Cause for concern: BDA v GDC - Nature
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OPINION
Cause for concern: BDA v GDC
R. A. Baker 1
Key points
Questions the success of the policy of the BDA Summarises the benefits of general, health and Makes suggestions to improve regulation and
towards the GDC with regard to the annual professional regulation. thereby reduce the number of charges brought
retention fee. before the GDC, the GDC’s expenses and so the ARF.
In this Opinion article I will discuss the relationship between the BDA and the GDC, the nature of the BDA’s and dentists’
language when communicating with the GDC and when discussing the GDC in public forums, such as this journal. I also
suggest ways this relationship can be improved for the benefit of dentists and the GDC.
Introduction registered dental professionals8 and that they patients and dental professionals. One can
are colleagues. The British Dental Journal is only hope that these articles have not further
As I approach retirement after 40 years, as a most certainly a public media, represent- divided the profession from its regulator and
dental student, a ‘wet-fingered dental grunt’ ing the UK dental profession; it is not only that those individual regulators will be under-
and continuous BDA member, I am disturbed, read by professionals but by non-registrants standing and forgiving. Understanding of
disappointed and disquieted by the recent edi- as well. Previous editorial policy was to be the emotions expressed and forgiving of the
torials1,2 and opinion pieces3–5 published in this inclined towards unbiased reporting rather language.
journal. Disturbed that a professional journal than influence,9 being concerned that indis- No one can doubt the sincerity of the
should publish these articles. Disappointed that criminate publishing of opinion papers could authors or their belief in the truth of what
colleagues should treat fellow professionals with be negligence on the part of the Editor.10 Like they have written, most especially because of
so little respect. Disquieted for the future regula- many readers I enjoy the Editor’s humorous the passion and emotive language. However,
tion of the profession which so many of us hope editorials. But should it not also be part of the the BDA’s leaders have been expressing these
will change positively in the near future. role of the Editor to moderate controversy by attitudes for some years, without any apparent
Section 9 of the General Dental Council both editing articles submitted and providing change in GDC policy.
(GDC) Standards6 states: reflective editorials: rather than invective? But perhaps the worst thing for me is the
• ‘9.1.1 You must treat all team members, It has probably always been the case that plain bad manners of our leaders with regard
other colleagues and members of the public the ‘angry young men’ will be outspoken; to Dr William Moyes, Chair of the GDC,
fairly, with dignity and in line with the law’ irreverent; show uninhibited disdain; and their addressing11 and referring5 to him as ‘Mr’ and
• ‘9.1.2 You must not make disparaging writings express raw anger and frustration as contracting William to ‘Bill’.11 He has a PhD
remarks about another member of the the changes fail to meet exalted aspirations for (Theoretical Chemistry from the University of
dental team in front of patients.’ genuine reform. But it is the role for older col- Edinburgh).12 Surely, after the ‘Call me Doctor’
leagues, especially those with influence in the controversial battle of the 1990s, of all profes-
The GDC as a body has been considered part profession, to proffer constructive advice: not sions we should be able to accord him his title.
of the dental profession,7 but at the very least to make immoderate statements undermining I was taught that when writing to people to
we should remember that the GDC includes the institutions which support the ‘system’? It never use nick-names. How do you react when
should not be for those who are about to exit people get your name or title wrong?
the profession to hold up progress by decrying Why did we have to refer to Dr Moyes’ reap-
1
OSCAR Dental, University Hospital Llandough, Penlan
Road, Penarth CF64 2XX the GDC and Care Quality Commission (CQC) pointment as a Chair of the GDC as a ‘missed
Correspondence to: Robert Baker etc – who do a thankless job with their own opportunity’?13 He is in post now until 2021,
Email: robert.baker2@wales.nhs.uk
human frailties. so he is the only game in town. As registrants
Refereed Paper. Accepted 20 March 2018 All of us should be aware that the ‘system’ can we really allow this situation to continue?
DOI: 10.1038/sj.bdj.2018.358
is there primarily for the benefit of all, both It has been going on for too long, can we really
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afford to wait a second decade before we start General regulation emotional cost to the responsible professional:
finding a solution? guilt, feeling of inadequacy. The purpose
We (the profession) have, however, con- Regulation is for our benefit and that of our of these regulatory bodies is to provide a
centrated, publicly at least, upon the cost of patients, but for some reason individual reg- framework of safety to prevent mistakes and
the Annual Retention Fee (ARF). Repeatedly istrants do not believe this. In my lifetime cut the costs of adverse events and the addi-
mentioning that the money raised through the regulation has changed from loose minimal- tional costs of repair.
