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Almost every dental desert item in the news is illustrated with a personal story from someone unable to find NHS dental treatment for their emergency, and who was left in pain. The usual response from the minister of the day has been that patients with a dental emergency should use the NHS 111 service. In a number of areas there are specifically contracted NHS emergency dental services accessed via 111.

Looking to buy a dental practice? Here, corporate law and dental specialists Eugene Pena and Kirsty McKenzie-Hopkins explore the six key steps in the purchase process, answering the most common questions from budding buyers.

1. Find the right legal team

In our experience, no transaction is ever the same. Once you have found the right practice and are in a position to start the buying process, your first step should be to find the right lawyers to represent you and guide you through the process. You can instruct lawyers even before you’ve made an offer.

You should consider working with lawyers that specialise in the dental sector — in particular, those with significant experience in buying and selling dental practices.

Most sellers are keen on a speedy transaction, so having the right team in place will put you in the best possible position.

2. Consider funding

Next, you’ll need to know how the purchase is going to be funded. Most lenders will require you to have a deposit, so having this ready and being able to show how this amount has accumulated will save you time further down the line.

The more information you have available at the outset, the better. Knowing what type of security the bank will take will also help your lawyers to determine what additional work (if any) will be required.

3. Terminate your contract

Buying a practice can be a lengthy process. Most first-time buyers are also associates working elsewhere and are required to give notice to terminate their contract.

Timing when to hand your notice in is key. While this decision is ultimately yours, having expert lawyers who are aware of the process and the intricacies involved in dental transactions, as well as the potential issues that may arise, can help to ensure that you aren’t left without work. They can provide guidance and help to reduce the risk of you being left without a source of income.

4. Recruit your team

You may be eager to make your mark as soon as you get the keys to the practice, but recruitment is a big issue in most sectors and dentistry is no exception.

You may be acquiring a well-established practice with members of staff that have worked there for many years. While there are regulations that protect employees’ rights, it’s possible to implement certain changes (known as measures) — but you’ll need to consider how any changes (whether big or small) would affect the workforce.

It’s usually a good idea to maintain the status quo (provided that it’s working) until you’ve embedded yourself with the team.

5. Register with the CQC

Be prepared to go through a CQC (Care Quality Commission) registration process. This may differ depending on the type of practice you’re looking to acquire.

First time buyers may be asked to attend a fit person interview with a CQC assessor, so preparation is key. Again, having lawyers who are familiar with the CQC process is crucial to enable a smooth purchase. Your solicitor may even be able to make the application for you.

6. Manage time effectively

Finally, a simple but critical piece of advice — don’t leave things until the last minute. Set time aside to deal with matters related to your purchase — sometimes, the last thing you want is to read an email from your lawyer or action any documents, but always try to keep your end goal in mind. Make sure that you know what you’re signing up to and allow time to negotiate any points that you’re not fully comfortable with.

If, for example, you have agreed that the seller will be remaining as an associate, try to finalise the agreement in advance of the exchange of contracts. Even if you have agreed headline terms with the seller, circumstances may have since changed — so you don’t want to be renegotiating terms late in the transaction.

How we can help

Buying a dental practice may well be one of the biggest decisions you ever make. Avoiding common pitfalls by having an expert legal team with specialist dental experience makes a huge difference. You need a team that can calmly guide you through each step of the process.

We are proud to provide market-leading legal solutions to dental practices across the UK. Our dental team contains true specialists who understand the unique pressures you face.

We play an active role in the market for dental practice sales and purchases, working alongside third-party brokers to ensure smooth transactions. Advice is provided across multiple specialist practice areas, including practice sales and acquisitions, property acquisition or leasing, property disputes, regulatory (including a CQC application service), fitness to practise, litigation, international recruitment, employment and litigation.

Talk to us by calling 0151 600 3000 or complete our contact form and have a member of our team get in touch.

We’re in the middle of a cost-of-living crisis and dentists are not exempt. When buying or selling a dental practice — likely one of the most important decisions in your life — cashflow is key. So should you spend money instructing a specialist dental lawyer or go with a generalist ‘high street’ option?

In our latest Q&A with leading law firm Brabners, corporate law and dental specialists Eugene Pena and Kirsty McKenzie-Hopkins weigh up the pros and cons.

Niche area of law

On average, dental sales and purchases take around six months to complete. However, this can be extended by a range of external factors, so a deep level of understanding and forward planning is key.

Law, like dentistry, has its specialist areas. The rules and regulations affecting the dental industry can be subject to change at both national and local levels. Instructing a specialist dental lawyer ensures that the advice you’re receiving is in-line with the most up to date law.

Dealing with complexities

There are also many dental-specific complexities during the buying or selling process that only those with years of sector expertise will know how to navigate. These include the transfer of NHS contracts from sellers to buyers, ensuring that the correct CQC (Care Quality Commission) applications are carried out, the transfer of capitation schemes and conducting due diligence.

For buyers, entering into an agreement without asking the right questions could be a costly mistake. It’s critical to take due care in reviewing all documents thoroughly. Any terms that are out of the ordinary in a standard general dental services (GDS) contract will be picked up by specialist dental lawyers, who review these regularly.

For sellers, the need to respond to specific questions about the NHS, CQC and capitation schemes is very common.

Providing tailored advice

A specialist dental lawyer will ask the right questions — tailored to your specific circumstances — and will ensure effective collaborative between you and your legal team. This is essential for smooth transactions. If issues arise, you need a legal team that can draw on its experience to get all parties back on track.

High street lawyers with little or no experience in dental practice sales and purchases may take longer to understand the process and suggest an appropriate strategy. This could cause huge delays, spiralling costs and ultimately jeopardise transactions.

Before you instruct a lawyer, think carefully about the level of support and experience you need.

How we can help

We are proud to provide market-leading legal solutions to dental practices across the UK. Our dental team contains true specialists who understand the unique pressures you face.

We play an active role in the market for dental practice sales and purchases, working alongside third-party brokers to ensure smooth transactions. Advice is provided across multiple specialist practice areas, including practice sales and acquisitions, property acquisition or leasing, property disputes, regulatory (including a CQC application service), fitness to practise, litigation, international recruitment, employment and litigation.

Talk to us by calling 0151 600 3000 or complete our contact form and have a member of our team get in touch.

Following the news of an urgent recall of emergency oxygen cylinders from one supplier, Hewi Ma of Brabners LLP writes a Q&A blog on the topic, especially aimed at a buyer or seller, in the present timeframe.

In the third of her series of articles for GDPUK, Hewi Ma of Brabners Solicitors discusses employing overseas workers.

In the second of her series of articles for GDPUK, Hewi Ma of Brabners Solicitors discusses common legal pitfalls in the business of Dentistry.

Jeremy Hunt revealed the contents of his 2023 Budget in the House of Commons last week. Amongst announcements on household energy bills, free childcare and corporation tax, the Chancellor unveiled surprise changes to the pension tax regime that could benefit anyone who is a higher earner.

In the first of her new series of articles for GDPUK, Hewi Ma of Brabners Solicitors discusses common legal pitfalls in the business of Dentistry.

Practice Plan Head of Sales, Zoe Close, talks to CSR expert and coach, Mark Topley, about the part CSR can play in helping practices beat the recruitment and retention crisis.

Donna Hall examines what practice teams need to look at when choosing the right plan provider to work with.

In this GDPUK exclusive interview, Guy Tuggle talks to Dental Therapist Eleanor Ridge about her recent trip to Malawi with Dentaid.

Suki Singh talks to dentist and Head of Indemnity at the BDA, Len D’Cruz, about the inevitability of complaints and how to prevent them from escalating.

Paul Barnfather, Specialist Dental Financial Adviser for Wesleyan Financial Services, shares how there is a cost when delaying financial planning for retirement.

Your NHS dentistry and oral health update

19 July 2022 (Issue 50)

An update from Sara Hurley and Ali Sparke

Amongst the many salaries that your GDC registration fee helps to fund is that of Daniel Knight. He has the title of Stakeholder Engagement Manager, where he leads on student and new registrant engagement.

For far too long, relations between dentists and their regulator have been fraught, to say the least.

This may be a situation that in practice suits the GDC very well, but appearances matter. In November last year, the General Dental Council [GDC] revealed the results of some research that it had commissioned. The aim was to ascertain dental professionals’ views on the GDC. It would be very reassuring for GDC leaders to be able to demonstrate that criticism of the regulator comes from a small and unrepresentative section of the profession. The results did not fit that narrative, indeed the GDC, experiencing a moment of insight, commented that the findings “don’t make comfortable reading.”

As reported on GDPUK at the time, negative perceptions of the GDC had actually risen from a bad 45% in 2018, to a worse 58% in 2020. To add to an already grim picture, responses also showed that over time, an increasing number of respondents felt that the GDC was actually getting worse. The finding that “students were more likely than dental professionals to associate positive words with the GDC”, could be said to offer evidence that the more dental teams came into contact with the GDC, the less they liked it.

By the GDC’s standards a veritable charm offensive followed, with Chief Executive Ian Brack and Executive Director Stefan Czerniawski explaining how they would be working to improve matters. It was announced that the recently installed Chair, Lord Harris, was starting his term by meeting key stakeholders. With the vast majority of UK dental care delivered in general practice by general practitioners and their teams, an outsider might expect that this would be reflected in some of this activity.

Since taking over from Bill Moyes, Lord Harris has written four blogs for the GDC which have been sent with its periodic emails and are also available on its website. In his first blog there was indeed reference to meeting some of those key stakeholders. He had met the English CDO, as well as the BDA, BADN and SBDN and been at the launch of the College of General Dentistry. He went on to express the view that “professional regulation is a privilege”.

By the time of his next blog Lord Harris had met the CQC and HCPC (Health and Care Professions Council) and was looking forward to meeting COPDEND and the Dental Schools Council to discuss education. He added that his belief that we should see (presumably the GDC’s) regulation as a benefit, had been reinforced.

The third blog announced a programme between January and April of meeting students and trainees which would be an “opportunity to hear from students in the early stages of their dentistry careers.” There was also a section about the benefits of regulating the whole dental team. He added that he would “continue to meet representatives of the dental professions in the next few months”

The beginning of February saw publication of the fourth blog. Lord Harris had now met with Healthwatch, and rightly pointed out that “understanding the views of patients and the public is critically important”. “However” he added, “the GDC also wants to engage with people at the start of their career in dentistry”.  They had met nearly 400 students and trainees, representing dentists, hygienists, and therapists, and were “finding them helpful to build understanding of our role and hear from members of the future dental team”.

GDP’s are trained to be observant, so readers will have spotted by now that in relation to the amount of care delivered, they barely register on Lord Harris’s radar. There was also a focus on those younger team members who the GDC’s own survey had revealed, were the group with a less poor opinion of the GDC.

Following publication of Lord Harris’s fourth blog, GDPUK contacted the GDC’s communications team with an enquiry about the Chair's meetings with GDPs and related groups. To provide some context, emails to the Department of Health and NHS England on the day of the 50 million dental funding were all answered within a couple of hours. If a respondent was unable to help they suggested a suitable colleague. It did not take long to get an answer that specifically dealt with each section of our request. GDPUK also asked the BDA about meetings with Lord Harris. A comprehensive reply came within 90 minutes.

With absolutely no response from the GDC, a follow up email was sent the next day. With the same result. After 3 emails sent on separate working days, and not even an acknowledgement, a colleague who has had similar difficulties provided an alternative contact to the one on the GDC’s website. Finally, a response confirming that our emails had been received came within a couple of hours, and not long after this, another GDC official provided their response to our enquiry. The Chair would appear to have had a busy diary which will continue over the coming weeks with many meetings. The most GDP related one to add to those in his blogs would appear to be the Association of Dental Groups (ADG). Scheduled were meetings with professional bodies including hygienists, therapists, dental technicians and dentists as well as indemnifiers.

To be fair to the GDC, when a subsequent enquiry was sent, it was responded to the following day.

GDP’s may be left wondering whether following last years uncomfortable feedback, the GDC’s chosen approach to them is one of engagement, or quarantine.

We need to talk about how dental practices manage their enquiries. Unfortunately all too often they are not treated with the attention and nurturing they deserve. 

Let me explain what I mean by that in 4 simple steps…

Over the past 20 years, I’ve been working within the UK  and American Dental Industry to support dental practices growth through a number of different engagement and marketing strategies. However, over the last couple of years, I’ve noticed that something has drastically changed.  Suddenly getting new, high-value patients has become increasingly difficult, expensive and confusing. So what’s happened?

Some truths for NHS dental commissioners

A personal opinion, by Michael Watson.

Where I live, on the borders of Essex and Suffolk, has gone from a quiet rural community where dentists just got on with the job of treating their patients to the centre of a movement, Toothless in Suffolk, which aims to go nationwide as Toothless in England.

Two of their aims are to have an NHS dentist for everyone and reforms to the NHS dental contract that will encourage dentists to provide NHS treatments. Both of these will require more associates, who to put it simply are not there.

Throughout 2021, the British Dental Association [BDA] has been at the forefront of moves to tell politicians of the challenges facing dental services across the whole of the UK. It joined with Healthwatch England in calling on the Chancellor to provide vital funding for the recovery and rebuild of services, a move backed by 40 cross-party MPs.

David Hallsworth, a solicitor at BLM specialising in healthcare claims, discusses a potential surge in future dental claims as a result of thousands of children missing crucial check-ups during the pandemic.

Backup is without doubt the most important element of your IT Infrastructure, without a robust backup process in place in your practice your patient data is at risk, and if you lose your patient data, your whole practice is at risk – 60% of businesses that lose their data close within 6 months

For the last 18 months I have been campaigning to get the government to change the policy to stop giving out dried fruit as part of the School Fruit & Vegetable Scheme.

GDPUK news was one of the first places to publish details about Raisin Awareness.

Following on from Marcus Rashford's incredible #EndChildFoodPoverty campaign, Sustain are lobbying for the School Fruit and Vegetable Service to be extended to include Key Stage 2 pupils so that it will reach all primary school children.

