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574 Dental Update July/August 2015
The Implications of the New GDC
Standards for Dental Professionals
Abstract: This article is about the publication by the General Dental Council in 2013 of the Standards expected of those members of the dental team who are registered with the Council, on each of their Registers, and discusses the implications of the new Standards for dental professionals. CPD/Clinical relevance: It is important that all dental Registrants are familiar with the current Standards publications. Dental Update 2015; 42: 574–
to establish what is expected of its Registrants in terms of conduct, performance and behaviour, the 2005 and 2013 publications rely heavily on the four principles of biomedical ethics as set out by Beauchamp and Childress. 6 Their four principles are one of the most widely used frameworks, offering a broad consideration of medical ethics issues generally, which can be applied in a clinical setting. The four principles are general guides that leave considerable room for judgement in specific cases:
1. Respect for autonomy : respecting the decision-making capacities of autonomous persons; enabling individuals to make reasoned, informed choices. 2. Beneficence : this considers the balancing of benefits of treatment against the risks and costs; the healthcare professional should act in a way that benefits the patient. 3. Non-maleficence : avoiding the causation of harm; the healthcare professional should not harm the patient. All treatment involves some harm, even if minimal, but the harm should not be disproportionate to the benefits of treatment. 4. Justice : distributing benefits, risks and costs fairly; the notion that patients in similar positions should be treated in a similar manner.
The General Dental Council (GDC) is the statutory regulator of dental professionals for the United Kingdom, established under the Dentists Act 1984. 1 The GDC regulates Dentists and Dental Care Professionals (DCPs), including clinical dental technicians, dental hygienists and therapists, dental nurses, dental technicians and orthodontic therapists. By law, all of the above must be registered with the General Dental Council to work in the United Kingdom. This ensures only appropriately qualified and skilled dental professionals are part of the clinical dental team. The main objective of the General Dental Council is the protection of patients and the public. It maintains registers for the above noted dental professionals. The GDC’s powers and duties also include setting the standards of conduct, performance and behaviour that Registrants are expected to adhere to, as well as investigating any complaints which suggest a Registrant’s
Aubrey Craig , BDS, FDS RCPS, MPhil MBA, Head of Dental Division, Dental Advisory Services, The Medical and Dental Defence Union of Scotland, UK.
Aubrey Craig
fitness to practise may be impaired. The GDC also sets standards for the education and training of dental professionals and requires all Registrants to undertake Continuing Professional Development (CPD) in order to ensure that they keep their skills and knowledge up-to-date and remain fit to practise. This allows the GDC to meet its main objective.
The standards history The General Dental Council (GDC) has been issuing guidance from the very start of its establishment in 1956 and this guidance included rules on behaviour and conduct. The history of the GDC setting standards expected of Registrants can be traced back to a document Professional Conduct and Fitness to Practise, published by the GDC in 1993. 2 In 1997, the GDC issued guidance entitled Maintaining Standards, with amendments in
- 3 This guidance was revamped significantly with the publication by the GDC of Standards for Dental Professionals^4 in 2005 with significant re-working and the production of an enhanced and significant document entitled Standards for the Dental Team^5 in 2013. Reflecting on this journey adopted by the GDC in attempting
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GDC standards for the dental team
The publication of the Standards for the Dental Team by the General Dental Council, that came into effect on 30 September 2013, was the culmination of an extensive period of consultation by the General Dental Council, including various workshops held throughout the country and meetings with many stakeholder groups and patients.^5 This document sets out the standards of conduct, performance and ethics that govern dental professionals in the United Kingdom. It specifies the principles, standards and guidance which apply to all members of the dental team who are GDC Registrants, as well as setting out what patients can expect from a dental professional. The document is based on nine principles which apply to all of the Registrant groups. Throughout the document Standards for the Dental Team, the words ‘must’ and ‘should’ are used. ‘ Must’ is used where the duty is compulsory; ‘ should’ is used where the duty would not apply in all situations and where there are exceptional circumstances outside the Registrant’s control that could affect whether, or how, the Registrant can comply with the guidance. 5 There are nine over-arching principles, all of equal importance and are not listed in any order of priority. They are:
- Put patients’ interests first;
- Communicate effectively with patients;
- Obtain valid consent;
- Maintain and protect patients’ information;
- Have a clear and effective complaints procedure;
- Work with colleagues in a way that is in patients’ best interests;
- Maintain, develop and work within your professional knowledge and skills;
- Raise concerns if patients are at risk;
- Make sure your personal behaviour maintains patient confidence in you and the dental profession.