ARF rise for 2015 was based on an unlawful ism to rigid direction. Why? Perhaps because We are getting the benefit of our medical col-
consultation in 2014. it saves lives? league’s experience. Brennan et al.17 identified
My late father was an old-fashioned solicitor The airline industry is usually taken as the in 1991 the cost of adverse effects in medicine.
who when asked what his best legal advice had example of the benefits of regulation. We all This has been taken forward in the UK by the
been, always responded with ‘never litigate.’ expect to be able to fly safely. We would not Chief Medical Officer, Liam Donaldson, with
Legal action in which one side (the profession) expect the pilot to just pop out to the plane, the document in 2000 ‘An organisation with a
gets to pay all the costs regardless of who wins kick the tyres and then take off. We want those memory’ and in 2001 the establishment of the
is unlikely to reduce the individual registrants’ pre-flight checks which ensure our safety. Why National Patient Safety Agency.
expenses. It is of course appropriate that the wouldn’t our patients want the same things as The concept is of safety through design,
BDA is reflecting upon the recent litigation we do? using the systems approach which we are
and the legal maxim of Quis custodiet ipsos Since the 1980s there has been a cultural all aware of from the airline industry. This
custodes?5 But perhaps this is something best change – as a society we have an expectation requires risk assessment analysis, communica-
left unspoken? of safety. When I bought my second practice I tion, standardised systems and check lists.18 It
Our leaders are persons of great experience acquired two seriously leaky gas fires (waiting recognises that many of the adverse events
but O’Donnell humorously described clinical room and surgery) and an aspirator which relate to psychology/human factors. Although
experience as ‘making the same mistakes with if you touched it in the wrong place gave you this may not be as clear cut as we might wish.19
increasing confidence over an impressive an electric shock! Few would argue that there The financial imperatives mean that as a
number of years.’14 Maybe if we want change should not be safety regulations throughout society we need to cut health costs by reducing
we need to reconsider our approach? society. Yes it represents a significant burden to adverse events. Mr Hunt the Minister for
In contrast Dr Moyes has been unfailingly comply with these regulations, both in time and Health is committed to making savings of
polite in the published correspondence which money. However, it brings benefits to everyone. 1.5–2 billion pounds from safer care across
I have read and has even written: ‘we should, Younger colleagues will perhaps be unaware that the whole NHS by 2020.20
both separately and together, be moving on to the safety features of modern cars have delivered One might have supposed that the benefits
tackle the substantial agenda of current and a fall in road traffic accident deaths which we of these regulatory changes would have been
future issues.’ and continued: would never have imagined possible. New cars self-evident to dental professionals.
‘I have set out above three important areas used to be built and sold without either seat belts Carried out correctly there will be:
where I would welcome the GDC and the BDA or air safety bags – perfectly legally! • A reduction in adverse outcomes
working together to benefit patients and regis- The dental profession has to comply with this • Happier patients
trants. No doubt there are many more. I believe regulation and individually we should accept it • Less litigation
it is time for our organisations to look to the willingly, it is the price we all, as citizens, pay • A level economic playing field.
future rather than the past. We know that the for our communal safety. Sadly, it is necessary
GDC will be stronger if it takes these matters for individuals to have a degree of fear of the These benefit all dental professionals. When
forward in partnership and it wants to do so consequences of non-compliance. I imagine I first started in practice there were colleagues
with the BDA, amongst others.’15 that this is greatly magnified for younger regis- still using boiling water baths (cheap) rather
As a child had I behaved in the way the pro- trants by their use of social media which means than autoclaves (expensive). Most hand-pieces
fession has there would have only been plain that they will hear about colleagues’ misfor- were not autoclavable – merely wiped with
bread and butter for tea and it would have been tunes in (possibly unreliably) lurid detail. My methylated spirit between patients. When I
early to bed to allow me time to reconsider. staff have to be reminded regularly that I do purchased, at great cost, autoclavable hand-
It would seem likely to me that the GDC has not need my happy work time upset hourly by pieces I was not unaware that there were col-
decided to keep the ARF and allow the profes- yet another ‘disaster’ brought directly to them leagues who were quite legally continuing to
sion to reconsider its position. We have been via their phones – ignorance is bliss! undertake what I felt to be outdated but signifi-
metaphorically sent to bed. cantly cheaper practices – the ‘good old days’!
