From Volume 42, Issue 4, May 2015 | Pages 324-325
This article explores the potential implications of the Francis Report for members of the dental team from a dento-legal perspective. It looks at the broad recommendations in light of the existing ethical environment in which dental registrants work and asks what is new and what the recommendations will actually mean for dental professionals in practical terms.
The Francis Report is referred to by informed individuals and pops up when healthcare failings are reported in the media. Accordingly, given the significance of the enquiry, it is difficult to admit to not being fully au fait with the findings. A bit like the student who does not want to look as if he/she is the only one in the class who doesn't understand something, dental professionals can find themselves nodding sagely, not really wanting to ask if they are the only one who is unclear about the practical implications for dentistry.
So, for anyone out there who doesn't want to ask the ‘stupid’ question … what does ‘Francis’ really mean for the dental team from a dento-legal perspective?…
The enquiries1,2 conducted by Sir Robert Francis QC into the care of elderly patients in Mid-Staffordshire left him unimpressed with his discoveries. Low standards, avoidable suffering, cost considerations and self-interest seemingly were put above patient care. There were failures to address concerns or improve standards: not a pretty picture of healthcare.
Contributing factors included target pressures, uncertainty about dealing with concerns, fear of implications for self and a lack of responsibility. A culture of acceptance and not wanting to ‘rock the boat’ ended up impacting seriously on patient care. It also seemed that ‘the system’ not only allowed short-cuts but actually made the right thing more difficult to do.
The view was put forward that there was a lack of openness on the part of those providing care and that something was needed to deal with this:
‘It requires a duty to patients, recognised in statute, to be truthful to them.’
The recommendation was that there should be a statutory ‘duty of candour’, with the deliberate obstruction of this duty being made a criminal offence – strong stuff indeed. As a clinician it is sobering to reflect that standards found in healthcare caused someone from the legal world (of all places) to suggest a need for legally enforceable truthfulness. Whatever happened to ethical care, and just doing the right thing?
Francis stated that the protection of patient interests requires an insistence on the three principles of openness, transparency and candour. These were required along with the adoption of a ‘patient-centred culture’ with a ‘commitment to serve and protect’ patients.
Also needed is the availability of accurate, useful and relevant information on standards of care, with an expectation that all professionals develop, use and publish more ‘sophisticated’ measurements of the effectiveness of the care they provide and of their compliance with fundamental standards.
In short, the recommendations were that all areas of healthcare should have a culture of:
Put simply, patients' interests should be put first and health professionals need to be open about outcomes and performance, regardless of consequences to self or the organization for which they work. So, is this news?
It is a while since the principle of ‘primum non nocere’ was expounded. It has never gone out of fashion in terms of expected ethical conduct. First, do no harm. Second, try to do some good. ‘Respect’, ‘dignity’, ‘honesty’ – sounds familiar? The ethical code governing our interactions with patients has been with us for a long time.
Essentially, the exhortations of the Francis Report that conduct should prioritize patient wellbeing are nothing new. The GDC makes it clear that we should put patients' interests first and act to protect these. So, there are no surprises here.
There is both a public expectation and a professional acceptance that the dental team observe the fundamental standards of patient care. We are already regulated to ensure these standards are met. There is a clear expectation from various bodies that available guidance is followed. Evidence is required to show compliance with the requisite standards of governance, cross-infection control, audits, practice inspections, IR(ME)R, CQC, and others. Non-compliant dental professionals can expect to hear about it.
The need for clear standards in respect of effective treatments was flagged up by Francis, who proposed enforcement of compliance with these standards. This brave new world is not that novel to dentistry. Clinical guidance such as that published by NICE, SIGN, FGDP and SDCEP is widely accepted as indicative of good practice. Although not legally ‘enforceable’, the dental professional who acts contrary to these guidelines needs to have good reason, as non-compliance with professional standards of care is not something upon which our regulator looks kindly. Once again, Francis is not telling us anything we did not know already.
Concerns or complaints should be able to be raised freely and without fear of consequences. Questions should be answered fully and truthfully. The need to ‘welcome complaints’ and to investigate and provide effective action and remedies should be familiar to registrants, as these expectations are contained within the GDC Standards (2013). In addition, ‘gagging clauses’ in contracts, which may prevent openness, are also frowned upon by the regulator. It is clear that dental professionals are already expected to be ‘open’.
Francis articulates the need to have available accurate, useful information on performance and outcomes. This should not be a surprise. Relevant information is necessary if there is to be any real meaning to a consent process. For a patient to make an informed choice about treatment there is a need to understand the options and the likely outcomes of these. A failure to advise a patient clearly and provide an accurate view of both the good and bad possibilities of a particular choice might be held to constitute a breach of duty.
Transparency requires honest, balanced information on quality which necessitates measurement and audit. Clinicians must have evidence of the effectiveness of the care they provide in order that information can be imparted appropriately to the patient. If your success rate for a procedure is not all that good, the patient has a right to know. Managing patient expectations is more effective if the patient understands the likely outcomes in advance. Many complaints arise simply because a patient did not know what to expect.
‘Fessing up’ and informing patients where harm has been caused can be a challenge. But once again this is ‘ethical’ territory and should be expected anyhow. The fact that Francis recommended criminal sanctions to enforce honesty is sad. Whether or not there is a legal obligation to be honest about outcomes, there is a clear ethical imperative to do the right thing for your patient. Trust should be a given.
Even if there is no criminal sanction, a civil remedy may, in effect, exist already for breaching the duty of candour. Many legal claims include allegations that a clinician ‘failed to advise of…’ or ‘failed to inform about….’. In many cases, the subsequent discovery by a patient of a previous failing in care causes anger at the betrayal of trust which sets the whole legal train in motion. If the matter had been explained at the time, the patient may well have been more accepting of a timely apology.
The GDC: is it interested in the trust, integrity and honesty inherent in a duty of candour? Suffice it to say that if any of these hallmarks of professional conduct are in doubt a registrant can be in a very vulnerable position.
Effective performance measures for healthcare should be useful and allow comparisons to be made in respect of treatment outcomes. We are not yet in the era of endodontic league tables and implant success rate comparison sites, but would it be too much to expect dental professionals to be able to give patients some indication of how good/satisfactory/mediocre their treatment outcomes actually are? Patient satisfaction ratings are one thing but auditing clinical outcomes as a means of both obtaining information and improving standards is no bad thing.
If standards are not as high as they might be then there should be an ethical imperative to address this. Put another way, it might be viewed as an ethical need to audit. Clinicians have a duty to care enough to measure their standards, be honest with results, share the information and take action to improve outcomes.
Perhaps it is about reminders rather than really new stuff, but what should the dental professional take from Francis?:
Like another Francis (Sinatra), you need to be frank with your performance.
