From Volume 42, Issue 6, July 2015 | Pages 574-579
This article is about the publication by the General Dental Council in 2013 of the Standards expected of those members of the dental team who are registered with the Council, on each of their Registers, and discusses the implications of the new Standards for dental professionals.
The General Dental Council (GDC) is the statutory regulator of dental professionals for the United Kingdom, established under the Dentists Act 1984.1 The GDC regulates Dentists and Dental Care Professionals (DCPs), including clinical dental technicians, dental hygienists and therapists, dental nurses, dental technicians and orthodontic therapists. By law, all of the above must be registered with the General Dental Council to work in the United Kingdom. This ensures only appropriately qualified and skilled dental professionals are part of the clinical dental team.
The main objective of the General Dental Council is the protection of patients and the public. It maintains registers for the above noted dental professionals. The GDC's powers and duties also include setting the standards of conduct, performance and behaviour that Registrants are expected to adhere to, as well as investigating any complaints which suggest a Registrant's fitness to practise may be impaired.
The GDC also sets standards for the education and training of dental professionals and requires all Registrants to undertake Continuing Professional Development (CPD) in order to ensure that they keep their skills and knowledge up-to-date and remain fit to practise. This allows the GDC to meet its main objective.
The General Dental Council (GDC) has been issuing guidance from the very start of its establishment in 1956 and this guidance included rules on behaviour and conduct.
The history of the GDC setting standards expected of Registrants can be traced back to a document Professional Conduct and Fitness to Practise, published by the GDC in 1993.2 In 1997, the GDC issued guidance entitled Maintaining Standards, with amendments in 2001.3 This guidance was revamped significantly with the publication by the GDC of Standards for Dental Professionals4 in 2005 with significant re-working and the production of an enhanced and significant document entitled Standards for the Dental Team5 in 2013.
Reflecting on this journey adopted by the GDC in attempting to establish what is expected of its Registrants in terms of conduct, performance and behaviour, the 2005 and 2013 publications rely heavily on the four principles of biomedical ethics as set out by Beauchamp and Childress.6 Their four principles are one of the most widely used frameworks, offering a broad consideration of medical ethics issues generally, which can be applied in a clinical setting. The four principles are general guides that leave considerable room for judgement in specific cases:
The publication of the Standards for the Dental Team by the General Dental Council, that came into effect on 30 September 2013, was the culmination of an extensive period of consultation by the General Dental Council, including various workshops held throughout the country and meetings with many stakeholder groups and patients.5 This document sets out the standards of conduct, performance and ethics that govern dental professionals in the United Kingdom. It specifies the principles, standards and guidance which apply to all members of the dental team who are GDC Registrants, as well as setting out what patients can expect from a dental professional. The document is based on nine principles which apply to all of the Registrant groups. Throughout the document Standards for the Dental Team, the words ‘must’ and ‘should’ are used. ‘Must’ is used where the duty is compulsory; ‘should’ is used where the duty would not apply in all situations and where there are exceptional circumstances outside the Registrant's control that could affect whether, or how, the Registrant can comply with the guidance.5
There are nine over-arching principles, all of equal importance and are not listed in any order of priority. They are:
The principles are supplemented by additional guidance documents. Each Registrant has a responsibility to behave professionally and follow these principles at all times. The GDC is clear that if a Registrant does not meet these Standards he/she may be removed from the Register and not able to work in the UK as a dental professional. The guidance notes are there to help the Registrants meet the Standards. Registrants are expected to follow the guidance, to use their professional judgement, to demonstrate insight at all times and to be able to justify any decision that is not in line with the guidance. Those Registrants who fail to meet these Standards may be subject to fitness to practise proceedings with the ultimate sanction being erasure.
The General Dental Council has a statutory duty to investigate all complaints that it receives in relation to any of its Registrants. These complaints will be intimated to the Fitness to Practise Department and an investigatory process will be started that involves information gathering as well as, in clinical cases, the obtaining of a Clinical Adviser Report. In misconduct and performance cases, this is crucial as it will provide assistance to the Caseworker in the drafting of the Charges. Medical advice may also be sought in health cases and, at the end of the pre-assessment stage, should matters be referred on to an Investigating Committee, the Registrant will receive a covering letter, a summary of allegations, as well as details of the Standards Guidance alleged to have been contravened by the Registrant.
The examples included within the text, following discussion regarding the principles, highlight how this information is disseminated to the Registrant. These examples are taken from cases managed by the MDDUS on behalf of its members and include a variety of GDC Committee Investigations.
This standard is very wide-ranging and covers a multitude of areas, including communication, respecting patients, acting with honesty and integrity, adopting a holistic approach to care, cross-infection control, being non-discriminatory, having appropriate indemnity and being up-to-date with the relevant law and regulations affecting your practice.