The GDC’s largest variable cost influencing the Health regulation Deep safety is the objective not a tick box
ARF is the level of complaints received and the culture. If as a profession we treat this only
number of charges brought before the GDC.16 Both medicine and dentistry involve multiple as a tick box exercise carried out to please
Surely what the profession and the GDC both interventions many of which can go wrong. others, then there can be little hope of success.
want is increased professionalism which, if Each adverse event has the economic costs of Characters like Mr Tickawayo the CQC
sorted, should reduce the number of charges reduced output and the costs of putting it right. inspector, who appears as slippery as a new
brought before the GDC and so inevitably the There are also emotional costs to the patient born baby weasel, depicted in Charlie and
ARF itself. Have we as a profession failed to of: pain, anger, sorrow, grief, revenge and the Rufus on YouTube is of course amusing, but
engage in regulation to our own disadvantage? desire for compensation. In addition there is should not be confused with reality.21
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Professional regulation my regulator to deal with the mad, bad, and mature consideration. All justice systems have
dangerous. inherent delay. It has always been the plea of
Only registered dental professionals can provide litigants that this delay is unacceptable. Students
dentistry in the UK, that is, we have a monopoly GDC and education of Cicero will recollect his eloquence appearing
on its supply. It is only appropriate that there as the prosecutor of the former Governor of
should be a regulatory authority. In the UK All dental professionals will I imagine have felt Sicily, Caius Verres, against the criminal delay
this is provided for by the Dentists Act 1984.22 the anxiety moving from a protected under- to influence the choice of judges.27 The National
Harold Shipman a general medical practitioner graduate environment watched over by clinical Audit Office reported that in the UK courts
was found guilty in 2000 of murdering 15 supervisors and clinical academics to the less delays are getting worse against a backdrop
patients and the subsequent Shipman Inquiry protected environment of vocational training/ of continuing financial pressure. Backlogs in
estimated the total number of victims at 250. The foundation training and then finally to inde- the Crown Court increased by 34% between
subsequent Government’s White Paper, ‘Trust, pendent practice. This is inevitable. 2013 and 2015, and waiting time for a crown
Assurance and Safety: The Regulation of Health I myself was only too aware that the very court hearing has increased by 35% (from
Professionals in the 21st Century’, concluding limited introduction to general practice finance 99 days to 134) since 2013.28
that regulation that is independent of govern- at dental school was inadequate as others have We would all hope for fair, impartial, informed
ment and practitioners is the way forward.23 described.24 It became quickly apparent that my assessment by the GDC. Inevitably this must
This led to the dental members of the GDC undergraduate training was incomplete. So I take time and costs money. The quality of this
being appointed rather than elected. went on postgraduate courses and did a clinical justice must be reflected in the price which we
In the early 1990s I was appalled at the attachment at a local dental school. This would as registrants pay in our registration fees. We
low fees paid under the NHS, certainly not a be I suppose normal. Whilst the GDC is respon- cannot hope for speed and thorough examina-
‘decent return’, and angry that I felt forced to sible for supervising undergraduate education it tion of the case at low cost. These are mutually
‘go private’. So I myself stood for election to is not acceptable to criticise the GDC because of incompatible. Would registrants actually wish
the GDC, as I could not understand why the individual personal failings. If, however, an indi- to have the minimum cost regulator dispensing
GDC did not stand up for patients and require vidual registrant is aware that a dental school is summary justice without proper investigation?
a fair NHS. Wisely the electorate did not vote providing a programme of education which is Fortunately, unlike the courts, the GDC does
for a young man who did not understand the deficient then surely they would have a duty to not have cash limitations; it can raise the ARF
system. But a kindly elder practitioner did take draw this to the attention of the GDC? as necessary to ensure justice.
me to one side and explained to me the role of Younger colleagues will be delighted to The level of the ARF has been an issue – since
the GDC. It is not to protect practitioners or know that when I first qualified, the older prac- 1998 when the GDC sought a 50% increase
patients from the pricing vagaries of the NHS. titioners, some of whom had served in WWII, in fees.29 The GDC’s finances have come in
The Act requires that: were far more patronising to us, in ways that for criticism. It must be difficult to estimate
‘1 Constitution and general duties of the would now be considered workplace abuse or how many complaints the GDC will receive,
Council. bullying. I recollect having instruments thrown how many will need to be investigated further,
(1)There shall continue to be a body at me and one consultant telling me that I how long the investigations will take and cost.
corporate known as the General Dental would not have any opinion worth hearing Conduct accounts for the largest proportion of
Council (in this Act referred to as “the until I had been qualified at least five years, the GDC’s expenditure.16 Whilst all registrants
Council”). but that he was doubtful if he would ever take would wish the GDC to keep a tight control on
(2)It shall be the general concern of the any notice of anything I said. finances I am sure that they would also wish
Council to promote high standards of dental for fast efficient process – justice delayed is
education at all its stages and high standards The GDC and regulation justice denied.