Campaigners celebrate reinstatement of school fruit and veg - Sustain Web

Public Health Minister Jo Churchill said to journalists that the School Fruit and Vegetable Scheme will resume as normal in Autumn when all children return to school. While we wait for official confirmation, this is not the end of the campaign for more fruit and veg in schools. The scheme should be expanded to all children in primary school and improved to include higher standard British produce.

www.sustainweb.org

Now that Sustain are calling for the expansion, I am asking the dental bodies to add their voices, and suggest that together we can approach the called-for extension as an opportunity to raise dental concerns and make this positive change at the same time. I'm hoping that we can use this to eliminate the dried fruit, if and when the scheme expands.

Sustain are delighted to get dental bodies involved, and have agreed to rewrite the calls to action to include dropping dried fruit from the SFVS scheme, and I have drafted a new version with Nigel Carter. We will also be detailing this in a joint letter to DHSC & Department of Education.
Many dental organisations including BDA, BSPD, OHF, BADN, BSDHT & BADT have offered their support.

In my correspondence with Jo Churchill at DHSC I was informed that their stumbling block is delivery logistics (the reason they say that they cannot swap from dried fruit).

I am currently arranging local vegetable delivery to my village primary school (on those 6 raisin days a year) with the hope of reproducing nationally - to overcome this. I am planning to use the Sustain network of local vegetable growers and sellers to provide the national supply web needed, whilst getting dental practices to link up to primary schools to initially pay for this veg and also long-term to input Oral Health Education.

I know that this can be overcome if we are determined.

I wonder if you, the GDPUK community, would also consider supporting this as a collective and as individuals?

There will be a number of ways you can get involved - look out for specific details of what and how in a series of articles coming out in the dental press, and I will also keep you updated with this blog.

If we can’t change it from the top down, let’s do it from the ground up.

Jo Dawson

Christmas Was February

Christmas Was February

As a committed Labour Party member it is quite something to be impressed by a Conservative Party Minister and Secretary of State for Health, but I have to say this is precisely the case. The recently published proposals on fluoridation represent a clear intention to act. There’s a lot of talk around reducing inequalities and levelling up but precious little action. This is different, it’s a clear intention to support communities and improve oral health and preventing the consequences of poor health, pain, sleepless nights, extractions, poor self-esteem.

Goodbye Lansley - Ministers to retake control of NHS

Last Friday (Feb 5) Health Policy Insight published^[i] the draft of the Government's forthcoming White Paper on Health, which was reviewed extensively in the media over the weekend. The main news in it for dentistry was that the paper included proposals to hand over control of water fluoridation to the health secretary and away from local councils. The move was widely welcomed in the profession especially by the CWF network (@network_cwf), the national organisation of dentists supporting water fluoridation.

Andrew (now Lord) Lansley’s 2012 reforms, when he was health secretary, handed control of the measure to local councils, which led, in October 2014, to a decision by Southampton City Council to scrap plans to fluoridate its water. This followed a vigorous campaign by ‘Hampshire Against Fluoridation’ and tentative plans to introduce the measure in other areas such as the North West of England and Hull were quietly dropped. Speaking in the January 14 Commons debate on dental services during Covid-19, health minister Jo Churchill said she was ‘extremely sympathetic’ towards the measure, so we may expect its revival perhaps.

In his report^[ii], the late Professor Jimmy Steele said the first priority of any NHS system should be ‘a strong, co-ordinated public health system’, something that has not been possible with it being devolved to individual local councils,

The Lansley approach, which was controversial in the Conservative/LibDem coalition, was to take power away from ministers and put it in the hands of administrators. NHS England was given ‘power without responsibility’ to quote Stanley Baldwin’s description of the press in the inter-war years^[iii].  But Ministers were still held accountable to Parliament for the NHS; ‘responsibility without power, the worst of all worlds’ as then Home Secretary David Blunkett, described it in 2002.^[iv]

Without going into any detail, the document says there will be ‘enhanced powers of direction for government’ to ensure that ‘those overseeing the health system’ are held to account. For dentistry this could mean that the focus moves from NHS England’s obsession with delivering UDAs to MPs’ demand that anyone who wants to see an NHS dentist can do so - a shift from activity to access.

Secondly the Lansley approach was to promote competition within the service, hence the over-long process of commissioning new services, typically a year or more and, arguably, the botched orthodontic recommissioning exercise.

The pandemic showed, though the commissioning of urgent dental care practices, that the NHS can move rapidly when circumstances demand and so it should be in the future.

In responding to the January 14 debate, health minister, Jo Churchill said that ‘a transformation in dentistry is necessary.’ She continued: “There is a huge opportunity to deliver a greater range of health advice monitoring and support, using dentists and their teams.”

The demise of the Lansley system could give her the opportunity to achieve this.

 _____________________________________

^[i] http://www.healthpolicyinsight.com/?q=node%2F1699

^[ii] NHS dental services in England: An independent review led by Professor Jimmy Steele, June 2009

^[iii] ‘power without responsibility – the prerogative of the harlot throughout the ages’, Stanley Baldwin speech on newspaper proprietors March 17, 1931

^[iv] Speech by home secretary, David Blunkett to Labour local government and women’s conference Cardiff, February 2002

A wake up for dental prevention, COVID is worse for patients with periodontal disease.

We are all (well most of us!) now actively involved in prevention and risk assessment. 

We stay at home, keep our distance, wash our hands and wear masks.  We know some people are at higher risk of serious complications and death from COVID than others, so we shield the elderly and those who are clinically vulnerable, and we require our medics, dentists and care workers to wear PPE and engage in comprehensive disinfection routines to protect them and their patients from the close contact they have to have in their essential work.  Our vaccination programmes have initially been targeted at those who, by nature of their inherent risks or lifestyle risk factors, are in most danger. 

It is the coming of age of risk assessment and prevention, a time when the public accept that the inconveniences of doing the right thing are essential to ensure a better future.

I strongly believe that NHS dentistry post-COVID will take on this challenge: the one that says prevention comes first, and to prevent you must first to know your susceptibility and what you personally can do to protect your health.  Treatment is a fix, not a cure and whilst essential to get patients out of pain, should not be the focus of a modern health service.  Advanced restorative treatment on an unhealthy periodontium should not be paid for out of the public purse. 

A study has just been published from Qatar on the impact of perio disease on COVID outcomes.  Qatar has electronic health records containing medical and dental data (definitely something for the NHS to aspire to!) which facilitated the analysis of confounding factors.  To quote the press release here:

 The case control study of more than 500 patients with COVID-19 found that those with gum disease were 3.5 times more likely to be admitted to intensive care, 4.5 times more likely to need a ventilator, and almost nine times more likely to die compared to those without gum disease.

Blood markers indicating inflammation in the body were significantly higher in COVID-19 patients who had gum disease compared to those who did not, suggesting that inflammation may explain the raised complication rates.

Professor Mariano Sanz, one of the study’s authors, noted that oral bacteria in patients with periodontitis can be inhaled and infect the lungs, particularly in those using a ventilator.

“The results of the study suggest that the inflammation in the oral cavity may open the door to the coronavirus becoming more violent,” said Professor Lior Shapira, EFP president-elect. “Oral care should be part of the health recommendations to reduce the risk for severe COVID-19 outcomes.”

Causality, which is very difficult to prove, is not claimed here, and as always, whilst confounding factors have been adjusted for, those with perio disease often also have other health issues. Maybe the periodontitis is just a manifestation of a tendency to inflammation, and the COVID response simply results from that.   However, the evidence for periodontal disease raising your risk for other systemic diseases is indisputable and growing.

The crunch is this:  gum disease is the easy part to deal with: it is not invasive, expensive or harmful.  When you can stop the disease in its tracks, why risk COVID complications?  Why accept the heightened discomfort and dissatisfaction with your teeth, and the tooth loss that results from periodontitis?  Knowing that gum disease is associated with diabetes, CVD, kidney disease, dementia etc, why would the susceptible patient not choose health over bleeding?

Now is the time to talk prevention: to explain to the susceptible periodontal patient how they are more vulnerable than others in the population; to identify and share the lifestyle factors which put them personally at risk of the disease; to explain the potential impacts on their systemic health, and persuade the patient that it is up to them to take the decision to work with you to take charge of their future. 

Liz Chapple

OHI Ltd, UK provider of PreViser and DEPPA technology

www.previser.co.uk

Hambley Trading Limited are looking to supply dental professionals, experienced in the delivery of local anaesthesia to patients, example prototypes of the SINCRO^TM system for them to examine and assess and compare with their current choice of syringe delivery device.

A questionnaire relating to the handling characteristics may be completed and returned electronically which will entitle the respondent to a FREE box of SINCRO^TM [50 syringes] after the device is launched into the UK dental market.

For a limited number of early respondents there is also the chance to be awarded a £25 Amazon gift voucher, so get your response in quickly.

The marketplace

We all, I would like to think, got into this profession for the reason of trying to help others and improve the health and wellbeing of patients. If we were in it solely for the money, there are plenty of other professions that can give the financial rewards without the types of stress that we face on a daily basis from all aspects of our wonderful profession.

Before I continue, I should note that yes of course we all need to make a living and there is nothing wrong with wanting to earn more. That is not my concern here, but more that I am worried that we are starting to see our patients as customers, and therefore trying to sell them a product rather than provide a health service.

A recent dental conference I attended had a stand hosting a lecture titled ‘How to earn an extra £100,000 a year through facial aesthetics’. Now my issue here is nothing to do with facial aesthetics at all, it could just as easily be swapped with dental implants, short term ortho, smile design or whatever aspect of dentistry one may be more interested in. For me, it’s more the headline like that got me thinking - are we becoming ever more financially driven and could this lead to us ‘selling’ patients treatments or rather a product they may not necessarily want or more importantly need. We are all part of the health care sector but are we making dentistry into an industry more than ever and forgetting that it’s actually a profession? I’ve even heard of undergraduates taking external courses on ‘how to sell private dentistry’ when they haven’t even passed their licence to cut exam yet so if that is the motivation from such an early stage, is there cause for concern?

There is already a misconception by members of the public that dentists are there to take patients money, so this made me think that we could be adding fuel to the fire.

This is not aimed at people wanting to be a successful practitioner and earn a good living or run a profitable practice, it’s a general concern about our profession losing its way a little bit and putting profits above patients.

We have all seen those cases on social media whereby unbelievably invasive dentistry has been carried out at both a financial and biological cost to patients, when really a much more conservative treatment plan would achieve just as good if not better results. I’m sure many of us have looked at those cases and thought that clearly there has been a financial objective here as why would a well-informed patient actually consent to some of these treatments.

That’s not to say that patients don’t have the right to elect to do these types of treatments and of course maintaining patient autonomy is key. However, with the continuing role and influence of societies’ obsession with achieving the perfect aesthetic (in many aspects not just dentistry), are we being lured into this type of dentistry by the financial gain and compromising our moral obligations to our patients? Is the ‘Love Island effect’ or the role of ‘social media influencers’ (not just celebrities but even dentists these days too) starting to influence us as dentists, not just our patients?

"Sunday in the City 338" by Carl Campbell is licensed under CC BY-SA 2.0

Medieval

The General Dental Council’s work in disciplinary matters is sometimes not fully understood by dental practitioners. The revelations over the past few weeks that the GDC is registering overseas dentists as dental therapists without a thorough check of their practical abilities, that they withheld evidence which resulted in a fraudulent dentist being restored to the dental register, and that they have used private detectives to entrap registrants, has opened the GDC’s registration and disciplinary processes to close scrutiny. These recent stories on the GDC suggest those disciplinary processes to be more mysterious than ever.

GDPUK has been fortunate in being given the opportunity to speak frankly with a recent ex-member of the GDC’s Fitness To Practice panel, which helps determine the professional fate of over 112,000 registrants.

Peter is a clinician with over 28 years of experience in dentistry. He is currently working full-time in private and NHS practice. We have been asked not to reveal his identity.

It sounds like a lot of hard work. What made you want to serve with the GDC?

Serve? An interesting terminology there. The GDC has the statutory function of regulating the profession and whilst to many it seems odd, I wanted to be a part of this. Someone has to do it. I thought it might as well be me. You can stand on the outside and criticise, or you can be on the inside and see how the machine really works

Briefly, what were your duties on the committee on which you served? What is the makeup of the committee on which you served?

I sat on the Fitness To Practise panel and as a consequence, you sat on all the statutory committees. They are independent of the GDC – which is a challenging concept, given the GDC writes the committee guidance. On the FTP panel, you read, listen to and evaluate evidence presented. The civil legal standard is used so you find evidence on ‘the balance of probability.’ I personally believe it should revert back to the criminal standard. Beyond reasonable doubt stops charismatic barristers winning you over.

What training do committee members get?

It really isn't as intense as it should be. There is far too much concentration on ‘soft skills,’ such as communication and people skills, rather than legal understanding. I often felt it lacked any real depth. That said, the whole selection process is (allegedly) designed to select individuals that are able to carry out the workload. I personally doubt that, and feel the recruitment process is biased since the GDC seeks to ensure diversity. That aim is incredibly important since the profession is diverse, yet there is a part of me that is convinced that the recruitment process is flawed for this very reason

What sort of cases did you hear?

I heard cases involving all classes of registrant. They were, in broad terms, clinical or criminal. In addition to this there are health cases. Some were easy, some were extremely challenging due to the nature of the allegations.

Did you feel the cases brought before you were justified?

Ah, well, that’s a very difficult question to answer. In some cases yes, in others, no. When a dental professional is convicted of paedophilia then there's no discussion, but when a registrant is in front of a committee with a huge list of allegations that were clearly gained after the original index complaint, then it becomes difficult to clear the mind. The committee can only hear the evidence presented to it (alongside the allegations) yet I personally struggled with the concept. Indeed, in some cases (more than ever should have been) the original index complaint never even made it into the hearing. This conflicts with my personal sense of justice. The GDC managing to amass a long list of allegations based on its investigation was, and remains, of concern to me.

