A developing problem

In his Malcolm Pendlebury lecture in June 2014 to the Faculty of General Dental Practice, Bill Moyes, Chairman of the GDC, made the following statement:1 'The users of dental services are now much more consumerist in their attitude. Dentists and dental care professionals now have customers, not clients, or, indeed, patients. Part of a consumerist attitude is an expectation that services will be organised around my needs and preferences, that quality will be good and the price fair. And if the service is poor or the quality unacceptable, consumers are willing to complain and to seek whatever form of redress seems appropriate to the circumstances of the case.' If managed well a complaint from a patient can lead to an improvement in service. Nevertheless, few dentists and dental care professionals (registrants) would be comfortable receiving one, even less if the complaint were to be taken up by the General Dental Council (GDC) or NHS England area teams (ATs). As well as the many other stresses that may arise from a complaint, a registrant may be concerned that he/she will lose the right to work in the dental profession, while for the authorities the primary concern, understandably, is patient safety.

The annual report from the GDC2 shows that the majority of complaints relate either to the quality of clinical care or clinical governance. With further training and support, the performance of some dentists and dental care professionals (registrants) in difficulty (DRiDs) may be improved such that it is not necessary to remove them from the register or performers' list. Conditions are placed on the registrant's practice and the regional teams of Health Education England (HEE) or the Welsh and Scottish deaneries are often asked by the registrant to assist in managing their training and support. Little research has been carried out into the vital service that these teams provide to registrants in difficulty. Even taking into account the increase in the number of dentists and dental care professionals on the register there has been a significant increase in registrants in difficulty with either the GDC, the local primary care trusts (PCT), until they were disbanded, and NHS ATs. In 2011 the GDC received 1,578 complaints or notifications, while in 2013 the number was 2,990.2,3 In 2013, the Interim Orders Committee imposed conditions on 33 registrants and renewed existing conditions for 36 in contrast to 2007 when they imposed conditions on 11 and renewed 4.4 The GDC has in recent years sought to streamline and more efficiently deal with complaints and is seeking changes in legislation to further speed up the process.5

The reasons for the increase in cases are multifactorial. Patients complain more often about the care they receive. The GDC's dental complaints service, which advises members of the public on private dental treatment, opened more than 2,000 complaints in 2012, nearly twice as many as when the service began in 2006, although two thirds were resolved within a week.6 There has been a change in attitude to the regulation of health professions. The main driver for this change has been a series of high-profile incidents within the medical profession, including the Shipman case and the failures around paediatric heart surgery at Papworth hospital.7,8 One consequence of such incidents was the realisation that it was no longer acceptable to ignore poor performance by a colleague. Whereas previously it was almost believed to be unprofessional to complain about colleagues, it is now a duty for healthcare professionals to report under performance and it is a requirement that is specifically mentioned in the new Standards publication by the GDC:9

'8.1.1 You must raise any concern that patients might be at risk due to: the health, behaviour or professional performance of a colleague;'.

There has been a significant increase in the number of dentists who qualified overseas on the register. The GDC statistical report for 2013 shows that just under 28% of dentists on the register qualified overseas.2 Of dentists added to the register in that year, just 58% were UK trained. While there are efforts to ensure that the training of dentists in EU countries is similar to that in the UK, these dentists still have to comply with the UK culture of dental care provision which can be significantly different from that in other countries.10 Systems are in place to maintain and improve the performance of health professionals; these have become more formal since the aforementioned cases of medical failure were uncovered in the 1990s. The GDC requires that all dentists complete 250 hours of continuing professional development (CPD) over a 5-year cycle. The number of hours that should be devoted to certain subjects that it considers to be important for safe practice is laid down. The medical profession, in addition, has mandatory yearly appraisal and revalidation every 5 years with the aim of maintaining and improving the quality of care and identifying poor performance at an early stage.11,12,13 Appraisal systems have been set up within dentistry but are not as yet in universal use. They have become more important for continued registration with the recent introduction of the new standards by the GDC.8 The GDC has also considered and consulted on introducing compulsory revalidation (now called 'continuing assurance') although this has not, as yet, been implemented.14

If professionals from medicine, pharmacy and dentistry get into difficulty while working within the NHS then the National Clinical Assessment Service (NCAS), set up by the Department of Health, can be asked to investigate the professional causing concern and identify problems with their practice. Usually, once it has completed its investigation NCAS will, among other measures, issue advice that the relevant regional office of HEE or the Welsh or Scottish deanery should be approached to instigate and support a training programme.