of professional conduct among dentists, and Numerically, concerns have risen since the
the Council shall in particular perform the Contemporary Britain is a post-modern 1980s. Had they continued to rise at the same
functions assigned to them by this Act.’22 society, characterised by individualism, con- rate in the past three years the GDC might
In very simple terms this requires the GDC sumerism and constructivism.25 This has led have needed all the money raised in the ARF.
to undertake two roles: to an increased demand for aesthetic proce- Speaking to colleagues, everyone feels we are
• Education/prevention: undergraduate dures as personal appearance is of increasing on a upward gradient, I do not think anyone
education (dental schools) and postgradu- importance. Evidence shows that over 50% expected the present plateau, and nobody feels
ate education (specialist training and post- of patients who subsequently litigate against that we have reached the summit yet. Sadly we
graduate training) plastic surgeons were assessed by a psychia- all expect further increases, where it will end
• Regulation/removal. trist (in the back of the court) to have mental nobody knows.
and behavioural disorders such as narcissistic
So whilst individual GDC members are disorder – so I suspect it is the same for dentists GDC improvements
interested, the GDC (as a body) is statutorily undertaking aesthetic procedures.26 We are all
disinterested in pricing. It is not turning a blind aware of the rise in litigation and FtP cases. The GDC has attempted to cut costs, for example
eye. The GDC only wishes to diminish patients’ The GDC only attempts to provide ‘just’ regu- it cut catering costs in 2001/2 by 42%.16 As a
access to poor quality care and prevent dentists lation, not retribution. Justice requires: collection young man it would never have occurred to
harming patients. As a professional I also want of evidence; thorough sifting of the evidence; and me that individual members of the GDC would
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leave the august halls of Wimpole Street. But 15 years ago.16 Moreover the GDC’s current Automated indemnity insurance
in 1998 they developed a web site. Shortly after proposals are surely too modest to make any
they formed the GDC Road Show,30 travelling significant impact. Perhaps they are limited Indemnity insurance should be improved.
the length and breadth of the country and have by the hostility of the profession? As a profes- This represented 22/510 of charges heard in
had stands at conferences. Whilst I suspect that sion we desperately need far better regulation a five year period.34 The present requirement
not all colleagues take the opportunity to attend to help us avoid the morass of litigation and for registrants to make a declaration that they
and hear first-hand the thoughts of our regula- Fitness to Practise (FtP) proceedings. have indemnity insurance is suboptimal. It
tors, these were significant steps forward, in an Perhaps we would be wise to recollect the should be expected that insurers be required
effort to engage which was most welcome. words of the Duke of Wellington: ‘Wise people to register with the GDC as providers and that
Whilst the old elected GDC was not in the learn when they can; fools learn when they each insurance provider should then notify the
past noted for its sensitivity as Dame Margaret must.’33 GDC of each policy in a similar way that the
Seward noted in her Valedictory message in Surely, when this situation is costing each police can check a driver’s motor insurance.
1999,31 things are changing. In 2017 the GDC individual registrant so much money and angst, Should then a registrant fail to renew, the
published ‘Shifting the balance’.32 Dr Moyes, the we have now moved to the point when even a GDC could advise registrants that their reg-
present Chair of the GDC, wrote in the intro- fool must learn that we need improvements? istration was suspended until their insurance
duction: ‘Increasingly, however, the system of As a child I used to be fascinated by a lone was renewed. No longer would registrants need
professional regulation in dentistry is losing the black swan (the emblem of Dawlish) with its red to make an annual declaration of indemnity
support of those regulated.’32 He went on to write: beak gliding across the water. Sadly, our problems insurance – another burden lifted.
‘We recognise that it is an antiquated system. We are not solitary black swans, they are more like
have come to the conclusion that our approach is magpies – ubiquitous birds of ill-omen. But at Continuing professional
outdated. We need to find a better way.’32 least there has been research,34 so we know what development
Surely every registrant should be happy to ends up at the GDC and can put the problems
read that the Chair of the GDC has come to the right if we so choose. I am confident that the whole profession
same conclusion that most registrants made Sadly, of the dozen most frequent charges would aspire to continue to improve continu-
some years ago? brought before the GDC,34 number 1 ‘Poor ing professional development (CPD). We need
The paper clearly states the problems: clinical treatment’ and number 12 ‘Management to lobby the GDC to alter the Standards to
‘the current system of regulation: of staff ’ would be probably be the most difficult. improve this. Presently, verifiable CPD in the
• Does not deliver clear enough benefits for But the remaining ten in the top dozen could be UK is largely (but not limited to) a mixture of
patients nor give them the confidence that amenable to fairly simple resolution. lectures or journal reading. The present trust
their concerns are being addressed within How can we encourage people to embrace based system is suboptimal.