The principles are supplemented by additional guidance documents. Each Registrant has a responsibility to behave professionally and follow these principles at all times. The GDC is clear that if a Registrant does not meet these Standards
he/she may be removed from the Register and not able to work in the UK as a dental professional. The guidance notes are there to help the Registrants meet the Standards. Registrants are expected to follow the guidance, to use their professional judgement, to demonstrate insight at all times and to be able to justify any decision that is not in line with the guidance. Those Registrants who fail to meet these Standards may be subject to fitness to practise proceedings with the ultimate sanction being erasure.
The nine principles The General Dental Council has a statutory duty to investigate all complaints that it receives in relation to any of its Registrants. These complaints will be intimated to the Fitness to Practise Department and an investigatory process will be started that involves information gathering as well as, in clinical cases, the obtaining of a Clinical Adviser Report. In misconduct and performance cases, this is crucial as it will provide assistance to the Caseworker in the drafting of the Charges. Medical advice may also be sought in health cases and, at the end of the pre-assessment stage, should matters be referred on to an Investigating Committee, the Registrant will receive a covering letter, a summary of allegations, as well as details of the Standards Guidance alleged to have been contravened by the Registrant. The examples included within the text, following discussion regarding the principles, highlight how this information is disseminated to the Registrant. These examples are taken from cases managed by the MDDUS on behalf of its members and include a variety of GDC Committee Investigations.
Principle 1: Put patients’ interests first This standard is very wide- ranging and covers a multitude of areas, including communication, respecting patients, acting with honesty and integrity, adopting a holistic approach to care, cross-infection control, being non-discriminatory, having appropriate indemnity and being up-to-date with the relevant law and regulations affecting your practice.
All treatment decisions must be in the best interests of the patient and the individual providing the care must be wary of how the planned/ actual treatment may impact on the patient’s general health. No treatment should be provided in isolation and all patients must be given a real choice, with no practice/individual being able to hide behind any ‘policy’ decision. Having appropriate paperwork, including accurate, complete and contemporaneous dental records, including a signed treatment plan, will all add weight to any defence, should a complaint be intimated. The issue of indemnity has been taken further in that, following an independent review across the regulated healthcare professions, which recommended making insurance/ indemnity a statutory requirement for access to these professions, the Health Care and Associated Professions (Indemnity Arrangements) Order 2014,^7 changed the requirement for Registrants to have indemnity from an ethical requirement to a legal one. Example: That being registered as a dentist, your fitness to practise is impaired by reason of misconduct. In that: You did not provide an adequate standard of care to patient X, from date Y to date Z, including by: (a) Providing amalgam fillings when composite fillings were requested; (b) Not providing adequate oral health instructions.
Principle 2: Communicate effectively with patients This standard reflects the many facets of communication, including the dissemination of information to a patient about the care proposed/ needed, allowing patients to recognize and promote their own responsibilities for making decisions about their oral healthcare. Information should be provided in a language free of dental jargon, using an interpreter where appropriate. Patients should receive a written plan, including reference to costs that should be signed by the patient, a copy being retained by them, as well
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Registrants should be aware of the guidelines available in terms of complaint management, 13 including a GDC publication on this topic, 14 as well as the content of the new Standards Guidance. It is important if any delays occur during the process that the Complainant is kept fully briefed. Should matters escalate to the jurisdictional Ombudsman, then compliance with the timelines of the process should stand the practitioner in good stead. Example: That being a registered dentist, dentist X’s fitness to practise is impaired by reason of misconduct and/or deficient in professional performance, in that you: (a) Did not maintain adequate complaints procedures, including by: (i) Maintaining inadequate procedures; (ii) Having conflicting procedures; (iii) Not following established procedures; (iv) Not recording complaints, actions undertaken, or follow- up from complaints received; (v) Not auditing complaints received and response provided and/or embedding any lessons learned.
