Stephen Henderson explores what a possible change to the overseas registration examination process really means, and raises questions about supervision and patient safety.
You might think a general election was imminent. The press has been full of stories about dentistry in the past couple of weeks, ranging from the often-told stories of DIY dentistry to police being called to manage the queue outside a new practice in Bristol. These were followed by the NHS dental recovery plan which had been promised for months and months.
The next piece in the jigsaw was released on 16 February – a government consultation on whether the General Dental Council (GDC) can create an additional register for those international dentists that have not yet passed the overseas registration exam (ORE). The proposed amendment to the Dentists Act 1984 is enabling legislation requiring the GDC to develop rules surrounding the administration of this provisional register. This will involve a further consultation.
Work to be done
The amendment proposes that the GDC will hold three lists: a list of dentists, a list of dental care professionals (DCPs) and a list of provisionally registered dentists. These dentists will have an overseas diploma in dentistry and will not have passed the ORE. The amendment indicates that a provisionally registered dentist will only be able to remain on that list for a given period. Once a provisionally registered dentist has been removed from that list, they will only be allowed to re-enter the provisional register ‘in exceptional circumstances’.
The GDC’s rules will need to be laid before parliament following the GDC consultation, and that may well run into the pre-election purdah delaying things further. The GDC will need to develop a process for approving individual supervisors, which will necessarily involve checking each applicant’s FTP history and suitability for the post. These approvals may well need to be marked on the Register.
As it stands, there is a lot of work to be done by the GDC and its stakeholders to move this project forwards. The two key questions for the public are when this change will impact their ability to access NHS dental care and how will concerns for patient safety be assured.
The answer to the first is that access will not be impacted in the short and perhaps medium term, because there will need to be six months of consultation – three with this stage and up to three more for the GDC rules. The answer to the patient safety question depends on how the supervision of the provisionally registered dentists will operate in everyday clinical practice.
Supervision requirements
The GDC has previously defined varying levels of supervision in terms of fitness to practice conditions, but these are all designed for fully registered dentists and DCPs. The provisionally registered dentists are starting sight unseen without a baseline of competencies that will require perhaps a different and more intensive supervision, at least at the outset. This amount of supervision will necessarily impact upon the supervisor’s ability to deliver UDAs themselves because the supervision may well be direct – even more than the supervision of a UK foundation dentist.
Provisionally registered dentists will have to work under the supervision of a fully registered and approved dentist. They will have to explain to every patient that they are not fully registered as well as explaining the role of the supervisor in relation to the patient’s treatment. The expectation is that these dentists will complete the ORE and enter the full register.
The supervision requirements and indemnity arrangements have not been discussed yet and will no doubt have to be thrashed out in the inevitable GDC consultation on the proposed rules. Indemnity providers will be interested to know how the scheme will operate and whether arrangements for indemnity will be made via the practice owners, rather like temporary registrants that have indemnity for claims via the Clinical Negligence Scheme for Trusts. This is because membership of an indemnity organisation requires the member to be fully registered as a dentist or a DCP to be eligible for the benefits of membership.
In January 2023, as part of its workforce development plan, NHS England permitted dental therapists and dental hygienists to open, complete and close courses of NHS treatment using their GDC number as the unique identifier required when submitting claim forms to the NHS. Therapists and hygienists cannot have performer numbers so NHS delegates performance management to the providers of the contract.
‘Far from clear’
The creation of a provisional register will introduce a further cohort of workers under the contract who will deliver UDAs but will not be eligible for the NHS pension scheme as they cannot be an NHS performer. The performance management of these practitioners will have to be delegated by NHS England to the providers and supervisors for the same reason.
This begs the question of who will, in practical terms, manage performance issues. The NHS cannot. The GDC has worked very hard to cut down the number of cases it addresses and will not want to spend precious resources on this new cohort.
The providers will have few tools other than dismissal if the supervisor cannot resolve the concerns, introducing a potential conflict of interests because that provisional registrant can only treat patients under the supervision of the named and approved supervisor. The rules will need to address a breakdown of the professional relationship, particularly if loss of the supervisor means removal from the provisional register.
In short, while it is a good idea to enable more international dentists to work in the UK, it is far from clear how the public will be protected given that the supervisors and the GDC will have little idea of the competencies of these dentists, unlike those entering via the UK and ORE route.
The key debates will accompany the consultation into drafting of the rules by the GDC. By that point we will have a better idea of the impact that this proposal will have on the delivery of dental care in the UK including what is expected of the supervisors, practice owners and contract holders.
None of this addresses the concerns the profession has about the 2006 NHS contract in England and Wales.
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