an appropriate timescale; changes that will be beneficial for patients Sadly, in lectures one often sees participants
• Has encountered difficulty in maintaining and ourselves? We should limit ourselves to managing their online status, texting or playing
the support of those regulated because it is solutions which have: games. On one memorable occasion I recollect
often cumbersome and stressful for those • An easy method of implementation a colleague (now sadly dead) cheering the
subject to enforcement, and does not do • Good-quality guidance cricket score! In addition we will all have sat
enough to promote learning; • Clear benefits – with numbers, feelings and through lectures which were poorly presented
• Is insufficiently flexible to enable a propor- experiences demonstrating that the change and perhaps even irrelevant to our own sphere
tionate and graduated approach, resulting in is better than status quo. of practice. Are these lectures made more
a reliance on expensive enforcement action. memorable by undertaking them whilst cruising
The status quo is not acceptable. So at a down the Volga? Try telling it to your patients
Good regulation should involve a very time when both sides want change and clearly and listen carefully to their body language!
broad spectrum of tools and mechanisms see the benefits we need to look for easy to Dr Rufus Fideo’s (the YouTube guru of the
designed to positively influence behaviour. implement solutions. Like the GDC I believe dental surgery) comments with regard to
Proportionate and fair enforcement sits at one that the answers lie ‘upstream’ but I would journal reading:
end of the spectrum. But good regulation starts suggest fishing in some other rivers for fish ‘Rufus: “What, you mean you actually read
‘upstream’ with communications, engage- which are easier to catch. With this in mind them!”
ment and learning; persuasion and influence; I am of the opinion we should lobby the Charlie: “Yes, don’t you?”
leadership, partnership and an expression of GDC for changes some of which may require Rufus: “No of course not, I fail to see how
common goals.’32 amendments (or Section 60 orders) to the reading an article on a school-based epidemio-
I cannot put it better than the Chair: Dentists Act 1984. logical study of dental neglect in adolescents in
‘Changing the system will be challenging, but I first played with computers in 1970, so am a deprived area of the UK is going to help me
one thing is certain; we have an opportunity to a computer Neanderthal, but even I am aware sort out Mrs Scoggins’ UL6.”
work together to improve dental regulation in that they can take on much of the routine work Charlie: “If you don’t read the articles how
the interests of both patients and professionals. which is tedious but essential. I believe that do you answer the questions?”
I hope you will join us in seizing it.’32 computerisation could be our salvation, saving Rufus: “Honestly Charlie, you guess.”’21
Sadly the principles underlying ‘Shifting us from the various vexations and vicissitudes The GDC seems to agree with Dr Fideo as
the balance’ were first stated by the GDC of modern dental practice. it writes:
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‘There was very little evidence to suggest required to inform the GDC when individual after a short warning period it turns off the
that current models of CPD have an impact registrants have undertaken education. So all X‑ray machine and the indemnity provider
on the quality of care delivered, performance CPD providers would register with the GDC and would receive an email. Radiation repre-
or competence. A further conclusion, however, send details of attendees to the GDC electroni- sented 59/510 of charges heard in a five
was that the public expects professionals to cally. No longer would registrants need to make year period.34
keep their knowledge and skills up to date an annual declaration of CPD – a burden lifted.
by carrying out CPD activities. We therefore Practice records computerisation
need to close the gap between those two con- Software training
clusions, and ensure that CPD meaningfully We should lobby the GDC to require that all
contributes to patient care, patient protection There is little point in having sophisticated practices should be required to computerise
and professional development.’32 software if the registrant cannot use it optimally. and use NHS BSA/GDC approved dental
Those of us who have attended the Dental Drivers are required to pass a driving test. practice management software. No longer
Protection Society’s Complaints Management No insurance company would underwrite a should registrants be expected to remember
training understand how good it is. It is small motor policy for a driver who had not passed so many details in a busy practice when the
group training, with professional tutors with an the driving test. Yet we do not ensure that software programmes can do so much more
excellent knowledge of the subject, and special- registrants are trained to use software which of the work. The programmes in general use
ist work books. Unlike other CPD providers they use every day? When you buy Software are over a decade old. They are no longer fit for
one does not see attendees playing with mobile of Excellence (SOE) you can receive training purpose; they need improvement for today’s
phones or tablets. We are engaged – I think which takes several days provided by qualified busy dental practice. Are you using games
largely because of the high quality and that trainers. Again, excellent small group learning from ten years ago?
