We explore what fitness to practise in dentistry is, recent changes that have come into force and what the profession thinks about the process.

What are fitness to practise investigations?

If there are concerns that a UK dental professional’s conduct or competence poses a serious risk to patients or public confidence in dentistry, they may be investigated by the General Dental Council (GDC). This process is called fitness to practise (FtP).

Concerns may arise directly, such as from a colleague or patient, through another body, such as a conviction, or from other sources.

If a dental professional is ‘fit to practise’, it means they have the appropriate skills, character, knowledge and health to practise dentistry safely and effectively. A registrant’s fitness to practise can also be impacted by any actions that may affect public confidence in dental professionals and their regulation.

The Covert surveillance in practice: Guidance on conducting surveillance in fitness to practise and illegal practice investigations sets out the stringent legal and ethical framework applied to covert surveillance in fitness to practise and illegal practice investigations. Covert techniques will be used in accordance with this guidance, says the GDC,  and ‘in very limited circumstances’.

What can trigger an investigation?

According to the GDC’s website, it investigates reports of:

• Serious or repeated mistakes in clinical care, for example mistakes in diagnosis or dental procedure.
• Failure to examine a patient properly, to secure a patient’s informed consent before treatment, keep satisfactory records, or to respond reasonably to a patient’s needs
• Not having professional indemnity insurance
• Cross infection issues (for example, using dirty clinical equipment during treatment)
• Serious breaches of a patient’s confidentiality
• Indications of a criminal offence including fraud, theft or dishonesty by a dental professional
• Poor health or a medical condition that significantly affects a dental professional’s ability to treat patients safely.

What actions can be taken?

If a dental professional is deemed unfit to practise dentistry, the GDC may:

• Take no action
• Issue a reprimand
• Place conditions on registration
• Suspend registration
• Remove an individual from the register.

What are the stages of FtP procedures?

Stage one – initial assessment

Once a concern is reported, the GDC will make an initial assessment and decide if there are any issues that could affect patient safety or public confidence. Where there is an issue that requires further investigation, a case is opened.

The GDC checks it is the right organisation to investigate at the initial assessment stage. It may refer to other organisations where they are better placed to enquire further.

A case will not be opened for issues that do not need further inquiry. It will tell the person (or organisation) who reported it the reasons for this. It does not, however, inform the dental professional in question.

Stage two – assessment stage

Cases that are opened are referred to the assessment stage. This involves:

• Informing the dental professional involved
• Collecting information relevant to the case, including patient records and clinical advice when needed
• Gathering any other relevant information, such as medical reports in cases about health conditions or police reports relating to any criminal offence.

The process set out above is streamlined for cases that relate to clinical practice and involve a single patient. In these cases, the GDC will first make initial inquiries. It only does this when the dental professional involved has not had any allegations referred to case examiners (see below) within the previous 12 months.

Our initial inquires will be limited to requesting the relevant clinical patient records. These will then be reviewed by a clinical dental adviser before a decision is reached on how to proceed.

Typically, the GDC closes around 85% of these cases at this stage of the process with no further action.  

When the regulator has all relevant information, it is reviewed and a decision is made to either:

• Close the case and take no further action
• Refer it to case examiners for a decision.

Cases are referred if there is an allegation that a dental professional’s fitness to practise may be impaired. At this point in the process, no decision is made on whether or not an allegation is true.

Have there been any recent changes?

Remote hearings

ln December 2024, it was announced that professional hearings would permanently be held online following a public consultation.  

The policy will take effect from 1 April 2025 to allow for guidance for all independent committees at the hearings service to be developed and for monitoring processes to be put in place.     

The move follows the implementation of remote hearings in recent years, with GDC data showing that 87% of the 508 substantive hearings held between January 2022 and May 2024 were conducted remotely.  

Under the new policy, dental professionals will retain the right to request an in-person hearing for any reason. The regulator says this will be granted in most cases. The GDC also maintains the right to request in-person proceedings where appropriate.

Where there is no consensus between parties, an independent panel will provide direction through a preliminary meeting.   