Other initiatives have been implemented in the past to help dentists who may be under performing. One example is a service developed in East Lancashire by the local dental committee with the support of the PCT to help such dentists with a view to preventing the situation deteriorating further and patients being harmed.15 Known as the Practitioner Advice and Support Scheme (PASS), this model was rolled out and continues to function in several other areas of England and was at one time championed by the GDC. Similar initiatives have been organised for the medical profession.16,17,18

Other professions

Other professions also have a need to investigate and take appropriate action against members who fail to meet the standards set by their professional regulators. Indeed it is one of the hall marks of a profession that it will expect members to comply with the standards set by the governing body and it is inevitable that some practitioners will fail to comply.19

If a complaint is made to the General Medical Council (GMC) about a doctor the council will investigate.20 They will gather evidence from employers, the complainant and other parties including clinical experts. They may also test performance, competence and language skills. Once the evidence has been collected it is considered by the case examiners – two GMC staff members, one of which is medical and the other non-medical. They can conclude the case with no further action, issue a warning, agree undertakings with the doctor or refer to the Medical Practitioners Tribunal Service (MPTS) for a fitness-to-practise panel (FTP) hearing. The MPTS is funded by the GMC but accountable directly to parliament and was launched in June 2012 with the aim of separating adjudication and management of FTP and interim orders panels from the investigatory function performed by the GMC.21 If an FTP panel finds impairment it can: take no action; agree undertakings; place conditions on practice for up to three years; or suspend/erase a doctor from the register. The British Medical Association (BMA) has been commissioned by the GMC to provide a doctor support service, which offers emotional help from fellow doctors to all, whether a member of the BMA or not, and functions independently of the GMC.22

The Institute of Chartered Accountants in England and Wales (ICAEW) has an investigating committee and disciplinary committee and publishes a list of members who have been disciplined each year.23 They have also made continuing professional development compulsory and taken steps to monitor compliance.24 Members can expect visits from the Quality Assurance Directorate to check compliance with regulations and this is seen as being supportive and formative in nature, unless serious breaches of regulation are uncovered, with remedial action being recommended and compliance with any requirements to improve reviewed and monitored.25 It also has an advisory service providing help and support, which appears similar to the services provided by the British Dental Association (BDA).26

In a similar fashion the Royal Institute of Chartered Surveyors (RICS) has a code of ethics and regulations covering the actions of individuals and firms.27 They have disciplinary panel hearings for serious breaches of their regulations and there were 27 hearings between January 2013 and 16th October 2013.28 They can remove a person or firm's registration, impose conditions or impose a fine. Surveyors must have professional indemnity insurance and register at least 20 hours of CPD a year.27 RICS organise courses, conferences and networking events. However, for these professions there does not appear to be a formal body, separate from their governing organisation, tasked with assisting a member in meeting the conditions imposed on their practice.

The Nursing and Midwifery Council received referrals for 0.7% (4,687) of its registrants (60,858) in 2013–14.29 This compares with 2,986 referrals in 2009–10. Their process for managing referrals is, in many ways, similar to that used by the GDC. However, two significant changes have recently been introduced to allow quicker and more efficient progress of cases. First, provided the registrar agrees that it is in the public's interest, a registrant in difficulty may apply to be removed permanently from the register without a full public hearing. It is also possible, if a nurse or midwife accepts that their fitness to practise is impaired, for a sanction to be agreed and then considered by a panel at a public hearing.