you cannot sit at the back. It is of high quality because the software providers want the Record keeping is the second highest
because the provider has a financial interest in software to work with minimum support. Yet category of charges – 61/510.34 Our electronic
its success. If we get the message and act on it when a newly qualified registrant arrives in record keeping systems should automatically
there will be fewer claims to pay out. my Health Board they receive local software include:
I am sure that our patients would hope for training provided by a colleague. Many of them
something better than guessing the answers to appear to struggle. We should lobby the GDC Medical history
journal questions as training for activities as to require indemnity providers to require reg- 1. If when completing the medical history the
important as medical emergencies. istrants to declare their software annually and box for smoking has an entry ‘yes’, then the
The GDC should alter the Standards to show that they have had training provided by programme should automatically print out
require that registrants should have indemnity the software provider, not a 1/4 of an hour with an ‘Advice Sheet’ for the patient and an item
insurance which includes mandatory training a colleague! Again, this could be automated by of treatment,‘Smoking cessation advice
as part of the insurance package (medical the software provider declaring the education given’, inserted into the treatment plan
emergencies; disinfection and decontamina- to the indemnity insurer. 2. The software I use has no mention of
tion; radiography and radiation protection; dementia. It was designed for fit healthy
legal and ethical issues; complaints handling; Radiography individuals, but with our aging population
early detection of oral cancer and safeguard- we need to expand the space for patients
ing for children, young people and vulnerable It is possible now for computer programmes with many complex diseases
adults) provided by the indemnity provider. to be used to read radiographs and provide 3. The software should recognise certain
This would mean that all registrants would diagnoses. Obviously this will only work for drugs/diseases and flag them to the prac-
either have to complete mandatory training or digital radiographs. We should lobby the GDC titioner. For example ‘bisphosphonate’
lose their insurance and so their registration. This to amend the Standards to require all radio- medications would produce a patient
could be approximately ten hours CPD provided graphs to be held digitally and be electronically advice sheet if an extraction were planned
annually. The indemnity provider would be able audited. and create a screen ‘pop-up’ of a link to
to electronically confirm direct to the GDC that Then the radiography programme could: the NICE guidelines. This must be kept
individual registrants had undertaken the CPD. 1. ‘Read’ the radiographs and grade each one minimal to avoid registrants ignoring it
There would be a shift of costs from the GDC (1,2,3) and record the score in a separate file. 4. No appointment should be completed
to the indemnity providers so there could be It could audit all radiographs taken and if the without a current medical history in place.
an immediate reduction of the ARF. The cost results fall below the necessary level could The lack of a current medical history rep-
to the indemnity providers could be lower than electronically inform the indemnity provider, resented 28/510 of charges heard in a five
the present costs as they would be providing a who could require the registrant to undertake year period.34
product across the UK and so would benefit further education in practical radiography.
from the economies of scale. It would also be No more scratched sensors now! Examination
hoped that the costs would be further offset by 2. Alert individual practitioners of potentially There should be a requirement for empty
the improved professionalism and skills of all cancerous boney lesions prompts within the examination item, for
registrants reducing litigation and FtP hearings. 3. Have a service indicator (just like in your example, mucous membranes, the examination
It would be reasonable to expect all other car) within it set by the service engineer so could only be completed with these subsec-
providers of postgraduate education to be that if it was not serviced in a timely manner tions completed first.
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The software should prevent: same approved software. This would greatly the theft: the man who leaves temptation in
1. Completion of the exam item without help when: the way or the thief who takes it away?’ With
recording either BPE or 6ppc • Fraud investigations are necessary better algorithms this could be a thing of the
2. A course of treatment with a BPE of above • Associates are negotiating with past. NHS fraud represented 57/510 charges
0 not including instruction in oral hygiene practice owners over a five year period.34
and if above 1 to include scaling, etc • Buying and selling practices.
