A closer look at Shifting the balance

Kevin Lewis takes the opportunity to look more closely at the issues raised in the General Dental Council’s discussion document, Shifting the balance: a better, fairer system of dental regulation.

Part one – core themes

Everyone needs a plan. The GDC published Shifting the Balance earlier this year alongside the latest (2017) update on its three-year plan and ‘roadmap’ covering 2016-2019. The two canvases were clearly painted with the same brush, always intended to be viewed as two strands within the same piece of work.

Shifting the Balance is a clever and well-considered title – not so much a double entendre but arguably a quadruple entendre. The GDC talks a lot of the balance between the necessary independence of the GDC and the first-hand detailed knowledge and/or special interests of all of its stakeholders, with whom the GDC is said to be increasingly keen to engage. Each party holds some of the pieces of an intricate jigsaw. Then there is the balance between prevention/quality promotion and enforcement, coupled with an acknowledgement that until now there has been too much emphasis and reliance upon the latter.

The GDC also speaks of the (im)balance between the specialised knowledge and understanding (and hence, power and influence) of the clinician and the relative dependency and vulnerability of the less well informed patient (who has no alternative but to trust the professional person).

Finally, and entirely appropriately given the rawness and animosity surrounding the 2014 annual retention fee debacle, there is the need to strike the right financial balance – focusing on the right things, working smarter and more efficiently and getting the best, fairest and most proportionate regulation for the registrants’ money.

Us and them

Two parallel and recurring themes throughout this document are firstly that regulation is as much about education, prevention, learning from experience and quality assurance as about reacting and responding after the event to instances of unacceptable performance and conduct. Modern regulation is, the GDC argues, a much wider concept, with a much wider brief than the one that has been assumed up to now.

The second theme is that the successful regulation of dentistry involves all of us – every organisation and individual working in and around dentistry – rather than just the GDC itself. So the responsibility for any shortfall in that regulation must similarly be regarded as a shared failure. I can see what the GDC is getting at, but wonder whether registrants are quite ready to buy that. ‘Buy’ it, I might add, in all senses of the word because the GDC’s ‘pitch’ is for how it would like to deploy the funds, which are wholly contributed by the registrants themselves.

However it is dressed up or varnished, the GDC will always be the ‘them’ to the registrants’ ‘us’ and the annual retention fee will always feel like a ‘distress purchase’ – especially while it remains the most expensive in the whole of UK healthcare. Like paying a utility bill but with no light, heat, power or water to show for it. Like giving money to charity but without the ‘feel good’ factor.

Looking upstream

This is another way of re-stating the laudable agenda to ask why the fitness to practise (FtP) machinery has been so clogged and dysfunctional for so long (looking upstream) rather than looking for new ways to process more and more cases through an existing or tweaked FtP sausage machine (downstream). It sounds a bit like the GDC might be taking refuge behind trendy new management jargon, but in reality it is recycling jargon that was first trendy almost 50 years ago in terms of the pursuit of quality in engineering and manufacturing processes. They reference its first appearance in healthcare in 1974, which confirms that someone has been doing their homework.

But jargon aside, the GDC does well to ask itself how on earth it found itself in the deep hole from which it is now working so hard to extricate itself. And properly understanding the causes makes so much more sense than rushing to identify the problems, let alone clutching at the nearest and most obvious solutions. 

The GDC has worked out, if nothing else, that its letterbox had become too big. It was opening its doors and allowing every organisation and disaffected individual to fly-tip all their baggage at the top end of Wimpole Street, whether or not it had the slightest thing to do with the genuine safety of the public or its trust and confidence in the dental profession. At risk of mixing my metaphors, it was operating a full-service laundrette free of charge to all comers. The guilty parties know who they are – and so do we.

The GDC sets out an admirable vision to work more closely and more collaboratively with all the stakeholders in dentistry whose activities have a part to play in securing and maintaining standards – of education, of knowledge, of technical skills, of professionalism, and of ‘soft skills’ like communication and customer care. I have explored the issue of continuing professional development (CPD) and joining up the experiences and the learning in my regular column within this issue of Dentistry on page 3.

Alternative dispute resolution (ADR)

The premise that patients need educating too, is a new and interesting one. The much-(mis) quoted ‘If we build it, they will come’ maxim really does resonate here and I have seen it for myself in many countries around the world.

Here at home, the GDC justifiably reminds us of the success of the Dental Complaints Service in responding to complaints regarding private dentistry over the past decade. This too is funded directly out of the ARF and has been money (very) well spent in my view. It is certainly not perfect, but it is far preferable to the alternative of having no alternative to the GDC or the solicitor’s office. 

In many countries, ADR in all its forms has worked brilliantly for the regulator, for patients and for the profession. The GDC should listen to the representations that will inevitably be made from those who have first-hand knowledge and experience of those successful systems.

Some of them are enhanced by a peer review element – which the GDC again touches upon and here they will certainly need to partner with the profession because ‘hired guns’ are not the way forward, as the GDC’s FtP experience has demonstrated.

Encouraging or building an informed and responsible advocacy service for patients also has to be better than leaving them to be gobbled up by the commercial ambitions of the ‘no win, no fee’ law firms. Community Health Councils still exist in Wales but ironically in England they were abolished 15 years or so ago, after having provided independent advice and advocacy services for a similar period. Ironic because their disappearance coincided with the arrival of the no win, no fee law firms into dentistry.

In short, the GDC sketches a very different regulatory landscape and it is up to all of us to help it to colour this in. We may even need brighter colours than seemed likely a couple of years ago.

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