There are some criticisms that caseworkers can be over zealous when preparing ‘charges’ against registrants. Are these justified?

My personal issue with the caseworkers is that they lack any real knowledge of the profession. It can be reasonably argued that they don't need it to just list allegations, but this argument is fundamentally flawed as their inability to understand what is important and relevant is only dictated by guidelines they work to. The system is evolving with dental professionals now involved, but it is currently still lacking serious input

Do you think the makeup of committee’s is balanced and makes for a ‘just’ system?

Committees have to contain various elements in order to make them work. Prior to 2003 the ‘old school tie network’ led to many cases that were serious, failing the patients. There was a time when committees sat with five members. Nowadays, because of cost-cutting, it is invariably three. (The cost per day, per person plus expenses, is considerable). A three-person committee is unbalanced. It comprises one Lay, one dentist and one Dental Care Professional (DCP). One strong individual can influence the other two in my personal experience and a dominant influence means the case will fall their way. It's inadvertent "bullying" and this is why there is a focus on soft skills in the training process. Reverting to the criminal standard would eliminate this bias and mean that an individual’s influence would be more difficult to exert. It's either that or revert to ensuring committees sit with five members. One strong personality has to try much harder to convince four other members of his view.

Do you feel that decision making is hampered by Lay people?

No. The Lay perspective is very important BUT this must be balanced. I have already suggested that a strong personality can influence a committee. The Lay person is potentially the most at risk yet, again, a five-person committee would reduce this bias.

Quite often, registrants complain that they can also face ‘dishonesty’ charges in addition to the main charge – why are these added?

The dishonesty allegation actually tends to be a "collection" of allegations. It seems to arise from (again) expert evidence where the report writer may suggest that a "thing" couldn't have happened. It tends to be termed ‘inappropriate,’ ‘misleading’ or ‘dishonest.’

This to me seems to be a ‘get you one way or another’ allegation. They are usually listed as individual allegations that seem almost a snare. The GDC has to work to the remit the Professional Standards Authority decides and that overarching organisation seems to take great store in allegations that demonstrate dishonesty. Apparently, it is extremely difficult to remediate someone one who is dishonest. I'll let people make their own minds up on that aspect, but will say, to err is human.

Do you feel registrants are treated fairly in the FTP process?

Yes. Whilst to many from the outside it seems a draconian process, as a tribunal it has to follow English law. It is a quasi-judicial committee and it relies on expert input. As a committee member, you are not party to the build-up of a case but as a process, it is probably far too protracted for the comfort of a registrant.

Is it justified or necessary to go outside the index complaint and delve into all aspects of a dentist’s practice?

In my opinion, no. Now, if there was a very obvious risk to patients then certainly. But one complaint of a seemingly simple problem seems to lead to an escalation of the issues by ‘investigating’ the individual. I personally believe that if the index complaint falls away then the investigation should be stopped. This is not a criminal court. It has no powers other than to stop someone practising dentistry. But, and this is where I struggle, many employers may ask if you have ever been subject to an investigation. It won't appear on any criminal record but you would have to declare it - potentially ruining someone's future prospects because they failed to record someone's smoking habits.

Do you feel lay members fully understand the seriousness of their decisions on the registrant?

That's extremely difficult to answer. I have worked with some outstanding people and a few challenging individuals. One thing they have to learn is that, the consequence of a previous decision needs to be put aside by committee members. You can't let previous decisions regarding a registrant influence your decision. An example would be a registrant convicted of fraud in criminal court, but you are not convinced they were as guilty as the court found them. You must take it at face value. As a committee member you can't hide behind a previous verdict and you can only base decisions on the facts presented.

I think it is important to remember that some Lay members are, in essence, professional committee members and may sit on several tribunals and be extremely competent in what they do. That has a flip side, because a ‘professional’ Lay person then ceases to be truly ‘Lay.’

Did you ever feel that you your views were disregarded or overruled by the GDC or other members of the committee?

Yes. But that isn't always a negative. The whole point of having a minimum of three people sitting is so that a majority decision can be made. Your opinion will be heard but not necessarily agreed on. The GDC never influenced my decisions other than the published guidance (which is a separate question).

Do you think the GDC is currently fit for purpose with regard to disciplinary matters?

It is very easy to be critical and I think we are no different to our nursing/medical colleagues regarding professional regulation. By that I mean as long as there is a process whereby a professional’s conduct is questioned then no one will be happy. I have already raised some points regarding this. I do find it very bizarre that committees sit and hear evidence even though a registrant has said they are not going to attend/engage and indeed, are no longer working within dentistry. I once asked the GDC about the costs of a case, in 2009. A three-day hearing for a dental nurse who was never going to attend (she had actually written in saying they could ‘stick’ dental nursing), yet the committee sat and suspended her for 9 months. It cost in excess of £50k to hear this. I never followed up the individual after the period of suspension ended. When this happens (another area that is far too common) then no, it isn't fit for purpose. That was (at the time) the equivalent of the ARF of 50 dentists.

There is another area that makes me question the ability of the GDC to consider itself fit for purpose. This relates to the whole world of eggshells that is inclusivity and diversity.

The drive for diversity and inclusion is extremely noble and proper but shouldn't be a reason to put people in to the role that are essentially carried by more illuminated individuals on panels. The drive to hit inclusivity targets has skewed recruitment into the role rather than ensuring individuals have the ability and capacity to deal with the huge amount of information they are fed"

Do you think the source of complaints has changed over the years? Are there more fellow registrants reporting on their colleagues as ‘whistleblowers?’ If so, what do you feel their motivations are. Could you estimate the proportion of patient-generated complaints vs dental professional-generated complaints vs those brought by health authorities?

I despise the term "whistleblower" but I do genuinely think that motives vary. They go from genuine concerns, to vexatious ex-employees, to other motivations. There was a time when it wasn't the done thing to criticise another individual’s work. I don't necessarily think this is right but I do think there seems to have been a drop in professional discretion. Simply criticising some previous work for personal gain is shocking.

A committee isn't there to judge whether a complaint is based on that, but you get some that come through and you know that the motivation was all wrong. Vexatious ex-employees should be simply filtered out. Part of the problem is that if someone decides to raise concerns then invariably mud is slung from one side to the other. This leads to bizarre accusations that damage everyone involved.

I think genuine concerns regarding safety of patients is important but those involved in the very early stages of a complaint should be more robust in filtering. When a legal firm is the initiator of a complaint then surely alarm bells relating to a litigation process should be sounding in the GDC s ears.

Do you believe that radical changes are necessary in the GDC? If so, what?

I'm not sure there is a need for radical change. Perhaps what is really needed is consistency. If you look at the turnover of staff at all levels then you realise there is a distinct lack of consistency in the executive function of the regulator. That can only lead to confusion over time.

It's a bit like Chinese whispers I guess. Over time, interpretation of the way things SHOULD be done, is diluted. That said, I am still puzzled why any dental professional would contact the GDC for advice on any matter other than their ARF. The shake-up maybe needs the GDC to again tell dental professionals they do not give advice. Go on, give them a call and ask for advice on something and they give it... especially interpretation of guidance. The only folk you should contact are your indemnity company

Despite the GDC’s stated intentions to reform their disciplinary processes, do you feel they will effect change?

I think change will be forced upon them. I think this is a little similar to something I've already said, without consistency then change will just be a hand grenade that will just cause mayhem. It also depends on what reforms they actually can make. What us registrants want would be very different to what they are allowed to do. The Professional Standards Authority is not blameless in all this. They (the PSA) have instilled a sense of fear in the executive function of the GDC by essentially threatening judicial reviews when it disagrees with a committee’s decision. They are the watchmen watching the watchmen. If they don't like something then they choose to challenge it. Change must happen top down, not bottom up

The GDC has recently been criticised for:

1. Registering overseas dentists as dental therapists without examining their practice skills
2. Withholding evidence from a PCC which resulted in a dentist wrongly being allowed back onto the register
3. Using private investigators to entrap registrants into acting outside their scope

What are your views on these recent controversies, if any?

The GDC should really hang its head in shame over certain aspects of these three areas.

I have read online discussions regarding all of these and have (unsurprisingly) formed an opinion on all three.

With regard to the registration story I read, it suggested that the GDC see no risk from registering overseas trained dentists as dentists despite the fact they may have failed aspects of the normal route of entry on to the register as a dentist. ‘Shocking’ is my only response. How long will it be before such an individual is in front of a committee? Will the committee have the kahunas to criticise the GDC for this? (Committees can criticise the GDC, I once sat on a case where we did and, as was stated in the determination, we would have awarded costs against the GDC if we had the power).

I sat on several cases where private investigators were used. I was always extremely uncomfortable with this process but was assured it was perfectly legitimate to attempt to get a professional to offer something they're not allowed to do. It feels wrong...very wrong and should be stopped and indeed, in cases where this evidence was used, I feel the cases should be re-sat without this evidence.

I'm no lawyer but withholding evidence is surely a miscarriage of justice? Remember it works both ways. In the case that has been highlighted, it has been demonstrated that all is not well at the GDC. Withholding evidence to prevent a hold (adjournment or postponement) is damaging to all parties involved. It's interesting how the GDC has been extremely quiet in not responding to enquiries in this and other areas. That is worrying because stonewalling only increases suspicion.

Do you believe the GDC uses the ARF money effectively?

I have never analysed the GDC accounts although there are many that do. I   think there may have been some mismanagement many years ago which left the GDC in a predicament. That aside, the ARF is, for all registrants, far too high. A dental nurse whose skill set is not comparable to that of a general nurse, pays far more yet is probably paid less - shocking and the hike up for dentists was shocking. The GDC is not ostentatious (any more) when providing lunch or accommodation so those outside the organisation that criticise this should be careful. The attempt to reduce costs is noble, but perhaps not severe enough.

Do you believe that it is difficult for individuals to effect change from within? Does the government need to take a role in regulation?

The GDC is attempting to reform but as an outsider it is easy to criticise. That aside, they really only have themselves to blame given that they choose not to answer enquiries and using underhand methods to gather evidence instils no confidence. They perhaps need to be open about their dealings with ministers and health ministry officials and about how they have to engage in order to ensure that the guidance they give reflects the changing nature of dentistry.

Endless consultations seem to only attract a certain type of individual to respond and they will never get a balanced response because that nineteen year-old dental nurse who works from 8 to 8 for £9 per hour just couldn't give a toss. And when she is called in front of a regulator that she isn't aware of other than they want money off her annually, she will just go and do something else if called before a committee. Who wants that stress when you feel like you're the bottom of the pile and getting paid peanuts? You are understandably not going to care. That is possibly where the GDC could easily reform. Look at how it manages dental nurses and dental technicians.

Employees and ex-employees often describe the atmosphere within the GDC as ‘toxic.’ What is your view?

I wasn't an employee. No FTP member is, so my fleeting visits to the various GDC locations would not give me an opportunity to assess the working environment adequately. But I do take websites that people post these comments on, with a pinch of salt. A vexatious ex-employee may put toxic postings on just to be mischievous or air a grudge.

Why did you give up your role with the GDC?

I realised that I had "done my bit" it is very easy to stagnate in the role. I think I intimated earlier, that there are essentially professional committee members. They're not all Lay. Whilst it is important to have a broad church on committees it is somewhat bizarre that academics and non-clinical registrants are making decisions about care standards in an aggressive UDA system or on private practitioners just trying to earn a living.

Now you are no longer involved with the GDC, do you have any views on the current state of regulation and the ‘fear’ that is said to be gripping the UK’s dental professionals?

Neglect, fraud and certain things need addressing for sure but sanctioning an individual for a speeding offence really pushes the remit. The GDC says these committees as not punishing individuals but I beg to differ. Suspend an individual for a year and you have denied them their income. These sanctions are punitive in even the simplest form. It was becoming, and continues to be, farcical – leading to protracted hearings for trivial matters that should be dealt with locally.

Back to the subject of reform, the GDC perhaps should engage an ombudsman in more cases to decide what the complainant REALLY wants. If it is retribution or just a matter of "where there's blame there’s a claim" then that doesn't protect the public. Look at the length of determinations for even trivial matters, amazing. The Professional Standards Authority forced that. No, I don't want to be a part of that anymore.

With regard to the culture of fear that has developed in dentistry over recent years - the professional indemnity companies are not playing ball either. Their fees are extortionate yet they have the audacity to criticise the GDC. In 28 years, I have had to contact my indemnification company just once. I wasn't impressed.

I actually believe the indemnity companies are mostly to blame for the culture of fear. Their courses are toxic and full of fear. “If you don't do X or Y then the GDC will have a case.” Having watched many, many cases I can hand on heart say, I often shook my head at the really useless arguments they would instruct the barristers to present. They use ‘expert’ evidence to counter GDC evidence rather than peer to peer evidence. The experts are invariably academics or specialists that are way out of touch with the pressures of general dental practice. There is a massive disparity there.

Finally, I would sometimes find the hypocrisy at the GDC amazing. The biggest example that STILL irks me to this day is in the Maintaining Standards document pre-2006. It clearly stated that “a dentist must not work to a target driven standard.”

Because of the new UDA-based contract, the GDC had to make sure that particular passage wasn’t included in the guidance following the introduction of the new contract.

And the GDC is independent of Government interference you say?

Image credit - Stefan Jurca under CC licence - not modified.

>A High Court Judge has criticised the General Dental Council’s Professional Conduct procedures after highlighting a “serious procedural irregularity” which allowed a fraudulent dentist to be restored to the dental register.

The Charity helps dental students, dentists and their families when they face hardship, supporting those who do not have the funds to pay for some of the normal things in life, ranging from contributions towards food and daily living costs, funds to improve the quality of life for those retired due to ill health, to more specific needs like paying someone’s annual retention fee or indemnity, to help them get back on their feet and into the profession.

For many years Hull LDC stayed away from the national conference of Local Dental Committees (LDCs). Our preconception was that whilst the Conference might be good for networking, it punched below its weight. We were wrong.

