In dentistry’s defence
The number of compensation claims exceeding £100,000 in dentistry has quadrupled over the last 10 years, according to the latest research from the Dental Defence Union (DDU). The NHS claims its compensation bill reached £1.1 billion in 2014/15.
It’s a worrying trend, and one that Rupert Hoppenbrouwers highlighted before he stepped down as head of the DDU. ‘Complaints to the GDC have increased by 110% since 2011 and we are also seeing clinical negligence claims rising at 10% per year,’ Rupert said.
‘While dental claims are traditionally seen as low value, this is no longer the case and our highest amount paid out in compensation to an injured patient in the last five years, together with the patient’s legal costs, was over £240,000. This trend is not due to a fall in dental standards, which remain high.’
After Rupert stepped down as head of the DDU towards the end of 2015, it was up to John Makin to take over the mantle. After a few months of being in the role, Seb Evans went along to the impressive DDU offices in One Canada Square, London to speak to John about his role at the DDU and the future of the profession.
The General Dental Council
The General Dental Council (GDC) is a hot topic for the DDU at the moment, in particular its fitness to practise (FtP) procedures. The GDC claims the number of FtP cases increased by 110% from 2011 to 2015, causing a huge jump in the annual retention fee for dentists. A number of leading dental figures have pointed the finger at the GDC and the FtP process, claiming the GDC is unnecessarily investigating some claims.
However, recent changes, including the permanent appointment of Ian Brack as a replacement to the outgoing Evlynne Gilvarry, have seen a slight improvement in the GDC’s performance and it is a continual improvement that the DDU has been involved in. ‘We engage with the GDC,’ John explained. ‘For example, there will be consultations and we’ll be quite robust, if needs be, in our views of anything that’s in there that we don’t think is to the benefit of our members. We’ll engage with the GDC and give feedback. And in fairness, the current climate is that they appear to be listening, which is encouraging.
‘Once a complaint gets into the GDC sausage machine it takes an awfully long time to come out the other end’
‘I’ll give you an example, we said to the GDC, one of the key things we think that you could do better, is what I would describe as demand management. Once a complaint gets into the GDC sausage machine it takes an awfully long time to come out the other end. What we said was that the GDC could engage in a bit of demand management by, right at the front end, explaining better to patients what the GDC’s role is and essentially what they don’t do. And we pointed out that unfortunately once patients do complain to the regulator, they’re obliged to follow it through. We suggested this and I’m pleased to say that they appear to have listened. They’ve amended their website in terms of it being clearer with explanations at the top of the funnel. And the GDC tell us they’ve got some statistics to show that it’s had a positive impact on the number of complaints coming in through that route.’
John believes it is up to the profession to steer the GDC in the right direction. ‘It isn’t the GDC that sets the standards, it’s the profession. Because the defence organisations and the GDC aren’t the arbiters of current clinical practice, it’s the profession,’ John says. He believes the profession should keep a close eye on the GDC and ensure it is applying the right standards and tests making the whole FtP process quicker, more consistent and more proportional.
The GDC is not the only regulator in dentistry of course. The CQC has received praise recently for the way it has trained its inspectors and, with John Milne as the dental adviser, made its inspections more dentally focused. This is reflected at the DDU, with issues surrounding the CQC ‘not filling up the mailbag’, as John Makin describes it. He also praised one of the CQC’s objectives, which was to accentuate the good and spread the positive.
One area John did feel regulatory bodies could improve on is leadership within the dental team. ‘Obviously the CQC is regulating the organisation, NHS regulations look at the application of NHS contractual standards, and then there’s the GDC looking at fitness to practise elements. They’re doing different roles, but the leadership needs to bring all these things together so that the practice moves forward, keeps up to date, is responsive to patient’s needs, is responsive to colleagues’ needs.
‘We don’t want to end up with more bureaucracy surrounding dentistry’
‘It’s increasingly difficult for small practices to do that and keep up with all of those things, so good leadership is really important and that’s where the team comes in. Good practice managers can really help the clinicians to focus on the important things of patient care by keeping all these other plates spinning in the air at the same time.’
With the GDC, the CQC and in some cases NHS England, is there a danger that there is too much regulation in dentistry? ‘Yes,’ John says. If that’s the case, what can be done to help the profession? ‘The Regulation of Dental Services Programme Board (RDSPB) has reported recently and is a combination of the CQC, the Department of Health, the GDC and NHS England. They’re suggesting more of a self-reporting, self-regulating type approach. At face value, the objective of that might seem a laudable one, but it’s important to be aware that the devil is often in the detail. We don’t want to end up with more bureaucracy surrounding dentistry. Yes, the regulatory burden has increased exponentially over the years, there’s no doubt about it. The board has reported, I’m not convinced all the actions are there, but the aim and the objective are laudable in the long run.’
