How has dental indemnity weathered the pandemic?

John Makin speaks to Guy Hiscott about the last 12 to 18 months at the DDU and what impact it’s having on the profession.

It’s been a fairly eventful 12 to 18 months. How has the DDU weathered the storm?

It certainly has. I don’t want to repeat too many clichés here, but it’s certainly been a tumultuous year for the whole profession and us included.

Health concerns, financial crashes, ever-changing guidance, certainly in the early days. One minute we are defending colleagues against allegations of overprescribing antibiotics; and the next minute it was the three As, advice, antibiotics and analgesia. It was a strange old world really.

Our immediate focus was on two fronts. Firstly, to maintain service levels for our members. And of course to cooperate with the additional members wanting immediate advice.

The second thing was to be flexible in terms of membership subscriptions – again immediately. Because financial needs were changing and the changes in practising.

Our advisory teams were home working. So we were able to get everything on board really quickly. Hopefully members found it a pretty seamless transition. I’d like to think so.

We know that when members call up for advice, they want advice there and then from a dentist colleague who knows what it’s like to be in practice. Our stat is that 98% of our calls are answered in 20 seconds.

I’m pleased to say that even though we have this real bulge in demand, we were able to maintain those stats.

Have you seen the uncertainty reflected in the sort of queries coming through to you?

Unusual circumstances prompted unusual questions. Interestingly, colleagues that we wouldn’t normally hear from were calling up for advice. Everyone wanted to stay the right side of the line, they wanted to do the right thing.

One of the questions interestingly that was asked a lot was: ‘Am I indemnified if…’, ‘Am I indemnified if I do this’, ‘Am I indemnified if I do the other’.

I think the very question suggested that we’ve got work to do in explaining to people how things work.

Our members can and could look to us however they interpret the guidance. But the key thing is if they act in accordance with a responsible body of opinion, then we’re much more likely to be able to successfully defend them.

We’re not the arbiters of current teaching and practice; we don’t tell patients what materials to use for a root canal filling. But clearly, if they act in accordance with a responsible body of opinion, which may not necessarily be a majority opinion, then we’re in a position to successfully defend them.

One of the things that we said was to start with the end in mind. You’ve got a tough decision to make, it’s an unusual decision that you wouldn’t normally have to make. If you make that decision you do ‘X’, and something goes wrong or there are complaints, what would you say in response to any criticism of you? What’s your rationale for that decision?

If you can comfortably look back and evidence the thought process and the logic, then you’re not likely to be justifiably criticised.

The other important thing is to show ones working out as they say in maths. Again, you and I might reach a slightly different decision on how to proceed. But again, if one can show the logic and patient focused decision making that goes behind that, again then we’re in a really strong position to successfully defend.

I think those general dental legal principles were the key things that we discussed with our members.

Have you seen the last year change the nature of complaints that are coming through from patients?

It was very interesting in the early days. The number of complaints fell. But we were getting way more enquiries from our members.

As the complaints have started to come through, I think that perhaps patience, if I can use that term, is starting to wear a bit thin. Understanding is starting to wear out.

We’re seeing complaints about treatment availability. To some degree there’s been a bit of shooting the messenger involved.

Most patients were quite understanding. But there’s been some issues around fees. Particularly capitation type fees: ‘I’ve paid you my monthly subscription and wasn’t able to come and see you.’

Fortunately, the vast majority of patients realised those fees meant the practice was still there when they needed it.

Communication has been difficult naturally enough. Colleagues weren’t seeing patients directly face to face, which gave rise to a whole new set of challenges; then of course the additional barriers to communication with PPE.

In terms of very specific complaints, we had some complaints about the COVID secure measures themselves. Colleagues are often between a rock and a hard place; some patients complaining that they were too heavy handed. Other people complaining that they didn’t feel safe and that they wanted even more.

I’m quite a visual person and ‘in my mind’s eye’ I see a sort of see-saw of practice life. All the happy grateful patients are on one side of the see-saw, and the relatively few patients who’re unhappy whatever colleagues do, will be on the other side. We know which way that’s tipped. But it’s all too easy to focus on the wrong side and feel that we’re always under pressure. Whereas the vast majority of people are really grateful with services the dental team offers to them.

Are we seeing the success rates of claims increase over the last year?

It’s slightly early days for us to see that. There’s often what we call a tail, a delay period between an incident and the claim happening.

In general terms we are pretty successful and we successfully defend the majority of claims across the board. In the majority of cases that are brought against our members, we successfully defend them.

It’s a little bit too early to say what the impact of the pandemic is. But one of the key things is context really. It’s really important that we remember the context of that decision making.

There’s an old quote from Lord Denning that some people will remember: ‘One shouldn’t look at a 1953 case through 1956 spectacles’.

That’s why record keeping has been really important. We’ve been advising colleagues to map their decision making to the guidance that was enforced at the time.

You’ll have seen some of the statements from the GDC, CQC, NHS England health boards to say that they’re aware of the difficult circumstances that colleagues are working in. And that they will take those into account. It’s really easy given the distance in time to forget that quickly; and if I asked you what the standard operating procedure was in May 2020 it is difficult to precisely put one’s finger on it.

But I promise you we’re keeping score on all of that. We’ve got reference to all of those things and we’ll certainly apply them in defending not just claims but regulatory issues as well.