LDC Conference is a fantastic forum, which provides the opportunity to debate Motions, to come to a consensus and to influence policy. In 2017 we saw the light and we decided to table a motion suggesting that we should solicit the support of Local Authorities for water fluoridation as part of Starting Well (SW) Programmes in relevant areas. We were basically “dipping our toes” in the (fluoridated) water. After all, SW is about investing in programmes targeted at the 13 worst areas for child dental health in England where need is greatest, including our “back yard”  - Hull.

The result of this motion was that it was supported by Conference – but not unanimously.

We’ve learned a lot along the way – including the importance of making the motion clearer which would have helped to avoid the voting result. Some delegates wanted CWF included as a short-term strategy!

The LDC also started to use the letters pages of the excellent BDJ to get their messages across. In response to a letter from Paul Connett of Fluoride Action Network¹ Hull LDC² highlighted the lack of credible evidence for his points that fluoride at 1ppm is chemophobic, neurotoxic and toxic as well as the emotionally charged language. This letter exchange was two and half years ago and   similar “tactics” remain the thrust of the Fluoride Action Network^3,4 position on CWF.

In 2018 we decided to build on the first motion and call for funding reform for CWF- because Councils simply don’t have the resources to implement schemes following years of central government budget cuts. This is also fair because as the motion explains, the majority of the return on investment⁵ falls to NHSE.

This time the motion was unanimously supported and the BDA picked up the baton:

The successful motion reflected the support for CWF at the sharp end of Primary Dental Care and created opportunities for the BDA to take forward issues generated by LDCs. Conference motions are effective and with support from the LDC community and BDA leadership, the momentum for change is building. This is huge credit to LDCs whose members work at the coalface and who over three years have supported CWF motions again and again.

The letter the BDA refers to was sent to Simon Stevens. It called for the reallocation of the recurrent costs of CWF schemes from Councils to the NHS. Interestingly, this concept was further developed in this year’s Prevention Green Paper where it was suggested that we need to look for ways of removing barriers to CWF. Councils should be encouraged to come forward and seek cost-sharing partnerships⁶.

In 2019 Hull LDC built on both of the previous motions to ask conference to support those local authorities moving forward with CWF.

Once again Conference supported the motion 100%.

At the beginning of 2019 Hull LDC began to work with the British Fluoridation Society and the BDA to form the National CWF Network. This alliance now has a large membership of dental organisations and a growing membership outside dentistry including the National Children’s Bureau (NCB). The partnership with the NCB is especially powerful, as this organisation exists to support change in society and deliver better childhood.

So we also began to learn that forming wider alliances off the back of campaigning for CWF could be powerful and effective. Working with partners or campaigning with fellowship is the way forward. The LDC national conference is a great organisation and an effective platform for change - it just took Hull LDC a while to work this out. So over time campaigning with fortitude has grown in to campaigning with fellowship.

1). Water fluoridation :Is fluoride chemophobic? P. Connett
https://www.nature.com/articles/sj.bdj.2017.198.pdf 

2). Water fluoridation: It really is this simple: Hull LDC
https://www.nature.com/articles/sj.bdj.2017.383 

3). Fluoride Action Network
https://fluoridealert.org 

4). https://ilikemyteeth.org/closer-anti-fluoride-leaders/

5). Return on investment of oral health improvement programmes for 0-5 year olds
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/560973/ROI_oral_health_interventions.pdf 

6). Advancing our health: prevention in the 2020s
https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s/advancing-our-health-prevention-in-the-2020s-consultation-document 

Removing a pair of latex gloves in a single movement with a “pop” is an art form and takes practice. Two deciduous teeth out, bite on this, a satisfying pop and I’m marching through to reception to take a call. “Mike Lennon here” said the voice at the end of the line. The last time I heard that voice was on the child dental health clinic at Manchester University way back in 1984.

So hop into the De Lorean for a quick spin. Mike, regional director of dental public health, was affectionately christened “Boss Hog” for his striking similarity to the character in The Dukes of Hazard and his straight talking. Fast-forward to 2012 and Mike, a Chairman of the British Fluoridation Society (BFS), had read my letter in the British Dental Journal and wanted to make contact with Hull LDC. The BFS as a Group are world experts on fluoridation and were keen to help and advise.

In 1984 Orwellian language, Mike talked in “old speak” and in 2012 he wanted to hear about my theory that CWF had indeed fallen in to a “memory hole”. Mike must have done something right at Manchester in 1984. Tom Robson leading the CWF campaign in the North East in 2019 is also one of Mike’s Manchester graduates. As Tom says – we all have the same hairstyle now.

Returning to the TV theme, the BFS are the Dental Public Health equivalent of the ‘New Tricks’ retired detective team. Not wishing to be age-ist, certainly mostly 65 plus but all of them with brains the size of planets and huge commitment. They have forgotten more about fluoridation than we have learned over the last seven years and, to be very honest, without them the towel would have gone in years ago. And boy they work hard at it. To say the BFS are inspirational is an understatement.

Mike was, however, a realist. Having been round the proverbial fluoridation block – the F-block - for many years he wanted to know if Hull LDC were in it for the long haul. I think we convinced him we were.

Alan Johnson was one of Hull’s MPs at the time and still the only Secretary of State for Health to state his clear unequivocal support for CWF so Mike suggested I contact him and try and set up a meeting in Hull to get the ball rolling. At this point in time the F-Word was not exactly a thought crime but it tended to be hidden in a “basket of measures” in new speak terms.

We were going for direct action – so we sent out a letter inviting local councilors to a meeting on Oral Health in the City to discuss how to improve the situation.

So in attendance at the Hull Ionians Rugby Club we had: a former Secretary of State for Health, several Councillors, NHSE Dental Commissioners, PHE representatives and this was the moment when Hull LDC made it’s pitch beside the pitch.

It was an important first step in bringing CWF to the attention of local Councillors who, at the end of the day, have the final say on policy. This is only right and proper. After all, targeted fluoridation is a local issue. The challenge for Hull LDC was describing the challenges we face daily, the poor oral health, the high numbers of child GAs, the very poor child dental health statistics, all in human terms and offering CWF as part of the solution because it is safe and effective. Councillors want to do the right thing but are also nervous about doing the wrong thing. It takes time and an attentive audience to provide the science and to reassure that most of the “googled” information needs to be critically evaluated. The best reassurance though existed across the Humber where parts of North Lincolnshire have a fluoridation scheme. As is often the case with CWF – the numbers speak for themselves.

The meeting went well and we knew we had Councillors who were supportive and understood the benefits fluoridation could and would bring to the City. But progress seems agonizingly slow, tedious and   frustrating for Dentists at the front line of Primary Care. In fact it is a necessary part of following the correct procedure and rightly so.

So, in the meantime, Hull LDC chose some direct action. We pledged to try and raise CWF at every opportunity and at any meeting we attended. So we quizzed Andrew Lansley at the BDA Conference and asked questions around fluoridation on every possible occasion. Hull LDC members attended an anti-fluoridation meeting in Hull and had the first of many encounters with the “Ministry of Truth” which bottomed out at CWF turning the public in to waste disposal units for the aluminum industry and boosting the profits of the Rockefeller pharmaceutical companies. By the end many of the more neutral in the audience were leaving incredulous. At first we were the “odd” ones at professional meetings but over the next few years we could sense that slowly but surely the F-word was no longer being avoided or whispered but was slowly making it’s way out of the basket of measures to become a single measure in it’s own right.

Slowly the “double speak “ of CWF being recognised as being one of the ten greatest public health achievements of the 20^thcentury ⁽¹⁾. but being too “hard” was being countered and challenged 2+2=4.

1. Centers for Disease Prevention and control: Community Water Fluoridation: A vital 21^st Century public health Measure

https://www.cdc.gov/grand-rounds/pp/2013/20131217-water-fluoridation.html
https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm
Ten great public health achievements - Us 1900-1999
Community water flouridation a vital 21st century public health intervention

Image credit: "retro" is licensed under CC0 1.0 

Part V - social media marketing in dentistry - Mark Oborn

Considering online marketing it's useful to look at:

• Traffic optimisation to a dental practice website, this typically includes:
  • search engine optimisation
    • On-site search optimisation using words and phrases
    • offsite search optimisation with articles linked back to your website which Google sees as votes
  • paid advertising (PPC)
  • social media marketing
  • e-mail marketing via permission-based list building on your own website
• Conversion optimisation to get more of those website visitors converting into patients, this typically includes:
  • calls to action and wording on the website
  • things for prospects to do, typically these are downloadable guides which are handed out in exchange for an e-mail address
  • e-mail marketing
  • social media campaigns

For a dental practice website to be effective in attracting the right type of new patients we need both traffic and conversions. In previous articles we’ve looked at various forms of traffic optimisation as well as conversion optimisation and e-mail marketing… In this final article we will take a brief look at social media which you may notice appears in both traffic and conversion optimisation.

Everyone knows that the best form of new patient attraction is word-of-mouth marketing, social media is simply word-of-mouth marketing on steroids. Social media gives us the ability to communicate with the widest number of people in one go.

In order to understand social media marketing and relationship building we need to understand some basic business marketing theory.

In a product-based industry (which dentistry is NOT) consumers can evaluate the product before purchasing by trying it out in the store. They can also take back that product after purchase. Marketing for a product is about encouraging the consumer to make a snap decision, product marketing is therefore special deals, offers and incentives such as buy one get one free, 50% off sale today etc.

This is what is known as transactional marketing.

Dentistry on the other hand is very definitely a predominately service-based industry. Let’s take a white filling for example, consumers are not able to evaluate what that filling is going to look like prior to purchasing, nor, after you have completed it and if they dislike it are they able to request you put back any removed tooth and give them back their decay back!

Because of this basic difference between a product and service it means that service based marketing is entirely focused on building trust and reducing risk… when a consumer purchases a service they are (on the whole) unable to make a snap decision and the marketing should reflect this by seeking to build a relationship with them.

This is what is known as relationship marketing. [1]

If we are to use relationship marketing, which happens to be almost tailor-made for social media, then we need to understand the core of how a relationship develops… When we understand how business relationship forms then we can take our social media marketing to the next level.

Business relationships, indeed almost all relationships, form in 3 distinct stages.[2]

1. Actor bonds.
2. Activity links.
3. Resource ties.

Actor bonds.

In order for any relationship to move forwards there need to be bonds between the actors, bonds between yourself and your prospective new patient. Basic human psychology means we tend to like people we are like… So help patients to like you.

This is where sharing personal stories and information really comes into force. Great examples of this are:

• Books you like
• Films you like
• Restaurants you like
• Practice birthdays
• Practice weddings
• People having babies at the practice
• Practice anniversaries and celebrations
• etc

Indeed, any type of invent at the practice which allows someone to say “Ooh, I’m just like them, I like that too…”

These are conversation starters, they opened the door to take the next step in the relationship building process.

Activity links.

The next stage in the process will only occur when someone feels as though they like you, this next stage is giving people something to do.

This is typically handing out useful, free and relevant generic dental health advice, great social media posts that fall into this activity link category are things like:

• When should I take my children to the dentist?
• How many dental implants that I need?
• How to overcome dental anxiety
• What to do if my gums bleed when cleaning my teeth
• How to overcome bad breath
• What’s the difference between a dental implant and dental bridge?
• Etc

The key here is to put a clickable link into your social media post, that link can either be to an image or to a website which has the answer to this particular dental question.

The key thing to understand here is that it DOES NOT have to be your own resources… You could link out to the British Dental Health Foundation, or Colgate or any other dental resource. The point of this type of post is that you are demonstrating that you care about solving patient’s problems over and above making a profit as a dental practice.

If you are trying to sell them something by deliberately pointing them to your website all the time it does not necessarily build trust.

Once we have spent some time building trust we can then move onto the final stage of the relationship building process.

Resource ties.

And this is the part of relationship building marketing which feels like conventional marketing, it’s the part where we tell people how great we are and how well we can solve their dental problems.

In the resource ties section of the relationship building process we are asking a prospective new patient to commit some form of resource to us, either money or time.

Time resources could be reading a blog post you have written (answering one of the questions listed above) or it could be to come and see you for an initial consultation.

Patients are not going to jump to the resource ties section of the relationship building process if you haven’t spent time developing that relationship in the first place and they don’t trust you or view you as a low risk option.

Too many practices can’t resist the urge to jump up and down, shout loudly and wave their hands talking about how great they are, how fabulous their free consultation is, how much they want to give patients 50% off for a particular treatment on a certain day of the week… Completely missing the point that social media is about RELATIONSHIPS, not TRANSACTIONS.

My recommendation is to keep posts in the following percentages.

• Actor bonds 40% of your posts
• Activity links 40% of your posts
• Resource ties no more than 20% of your posts

Each time you go to write a social media updates, think about which of these categories it falls into, it’s absolutely fine just to seek to deepen the relationship with someone… Not all of your posts need to be about teeth -  posting a picture of your dog, or a book you are reading, or restaurant you have recently visited may be the right thing for a person to see for the very 1st time on social media… You can then develop their relationship with you over a period of time as they see things about you in your practice that they can connect with.

Social media is about connecting with people as human beings, developing the relationship by increasing trust and lowering risk… Follow this advice and your social media marketing will work incredibly effectively.

[1] Gummeson E. (2002), Total Relationship Marketing, (2^nd edition), Oxford, Butterworth Heinemann

[2] Hakansson, H. and Snehota, I. (1995) Developing Relationships in Business Markets, London: Routledge

If you check out the word fortitude you get a sense of the characteristics necessary to campaign on Public Health. Resilience, endurance, perseverance, patience, tenacity, resolve, determination, grit and pluck. I wish we’d looked this up in 2012 when we started all of this – we may have decided to duck the challenge. We didn’t, and now we know why fortitude is essential, necessary, imperative, obligatory paramount, courage over a long period, plucky………

Back to 2012 then - let’s fire up the De Lorean although for the petrol heads it’s a metaphorical one as we know they stopped making them in 1983 which coincidentally was the same year that McColl v Strathclyde set a 201 day record for any legal case in Scotland over you guessed it Community Water Fluoridation. Manchester City win their first league title in 44 years, the Olympics come to London, Bruce Springsteen releases Land of Hope and Dreams and Hull LDC wake up.