All treatment decisions must be in the best interests of the patient and the individual providing the care must be wary of how the planned/actual treatment may impact on the patient's general health. No treatment should be provided in isolation and all patients must be given a real choice, with no practice/individual being able to hide behind any ‘policy’ decision. Having appropriate paperwork, including accurate, complete and contemporaneous dental records, including a signed treatment plan, will all add weight to any defence, should a complaint be intimated.
The issue of indemnity has been taken further in that, following an independent review across the regulated healthcare professions, which recommended making insurance/indemnity a statutory requirement for access to these professions, the Health Care and Associated Professions (Indemnity Arrangements) Order 2014,7 changed the requirement for Registrants to have indemnity from an ethical requirement to a legal one.
That being registered as a dentist, your fitness to practise is impaired by reason of misconduct. In that: You did not provide an adequate standard of care to patient X, from date Y to date Z, including by:
This standard reflects the many facets of communication, including the dissemination of information to a patient about the care proposed/needed, allowing patients to recognize and promote their own responsibilities for making decisions about their oral healthcare. Information should be provided in a language free of dental jargon, using an interpreter where appropriate. Patients should receive a written plan, including reference to costs that should be signed by the patient, a copy being retained by them, as well as by the practitioner. Practices should display information on the range of costs of dental treatment being provided and this information should also be available on the practice website.
Practitioners should be sufficiently fluent in written and spoken English to communicate effectively with patients. Registrants may have to adopt a change in communication from diagnostic to active listening, a concept that few may be familiar with, but when adopted significantly enhances one's ability to communicate with patients.
That being registered as a dentist, your fitness to practise is impaired by reason of misconduct. In that: You did not provide an adequate standard of care to patient X, from date Y to date Z, including by:
The General Dental Council in this standard has used the term ‘valid consent’, essentially a decision made freely in appreciation of its consequences. For consent to be valid the patient should receive appropriate information, be competent to make a decision and this decision must be made entirely voluntarily. The capacity of the patients must be assessed in terms of their ability to understand, remember and weigh up the relevant consenting information. Valid consent should be obtained before starting treatment and all patients should understand the decisions that they are making with reference to the proposed treatment. Valid consent is not permanent and can be withdrawn by the patient at any time. It is particularly important, during extended courses of treatment, that consent is obtained at each visit, with the patient re-affirming his/her understanding of the proposed care and agreeing to it. The use of the acronym ‘VCG’ – ‘Verbal Consent Gained’ is popular among the dental profession. Registrants should be aware of the impact that drugs, alcohol or dementia may have upon a patient's capacity to consent. Consent remains a very complex area, requiring dedicated time to be provided to ensure that the consent obtained is valid.
That being registered as a dentist, your fitness to practise is impaired by reason of misconduct. In that: You did not provide an adequate standard of care to patient X, from date Y to date Z, including by:
This principle reflects the importance of the dental record. The dental record acts as a historical record, recording the events that have happened during a patient's journey with the healthcare professional. It protects both the practitioner and the patient. The governing legislation is the Data Protection Act 1998,8 with additional legislation applying if the patient is deceased,9 or if there is an issue with regard to NHS treatment in terms of the record itself.
Dental records should be accurate, complete and contemporaneous. Contemporaneous means made at the time of the appointment. If a record is made at the time of the appointment, there is a greater chance that it is accurate and fully records the events that happened. If made later, events may be forgotten, or inaccurately reported. The increasing use of computer software in dental practices has removed the concern with regard to the illegibility of records. Use of templates may be considered by practitioners, but these must be customized for each patient, at each visit and for every item of treatment.
All information must be treated confidentially and this is the bedrock of a patient putting his/her trust in the practitioner with regard to care received. This information must not be released without the patient's consent, with the exception of certain circumstances when, for example, consent could not be obtained.10 Patients should be provided with a copy of their records, should a written request be received and there is separate advice regarding the timelines for disclosure. All the information must be stored securely.
Practitioners are reminded with regard to the security of this information when back-ups may be carried out by third parties at a remote location. Concern has been raised with regard to the use of the Cloud as a storage vehicle. Here the practitioner has no control over which country this information may be stored in or, indeed, where within that country the storage facilities exist.
That being a registered dentist, dentist X's fitness to practise is impaired by reason of misconduct and/or deficient in professional performance, in that you:
This principle deals with addressing concerns raised by patients regarding the care provided. An effective and efficient complaints process affords the practitioner the opportunity to attempt to resolve concerns at a local level, hopefully preventing escalation. By responding in a timely, courteous and comprehensive manner, it demonstrates, on behalf of the practitioner, a willingness to engage with the Complainant. All members of the team should be trained in complaint handling. This is also a CQC11 requirement, for those working in England, under Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities).12
Registrants should be aware of the guidelines available in terms of complaint management,13 including a GDC publication on this topic,14 as well as the content of the new Standards Guidance. It is important if any delays occur during the process that the Complainant is kept fully briefed. Should matters escalate to the jurisdictional Ombudsman, then compliance with the timelines of the process should stand the practitioner in good stead.