Initial enquiries process

In November 2024, an initial enquiries process was adopted to speed up FtP investigations.

The new process limits the amount of information requested by the GDC at the initial stages of an investigation. Only relevant clinical records are now being gathered, as a result reducing the amount of time taken to review the documentation.

This change will only apply to single-patient cases involving a dental professional with no other FtP concerns raised in the previous 12 months.

The regulator said this was to ‘ensure investigations were proportionate to the potential risks’ because these cases have a high likelihood of being closed at the initial assessment stage.

This follows a pilot scheme to test the approach in September 2023. According to the GDC, the pilot ‘demonstrated that the approach can significantly reduce the average time it takes to conclude an investigation’.

Cases took an average of 13 weeks to conclude during the pilot, say GDC findings, compared to 30 weeks for single-incident cases outside of the scheme. Of around 250 cases investigated during the pilot, 84% were concluded at the assessment stage with no further action.

Interim Orders Committee

In July, the GDC announced it will change what information is published following decisions by the Interim Orders Committee (IOC).

After a review of its policy, the Dental Professionals Hearings Service said it will no longer publish determinations made by the IOC.

Instead, the outcome will be published on its website after a hearing or review has taken place. This includes any action taken to protect the public, patients or dental professionals. However, any restrictions on registration will continue to be added to the online register on the GDC’s website.

The regulator said this follows acknowledgement that investigations can be ‘intrusive’. It says it recognises that stress can be caused not just by the experience but also by the public availability of information while an investigation is ongoing.

All previously published IOC determinations were also removed. These were replaced with the outcome of any hearing or review.

Where no order is imposed by the IOC, the outcome will be published for one month and then removed.

Are fitness to practise processes fit for purpose?

According to the Professional Standards Authority (PSA) annual review, the GDC met 16 out of 18 Standards of Good Regulation for 2023/24.

One of the standards it failed to meet was fitness to practise timeliness.

Released in December 2024, the report found the regulator is ‘taking too long’ to handle fitness to practise cases. While it acknowledged that the GDC has put in place measures to improve its fitness to practise timeliness, these have not yet made sufficient improvements to the time it is taking to reach decisions in cases.

Whilst there was a slight overall reduction in the total number of older cases, the GDC had more cases older than 156 weeks than at any time in the last three review periods.

Speaking at the time, Tom Whiting, GDC chief executive, said: ‘We welcome the PSA’s recognition of our progress across multiple areas, particularly in registration, while acknowledging there is more work to do. We remain firmly committed to improving fitness to practise processes and implementing our EDI strategy.

‘Our priority is ensuring we deliver effective regulation that protects patients and supports dental professionals. We welcome close working with partners and stakeholder organisations to build trust in effective regulation and achieve a goal that we all share, which is patient safety and public confidence in the dental professions.’

‘We need a caring, empathetic regulator’

We hear from dentist Nishma Sharma who explains some of the challenges she believes the profession faces when it comes to fitness to practise – and why she thinks the GDC itself is just as frustrated. 

‘A regulator is essential if we are to remain a profession. The primary issue with our regulator in particular, is its heavy-handed big bad wolf reputation which it has unwittingly earned itself over the years but I feel is now trying hard to rid.

‘The impact this image has on clinicians is significant in the way in which they will then practice defensive dentistry due to being fearful of the sometimes disproportionate consequences should they fail to be anything other than perfect. The types of treatment they will then offer, and more importantly, the general dentistry they will not, has a direct impact on the population at large leaving an increasingly large number of patients with unmet needs.

‘What we could consider here is that a lot of our fear is about perception. For instance, if the GDC disappeared over night what do we think would happen? Would we all celebrate the night away, wake up to an apocalyptic workforce going about pulling out teeth just for fun, treating patients with disrespect and drilling and filling willy-nilly? Unlikely.

‘For 99.9% of us there would be zero impact. We would continue to work hard with integrity to gain the trust of our valued patients, do what’s right by them by putting their interests first and treat them with the highest of regards as we always have done. This is because we all are inherently ethical and good people with strong moral compasses, thus we needn’t fear the regulator. However, like all civilised communities, we need policing for that 0.1% of bad apples who do get trigger happy and stray from the path of guidance, and for that we need a body to enforce principles.

