dentistry, which would also act to better hold the regulator to account. The FGDP(UK) has stated clearly its ambition towards establishing a College, and we believe that such an institution will provide the necessary support and guidance to bring about improvements in dental care and oral health within the population. We would like to seek your views on this, and whether we may find support towards this aim from Government.

9.              Recommendations for action by Government

9.1              We call on the Government to expedite the approval of changes to the Section 60 order that proposes amendments to the GDC’s FtP processes.

9.2              We call on the Government to urge the GDC to define a timeline of changes to be made in light of the PSA report, the judicial review and Section 60 order, including a commitment to review and report after a defined period of time.

9.3              We believe that this accountability hearing is an opportunity for the Health Select Committee to scrutinise the GDC’s evidence for increasing the size of its ARF beyond the Government’s expectation of regulators when setting fees.

9.4              We call on the Government to encourage the GDC towards establishing a suitable system for the local resolution of complaints.

9.5              We believe that the Government needs to give consideration to the costs involved in regulating all groups of dental professionals.

9.6              We urge the Government to provide the necessary support to the GDC and the profession to ensure that the development of a system for continuing assurance remains a key priority within the profession.

9.7              We call on the Government to expedite the review of the over-arching statutory framework for regulation in health and social care.

9.8              We seek support from Government for the formation of a College of Dentistry.

References

1. Hansard, Westminster Hall, 9 December 2014. General Dental Council adjournment debate. (http://www.publications.parliament.uk/pa/cm201415/cmhansrd/cm141209/halltext/141209h0001.htm, accessed on 17 February 2015)
2. Professional Standards Authority, February 2013. An investigation into concerns raised by the former Chair of the General Dental Council. Advice to the Department of Health (http://www.professionalstandards.org.uk/docs/special-reviews-and-investigations/130204-gdc-investigation-report-final.pdf, accessed on 17 February 2015)
3. Professional Standards Authority, 26 June 2014, Volume II. Annual Performance Report for 2013/14 (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/328077/Professional_Standards_Authority_Volume_II.pdf, accessed on 17 February 2015).
4. Transcript of the judgment of Case No: CO/4825/2014, Neutral Citation Number: [2014] EWHC 4311 (Admin), Administrative Court, Queen’s Bench Division, High Court of Justice. 18 December 2014
5. GDC Council meeting, 10 February 2010. Item 6 Enclosure F, Council Meetings and Stakeholder Engagement. (http://www.gdc-uk.org/Aboutus/Thecouncil/Meetings%202010/Item6PaperF_Council%20Meetings%20and%20Stakeholder%20Engagement27.01.10.pdf, accessed on 17 February 2015).
6. GDC statement on its consultation on fitness to practise processes, 17 November 2014 (http://www.gdc-uk.org/Newsandpublications/Pressreleases/Pages/Consultation-on-GDC-Fitness-to-Practise-processes.aspx, accessed on 17 February 2015).
7. FGDP(UK) press statement on the outcome of the ARF judicial review, 18 December 2014. GDC Must Review ARF Rise Says FGDP(UK) (http://www.fgdp.org.uk/content/news/gdc-must-review-arf-rise-says-fgdpuk.ashx, accessed 17 February 2015)
8. General Medical Council. Internal Review, 14 December 2014. Doctors who commit suicide while under GMC fitness to practise investigation (http://www.gmc-uk.org/Internal_review_into_suicide_in_FTP_processes.pdf_59088696.pdf, accessed on 17 February 2015)
9. UK Committee of Postgraduate Dental Deans and Directors. DFT Curriculum National Consultation Exercise, June 2014 (http://www.copdend.org/content.aspx?Group=consultations&Page=consultation_copdenddftcurriculumnationalconsultationexercise, accessed on 17 February 2015).
10. UK Committee of Postgraduate Dental Deans and Directors. Quality Assurance Framework for Dental CPD Booklet, November 2014. (http://www.copdend.org//data/files/Research/Dental_booklet_24pp.pdf, accessed on 17 February 2015)

About the FGDP(UK)

The Faculty of General Dental Practice (UK), based at The Royal College of Surgeons of England, is the largest of the UK dental faculties. It works to positively influence the oral health of the population through education of the dental profession and the provision of evidence-based guidance. The FGDP(UK) also provides a national voice for over 4700 fellows and members.

Around 95% of dental care in the UK is provided in the primary dental care setting. The FGDP(UK) improves the standard of primary care dentistry delivered to patients through standard setting, postgraduate training and assessment, publications, policy development, and research. The FGDP(UK) offers continuing professional development and training opportunities for all registered dental professionals.

23 February 2015