Principle 6: Work with colleagues in a way that is in patients’ best interests The provision of dental care is enhanced by effective teamwork. Each member of the team must be appropriately trained for the job that he/she is required to do, with each individual being responsible for his/her own acts, omissions and commissions in the provision of this care. A second, appropriately trained person needs to be available in case of a medical emergency. However, being appropriately supported ensures greater efficiency of care provision, as well as offering the security of a chaperone. All provision of care must be within the Scope of Practice^15 (GDC May 2013) of the individual who must be competent and indemnified for the task that he/
she has been asked to do. Practice Principals must demonstrate effective management and leadership of their team, ensuring all team members are GDC registered, where appropriate. Communication surfaces again and is key in healthcare delivery. Example: That being a registered dentist: (a) On or after 27 November 2012, you: (i) Inappropriately referred Patient B for secondary care.
Principle 7: Maintain, develop and work within your professional knowledge and skills This principle focuses on the knowledge and skills of the healthcare provider. Registrants should keep up-to-date with current developments regarding care provision and, if a decision is made to deviate from normal practice, then the reasons for doing so must be fully recorded. Training and competence are key to safe care provision and all practitioners must keep up-to-date with their continuing professional development. The General Dental Council has provided extensive guidance on this subject for all Registrants and everyone must ensure that they demonstrate compliance with the core topics, learning reflective of their sphere of practice and complete these within the cycle of learning.^16 Example: That being a registered dentist, dentist X’s fitness to practise is impaired by reason of misconduct, in that between January 2010 and December 2014, you: (a) Did not maintain adequate CPD reflecting your sphere of practice; (b) Did not submit an annual return of your verifiable and non- verifiable CPD to the General Dental Council; (c) Did not partake of verifiable CPD reflecting the suggested core topics; (d) Did not maintain any non- verifiable CPD during this time period.
Principle 8: Raise concerns if patients are at risk This effectively new principle raises, for some, the thorny issue of ‘whistleblowing’. Registrants now have a professional duty to raise concerns if patient safety may be at risk. This is not an easy thing to do. Concerns should be raised in a timely manner, over-riding personal or professional loyalty that one Registrant may have towards another. Concerns should be raised at a local level in the first instance. If the individual concerned is not insightful in accepting and reflecting on the constructive criticism and does not demonstrate improvement, then the concern should be raised with the General Dental Council, dependent upon the working relationship of the Registrant and the ‘whistleblower’. The different UK jurisdictions have different bodies to which concerns can be raised. These include the Care Quality Commission (England),^11 Health Inspectorate Wales, 17 Healthcare Improvement Scotland^18 and the Regulation and Quality Improvement Authority in Northern Ireland. 19 The protection of vulnerable groups is paramount in all healthcare provision and all Registrants should be familiar with the local and national guidelines for raising concerns.^20 Example: That being registered as a dentist, your fitness to practise is impaired by reason of misconduct, in that between October 2013 and June 2014, you allowed your vocational dental practitioner to carry out treatment for patient X that was to a standard far below that of the reasonable dentist.
Principle 9: Make sure that your personal behaviour maintains patient confidence in you and the dental profession This reflective principle is really a ‘catch all’ for personal and professional behaviour, attempting to maintain the confidence of the public in the profession of dentistry. The life of a Registrant is under scrutiny 24/ and it is incumbent on the Registrant
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to ensure that his/her personal and professional lives do not put patients at risk. The increasing use of social media in the 21st Century is to be accepted, but is not without its problems. The General Dental Council has taken this point seriously enough to provide separate guidance on the use of social media. 21 It is important for all Registrants to maintain appropriate boundaries with all individuals. A change in relation to disclosure to the Council in terms of criminal proceedings now sees all Registrants being required to inform the GDC immediately if they are subject to any criminal proceedings anywhere in the world. Example: The factual particulars of allegation are that:
1. On date X you were convicted of a speeding offence under the Road Traffic Regulation Act 1984 S and 89. You were ordered to pay a fine of Y and your licence was endorsed with? penalty points and that therefore your fitness to practise as a dentist is impaired by reason of: conviction.