With all the additional regulatory burdens, there have been calls for more support for dentists going through regulatory investigations. Before she left, Evlynne Gilvarry admitted dental professionals do need support, but ‘where is the support best coming from?’ she asked. At the time she pointed to other regulatory bodies, the British Dental Association and possibly defence organisations.
‘I think I’d go back a step,’ John Makin said when asked whether more support should be offered to dentists undergoing investigations. ‘I think one of the key things we need to do is make sure the process improves such that the pressure is there for the absolute minimal time, that the process is proportional and that we’re not getting this double jeopardy approach where more than one regulator is dealing with the same matter.
‘The regulatory burden has increased exponentially over the years, there’s no doubt about it’
‘Our members really do care about what they do and their patients and their dentistry, and they take any criticism very much to heart. It’s heartfelt and it’s not just our members it’s their family, it’s their teams who all feel these things when they happen. So any support that can be offered is key and it’s really important.
‘What I would say is, and I can speak for the DDU, we live and breathe what we do for our members, our team is absolutely mindful of how it would feel [going through an investigation]. Dental professionals have empathy for their patients and similarly, at the DDU, we have empathy for our members. So what we do, our knowledge of the process from the outset, we can identify where the pressure points might be helping prepare for an investigation. We can help members with that journey and with that process, but at the same time encouraging them to share with colleagues and family and gaining their support is important.’
Issues facing dentists
Being on the frontline, the DDU is well-placed to warn the profession on any upcoming crisis and highlight the major issues facing and those practising in it. But John believes it’s not necessarily one major issue that will be the problem facing future dentists, it’s the number of issues. ‘It’s spinning all those plates in the air at the same time and keeping everything going,’ John says.
‘There’s a lot out there for people to deal with. Clearly our members contact us primarily when they want some advice about a complaint or a claim. But they’ve got all sorts of issues going on all the time. A lot of the issues that we’ve touched on in terms of regulation are key issues for dental professionals. They feel that they’re being backed into a corner sometimes by a lot of litigation, and it gives them a sense that sometimes what they do isn’t appreciated.’
John believes dental professionals should look to the ‘seesaw of life’ as he calls it. The majority of patients are hugely appreciative, they want treating and they’re delighted with the care and service they get. On the flip side, there are patients that cause difficult situations creating anxiety and stress. ‘There’s no doubt which way the seesaw has tipped, but it’s human nature to tend to focus on the negatives and not on all the thank you cards that come in,’ John says.
So how can dental professionals avoid being called up in front of their regulators? ‘We absolutely encourage members to contact us at the very earliest stage of any matter. And by the way, contacting us doesn’t in any way impact on their subscriptions. Why would it? It’s clearly in everyone’s best interest, the earlier they seek our advice, the more likely they are to be able to deal with the thing at a local level, keep a lid on it and stop it escalating.’
One of the key defenses for dentists against any kind of regulatory action is good note taking. In fact, they’re so important John describes records as: ‘Central to everything that we do in terms of defending our members.’
Despite appreciating the time constraints and difficulties with keeping good records, John has a few tips for dental professionals. ‘Whenever a claim or a complaint comes up and one of our members has really good records, boy do they think that was a good investment in time,’ John says. ‘We do lots of risk management lectures, talks and webinars to help with note taking. There are ways of producing sufficiently detailed and reasonably concise records that are sufficiently robust without it taking forever.
‘We absolutely encourage members to contact us at the very earliest stage of any matter’
‘Colleagues need to be very careful about over reliance on template records. If they’re using templates, they need to be an aide memoir and populated there and then at the time. Over reliance on them can then introduce elements where something’s in the records that didn’t actually happen.
‘It’s also very easy for a template to be inadvertently included in a record and then it’s called into question later on.’
With the burden of regulation ever increasing, compensation claims going up in value and the sheer volume of work in dentistry not slowing down it’s a tough time to be the head of a dental defence organisation. Coming from a dental background, John understands the pressures modern day dentistry places on, not just the dentist, but the whole dental team, and that gives him a good basis to start from.
Being the head of the DDU, John has the unique opportunity (or challenge depending on which way you look at it) to make the regulatory bodies understand these pressures and to help influence change. It appears the GDC is beginning to listen to the DDU and the profession, but it’s the start of a long road for John and the DDU.
John Makin BDS PgDL PgCDE FHEA is head of the DDU. He qualified in Manchester in 1983 and has worked as a general dental practitioner in Lancashire and Devon before joining the DDU as a dento-legal adviser. He was involved with foundation training for many years as both a trainer and VT adviser/training programme director with the Manchester and Exeter DFT Schemes.