3. Examination appointments could not be Supporting professionals from
completed without a written treatment plan This would ensure that all sides would be overseas
automatically being printed and emailed able to understand the accounting. The GDC is on record as stating: ‘New reg-
to the patient. Consent issues represented istrants who have undertaken their training
53/510 of charges heard in a five year period Provision of records to the NHS outside the UK may face specific challenges
4. If there is mixing of NHS and private within Business Services Authority [NHS BSA] in their transition to working here. These
the one course of treatment there should We should lobby the BSA to change the may include understanding the workings of
be automatic printing of an approved GDC SGDSC. All NHS practices should be required the NHS and contracts, adapting to different
statement also emailed to the patient. to automatically allow the NHS BSA to inter- patient expectations or different ways of
Mixing of NHS and private represented rogate the practice system – so that never again working within a dental team. We are consid-
24/510 charges over a five year period34 would there be a failure to provide records to ering the role we should play in assisting these
5. The software should be able to create the the BSA. This represented 25/510 of charges registrants in overcoming such challenges and
recall interval using an algorithm based heard in a five year period.34 helping to ensure that avoidable problems for
on the charting, the BPE, number of new patients or registrants do not arise.’ 32
cavities, patient age etc. Root out our ‘rotten apples’ All new registrants face problems. We
NHS dental fraud has been with us all my prac- should lobby the GDC to amend the Standards
Diagnostic radiographs and intervals tising career – it should have been dealt with so that all new registrants have training in legal
The programme should be able to examine years ago. The sad case studies presented by and ethical issues, and complaints handling
the individual patient’s past records and auto- Professor Trevor Burke36 recently of practitioners provided by their indemnity provider prior
matically insert routine bitewing radiographs providing repeated over-treatment of 12 units to commencing practice. In addition, all
if required of dental activity (UDA) courses of treatment registrants undertaking NHS general dental
1. Radiographs should not be able to be should never be allowed. This is in clear breach practice for the first time, or after any signifi-
completed without a report of SGDSC Clause 177 which states: cant break from practice, should have training
2. Certain items would automatically ‘A prescriber shall not prescribe drugs, outlining their responsibilities provided by the
generate radiographs in the treatment medicines or appliances whose cost or quantity, NHS BSA before they (re)commence practice.
plan, for example, crowns, bridges, inlays in relation to any patient, is, by reason of the
and prolonged gum treatment. Then these character of that drug, medicine or appliance, in First tier complaints/Independent
items could not be completed without the excess of that which was reasonably necessary concerns management
radiographs being previously closed. for the proper treatment of that patient.’37 We need several nationwide universal dental
The dental practice management software concerns services which are independent and
Sedation should include within it coding which would work. By the way it is ‘concerns’ rather than
Sedation items should not be completed without inform the practitioner that this item of ‘complaints’ if you are politically correct. These
a second appropriate person logged in. This rep- treatment has been recently provided for the should be in competition with each other to
resented 21/510 charges over a five year period.34 patient. If the practitioner then attempts to bill ensure minimum costs. Managing many of
the NHS BSA the software could also inform the the concerns before they get near the GDC.
Advice sheets NHS BSA. One of these case studies indicated The GDC on its website states that it is unusual
All items of treatment for which advice is that patients were having repeat treatment for the Dental Complaints Service (DCS) to
necessary should be automatically printed, by different dentists but at the same practice. be financed by the regulator, implying that it
emailed and/or texted to patients. Clearly the NHS BSA could tackle this by was not a role for the GDC.35 This is something
altering the practitioner numbers for corporate which perhaps the BDA, the FGDP, the NHS
Drug prescription associates to reflect the reality. Then the tacit or the Royal Colleges could organise for their
All prescriptions should be printed through collusion at over-prescribing would be at an end. members/staff. Clearly, it would be inappro-
the dental practice management software. This Moreover, the NHS BSA needs to update priate for the indemnity providers to have
could automatically prevent (or make more its computer system. The recent nationwide this role as there would be a clear conflict of
difficult) self prescription and prescribing for collapse of NHS computers is indicative that interest. The GDC should be lobbied to make it
staff. This represented 16/510 charges over a they are old and ill-maintained. There is no a requirement of the Standards to be part of an
five year period.34 reason to suppose that the NHS BSA is any independent concerns service. This could sig-
different. One suspects that like UK banks nificantly reduce litigation and certainly GDC
Accounting they expect and accept that there will be fraud costs as they will no longer be referring minor
All practices could be required to produce (8.3p per £100 in 2015 for credit cards).38 My concerns on to the appropriate person or
their accounts in a standardised way using the Grandmother would have asked, ‘Who causes funding the DCS. It will also make individual
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registrants more comfortable knowing that who were erased. It was difficult reading. But We can all conclude that the relation-
minor troubles are not going to the GDC. unlike the website which requires a positive ship between the BDA and the GDC is not
But it will only work if patients are aware action to visit, (which we [registrants] would working as we would all have wished. Perhaps
of its existence! In my own hospital there not wish to access) the Gazette sat hauntingly we should change tactics? Perhaps we should
are notices explaining how to raise concerns upon the desk. The GDC needs at least to email change our negotiators? Clearly this is a matter
in virtually every waiting room. It was truly all registrants the electronic equivalent of the for the BDA in private.