Hull LDC met at the Ionians Rugby Club back then and that evening we meant business. Ionians were known for their love of democracy, philosophy the arts and pleasure. We were more in to treating our patients and staying healthy and solvent as NHS Practitioners but we did enjoy a beer. That night we were fed up as usual. Fed up with the tsunami of decay and the human consequences, the pain, the extractions the relentless tide of poor dental health. We were all very committed to prevention. We were all very committed to our patients and to the community of Hull. But we felt powerless and we knew we needed change. Hull has very poor oral health and is one of the most deprived areas in England. We understand the social health gradient now, but we were embedded in it in 2012 (as we still are) and we finally decided to do something. This isn’t surprising. People from Hull have a track record of standing up. In 1642 Hull refused the King entry to the City even though he turned up personally, endured a long siege militarily outnumbered by 2:1 and finally saw off the threat. That definitely takes pluck, grit, and fortitude.

Over a pint of bitter and a sandwich we voted to try and drive a Fluoridation agenda. We would start with a letter to the BDJ and publish an e – petition. So we did, convinced in our own minds that by the next AGM we would have cracked it.

We even developed a QR code link to the e- petition on the Petition Parliament site. Like a deluded punter down the bookies – we couldn’t lose could we?

The BDJ printed the letter and we waited for the e-petition to take off, soar,go viral. But it didn’t and in October six months after our rallying call for something to happen, it closed on 315 signatures.

So in October 2012 it seemed like Hull LDC were standing at the Fluoridation barricades alone or at least there were only 315 of us. Then the phone rang in Reception and my Nurse whispered in my ear – “there’s a Prof on the phone who wants to speak to you about your letter in the Journal.” I finished my fifth extraction on a child that morning and took the call.

To be continued...

Email marketing works!

In the last blog post we talked about ensuring that your website had some form of longevity. One of the biggest problems of a website is you spend so much time and effort attracting visitors to the site yet when they visit the simply bounce and leave again, off to go back to doing whatever it was they were doing before.

To get the most out of digital marketing we really need to work to ensure that your website has ongoing marketability, even if people don't visit the website any longer!

Sounds strange… So how do we do that?

Let me introduce you to gentle e-mail marketing. If we can collect someone's e-mail address whilst they are on your website, whilst they are a hot prospect and interested in your services then we can continue to communicate with them after they leave your website.

I can almost hear you groan, “e-mail marketing is spam”, I can hear you saying.

Wait one moment – here’s an example…

If you do the National Lottery online you will know that if you win something then they send you an e-mail.

Every Saturday I'm avidly checking my phone waiting for that e-mail notification that I'm a lottery winner… I've occasionally received an e-mail which tells me I need to log into my account and check, my heart is racing as I visit their website to find out I've won an almighty £25!

This example shows the e-mails per se are not spam, it is the CONTENT of that e-mail that makes it spam, some e-mails (like ones from the National Lottery) we are eager to receive and waiting to turn up. How great would it be if you had a prospective patient anticipating the next e-mail from you?

Let me show you how.

The trick is to turn marketing backward, rather than ask “what can I get out of this prospect?”, ask the question “what can I give this person for free that will build trust and reduce risk?”

The answer is generic dental health advice and information.

If you create a free guide, place it on your website on relevant pages and allow people to download the guide for FREE but in exchange for an e-mail address you can help to demonstrate you care about the readers of your site at the same time as collecting their e-mail address. You can then follow them up with a gentle series of e-mails which continues to build a relationship and answer their dental questions.

Here's an example.

On your dental implants page create a free guide entitled “Everything you need to know about replacing missing teeth.” In your guide you can talk about

• dental implants
• dental bridges
• dentures
• not doing anything at all and the consequences of not doing anything at all on the adjacent and opposing teeth, retention of surrounding bone and possible consequences of restoring at a later date with a compromised bone quantity and/or tooth position.

We can then follow-up that free guide with a gentle series of e-mails which looks at:

1. How comfortable is it to replace missing teeth? (Notice we don't talk about pain or discomfort rather, how comfortable we can make it)
2. How much does it cost to replace missing teeth? Here's your opportunity to talk about the various different options.
3. Where else to go to find out more about replacing missing teeth? Direct them to various dental implant company websites and other useful resources.
4. How many dental implants might they need? this is a great opportunity to talk about different options and how you can help.
5. What's the process for replacing missing teeth? This is where you can talk about planning stages, diagnostics and allow the patient to understand more about the process.

I could go on, but you get the picture…

As you can see, each e-mail is simply answering various patients concerns, each e-mail may not be entirely relevant to that person depending upon what their particular question is, but because we've written a series of e-mails we can be assured that at least one e-mail is going to be absolutely applicable to that person.

Now, we don't send all of these e-mails out in one go. We want to make sure they look natural and don't clog up someone's inbox.

The best sequence to send these e-mails out is based upon the Fibonacci series of numbers and the golden proportion, exactly the same formula you would use to calculate the width of centrals, laterals, and canines when doing cosmetic dentistry. This sequence of numbers is a beautiful sequence which appears often in nature and looks extremely natural.

So send your e-mails out with the following number of days between each e-mail 0, 1, 1, 2, 3, 5, 8, 13, 21, 34, 55 etc continuously add the previous 2 numbers to give you the 3rd number and then continue to repeat this process will give you the full Fibonacci series of numbers.

As you can see the e-mails get further and further apart as the prospect gets further down the e-mail series. I get a HIGH open rate of 70-100% using this system, so I know it works.

In each of the e-mails resist the urge to sell, sell, sell, rather handout your useful free and relevant advice to build trust and lower risk and at the same time give the patient a simple way to move into the next stage of the process, typically this may be a discounted dental health check or free consultation.

Make sure your e-mails have a button which is clickable that drives the person to this consultation. Again, this should not simply be phoning you, this should be a free consultation which is claimed by downloading a voucher from the website, this voucher then means that this marketing is then trackable when people come in to the practice but also if you have a voucher downloaded from the website means that we are again collecting people's e-mail addresses rather than simply suggesting they phone us which they probably won't remember to do the next day!

If you are then really clever you can use e-mail automation to drop people into additional campaigns, for example, let's say they click the free consultation button in one of the follow-up e-mails but do not take action, we can have an intelligent e-mail system recognises this and then drops them into an additional campaign letting them know the advantages of a free consultation, how gentle you will be, how much you will listen to their concerns and how easy it is to book.

All of these e-mails should be run from an e-mail management system, I recommend Aweber which starts at $19 per month (a highly affordable option) if you repeat this process with straightening crooked teeth, dental health, cosmetic dentistry and facial rejuvenation you will have built a robust marketing strategy which works off of your website 24-hours a day, 7 days a week never sleeping.

What you will find is that your return on investment from the website goes up enormously, no longer are people visiting your site and bouncing off again, they are now interacting with your site, we are collecting their e-mail address and we are using your website as simply the starting point in building a relationship with your prospective new patient.

Everything gentle.

Everything with the patient at the centre and not you.

If you treat e-mail like this, as a way to help people you will find e-mail can be one of THE best ways to maximise the benefits of digital marketing.

If you have a dental practice website then you want it to work, otherwise it's a completely wasted resource!

For a website to work, in my opinion you need to have 2 primary functions in place.

1. Traffic optimisation.
2. Conversion optimisation.

Without either of the above the website becomes ineffective.

If you had wonderful traffic optimisation and 100,000 visitors to the website per month yet only had a 0.001% conversion rate then you would only have 1 new patient per month. This scenario is highly unlikely to give you a good return on investment on your website.

Equally, if you had wonderful conversion optimisation with a 100% conversion rate yet only had 1 visitor per month then you would still only have 1 new patient per month. This scenario is equally highly unlikely to give you a good return on investment from your website.

You ALWAYS need traffic and conversion optimisation working hand in hand. If you work with a search engine optimisation company and all they do is get more traffic to your website then, in my opinion, this is completely worthless unless conversion optimisation is also worked on.

In my experience I have found that a dental website needs to be performing in the following areas:

Each of these five key areas provides an excellent way to audit your own website, so open your website now and compare your site with these performance areas.

Findability.

This is pure search engine optimisation and includes (but is not limited to) the following areas:

Website title, description & headers - these should accurately reflect the content of each page. Every single page on your website should have a different title, description and headers.

Image alternate tags - these describe images for people with visual impairment, Google is able to read the description and may give a slight boost your website if the descriptions are relevant.

Text - Google is (currently ) unable to read text on images. For the moment at least we need to ensure that we have excellent and expansive content on your website which uses a range of keywords and phrases that people type into Google. If Google isn't able to understand what your website is about and/or it is not relevant to what people are actually looking for then Google will not send traffic to your site.

Inbound links (votes) - if your website is good then people will talk about it, Google knows if people are talking about your website online because it will notice the links back to your site. The more of these links you have then the higher you will rank in the search results.

Link authority - but it’s not only about volume of these links. If you manage to get a quote about your dental practice and a link back from the BBC website then this link would have MASSIVE authority. With this one single link you would almost certainly see a huge improvement in your search engine results

Internal linking - Google is able to crawl around your website following all of the links. If you have orphaned pages (pages with no links) then this is an indication to Google that this page is not important, think about it, if you had a really important page on your website such as the dental implants page then you would obviously link to it from multiple other places within the site! If your dental implants page is an orphan, with no links from anywhere else then you are indicating to Google that your implants page is not very important… And Google may choose not to rank it very highly.

External linking - good quality links out from your website to high quality sources can help your website be seen by Google as a useful resource. Example, let's say you're talking about dental implants and want to communicate more about bone grafting, linking to a good quality bone grafting information website could help the way Google sees your site is a useful resource.

Usability

Good usability helps both the user and your search engine optimisation, Google ranks some usability factors quite highly.

Video -having videos on your website enables patients which like to see visual moving images and/or listen to audio engage with your site more. Particularly patient stories and testimonials.

Calls to action - in marketing terms this is telling someone what you want someone to do from your website, every single page should have a very specific action that you want the patient to do… This could be download a guide, request a free consultation, book an appointment, send you a message or phone you.

General enquiry - you should have an ability for a patient to make a general enquiry, this should be separate from the request an appointment form.

Request an appointment - you should have a specific request an appointment form which potential patients can complete requesting an appointment at the ideal day and time, this should then drop into an automated e-mail marketing system which follows up automatically.

Flow through the website - your website should flow smoothly and guide patients, try to think big and then narrow your thinking down, for example:

Straightening crooked teeth (the problem) > Invisalign (the solution) > Invisalign cost (potential questions about the solution)

As we granulate the problem down into solutions and questions you can have separate pages on the website, this means patients can be guided through from their general problem through to potential solutions and then answer the questions about those solutions.

Shareability.

Put quite simply social media is word-of-mouth marketing on steroids. Your website should have a simple facility (usually a button to click) which encourages patients to share the page they are on with their friends on social media… It sounds simple but can work really well to get your website shared.

Effectiveness.

Is your website focused around trying to sell treatments or help patients? A website that is dedicated around selling will be focused on YOU… A website which is dedicated around helping patients will be focused on the user. The latter will be considerably more effective.

Social proof - social proof is the technical marketing name for testimonials and reviews, you should be collecting these on Google and Facebook and then displaying a selection on your website. Testimonial videos can also be used to enhance this.

Longevity.

One of the things we want to do is to get your website working over the long-term for EACH user. Most websites only work whilst the visitor is on the site, the best websites manage to capture visitor details whilst the visitor is on the site, if we do this then we can continue to communicate with that person over the long-term. This means your website doesn't just work for the minute or so that each visitor is on, if you can capture their details then you can drop them into an automated and extremely gentle relationship building marketing system.

In the next blog posts in this series we are going to look exclusively at this gentle relationship building marketing system, we will look at how to use it on your website, how to automate it and how to ensure your website works 24/7, never sleeping, never tiring and continually providing new patients for the practice… Until then.

Mark Oborn-dental-marketing-trackers-hunters-explorers

In the last blog post we looked at the meaning of dental marketing, how (in my opinion) it should change in dentistry and focus entirely on the patient. I talked about flipping the focus of our marketing to not be about what we can sell as a practice or be about the treatments we want to do, rather, it should be about solving patients problems in an engaging and relationship building way. The natural result of that is that people are attracted to us.

In this post I'm going to begin looking at some of the more specific ways that we can make that happen, future posts are then going to look at each of these individual ways that we can build relationships with patients.

When we look at digital dental marketing is useful to break down into 2 primary areas:

1. Traffic optimisation to a dental practice website, this typically includes:
   • search engine optimisation
     • On-site search optimisation using words and phrases
     • offsite search optimisation with articles linked back to your website which Google sees as votes
   • paid advertising (PPC)
   • social media marketing
   • e-mail marketing via permission-based list building on your own website
2. Conversion optimisation to get more of those website visitors converting into patients, this typically includes:
   • calls to action and wording on the website
   • things for prospects to do, typically these are downloadableguides which are handed out in exchange for an e-mail address
   • e-mail marketing
   • social media campaigns

Now that you've broken down digital marketing into very specific areas you can begin to understand more about whether you can do this yourself, who could do it in your practice or what you may need to outsource.

In general, I recommend 3 marketing strands:

1. your website
2. e-mail marketing
3. social media marketing

Each of these should work in unison, as a system, referring patients backwards and forwards to the correct pace at the correct time in order to answer their dental problems and subsequently to gently attract them into your practice.

No single strand is more or less important than the other.

This is typically how I might approach this.