By the way we’re talking about claims. But just to add a myth buster as well, it’s said that we’ll settle claims to save costs. Our members reputations are really important. We would never ever settle claims just for that reason. We’ll defend claims wherever possible.

You’ll have seen a case recently that we were successful in and always we would involve members in those decisions. If ever you see that myth peddled, don’t believe it.

Do you get a sense from members that they feel differently about the importance of indemnity post-COVID?

Our members have never been higher. And as I said, we’ve certainly engaged with lots of colleagues with whom maybe we wouldn’t normally. So I’d like to think that we’ve been able to demonstrate to them our strength and depth in terms of the knowledge of the team, the empathy that colleagues have because all our dentalegal advisers are dentists with experience across a wide variety of clinical settings.

We’ve been around a long time – over 135 years. But it’s not just access to indemnity for claims, it’s risk management advice, it’s support on a day to day basis.

Across the organisation we assisted 35,000 enquiries last year.

There’s often a focus on GDC cases and things like that. But given the number of patient interactions and registrants, it’s a comparatively small number who end up with a GDC case. Certainly in the latter stages. But that concern is constantly there.

I think it’s really important that we put it in perspective for colleagues; the chances of a career changing dental legal event are incredibly low. With prudent risk management advice then we can make that even smaller.

For those who unfortunately do get there we have expert in-house lawyers. And 82% of our GDC cases that involve our members at case examiner stage didn’t reach a hearing. So that again is a stat we’re very pleased with.

For those relatively few that did reach a hearing, again 82% were concluded without any finding of impairment.

While we’re talking about indemnity I certainly think one of the current questions that’s out there is about discretion; and I’m sure you’ve heard an awful lot about that.

We assist out members with over 99.5% of cases. I think it’s important to recognise that, not to believe any mischievous suggestions we do otherwise.

Without members we wouldn’t need to exist. There’s nothing wrong with insurance per se, and indeed we’ve offered insurance in the past and may well do so in the future. But it’s the nature of the organisation that’s offering it.

We’ve got no shareholder profits, we’re here just solely for our members. Indeed, in the past when we had insurance and an occurrence sort of scheme, there were occasions when the insurance wouldn’t pick up a matter. We used our discretion to support members, with the discretion as a safety net if you like.

Aside from COVID, what are the big concerns voiced to you by your members?

There’s a whole variety of things. One of the issues that is important is described as blue on blue. Complaints by colleagues about colleagues.

They’re not all vexatious. Some are colleagues genuinely concerned and it’s their duty as a registrant to raise concerns.

There are steps, it’s a step wise thing and before anybody ever raises a concern, they should certainly speak to their defence organisation and get a steer on that.

I don’t think one can separate the nature of modern practice and the contractual things that go with it, the circumstances under which principals operate, associates operate etcetera, from what goes on; it’s really important that patients don’t end up caught in the crossfire of some of those business and contractual issues that arise.

Things like robust associate contracts and the like are really important. We’ve introduced a contract checking service that’s intended to be equitable to both parties.

If anything, we’re seeing a lot of calls around those types of business and contractual things that inevitably have fallout for patients.

How do you see the next 12 months changing things as a profession given the amount of disruption that we’ve seen?

Yes, some of the disruption has been really difficult and disruptive. But I think there’s been some really positive points to come out of it.

I think dentistry and patient access to information and things of that nature will continue and develop.

CPD will be delivered digitally. I think it’s important to meet colleagues face to face and not to do all of our CPD online. But I think the reach that CPD providers have to colleagues in rural environments for example, I think that’s going to be really positive.

In our world the vast majority of GDC hearings are held remotely. That’s been incredibly successful and indeed arguably less stressful for those who’ve been involved.

For certain cases we’ll still insist on a face to face hearing where it’s in members interest.

Some things don’t change, however, and I‘ve been in this business longer than I care to remember.

The key thing at the core of everything that we do and see is that it’s a people business.

If you think of the four domains of dentistry – clinical, communication, management and leadership, professionalism. All of those four bits that jigsaw together are really important.

I think there’s a real demand, a real opportunity for success to deliver good quality, high street, family dentistry. For dentistry that is done well and delivered empathetically.

Other people will go in a different direction and set themselves up as purveyors of youth and beauty, which is fine.

But we need to understand that’s a different group we’re working to and we need to understand and manage their expectations.

Patients are quite sophisticated. They can tell the difference between when they’re treated as a patient and when they’re treated as a consumer.

Interestingly, the bar for suspicion over trust and dishonesty is lower when they think they’re being treated as consumers.

The DDU has a new chief executive joining in September. Are you able to talk about their plans for the organisation, or what the future holds for the DDU?

Dr Matthew Lee is taking over for Dr Christine Tomkins who’s retiring in September after a long and illustrious career supporting members.

Christine’s been in the role since 2009. She’s worked for the company for more than 36 years. Matt’s been with the DDU for more than 20.

I’m sure he’ll broaden the number, level and range of services to meet members’ ever-changing needs. But we’ll do it on the basis of guiding, supporting, defending in accordance with our principles and our ethos as a non profit mutual.

You might not realise, but for a number of years we’ve been the only UK defence organisation to have a clinician at the helm.

Of course with Matt in place that will continue, which I think is really important. We put our members’ interests front and centre in all that we do. After all, our members are our employers.

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