Murray found that staff shortages, increased workload, bullying and harassment, and poor interactions with colleagues or managers in the nursing profession increased the likelihood of complaints leading to suspension.30 This, as might be expected, can cause significant physiological distress and Murray found that suspended nurses thought that formal and informal support was important both while suspended and on returning to work. Indeed there have been cases where nurses have committed suicide as a consequence of facing fitness-to-practise hearings and the Royal College of Nursing has piloted a peer support group of mentors who have themselves been through the same experiences to help these nurses.31

Support for registrants in difficulty

Registrants in difficulty with the GDC and other organisations such as NHS ATs will receive support from a number of different sources be it their defence society, HEE regional offices, BDA, colleagues, etc. A significant proportion of this support will be provided or coordinated regionally by the postgraduate medical and dental teams (formerly known as deaneries) in HEE's regional offices. Informal discussion by the authors with persons responsible for managing the service within HEE's regional offices suggests that the number of DRiDs they are helping is increasing very significantly every year. Also of relevance is that the way the service is managed by different regional offices varies significantly across the UK. The service has developed rapidly over the past few years to cope with the increase in demand and it is apparent that each regional office has taken an individual approach both in how personnel are used and how the service is funded.

There appears to be little published research into dental registrants' views on the type and level of service provided by the HEE regional offices and the Welsh and Scottish deaneries. There is currently no information, for example, on whether dental registrants in difficulty believe they are receiving the right sort of support delivered by the appropriate person in a timely manner and whether the charges levied for that support are reasonable. In parallel, an increasing number of dentists and other professionals below management level (supporters) are being recruited by HEE's regional offices to provide support for DRiDs. There is a need to investigate the characteristics of the professionals recruited and how they are trained, managed and paid from the HEE regional offices' perspective. The views of these professionals on how they perceive their role and the support they receive in what can be a difficult task with potential risks to their own professional status also needs to be investigated.

A national study is currently being piloted by a research team based at Health Education North West to investigate how HEE's regional offices, as well as the Welsh and Scottish deaneries, manage the service they offer for DRiDs. Using information gathered from management, DRiDs and supporters, the research is being conducted in order to inform the development of effective and equitable provision for DRiDs in England, Wales and Scotland (the deanery in Northern Ireland does not provide a service to registrants in difficulty at present). This is the first investigation of its kind; it is hoped that capturing detailed qualitative evidence of current practice will help to standardise and improve the quality of support available to DRiDs.

If current trends in the UK are maintained, a registrant might expect at least one referral to either the GDC or local NHS authorities in a practising lifetime. When this stressful event occurs it is vital that the HEE teams and other agencies provide support that is timely and effective no matter where a registrant practises. This is important for several reasons. An effective remedial process is first of all crucial for patient safety if the registrant is to continue to practise. With the potential for significant numbers of registrants getting into difficulty there would be implications for service delivery if all such registrants were simply removed from the register. Such a policy would also not be proportionate if one considers the human costs to the registrant and immediate family arising from what may be a temporary lapse, one mistake in an otherwise blameless professional life or from a malicious complaint from a patient.

For the registrant the event can be very stressful. It can involve significant changes in clinical practice combined with close scrutiny of all aspects of their practice and professional development via educational and clinical supervision and audit. These registrants frequently need advice on how to access appropriate further education, organise their logs of continued professional development (CPD) and how to carry out audits. A complaint can lead to loss of employment and they may need financial advice. Some, if not all, will suffer from debilitating physiological stress. As professional clinicians there is perhaps an expectation that a significant mistake or error of judgement will never be made and having such an event happen may lead to a feeling of inadequacy and loss of confidence which in itself can have serious effects on clinical practice.32 Alternatively, some registrants will deny that they are at fault and possibly as a consequence fail to engage in the remedial process. The appropriate type of support should be available when needed. We hope that this investigation will aid the current initiative to further develop the service from HEE teams for registrants in difficulty that is also more consistent in character across the whole of the UK.

Finally, it would be better for all concerned – patients, registrants and those regulating the profession – if the 'difficulty' could be prevented. Research has been carried out into those factors that affect performance and the National Safety Agency published a literature review in 2011.33 We aim to contribute to this research by investigating the pathways, as perceived by the registrant, which leads to registrants getting into difficulty. Surely, the 'Holy Grail' for all concerned is to reverse the current trend of ever increasing numbers of registrants getting into difficulty.