Patients that engage with you in some way via your website or social media stream  may not be ready to book an appointment straightaway, They may be:

• TRACKERS : They know exactly which treatment they wish to buy and are using your website to check the price, availability and your service.
• HUNTER: They don't have a specific treatment in mind yet but they do know what type of treatment they are looking for e.g. orthodontics, they probably have a few more features in mind. They are using your website to compare alternative options.
• EXPLORER: They don't have a particular treatment in mind yet but they may have a particular objective e.g. straighten crooked teeth. They may even be looking on behalf of someone else.

We therefore need to provide things for each of these people to do, in order that they can feel as though they have taken action whilst on your site (at the same time we get to collect their information!)

For the respective categories this should be:

1. HUNTERS or EXPLORERS: Free guides and downloads for patients wishing to solve a dental problem.
2. TRACKERS or HUNTERS: An incentive to request an appointment, this could be a free consultation, refund of initial assessment or explicit promotion of your new patient health check. This will help to convince patients if they are wavering about requesting an appointment.
3. TRACKERS: A request an appointment facility.

As you can see, explorers are not going to book an appointment yet, so what are you going to do to ensure you don’t lose them at this early stage in their decision?

We are using social media to drive people to your website, your website to collect their details, e-mail marketing to answer their questions which then sends auto responses (assuming we have permission) to drive them to make an appointment if appropriate.

Most of this is automated and all of it will work 365 days of the year, 24 hours per day. Never sleeping!

My opinion is that if you don't use all of these mechanisms, all of them working today as a cohesive system then your digital marketing will be less effective and you will be able to help fewer patients.

In the next article going to go through marketing on your website specifically, looking more at hunters, trackers and explorers and how you can get your site to be more effective.

Until next time…

Let's talk dental marketing.

Actually, let's not!

That word “marketing” often has negative connotations.

• Trying to get someone to buy something they don't want
• Annoying people with multiple adverts
• Spammy e-mails
• and from the point of view of the patient, trying to be sold treatments just to make you more money! (Yes, that's what lots of people think)

This old school way of marketing is what is known as a push strategy. You have your marketing message and the treatments/products you wish to ‘sell’ (I hate that word in health care), you then push that message out to the maximum number of people in the hope that someone, somewhere sees your message, identifies with it and buys whatever it is you are selling.

It's a strategy often used in transactional marketing, we simply want someone to engage in a single transaction, part with their money, take the goods, go away and not come back again… Is that something you really want to do in a dental practice?

Let's flip this completely on its head. Let's look at this from the point of view of relationship marketing. [1]

Relationship marketing often uses a pull strategy instead of the classic push strategy.

A pull strategy involves allowing prospects (new patients) to pull the relevant information towards them at a time that is right for them. It's about handing over control, they control what they see, when they see it and what happens next [2]

Rather than try to force our message on these people, we simply generate a range of content which answers various dental problems, we put that content in various places on the Internet (think your website, e-mail marketing, social media, YouTube) marketing is then simply driving people towards this relevant content which helps them solve a dental problem.

Here's the thing…

Stop thinking about treatments, services and products.

Start thinking about the problems that those treatments solve.

• I want to replace missing teeth.
• I want to have straighter teeth.
• I want to overcome my dental anxiety.
• I want to look and feel good whilst being able to eat more efficiently.

These are the concerns that patients have, NEVER has a patient woke up one morning and decided out of the blue that they want to have dental implants, what they will do, is wake up one morning and think that they wish to solve their problem of missing teeth, they then go on a search to find out the best way to do this… This search (hopefully for you) ends with them deciding to have dental implants in your practice.

And by the way, by the time you get to the end of this series of blog posts you will see how this search absolutely can end up with them coming to see you in your practice.

If we begin focusing on solving patients’ problems (pull strategy) rather than trying to sell treatments (push strategy) we turn marketing into a relationship building mechanism whereby we genuinely help people with their dental health, and isn't that what dentistry is all about?

In the next blog post I'm going to go through some definitive techniques that you can use in order to implement your new relationship building marketing strategy. I will show you how you can attract new patients in an ethical, friendly, kind and gentle way which builds trust [3] and reduces risk.

Something which pushing your messages on people absolutely does not do!

Until next time…

[1] Gummeson E. (2002), Total Relationship Marketing, (2^nd edition), Oxford, Butterworth Heinemann
[2] Urban, G L. (2005), Customer Advocacy: a New Area Marketing?, Journal of Public Policy and Marketing May 2005
[3] Bibb, S. and Kourdi, J. (2004) Trust Matters, Hampshire UK, Palgrave Macmillian.

The Boundaries4Life team at Lords with mascot.

Boundaries for Life and sponsors, Simplyhealth Professionals, are celebrating their most successful season of health checks this summer, helped by the introduction of new diagnostic software.

Founded in 2010 by Dr Chet Trivedy, a dual-qualified dentist and doctor, Boundaries for Life offers free health checks at major cricket fixtures throughout the UK. Made possible through a team of volunteer health professionals, spectators and ground staff are checked for signs and risks of health issues, including mouth cancer, blood pressure, diabetes, cholesterol, heart age, and obesity.

Commenting on this year’s success, which ran between April and September at high profile cricket venues including Lord’s, Edgbaston, Old Trafford and the Ageas Bowl to name a few, Chet Trivedy said: “It’s been a fantastic year with the team conducting over 250 checks and raising awareness of good general health and oral health with a huge audience.

“It was a particularly exciting season, as this was the first year that we conducted heart age checks in addition to our regular checks. This provides users with an opportunity to know how old their heart is medically, compared to their actual age. Many people were shocked that their heart was a lot older than they thought it was. As we were using a software system to calculate the heart ages - provided by Health Diagnostics - every user had the opportunity to understand how they could reduce their heart age. This was not possible in previous years as the health checks were not automated.” 

As well as a detailed medical check from a health care professional, users also benefit from a mouth cancer check from a dentist – many of whom were volunteers from Simplyhealth Professionals’ network of member dentists. At the end of the checks, each user is given a five-page health report and access to an online interactive dashboard.

Henry Clover, Chief Dental Officer at Simplyhealth Professionals, said: “Supporting Boundaries for Life is a great opportunity to champion a very important cause, as well as to highlight Simplyhealth’s approach to preventive wellbeing. We’re delighted and very grateful that many of our member dentists volunteered their valuable time to assist with mouth cancer checks.

“The health checks offer the chance to identify people who might be at risk of future health problems at an early stage, particularly those who might not be regularly visiting a dentist or GP. Importantly, the health checks help users to understand the links between general and oral health. It encourages them to reassess lifestyle choices such as alcohol consumption, smoking and diet, which could potentially contribute to issues such as mouth cancer, diabetes, and high blood pressure.”

Not only does Boundaries for Life provide the means to help users to understand their current and future health, the initiative also has the additional benefit of collating valuable insights into the nation’s health. Data insights discovered that 34% of users were obese, 42% had a raised BMI, and 70% had a waist measurement that is considered to be medium or high risk for diabetes. Shockingly, almost half of users (48%) were at an increased risk of developing diabetes according to the Diabetes UK risk scoring system. Furthermore, one in four users had raised blood pressure, and 40% had raised cholesterol.

As a result of their health check, nearly 50 users were referred to see a GP, dentist or other health professional for further advice or treatment - potentially saving lives.

“We’re proud to have helped so many people, but these figures highlight that there is still a lot of work to do,” says Chet. “We’re keen to keep building on our success and provide an ever-broader range of checks at next season’s cricket fixtures. The checks are only possible due to our fantastic team of volunteers, including Simplyhealth Professionals member dentists. They have all promised to do more next year and that is the best endorsement we can get.”

For more information, visit http://boundariesforlife.co.uk/

About Simplyhealth

For 145 years we’ve been helping people to make the most of life through better everyday health.  In 2017 Simplyhealth and Denplan united under one Simplyhealth brand and today we’re proud to be the UK’s leading provider of health cash plans, Denplan dental payment plans and animal health plans.

We help over three million people in the UK access the health and care products, services and support that they need, when they need them and at a price they can afford.

• 1m health cash plan customers
• 1.5m patients with a Denplan payment plan
• 6,500 member dentists
• 1,900 member vets
• 1m animals covered
• 11,000 corporate clients

We’re proud to donate 10% of our pre-tax profits to health-related charitable activities every year, and this amounted to over £1 million in 2017. Our Simplyhealth Great Run Series partnership raised an additional £42.6 million for charity.

Simplyhealth is a trading name of Simplyhealth Access, which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.

Dental

Simplyhealth Professionals is the UK’s leading dental payment plan specialist with more than 6,500 member dentists nationwide caring for approximately 1.7 million patients registered to a Denplan product.

Simplyhealth Professionals provides the following range of leading Denplan dental payment plans under the Denplan name:

• Denplan Care: all routine and restorative care + worldwide dental injury and dental emergency cover
• Denplan Essentials: routine care only + worldwide dental injury and dental emergency cover
• Denplan for Children: routine and other agreed care + worldwide dental injury and dental emergency cover
• Denplan Membership: registered with the dentist + worldwide dental injury and dental emergency cover
• Denplan Hygiene: A dental payment plan without dental insurance for all types of practice from NHS, mixed and private to support patients commit to a consistent hygiene programme.
• Denplan Emergency Insurance: worldwide dental injury and dental emergency cover only

Simplyhealth Professionals also provide a wide range of professional services for its member dentists and their practice teams, including the Denplan Quality Programme and Denplan Excel Accreditation Programme. Plus regulatory advice, business and marketing consultancy services and networking opportunities.

Dentist enquiries telephone: 0800 169 9962.

For patient enquiries telephone: 0800 401 402   

www.simplyhealth.co.uk

www.simplyhealthprofessionals.co.uk

more sporting events in the future, dependent on their team and their funding.  

​

Links:

http://boundariesforlife.co.uk/

Twitter @Boundaries4Life https://twitter.com/boundaries4life

Twitter @SHP_Dentists https://twitter.com/shp_dentists

Lancashire Foundation http://foundation.lancashirecricket.co.uk

Healthy Stadia http://healthystadia.eu/  - Enabling sports clubs to influence health and behaviour.

news article http://healthystadia.eu/boundaries-for-life-fixtures-2018/

Blood biochemistry tests https://www.bhr.co.uk/  - small machines which run rapid tests of blood biochemistry.

What is HbA1c? https://www.diabetes.co.uk/what-is-hba1c.html

GDPUK article https://www.gdpuk.com/blogs/entry/2133-knocking-mouth-cancer-for-six-simplyhealth-professionals-announce-boundaries-for-life-sponsorship

It’s the Tortoise and the Hare all over again…

Boota Singh Ubhi, Principal of Birmingham Periodontal & Implant Centre (BPI Dental), Specialist Periodontist and implant dentist, shares a long-term referral case that highlights some important lessons.

The patient was initially referred to us for full arch reconstruction with guided surgery in 2006. She presented with failing upper bridgework, which was partially implant-retained. There were multiple problems including failed apicoectomies, fractured roots, and the two anterior implants were failing as well (Figures 1-3).

The treatment options discussed with the patient were to either do nothing for as long as possible or to replace all existing restorations and implants. As the patient was keen to find a solution sooner rather than later, she chose the latter option.

A full clinical assessment was conducted with radiographs (Figures 4-5) and photographs. The only good tooth remaining was the upper right canine, but other than that the natural upper dentition had a hopeless prognosis and was unrestorable. A very large lesion was detected on the UL5, the UL3 was 

apicoectomised and both the anterior implants were positioned very poorly, which had affected the smile aesthetics with a midline shift to the left. These implants had been placed about 13 years previously, so they featured very old designs. 

Initial treatment and surgical planning 

The treatment process was explained to the patient and informed consent obtained to proceed. The existing implants were removed (Figure 6), as were the few remaining natural teeth. As poor bone quantity had been identified in the assessment radiographs, bone augmentation was indicated if we were to place new implants with a good level of primary stability. The procedure was performed at this time around the implant site to preserve the sockets and in the upper left quadrant. This was left to heal for about six months, during which time the patient was provided with a removable temporary denture.

After this healing time period, the patient returned to the practice for a follow-up CT scan and wax-up, which was used for the guided planning process of the implant placement. The ideal implant positioning, angulation, length and width were determined using Simplant software.

Surgical treatment

On the day of surgery, mid-crestal and midline reliving incisions were made (Figure 7) and a full thickness mucosal flap was retracted back. A bone-supported guide was used (Figure 8) to place six Astra Tech dental implants (Figure 9), which at that time enabled the guided planning process with Simplant software. The flap was closed and sutured (Figure 10). Six multi-unit abutments were then placed (Figure 11) in preparation for the new screw-retained bridge. The post-operative X-ray demonstrated good positioning of the implants, which were all parallel to each other (Figure 12). The bridgework was fabricated (porcelain fused to Cresco gold framework), once again utilising compatible products. Due to the effective angulation of the implants, there was no need to angle the screw channels and we achieved a very passive fit for the bridgework. In this time, two implants were placed in the LL5 and LL6 areas, which were restored with two splintered crowns (Figure 13). The lower right bridgework was left alone despite the distal cantilever, as it was causing no problems at all.

Several try-ins of the upper bridge were conducted with the patient in order to achieve the right aesthetics. Once the patient was happy, she went on her way.

Review

After about a year – during which time the patient saw her routine dental team for check-ups and general care – she returned to our practice for her annual clinical review, involving X-rays and full six-point pocket charts on every tooth and implant. The restorations still looked great (Figures 14-17) and the patient reported no issues.

Images show the result at one year review.

The patient continued to frequent her routine practice to ensure on-going maintenance of the dental implants and restorations and to help optimise her oral health. She also had access to our dental hygienist at BPI Dental on a yearly basis to support this maintenance programme. Around 10 years after we performed the surgical treatment, we were lucky enough to see the patient again and, as shown in the photos, the restorations still looked great (Figures 18-20). There had been very little soft tissue change and the aesthetics were fantastic, so the patient was still delighted with the final outcome.

Images show the result at ten year review.