‘However, a caring empathetic healthcare profession such as ours needs a caring empathetic regulator, which leads by example.

‘Contextual factors must be taken into account when dealing with fitness to practice cases by these so-called experts who sit in judgement of members of our profession. Frowning down upon a molar RCT which has remained in Mr Patel’s mouth for 20 years and deeming it a failure because heaven forbid it was short of the apex by 3mm is absolute nonsense. As is expecting that endo carried out for a patient despite being told it’s in a dire state, in a 45 minute appointment for 12 UDAs (potentially, £120 to the performer, including the exam and crown) to last forever, or even a year!

‘Privately, that same tooth could have cost the patient £2,000 and taken the clinician or clinicians involved hours hours plus… Are we really expecting the two teeth to last the same amount of time? Have equal amounts of success? Have these experts themselves worked under such circumstances so as to be able to judge whether or not another clinician in that position shoulda woulda coulda done a better job? How can we measure against a gold standard when the majority of hardworking NHS practitioners work under a tin pot contract?

‘A secondary issue is that of compassionate communication. When we meet patients, we take into account who they are, their wellbeing, we offer compassion, empathy, dignity, personalised care and we as a team do this from the moment they step into our practices to the moment they leave.

‘Where is this personalised care from the GDC?

Processes are binary

‘Whilst not a disciplinary issue, I recently had an interaction with the GDC regarding my CPD, and I can honestly say it was disappointing at best, but one of the most stressful times in my career so far at worst.

‘The language, tone and even font used in the letters and correspondence I received was threatening, anally-retentive and unpleasant. The customer service team were unhelpful and seemed unable to think outside of the box, contextualise or treat me as an individual. It was a horrendous experience and had I been in a bad place mentally, suffering burnout like I had been a few years ago, I think a simple error like mis-logging my CPD would have pushed me over the edge. And in a profession where statistics have shown over 65% of us feel in a less-than-ideal place mentally, that is not okay.

‘What I have come to realise is that the regulators are blindly process driven whereas we as healthcare professionals are not. I would never ever dream of speaking to my patients, writing to them or treating them with such a lack of empathy, compassion or humility in such a binary way as I was treated by the GDC. (The irony being, had I ever done so I am sure I would have been hauled over those coals faster than I can say tick-box!)

‘The GDC processes are binary, as it usually is in the corporate world. Have you done this? Yes? Tick box. No? Go straight to jail, do not pass go, do not collect £200. Our profession is human-factor driven and hence why we clash. Can you imagine using the same ideas in dentistry? Do you brush twice a day? No? Get out. Do you smoke? Yes? Eject chair. (Hmmm, maybe worth a thought?!)

‘For clarification, the GDC as a regulatory body and system lacks the agility to bend and flex and take in contextual circumstances in the way it regulates due to it being based on historical, outdated rules and statutory acts. I have met with many of the humans (yes, they are actually humans) that work there and they are not demented sadists as some might have you believe, but very intelligent people who can see where they are going wrong and have a desire to try and affect change.

‘I genuinely believe they feel as frustrated as we do at the heel dragging from the government and civil service who are not prioritising any sort of system overhaul which we badly need. Let’s hope the areas such as compassionate communication with the profession, something that is within their reach, can be improved imminently.’

Views from the profession: what changes need to be made?

John Makin is head of the DDU. He said: ‘While the majority of dental professionals will not be the subject of a GDC fitness to practise (FtP) investigation, the process is likely to be a stressful episode for any colleague unfortunate enough to become involved in an FtP matter.

‘In the DDU’s experience, the process can often be protracted to the extent that, even where there are ultimately no adverse findings, it amounts to a sanction in and of itself.

‘At the DDU we are tirelessly advocating on behalf of our members and doing all we can to raise awareness of the impact of the current FtP delays on the careers and health and wellbeing of our members and to encourage that the process be conducted in a timelier manner.