facile to complain when the GDC placed public Gazette. This would help DCPs to understand Very truly I tell you that we cannot break
advertisements in newspapers informing the what happens when things go wrong, perhaps the chains, neither can we loosen the shackles
public of the DCS. Rather we should lobby allowing them insight into their own practice of regulations, nor should we want to – as they
the GDC to mandate the placement of ‘How circumstances. Additionally it would be better are for our benefit. If we reject our regulators
to raise concerns’ notices including the details to send an A5 (cheaper postage) paper copy of there can only be a confrontation which cannot
of the service not just in every dental waiting the Gazette to all registrants’ home addresses be won. In fact we can lose much more. Self-
room but on all appointment cards. Do we so that the significance is not lost in the hurly regulation was largely removed because it was
really believe complainants go back and read burly of daily practice. Have you actually read not working. If the present regulation fails we
notices? Wouldn’t this be better than patients ‘Shifting the balance’? could have something more draconian.
popping something into their search engine Some will feel these measures are a ‘spy in Very truly I tell you that to win as a pro-
and getting the Dental Law Partnership? the cab’, but in reality they are just allowing fession we must engage with regulation. The
technology to support our busy lives and solutions to our problems lie in our own hands.
Emergency drugs/electrical safety/ thereby prevent us walking on the GDC’s We need to be pro-active: advise our regulators
pressure vessels/workplace insurance carpets. Surely, a timely reminder is better and support them. We must reach out to them.
etc than falling foul of Wimpole Street? The HM The BDA should enter into meaningful private
We should lobby the CQC as it should be Revenue & Customs (HMRC) now advertise dialogue avoiding public confrontation. Jaw,
ensuring that no practice ever falls out of date. the closing date for tax returns on the radio – to jaw not war, war. We should aim for amicable
Providers of these products could be required ‘help us’, why cannot the GDC also ‘help us’? discussion, moderation, forbearance and
to register with the CQC and advise them two These simple measures could reduce, by 50%, courtesy amongst the disputants. The thoughts
months before the product will expire/require the charges brought before the GDC. of younger colleagues should be received with
inspection etc. Then the suppliers can warn the The measures would go a long way towards the same attention as those from the maturer
registrant in good time, but if an order is not improving the external view of the profes- wisdom of older colleagues. All sides should
placed then CQC can contact the practice prior sion. Moreover the reduction in the number avoid impatience and take time to meditate
to expiration warning of practice closure if the of charges brought would reduce the GDC’s and deliberate before speaking.
products are not replaced. Health and safety expenses making a reduction in the annual It is appropriate that the BDA should com-
accounted for 18/510 charges brought over a retention fee inevitable. Were the GDC then municate with its members, but should keep
five year period.34 to amass treasure and sit Smaug-like astride it, that reporting factual.
judicial review would inevitably be successful. Very truly I tell you that if we reduce the
Payment of the retention fee In the longer term we will need a new number of charges brought before the GDC
Two registrants known to me have failed to renew Dentists Act, which hopefully will incorporate by improved professionalism through better
their registration. One was due to the worry and many of the aspirations of our younger col- regulation we will reduce the work of the GDC,
anxiety of family sickness. This could happen to leagues, hopefully guided by older colleagues’ its costs and our retention fees.
any of us. We all make mistakes. We should lobby wisdom and experience. This will be the time However, the GDC have been considering
the GDC to improve the payment of the retention to consider Quis custodiet ipsos custodes and these changes since 2002: all my practis-
fee. Payments should be made due two months ensure that the regulator is also regulated. This ing career we have waited for a perfect NHS
before the end of the year. Then if the registrant can only be achieved with extensive lobbying contract. So perhaps we should take Milton’s
did not pay the GDC could send letters and of Parliament which will require a Herculean angel Raphael’s advice: ‘Think onely what
emails advising that the registrant would cease effort of will across the four nations in each concernes thee and thy being; Dream not of
to be registered well in advance to minimise the and every Parliamentary constituency by the other Worlds.’40
chances of accidental failure to pay. The BDA and regulator and profession working together. A Good luck to you all. This will be my last year
or the FGDP could also locally contact members daunting prospect which will only be possible Cassandra-like telling patients and managers
as well as part of the membership benefits. if the profession stands together, supporting truths which they do not heed. But I fervently
our leaders within the BDA, and that leader- hope and pray that our profession, which has
GDC communications with the ship carries the membership with it. provided me with a good living and many
profession happy memories, can reach a better place.
Conclusions Deo volente I hope to travel south soon.
We need to lobby the GDC to improve com- Perhaps sometime in the future you will drive
munications with the individual registrants. We should accept that we individually are all through the mountains behind the Portuguese
In the past each registrant received a copy of fallible and that our institutions are also fallible. Algarve. If you should hear the tune Sarie
the GDC Gazette, which itemised changes and As Don Berwick wrote: ‘Improvement is a Marais and spy an old man, a Rhodesian
gave details of the charges against registrants continual journey and new challenges will arise.’39 Ridgeback and a flock of goats – come over
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