Discussion

This case highlights a few important aspects worthy of note. First, we don’t always need to rush treatment – this case required treatment over several months and the final outcome was highly appreciated by the patient. Secondly, dental implants placed in the right positions will facilitate long-term soft tissue and hard tissue stability for durable outcomes.

As in all dental implant cases, the presented case emphasised the importance of excellent maintenance by the patient – only by attending on-going review appointments and adhering to strict hygiene routines at home can patients enjoy long-lasting results. Finally, this case demonstrates the superior aesthetics of porcelain both in the short- and long-term – I don’t think it can really be bettered and therefore it would remain my gold standard restoration material wherever possible.

For more information on the referral service available from BPI Dental, visit www.bpidental.co.uk, call 0121 427 3210 or email This email address is being protected from spambots. You need JavaScript enabled to view it.

Author biography:

Boota graduated in 1992 and later gained an MSc in Periodontology from Liverpool University. He became a lecturer at the University and passed his Membership in Restorative Dentistry form the Royal College of Surgeons of England in 2000 to become a registered Specialist in Periodontology. Since then, Boota has lectured at universities and educational events in the field of periodontics, dental implantology and bone / soft tissue augmentation, running his own implant training programme for colleagues as well. He is also an active member of the British Society of Periodontology, the Association of Dental Implantology and the American Academy of Periodontology.

#GDPR [Image by Jon Worth]

Roger Matthews further examines the EU’s forthcoming General Data Protection Regulations and its potential impact on dental practices. Have you drawn up your privacy notice yet? Are you up to speed on how you can lawfully process the data you hold on patients?

In the first two articles in this series (part 1 and part 2) I’ve taken a look at how the new Data Protection Bill – incorporating the EU’s General Data Protection Regulation (GDPR) - is coming along. I’ve highlighted the importance of preparing by taking a good look at all the personal data you currently hold in the practice (a Data Audit). Where does it come from? With whom do you share it (or might disclose it to)? How long will you keep it? Do this as a practice team, because ultimately everyone is responsible for good Data Protection.

The Data Protection Bill is still working its way through the parliamentary system and further amendments are still possible, although unlikely to impact dentistry. We will continue to watch this progress closely and to update Simplyhealth Professionals practices as we move towards the implementation date of 25th May 2018.

Fees

I gave some clues as to future Data Protection fees payable by Data Controllers last month, and now we have a clearer idea, although still subject to Parliamentary approval. As predicted there are three ‘tiers’, but some careful thinking may be needed to know which one you fall into.

Firstly, if you do not do any electronic processing (at all – that includes computers, tablets, smartphones, CCTV or any form of digital equipment) – and that’s pretty unlikely I would say in 2018, or if you only use a computer for the purposes of staff employment, PAYE, business administration, and payment processing (i.e. only basic personal details) it might appear you are technically exempt from paying a fee. But, the ICO has stated that any personal data processed for the purposes of ‘healthcare administration’ you will still have to pay. (See The Data Protection Fee – A guide for Controllers at ico.org.uk)

If you have a small practice, with 10 or fewer staff (every part-timer counts as ‘one’ and that includes the cleaner, gardener, and self-employed associates, hygienists etc), and if your annual turnover is less than £632,000 then you are in Tier 1. The fee will be £40, or if you pay by direct debit, then £35. Yippee, no increase! You will get a reminder when your current registration runs out, and an opportunity to set up the direct debit then.

(A little complication: if you have an NHS contract, then you are regarded as a ‘Public Authority’ in respect of processing and fees from that contract only. Public Authorities are exempt from the turnover threshold above, so if your NHS contract turnover is more than £632,000, then you are rated only according to your sGDPRtaff numbers. So a very big NHS contract but low private fee income might keep you in Tier 1.)

Larger practices, who do not fall within the above criteria, will pay a Tier 2 fee of £60 (again presumably with a direct debit discount of £5). This covers Data Controllers with 250 or fewer staff and a turnover of less than £36 million. Large Corporates may need to do some calculating, but otherwise this Tier will cover just about every other large-ish practice or small chain.

Tier 3, at £2,900 annually, is probably not an issue for dentists!

If you are currently registered (‘notified’) with the ICO – as you almost certainly are – there is no need to take any action until you receive your reminder to renew after 25 May 2018.

Your fee level will, in most cases, be accurately anticipated by the ICO but you should check to make sure it is correct and either call or e-mail them if not. It seems likely that if your renewal date is shortly after the implementation of the new law, there will be significant delays in getting changes made, but so long as you can show you took all reasonable steps then this should not disadvantage you.

Remember that Associates will only need to register – as now – if they act as Data Controllers in their own right (see the ICO’s Information Governance in Dental Practices, September 2015).

Action Stations!

Between now and 25th May, practices will need to:

• Complete their data audit (as above, if not already done)
• Check where back-ups are stored (ask your software provider/s)
• Consider how to present Privacy Notices to patients (see more below)
• Consider revising their Data Protection and Information Security policies
• Update their Cookie policy if they have a website
• Carry out and document a Legitimate Interest Assessment
• Draw up a Data Breach policy and procedure (if not already done)
• Appoint a Data Protection Officer

Whew!

Helping Member dentists

To help with preparation, Simplyhealth Professionals will be publishing further guidance for members on all the above, including templates for the necessary policies and assessments. However, in every case, it will be necessary to consider how these templates should be adapted for your own particular circumstances and practice.

This information will be published on the web portal for member dentists to access and it is hoped that all the necessary policies will be in place by the end of March. However, the new law is still Parliamentary ”work in progress”, so you should keep aware of any updates in monthly newsletters and e-mails.

Although ICO has said they will take a “proportionate” approach to enforcement in the early days of the new legislation, we cannot be sure the healthcare regulators (or NHS Commissioners) will take a similarly sympathetic approach. So preparedness is necessary!

A Lawful Basis

As noted when writing about Privacy Notices in previous articles, a Data Controller can only process data under the new legislation if they have a Lawful Basis to do so. Sounds reasonable, and GDPR gives six options to choose from.

Consent sounds like a good idea and as dentists we are well versed in this topic. However, remember that consent can be withdrawn at any time, and whilst you might simply and rightly stop treating a patient who decides, for whatever reason, to exercise this ‘right’ it would make life difficult for all concerned.

Necessary to fulfil a contract would apply in the case of self-employed staff members, such as associates, hygienists and so forth, so is appropriate for those cases.

Necessary for a Public Task is actually appropriate for all processing to do with NHS Contracts, since if you have one, you are regarded as a ‘public authority’ and are carrying out processing as required by legislation. So that ticks off the NHS patients and their care.

Legitimate Interests of the Controller is really the catch-all that would be appropriate for most of your private patients’ care and treatment. A ‘legitimate interest’ is really any self-evident need that an organisation has in order to function, and where a ‘data subject’ (patient) would ‘reasonably anticipate’ that such processing is necessary, provided it does not undermine any of their rights.

In order to use Legitimate Interests as your Lawful Basis, the legislation requires that you complete a Legitimate Interests Assessment (LIA). This is not too difficult provided you follow the detail of the law: firstly do you need the information? Secondly is there any alternative? Thirdly can you balance your need against the patients’ rights? And finally what actions do you take to ensure the security and confidentiality of the data? There will be a template for an LIA provided on the member dashboard during March.

Why the fuss about ‘Lawful Basis’? The legislation requires that your full Privacy Statement, freely accessible to all those persons whose data you process, specifies clearly what this basis is. On a website this must be clearly signposted (not buried in the small print), and in the practice its availability can be pointed out within a brief statement given verbally or, I would suggest, added to medical history forms and updates.

Finally…

A few odds and ends.

If your practice software provider stores or backs up your data, you should have a fully documented contract showing where the data is kept, and if it is overseas (especially if outside the European Economic Area) does it conform to GDPR requirements?

If you use patient data for marketing purposes, and also if you routinely contact patients by e-mail or text message, you will need to have specific marketing consents for these activities. Again, simple messages about forthcoming appointments can be consented with specific ‘opt-in’ boxes to be ticked and signed for. The medical history form is a good place for this too. ‘Opt-outs’ or other non-explicit methods will no longer be acceptable.

Do you need a Data Protection Officer? If you have an NHS contract (however small) the answer is “yes” as you are considered a ‘public authority’. However, authoritative guidance (from an EU Working Party) states that although ‘large scale’ processing of ‘special’ (e.g. health) data, such as by a hospital, does require the appointment of a DPO, processing of patient records by ‘an individual physician in practice’ does not. You may however feel that it is worth appointing one anyway: note that their identity will be shown in a public register held by the ICO. They are not ‘responsible’ for compliance (that remains with the Data Controller), but may be a source of expertise and advice, and may, if desired, be an external appointment.

Check your website cookie policy and make sure it is compliant (a template is on the way!)

Finally, make sure everyone in the team is aware of the changes coming up, of their increased responsibilities around data security (no more passwords on Post-It notes!), data breaches, and confidentiality, and review your training at regular intervals!

Part 1 of this blog

Part 2 of this blog

Errata - Postscript by Roger Matthews

A quick note before you read through my blogs on GDPR (or if you’re reading them again). The complexities of this new legislation (and the amendments taking place at the eleventh hour in Parliament) mean that my commentary has been “on the hoof” so to speak and based on available knowledge at the time of writing (starting last December). So there are a few points I now need to clarify and correct.

In Part 1 ‘GDPR - The New Millennium Bug?’ I mention specific consent from patients for processing data. It’s now clear that this is a bad basis to use since patients can withdraw consent. I correct it in Blogs 2 and 3. Oh, and the new law will be the Data Protection Act 2018 (not 2017).

In Part 2 'GDPR - Privacy Notices and Consent' I refer to patient consent possibly being needed for referrals. This arose from some EU commentaries on GDPR (The Section 29 Working Party if you must know) whose advice was rather vague. I now think that this is unnecessary by virtue of exemptions in the Act. I also got the new ICO fees wrong – but those were the ones she was suggesting to the Government at the time… plus ça change…

Finally in Part 3 'GDPR and Data Protection', written as recently as March, we have again been overtaken by events. It seems the ICO will ‘assume’ everyone is in Tier 3 for fees, so unless you want (or need) to pay £2,900 a year, make sure you correct her when your renewal notice comes around (on the anniversary of your current notification fee). The Report stage of the Data Protection Bill happened on Wednesday 9th May when there was a whopping 138 amendments to be considered. One of those of particular note was an amendment to exempt primary care providers with NHS contracts from appointing a Data Protection Officer. Sadly for NHS providers, the Government rejected this amendment.

The Bill now returns to the House of Lords for the final stages.

Roger Matthews

GDPUK thanks SimplyHealth Professionals and Roger Matthews for their permission to reproduce these three blog articles.

Image credit - Jon Worth under CC licence - not modified.

Part of GDPR blog by Roger Matthews

Roger Matthews further examines the EU’s forthcoming General Data Protection Regulations and its potential impact on dental practices. Have you drawn up your privacy notice yet? Are you up to speed on how you can lawfully process the data you hold on patients?

Hopefully you’re reading this after digesting the first part of this GDPR blog. If so, then even more hopefully, you will by now have done a “data audit” as recommended by the Information Commissioner’s Office (ICO).

You haven’t? Then you should: it won’t take too long. Work out all the personal data you hold: on patients, staff and contractors (Associates etc.), where do you get it from? And with whom do you share it? If you export data to a third party (a laboratory, patient referrals or cloud storage for your Patient Management Software maybe), do they have good data security (can they describe it or have a policy you can see?) and where is it stored or backed up? In particular is cloud storage in the EEA or in another country?

When you’ve completed your audit, the next thing is to consider “why” you hold the data – the “purpose of processing”. For the vast majority of practices, this is blindingly obvious – to you at least! You process patient data in order to provide safe and effective dental healthcare, you process staff data for employment law purposes, and you process contractor data to maintain effective financial and performance records. Simples!

A few practices may undertake forms of marketing which go beyond those simple purposes. They may buy in mailing lists to attract new patients, or may offer additional services to existing patients. If you undertake direct marketing in this way, you should look at the advice given by ICO (Google: ’ICO direct marketing’).

One of the relatively few (for dental practices anyway) major changes that the General Data Protection Regulations (GDPR) will introduce is that ‘data subjects’ (i.e. living individuals) whose data you will hold, store, process and ultimately delete, must be given prior notice about the data you hold, the reason/s you hold it, who you disclose it to and what their rights under the new Data Protection regime will be. This is called a Privacy Notice.

If that sounds like a complicated document, it is! At least in the sense that it needs to be drawn up carefully. It must not read like a complicated document, since you must, by law, be transparent and clear in your communication.

The ICO helpfully suggests that you do not need to spell out the full details of your Privacy Notice when patients (or staff, or contractors) first engage with you, but you must signpost it to them so that they can easily find it. That’s easy on a website (“click here for further details”), but perhaps a little more difficult when patients telephone or present in person.

You could, for instance have a short Privacy Notice at reception, or on a practice information leaflet, and either display a full version on the premises or laminate one that is available for patients to read. However you do it, a Privacy Notice is a must!

Again, you can read about Privacy Notices on the ICO website, and/or you can sign up (for free) to www.dpnetwork.org.uk which is an open access website for small businesses and charities. They have good legal opinions backing them.

Now let’s have a closer look at “consent”. Don’t confuse this with the professional and dento-legal term: in this case, it is defined as one of six ways in which you can lawfully process personal data. I have seen it rumoured that you will need to have explicit, clear and unambiguous consent from every patient/employee/contractor before you can even access the personal data you already hold! Whilst possible (maybe), that’s a very big ask.

Fortunately, the GDPR allows other ways for organisations to lawfully process data. One of these is the “legitimate interest” test. Essentially, this means that if the data subject would reasonably expect you to collect, hold, etc., their data for, effectively, self-evident purposes, and you only collect and process data for such essential purposes, and you are not contravening or infringing their rights to privacy in the process, then that’s OK.

