'If there's someone to walk you through it, it can make all the difference'

When I started out in dentistry, I didn't know it at the time, but a ruckus between the British Dental Association and the General Dental Council was brewing, and before long, it blew up completely. It was a time few practitioners enjoyed working in, and it took years for the feelings of mistrust to ebb away.

Things are eminently different now, and I spoke to Head of BDA Indemnity, Len D'Cruz, about the relationship between stress, enjoyment, the profession and litigation.

How would you describe the climate of litigation and mental health of the profession in the last few years?

LD'C The GDC has improved without a shadow of a doubt, and they should be commended for the work they've done. What I think we're potentially dealing with is a legacy of the climate of fear many practitioners still in practice today can recall from that period where relations were fraught.

I think that legacy continues partly because it is maintained by people who haven't recognised things have moved on - practice owners and/or older associates who were finding their feet in the profession at the time, for example. Kathryn Fox's paper in the BDJ discussed graduates fearing litigation when they've had no experience and/or exposure to situations where litigation would be brought upon them, so that 'climate' has come from somewhere; lecturers, friends and family who worked in the profession at the time. Indemnity organisations in the past have also gone into dental schools to offer talks on ways of avoiding getting in front of Fitness to Practise. Now? Well, the screening and filtering process of what is 'serious' is being done more assiduously by the GDC so that many more cases don't even get as far as Case Examiner.

We do have to accept that while GDC cases are going down, complaints are still there, and will be for a long time to come. They're inevitable, and if you think of this in a slightly different way, it could be less problematic. We work in a service industry where people pay money for it, so that relationship between expectations and money won't be going away anytime soon. If we look at how problems are resolved, people are now heading back to the dentist to seek a resolution and getting the problem fixed. Like most disgruntled service users patients don't normally go to lawyers or regulators. So complaints can be within our control. The online triage tool has had a lot to do with that - so some of the more spurious claims have been sieved out and patients signposted to seek resolution in the practice. That's been a vast improvement.

Finally, the introduction and improvement of the role of Case Examiners has helped immeasurably. They have to decide whether cases can be proved, and their threshold has been raised time and time again to weed out the more serious cases that do deserve to be moved onto hearing. Stats show this is having a positive effect - of 100 cases that went through last year, 84 were closed within the first three stages of the triage process, so a significant number don't go anywhere.

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You mention a legacy. How much of that is down to a practice owner's scar tissue of that period you discuss?

LD'C Scar tissue is a good description. For those who practised during that 2014/15/16 phase where relations were very strained between the BDA and the GDC, the ARF case left a very toxic feeling in the profession and a huge sense of mistrust in the regulator.

At its peak between 2010-2017 you had the GDC and the Dental Law Partnership hanging over you - or at least had the prevailing feeling given the ambulance chasing lawyers that grew and supported patients to make claims when they could have - or should have - been settled in practice. For those who still have that feeling, they may have not seen the changes that have gone on both behind the scenes and in conjunction with the BDA and indemnity organisations to make improvements for practitioners. If anyone says gloomily and perhaps with a hint of paranoia 'be careful they are all after you', that's probably where it comes from. It's understandable, but things have moved on.

You mentioned we're a service industry and trust. To what extent has the pandemic affected the level of trust between patient and dentist?

' We do have to accept that while GDC cases are going down, complaints are still there, and will be for a long time to come. They're inevitable, and if you think of this in a slightly different way, it could be less problematic'

LD'C I think we need to consider the Trust Equation: credibility, reliability, intimacy, and the denominator is self-orientation. In the context of dentistry, credibility comes from the relationship I've previously discussed - understanding the patient, knowing their problem, they understand you, they believe you. Reliability comes from you saying something is going to happen and it does, and the intimacy part of the equation comes from the patient's confidence that what they tell you, even if it embarrassing, will not go any further through trust. Self-orientation undermines all of these.

' We do have to accept that while GDC cases are going down, complaints are still there, and will be for a long time to come. They're inevitable, and if you think of this in a slightly different way, it could be less problematic'

My belief is complaints have increased as a result of the pandemic because of a loss of trust - in the eyes of patients, one or more of these pillars has dropped off. Patients see that you're still asking them to wear masks, social distance and follow heightened infection control procedures at a time when the government says you don't have to. COVID-19 means staff sickness, isolation and cancelling patients left right and centre. Your labs and technicians may be struggling, so they're not getting their dentures or crown on time. And, through all of this, patients are questioning why and what's going on. They may be able to see you're trying your best, but they feel you're no longer credible or reliable or can trust you. There is the potential to build that trust again, but it will take time.

With the lack of time some fourth and fifth year students had with patients, and for those who were in DCT placements or just starting, are you concerned about how little opportunity new and young dentists have had to hone these soft skills and rebuild that trust?

There is a concern. Deaneries have told training practices 'if you think this year is bad, next year's going to be worse' and yet communication is probably one of the stronger points. What undermines this is fundamental holes in your training - caused by the pandemic - you will be concerned about the technical aspects and perhaps lose that confidence and ability to communicate clearly. There is a risk going forward, and no-one really knows how it will play out in the long-term.

The pandemic has impacted the mental health of the workforce and levels of stress have increased. What steps are there for practitioners and the dental team to safeguard against problems snowballing and escalating?

I would go back to the in-practice support structure. If a complaint is made against you, what support do you have, what procedures are in place, do you know who to speak to, do patients know who they need to speak to, is there a resolution pathway? If you have those building blocks in place, that can go a long way to stopping problems from escalating. You don't want a situation where you're handed information about a complaint made against you first thing in the morning when you're just about to go to see your first patient of the day, or being sent the files when you're on holiday. I have always advocated that there is no immediate rush. Receiving a complaint is stressful for a dentist so timing of when to hand the complaint to them should be thought about to avoid adding to their stress.

A complaint can have a big impact on the dentist involved, and the team needs to recognise this. It's not healthy dealing with a complaint on your own without support. If there's someone to walk you through it, it can make all the difference. Because we're so busy in practice, no-one ever stops to ask if you're ok, how are you or if you are you coping. Fostering an environment where you can do this and reach out does take effort, but it can reap rewards.

Does the feeling of immediacy of dealing with a problem come from the fact it is a service industry and there is an exchange of money?

Yes, which is why managing a patient's expectations is hugely important. The reason a patient makes a complaint is because they want their issue resolved relatively quickly. You empower your receptionist to deal with the problem if the dentist involved is away, for example. Deal with them quickly, make sure they stay within the practice and you can control what happens from there. There will be complaints, but in terms of litigation, dentistry is on the right path. ◆