Kevin Lewis: Blind spots and unlevel playing fields

The law of unintended consequences is alive and well, Kevin Lewis discovers, as he explores the complexities surrounding the proposed reforms to ease the NHS dental workforce crisis.

It is blindingly obvious that no government (of any complexion and whether central or devolved) can hope to resolve the current NHS dental access crisis without a stepchange in the dental workforce – more people in more places and with a greater appetite for providing basic NHS care and services.

Albeit to a varying extent, there is currently a serious dental workforce shortage and recruitment crisis in all four countries of the UK.

Desperate situations call for desperate solutions, as the saying goes, and we should view the Department of Health and Social Care’s recent consultation on provisional General Dental Council (GDC) registration through that lens; dressing it up any other way would be grossly disingenuous and insulting to the intelligence of existing UK registrants, as well as the general public.

These are early days in the process of designing and implementing such a radical new system, and a balance needs to be struck in terms of how it is being presented to the wide range of interested and affected parties.

ORE process changes

It is proposed that overseas qualified dentists, once provisionally registered by the GDC, would be free to practise immediately in any dental setting (including primary dental care) under ‘appropriate supervision’. Quite what this would mean in practical terms is open to conjecture but critically important.

What it won’t mean, you can be quite certain, is the same level of supervision as exists in a UK dental school or even in foundation training. Final year dental students must not be left clutching their overdrafts and loans and wondering why they were given so many more hoops to jump through than the new arrivals.

Those who are scanning the horizon for the first signs of approaching dentists want the business opportunity and revenue that they will bring, not the accompanying supervisory responsibilities. It is not widely known that this kind of loose, informal and sometimes virtual supervision of unregistered dentists is already happening under the auspices of certain dental schools and corporates.

Making the journey through to full registration easier, quicker and more attractive than the recent overseas registration exam (ORE) experience will almost guarantee an increase in demand, and the 2,000 dentists said to be stranded in the ORE process and waiting room may turn out to be either the prow of yet another approaching inflatable life raft or the tip of an approaching, and much larger, iceberg.

Time will tell.

Beware what you wish for

In many parts of the country, it is a huge challenge to recruit and retain associates and no doubt many of those desperate practice owners will welcome these proposals with open arms, even accepting the inevitable delay in implementation.

I hope they do so with their eyes open too, recognising the new reality that they may end up being vicariously liable for any negligent acts and omissions on the part of these provisionally-registered new colleagues.

Certainly the indemnity providers will need to balance an unusual combination of risk factors and gaps in underwriting information, and these new dental arrivals will be much more attractive to some types of indemnity provider than others.

Expect to see a proliferation of cheap ‘cut and run’ claims made policies with little or no ‘run off’ cover. The GDC’s guidance on indemnity seems not to realise that insisting upon run off cover looks logical enough but ceases to be relevant or effective once GDC registration ends and the dentist is no longer under the GDC’s regulatory jurisdiction just when it matters most.

As a result, the government and the GDC may be storing up problems that will come home to roost further down the line.

Broken system

Similarly, the dental corporates have a huge vested commercial interest in securing access to a ready-made source of new recruits to their units of dental activity (UDA) factories.

The Association of Dental Groups (ADG) is the representative body for the corporates, and it has been lobbying the government and GDC relentlessly, and very effectively, under Neil Carmichael’s leadership, especially to work harder and with greater urgency to unjam the ORE gridlock.

But while I can understand that frustration and impatience for a solution to be found, and the attractiveness of an oven-ready 2000-strong workforce, I can’t understand the apparent short-sightedness.

How long do you think it will take for the novelty to wear off? What’s to stop the new arrivals gaining full registration and then quickly reaching the same conclusions as most of their other dentist colleagues and starting to reduce their dependence upon the NHS?

This Elastoplast won’t fix a broken and discredited system.

Accountability

I have mentioned in this column previously (and elsewhere) that the law protects the NHS itself from any responsibility or vicarious liability for NHS care and treatment it has contracted/commissioned – great care has been taken to ensure that the buck stops with the practice owner and his/her provider contract, which agrees to indemnify the NHS and take responsibility for any failings by the NHS, as well as by dentists and other staff members working in the practice.

In fairness to the corporates, they are in much the same position as other practice owners (other than their limited liability) in that regard, but there is a key difference in other respects.

While an individual registrant practice owner is personally accountable to the GDC, the dental corporates are almost completely unregulated and beyond the GDC’s reach. The proposed supervision of provisionally registered dentists is to be by individual registrant dentists.

It is those individual dentists who will be accountable, not the corporates (and not the NHS either), so yet again all roads of accountability begin and end at the feet of the dentist practice owner.

Nobody ever said it was fair, but it is starting to be rather repetitive, predictable and tiresome.

Meanwhile, some corporates are infamous for their readiness to raise concerns to the GDC about dentists with whom they have had a falling out.

Medical parallels

And so also the NHS and bodies operating under its umbrella, such as NHS-BSA. Easy to do when you know you can’t be caught in a volley of return fire from any direction.

Our medical colleagues find themselves in a similar situation where NHS managers are concerned – another group with enormous power but zero accountability. The lobby group Justice for Doctors (JfD) has been highlighting a pattern whereby any doctor who raises concerns about the trust they work for, or its management, is quickly identified as a hostile whistleblower.

They can expect to be marginalised by managers, suspended and investigated themselves for sometimes extended periods and on spurious grounds and/or then forced out or dismissed.

A common tactic is the threat of being reported to the GMC. A recent member survey conducted by the Hospital Consultants and Specialists Association (HCSA) revealed that a staggering 70% of respondents believed that reporting concerns/blowing the whistle would always damage their career in some way.

The leader of JfD, Dr Salaam Al-Sam, describes the range of ‘dirty tricks’ regularly deployed by NHS managers in their determination to quell dissent and present their trust’s performance (and their own) in the most favourable light possible.

If that sounds vaguely familiar, it should do. Dr Al- Sam and his campaign has been likened to that of Alan Bates and the sub-postmasters, and it is certainly an interesting parallel.

Power imbalance

In one scandal after another, we find that one group of people hold all the power and are encouraged to believe that they can act with impunity and invent their own rules as they go along, while another group of people bear the consequences.

Every healthcare scandal back to the Mid-Staffs inquiry and beyond, through to Lucy Letby and the other recent maternity tragedies, has resulted in a call for the mandatory and urgent regulation of NHS managers, creating a level playing field with the clinicians they oversee and sometimes persecute.

But the clout of the NHS has ensured that they have got away with a voluntary, unregulated code of practice instead. Similarly, clinicians have had a professional duty of candour for decades and additionally a statutory (legal) duty of candour since 2008 (in England, and later elsewhere).

But in the self-serving shadows of the NHS and its management, openness, transparency and adherence to the truth remain strangers. This inexplicable protectionism and imbalance of power is part of the problem, and it should not be (and must not be) part of any proposed solution.

It cannot be right, nor in the public interest, that discredited managers walk away to lucrative new jobs while clinicians are named and shamed and their careers and lives are ruined.

Not in the Post Office and not in healthcare either.