‘Indeed, we welcomed the recent introduction of a permanent change to GDC processes aimed at speeding up the initial inquiries made to assess FtP cases. This followed a successful pilot which found that the time taken to assess cases was roughly halved to an average of 13 weeks and the vast majority (84%) of cases were concluded without further action.

‘Initiatives such as this show that it is possible for the GDC to discharge its duty of public protection while taking a more proportionate approach. However, to take this further it is essential that the government now plays its part by introducing the legislation needed for the regulator to overhaul the current outdated system. 

‘We would encourage any DDU member who receives a notification of a complaint to the GDC to contact us as soon as possible. It is never too soon to ask for help and guidance.’

Nishma Sharma added: ‘I feel a reform of the whole system of regulation is required, but much like the NHS, this isn’t going to happen any time soon. If the remit of the GDC is truly the safety of patients, I would argue the current biggest threat to patient safety is the nonsensical, inadequate, perverse, incentive-based NHS contract blighting the lives of our workforce.

‘Maybe some heavy lobbying and pressure from the GDC on the incompetent powers that be in central commissioning and DHSC would help? Otherwise I fear the current contract coupled with defensive dentistry, does not bode well for the future of our nation’s oral health.’

What does the GDC say?

Theresa Thorp is executive director of regulation at the General Dental Council (GDC): ‘As the regulator of dental professionals, our primary purpose is to protect patients and maintain public confidence in the dental professions we regulate. However, we understand that FtP is a stressful and difficult process and we’ve taken various steps to minimise stress and anxiety where we can, ensuring that the small number of dental professionals involved in an investigation feel supported. 

‘We’re focused on improving operational efficiency and addressing wellbeing concerns. Reducing the negative impacts of investigations is a priority for us. We also continue to press for the opportunities that legislative reform could bring. 

‘We say this a lot, but the number of concerns raised with us each year is small. The number of cases referred to the Dental Professionals Hearings Service for a hearing is even smaller. In 2023, we referred just 132 cases, or around one registrant in every 1,000. Of these 132, only 24 were removed from the register. In exploring ways to strengthen local complaint resolution, we are seeing signs that efforts to improve complaint handling at the dental practice is having an impact. 

‘The number of concerns initially assessed has reduced by more than half over the last decade. Work across the sector to emphasise the importance of good complaint handling has certainly contributed. The Dental Complaints Service has grown, helping to resolve issues raised in private practice, while reducing the number of issues they refer to us for an investigation.  

‘It is important that we tackle some of the long held but increasingly outdated beliefs that persist around fitness to practise. We are not out to get professionals, but we have been told that it can feel that way when an investigation is underway. 

‘In November we reported on dental professionals who died while fitness to practise concerns were investigated or remediated, between 2019 and 2022. The report made clear that some individuals took their own life while fitness to practise concerns were being investigated or remediated. The impact on the health and wellbeing of dental professionals during what we know can be a difficult and stressful process is of deep concern to us.’

Reducing negative health impacts

She continued: ‘The introduction of our initial inquiries process to speed up investigations into clinical concerns where they relate to single patients in 2023 represented another significant step forward. The new process limits the amount of information we will request at the initial stages of an investigation. Only relevant clinical records are gathered for an early assessment by clinical dental advisers, reducing the time it takes to reach a decision on whether a full investigation is required in the public interest.   

‘By taking a different approach with these types of cases, we are working to reduce the negative health and wellbeing impacts of our investigations for all participants. 

‘Other improvements have included the introduction of regular training for our caseworkers and managers from a specialist mental health charity, helping them identify those who may be in distress and signposting them to support earlier and more effectively. Independent panellists and legal advisers at the hearings service have also received training to help them to support vulnerable individuals during hearings. 

‘This year we will continue reviewing and modernising our suite of fitness to practise guidance, providing decision makers with an improved framework that supports fair and consistent decision-making. 

‘Within fitness to practise, we want to get faster without compromising public protection, and make sure the process continues to be fair to participants and proportionate to the issues raised.’

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