That being a registered dentist, dentist X's fitness to practise is impaired by reason of misconduct and/or deficient in professional performance, in that you:
The provision of dental care is enhanced by effective teamwork. Each member of the team must be appropriately trained for the job that he/she is required to do, with each individual being responsible for his/her own acts, omissions and commissions in the provision of this care. A second, appropriately trained person needs to be available in case of a medical emergency. However, being appropriately supported ensures greater efficiency of care provision, as well as offering the security of a chaperone. All provision of care must be within the Scope of Practice15 (GDC May 2013) of the individual who must be competent and indemnified for the task that he/she has been asked to do.
Practice Principals must demonstrate effective management and leadership of their team, ensuring all team members are GDC registered, where appropriate. Communication surfaces again and is key in healthcare delivery.
That being a registered dentist:
This principle focuses on the knowledge and skills of the healthcare provider. Registrants should keep up-to-date with current developments regarding care provision and, if a decision is made to deviate from normal practice, then the reasons for doing so must be fully recorded. Training and competence are key to safe care provision and all practitioners must keep up-to-date with their continuing professional development.
The General Dental Council has provided extensive guidance on this subject for all Registrants and everyone must ensure that they demonstrate compliance with the core topics, learning reflective of their sphere of practice and complete these within the cycle of learning.16
That being a registered dentist, dentist X's fitness to practise is impaired by reason of misconduct, in that between January 2010 and December 2014, you:
This effectively new principle raises, for some, the thorny issue of ‘whistleblowing’. Registrants now have a professional duty to raise concerns if patient safety may be at risk. This is not an easy thing to do. Concerns should be raised in a timely manner, over-riding personal or professional loyalty that one Registrant may have towards another.
Concerns should be raised at a local level in the first instance. If the individual concerned is not insightful in accepting and reflecting on the constructive criticism and does not demonstrate improvement, then the concern should be raised with the General Dental Council, dependent upon the working relationship of the Registrant and the ‘whistleblower’.
The different UK jurisdictions have different bodies to which concerns can be raised. These include the Care Quality Commission (England),11Health Inspectorate Wales,17Healthcare Improvement Scotland18 and the Regulation and Quality Improvement Authority in Northern Ireland.19
The protection of vulnerable groups is paramount in all healthcare provision and all Registrants should be familiar with the local and national guidelines for raising concerns.20
That being registered as a dentist, your fitness to practise is impaired by reason of misconduct, in that between October 2013 and June 2014, you allowed your vocational dental practitioner to carry out treatment for patient X that was to a standard far below that of the reasonable dentist.
This reflective principle is really a ‘catch all’ for personal and professional behaviour, attempting to maintain the confidence of the public in the profession of dentistry. The life of a Registrant is under scrutiny 24/7 and it is incumbent on the Registrant to ensure that his/her personal and professional lives do not put patients at risk.
The increasing use of social media in the 21st Century is to be accepted, but is not without its problems. The General Dental Council has taken this point seriously enough to provide separate guidance on the use of social media.21 It is important for all Registrants to maintain appropriate boundaries with all individuals.
A change in relation to disclosure to the Council in terms of criminal proceedings now sees all Registrants being required to inform the GDC immediately if they are subject to any criminal proceedings anywhere in the world.
The factual particulars of allegation are that:
The Standards for the Dental Team, published by the General Dental Council and being effective from 30 September 2013, is Professional Guidance for Registrants and is an extensive booklet that has been published, following extensive consultation.5 With the increased Registrant groups within the Council, there were several options available to the GDC in terms of how each Registrant Group would be expected to abide by a particular Standard. By having one Standard for the whole team, then each Registrant is clear in terms of what is expected of them.
The new Standards are wide-ranging in volume and scope and, as such, will have significant implications for some Registrants.
In clinical cases, the Council have adopted the practice, in summarizing the allegations, to include allegations that the Registrant ‘did not provide an adequate standard of care’ but also did not ‘maintain an adequate standard of care’. The former, relating to the actual care the Registrant, provided the latter, referring to his/her clinical record-keeping.22 A plethora of guidance is available for all Registrants and, indeed, throughout the jurisdictions within the United Kingdom. All Registrants should keep up-to-date with the laws and regulations pertaining to their practice and for those who are team leaders, it is important that clear demonstration is made of leadership and management skills.
In essence, and put very simply, there is less ‘wriggle room’ for any Registrant, given the breadth of the Standards contained within the publication and, therefore, for many Registrants, it will become increasingly difficult to put forward information, in relation to any allegation of misconduct, performance or health, to defend their position at the Investigating Committee stage.
The General Dental Council publication, Standards for the Dental Team, September 2013, is wide-ranging.5 It covers all members of the dental team, who are Registrants, and it is important that all Registrants are familiar with the document so that, should their fitness to practise be questioned, they can clearly demonstrate full compliance with the expectations of their registered status.