Discussion
The Standards for the Dental Team, published by the General Dental Council and being effective from 30 September 2013, is Professional Guidance for Registrants and is an extensive booklet that has been published, following extensive consultation. 5 With the increased Registrant groups within the Council, there were several options available to the GDC in terms of how each Registrant Group would be expected to abide by a particular Standard. By having one Standard for the whole team, then each Registrant is clear in terms of what is expected of them. The new Standards are wide- ranging in volume and scope and, as such, will have significant implications for some Registrants. In clinical cases, the Council have adopted the practice, in summarizing the allegations, to include
allegations that the Registrant ‘did not provide an adequate standard of care’ but also did not ‘maintain an adequate standard of care’. The former, relating to the actual care the Registrant, provided the latter, referring to his/her clinical record-keeping. 22 A plethora of guidance is available for all Registrants and, indeed, throughout the jurisdictions within the United Kingdom. All Registrants should keep up-to-date with the laws and regulations pertaining to their practice and for those who are team leaders, it is important that clear demonstration is made of leadership and management skills. In essence, and put very simply, there is less ‘wriggle room’ for any Registrant, given the breadth of the Standards contained within the publication and, therefore, for many Registrants, it will become increasingly difficult to put forward information, in relation to any allegation of misconduct, performance or health, to defend their position at the Investigating Committee stage.
Conclusion The General Dental Council publication, Standards for the Dental Team, September 2013, is wide- ranging.^5 It covers all members of the dental team, who are Registrants, and it is important that all Registrants are familiar with the document so that, should their fitness to practise be questioned, they can clearly demonstrate full compliance with the expectations of their registered status.
References
- The Dentists Act 1984. Available at www.legislation.gov.uk/ ukpga/1984/2x
- Professional Conduct and Fitness to Practise. General Dental Council,
- Now unavailable.
- Maintaining Standards. GDC, 2001. Now unavailable.
- Standards for Dental Professionals. General Dental Council, 2005. Available at www.gdc-uk.org
- Standards for the Dental Team.
General Dental Council, 2013. Available at www.gdc-uk.org
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics 5th edn. London: Oxford University Press, 2001.
- The Health Care and Associated Professions (Indemnity Arrangements) Order 2014. Available at www.gov.uk
- Data Protection Act, 1998. Available at www.gov.uk/data-protection/ the-data-protection-act
- Access to Health Records Act 1990. Available at www.legislation.gov. uk
- Information Commissioner’s Office (ICO). Available at www.ico.org.uk
- Care Quality Commission (CQC). Available at www.cqc.org
- Health and Social Care Act, 2008. Available at www.legislation.gov. uk/id/ukpga/
- Please refer to the relevant NHS Regulations pertaining to the appropriate jurisdiction where the Registrant works. Available at www.gov.uk
- Principles of Complaint Management. General Dental Council, 2006. Available at www. gdc-uk.org
- Scope of Practice, 2013. GDC. Available at www.gdc-uk.org
- Continuing Professional Development for Dental Professionals, 2013. Available at www.gdc-uk.org
- Health Inspectorate Wales. Available at www.hiw.org.uk
- Healthcare Improvement Scotland. Available at www.hiscotland.org
- Regulation and Quality Improvement Authority. Available at www.rqia.org.uk
- The Child Protection in the United Kingdom. Available at www.nspcc. org.uk
- Social Media Guidance. General Dental Council. Available at www. gdc-uk.org
- Clinical Examination and Record Keeping, Good Practice Guidelines 2nd edn. London: The Faculty of General Dental Practitioners (UK), The Royal College of Surgeons of England, 2009.