Well, it’s sort of OK!! It is recommended that in order to validate your choice of “legitimate interest” as a lawful basis for processing, you should carry out a Legitimate Interest Assessment (LIA). This would set out firstly, what those essential interests are; secondly,  identify the necessity for processing the data; thirdly, to balance the needs of the organisation against the rights of the data subject; and finally, what actions will be taken to ensure that processing is not excessive or invasive. 

Again, the ICO and DPNetwork have excellent advice on how to carry out an LIA and it’s strongly recommended that you do this before relying on this basis. But it does avoid the need for a blanket consent exercise.

All that having been said, it remains true under the new legislation that health-related data about an individual is regarded as more sensitive (“special” in GDPR-speak). Thus article 9 of the GDPR states that processing health-related data (and other categories, similar to the existing UK Data Protection law) is prohibited, unless one of a number of exceptions apply. One of these is ‘…medical diagnosis, the provision of health or social care or treatment …pursuant to contract with a health professional’. So again, that seems OK, but… the EU Working Party looking at consent still hasn’t produced its final guidance and in its final draft it gives an example which suggests that explicit consent is required, for instance, when transferring a patient’s health data to a referral practitioner or specialist.

So for caution’s sake, when getting updated medical histories, having patients sign treatment plans, or submitting treatment claims, it is probably advisable to get patients to clearly indicate that they consent to the use of data as in your Privacy Notice (which should be available to them to read if they wish). And refreshing that consent (e.g. at medical history updates) is a good idea too. The use of pre-ticked boxes, inaction or silence on the part of a data subject can no longer be relied on, either.

It’s anticipated that generic templates will be available for Privacy Notices, LIAs and other key components of the new Data Protection legislation in the coming months, but it’s a good idea to have some drafts in your mind now to stay ahead of the game.

In the third and final part of this GDPR blog, we’ll look at Data Security, dealing with Subject Access Requests and complaints, and an update on how the new Data Protection Act is going through Parliament.

PS: Annual Registration Fees with the ICO

Parliament hasn’t yet approved a new fee-scale for registering with the Information Commissioner after the new Data Protection Act becomes law in May 2018. But the ICO’s draft guidance to the Government has suggested a three-tier approach. Very small, or new dental practices which process fewer than 10,000 personal records will be Tier One with a fee “up to £55”; but those with larger patient bases will fall into Tier Two: “up to £80”. It’s likely that existing annual notifications will be valid until their expiry date. Watch this space!

Part 1 of this blog https://www.gdpuk.com/blogs/entry/2123-gdpr-the-new-millennium-bug

Part 3 of this blog https://www.gdpuk.com/blogs/entry/2125-gdpr-and-data-protection-part-three

Errata - Postscript by Roger Matthews

A quick note before you read through my blogs on GDPR (or if you’re reading them again). The complexities of this new legislation (and the amendments taking place at the eleventh hour in Parliament) mean that my commentary has been “on the hoof” so to speak and based on available knowledge at the time of writing (starting last December). So there are a few points I now need to clarify and correct.

In Part 1 ‘GDPR - The New Millennium Bug?’ I mention specific consent from patients for processing data. It’s now clear that this is a bad basis to use since patients can withdraw consent. I correct it in Blogs 2 and 3. Oh, and the new law will be the Data Protection Act 2018 (not 2017).

In Part 2 'GDPR - Privacy Notices and Consent' I refer to patient consent possibly being needed for referrals. This arose from some EU commentaries on GDPR (The Section 29 Working Party if you must know) whose advice was rather vague.  I now think that this is unnecessary by virtue of exemptions in the Act. I also got the new ICO fees wrong – but those were the ones she was suggesting to the Government at the time… plus ça change…

Finally in Part 3 'GDPR and Data Protection', written as recently as March, we have again been overtaken by events. It seems the ICO will ‘assume’ everyone is in Tier 3 for fees, so unless you want (or need) to pay £2,900 a year, make sure you correct her when your renewal notice comes around (on the anniversary of your current notification fee). The Report stage of the Data Protection Bill happened on Wednesday 9th May when there was a whopping 138 amendments to be considered. One of those of particular note was an amendment to exempt primary care providers with NHS contracts from appointing a Data Protection Officer. Sadly for NHS providers, the Government rejected this amendment.  

The Bill now returns to the House of Lords for the final stages.

Roger Matthews

GDPUK Thanks SimplyHealth Professionals and Roger Matthews for their permission to reproduce these three blog articles.

Roger Matthews looks at the significance to you of the EU’s forthcoming General Data Protection Regulations.

If it hasn't already happened to you, it will! Over the next few months you'll be approached with numerous offers to guide you (for a fee) through the 'demanding processes' of compliance with the EU's General Data Protection Regulations (GDPR).

"Aargh," you may say, as you read the doom-sayers' predictions of harsh fines and imprisonment (or both), here comes yet more compliance pressure on my overworked dental team!

However, you should be reassured by the Information Commissioner's statement that anyone (or any organisation that complies with the existing Data Protection law, is already well on the way to achieving compliance with the new requirements.

New Data Protection Act from 25th May

GDPR was issued by the EU in May 2016, giving all member states two years to comply. It's provisions will apply in the UK from 25th May this year. However, each country has some freedom to amend a few details and the UK Government has also decided to 'tidy up' and 'tighten up' on the existing law, the Data Protection Act 1998.

so, on 25th May there will be a new Data Protection Act 2018. This will encompass the GDPR requirements and the draft legislation is currently lumbering through Parliament. The

House of Lords has been debating it since October and it probably won't get the Royal Assent until sometime around Easter.

While we don't absolutely know what the final version will look like, we do know most of it, given that much of the discussion will not really be relevant to dentistry in particular, or primary healthcare in general.

12 step guide

The Information Commissioner's Officer (ICO) has already issued a '12 step guide' to the GDPR which is a useful start to check your current status. As a responsible practice you'll already be registered ('notified') with the ICO (don't be fooled by the earlier news that GDPR will abolish notification or annual fees!) Plus, you'll have a Data Protection Policy and an Information Security Policy (Information Governance compliance too, if you're an NHS contract-holder).

It is worth checking some things at this early stage, however. Do you obtain 'specific and explicit' consent from your patients to store their data? Do you have a privacy notice that tells patients (and prospective patients, for instance on your practice website) exactly what data you hold and who you share it with?

Data flows

It may seem simply - you keep their personal details and health records and because you know all about professional confidentiality, you

keep it all to yourselves. But what about your IT system? Is it backed-up in-house? Is it held in ‘the Cloud’? And if so, where exactly? Do you send patient information to any third

parties, such as insurance companies or Simplyhealth Professionals, for instance? You can be certain that Simplyhealth has rigorous security, but do others? Do you? Is any data taken home or stored on USB sticks or personal computers? It’s worth thinking it through and conducting an audit to look at all the data inflows and outflows.

When you know exactly where all your patient and staff data comes from and where it goes, you can rest assured that you’ll have ticked off one important stage in preparing for the 25th May deadline.

Read Part 2 of this blog

Read Part 3 of this blog

Errata - Postscript by Roger Matthews

A quick note before you read through my blogs on GDPR (or if you’re reading them again). The complexities of this new legislation (and the amendments taking place at the eleventh hour in Parliament) mean that my commentary has been “on the hoof” so to speak and based on available knowledge at the time of writing (starting last December). So there are a few points I now need to clarify and correct.

In Part 1 ‘GDPR - The New Millennium Bug?’ I mention specific consent from patients for processing data. It’s now clear that this is a bad basis to use since patients can withdraw consent. I correct it in Blogs 2 and 3. Oh, and the new law will be the Data Protection Act 2018 (not 2017).

In Part 2 'GDPR - Privacy Notices and Consent' I refer to patient consent possibly being needed for referrals. This arose from some EU commentaries on GDPR (The Section 29 Working Party if you must know) whose advice was rather vague. I now think that this is unnecessary by virtue of exemptions in the Act. I also got the new ICO fees wrong – but those were the ones she was suggesting to the Government at the time… plus ça change…

Finally in Part 3 'GDPR and Data Protection', written as recently as March, we have again been overtaken by events. It seems the ICO will ‘assume’ everyone is in Tier 3 for fees, so unless you want (or need) to pay £2,900 a year, make sure you correct her when your renewal notice comes around (on the anniversary of your current notification fee). The Report stage of the Data Protection Bill happened on Wednesday 9th May when there was a whopping 138 amendments to be considered. One of those of particular note was an amendment to exempt primary care providers with NHS contracts from appointing a Data Protection Officer. Sadly for NHS providers, the Government rejected this amendment.

The Bill now returns to the House of Lords for the final stages.

Roger Matthews

GDPUK Thanks SimplyHealth Professionals and Roger Matthews for their permission to reproduce these three blog articles.

By Chris Tapper

One working day in April 2018, precisely at 4.50pm, ten minutes before the unseemly scramble by the dentists to get out the door to avoid the dry-retching of the nurse’s as they clean the filters out, I was presented with a sheet of paper.

A nurse delivered the A4 sheet with a flourish and the warning that our corporate practice manager required my signature before five, since she was going away for a few days.

A space had been left for me to make my mark and I noticed all my colleagues had already signed the sheet, with that day’s date. My colleagues had all apparently attested to the fact that they had completed in-house training in needlestick injuries, they had all read the practice policy on needlestick injuries, and they had then participated in a ‘facilitated practice discussion’ about needlestick injuries. The top of the sheet stated that all the training and accompanying requirements had to be completed by the end of January 2015.

I certainly hadn’t completed the in-house training in question personally and definitely hadn’t noticed a facilitated practice discussion, unless I missed it because I was engrossed in Facebook at the time, doing a fun quiz on ‘is your line manager a homicidal psychopath?’ (My answers were probably of great value to Cambridge Analytica and the ‘Leave’ campaign).

More interestingly, three of my colleagues hadn’t even been employed by the corporate around the date mentioned and I figured that two of them couldn’t possibly have done the training since they are new trainees, though they MAY have read the policy during induction. One of them admitted they had only signed the policy sheet “To avoid a lot of hassle.”

I dismissed the nurse with an “I can’t sign it since I haven’t done the training,” to be met a few minutes later by a text from the head nurse with a link to a video on, presumably, needlestick injuries.

The upshot was that I actually went online and found the subject on the website of a training organization I occasionally use, and produced a CPD certificate before six and signed the form anyway.

Yup, I wimped out rather than be met with the ‘I’ve Been Bagging Angry Wasps Into A Sack With My Bare Hands Face’ of my corporate practice manager.

Of course, the nub of the above was that someone in management (I don’t know at what level) had fouled up and had realised that CQC requirements had not been met. In order to meet requirements, staff had been browbeaten into fraudulently signing a statement that would give the authorities the impression the company was complying with regulations.


And the reason I have outlined the above?

Corporate Bullying

At this time of year, independent dental providers are bidding for contracts against the corporates and increasingly, they are being undercut by the latter, who use their low wage, high trainee workforce ratio and dubious interpretation of NHS regulations to undercut independent practices.

NHS commissioners are desperate people. They need to secure services at the lowest possible rate and the corporates present them with exactly what they need to satisfy the number-crunchers at the Department of Health - high numbers at low prices. To quote from a popular 70’s sitcom, “Never Mind The Quality, Feel The Width.”

It’s a subtle form of bullying, but it’s bullying nonetheless. The Independent practices cannot possibly hope to compete on an equal footing with companies that run their practices on trainee nurses and (largely) EU dentists willing to work for £8 to £9 per UDA until Brexit is put into effect.

It’s the equivalent of being elbowed in the face by the school thug as he pushed into the lunch queue.

I have worked for a corporate for over five years after selling my own practice, and during that time we have had a huge turnover of nursing staff. As nurses qualify, they leave within months for the independent sector - not once has a qualified nurse been replaced with a qualified nurse. The company just takes on another trainee, and often the £9-per-UDA associate finds him/herself providing the in-surgery training.

The playing field is definitely not level. Low quality materials, poorly maintained equipment and restrictions on which laboratories can be used all contribute to the ‘Poundstretcher’ mentality. At one point last year, we had absolutely no x-ray facilities while head office sourced the cheapest scanner possible.

Unfortunately the commissioning Area NHS Teams are either oblivious to what is happening in the corporates, or are turning a blind eye. And by no means is my corporate the worst offender - I’ve seen worse with my own eyes. As corporates go, mine is considered to be one of the ‘good guys.’

So what is to be done? Your guess is as good as, although I would LOVE to see widespread and coordinated unannounced CQC inspections nationwide at 9.00am. Or else a mass walkout of the Nash by the independents? The corporates definitely wouldn’t cope - few of them hit their contracts annually anyway.

As for me, I’m off to Poundland.

By Chris Tapper

Six years ago, I attended a two-day residential course. It was a CPD course I hasten to add, not the usual anger management or ‘appropriate behaviour in the workplace’ type of thing I used to have to attend before they found the right tablets for me.

Anyway, it was very interesting, although I freely admit I never put a single thing I learned into practice – mainly because the dental corporate I work for wouldn’t shell out for the equipment I needed unless I could produce a business plan that proved I could earn them at least a tenner for every quid they invested. But that is by the by.

On the evening of the first day (a Friday if I recall correctly), the ten participants plus the lecturer and two representatives of the sponsoring company, enjoyed a meal in the hotel where the course was being held. After a very pleasant starter and main course, I moved to where a gaggle of four youthful dentists were sitting and enquired as to where they were in terms of their careers. It transpired that all four had graduated from the same Northern dental school and had all been qualified roughly two years. They were all general dental practitioners and had all taken up associateships in NHS practices.

As the most experienced dentist on the course – actually, why mince words, the oldest – I was interested to see if the youngsters were enjoying their chosen profession so far. I think I was trying to vicariously re-establish myself with my early enthusiasm for dentistry.

I posed, what I felt, was a fairly innocuous question to the group:

"How’s it going?"

One female dentist confessed that she cried every night when she arrived home from work, and sometimes did it during surgery sessions. One of the males said he was so anxious about work that he threw up most mornings and that brushing the lingual aspects of his teeth was impossible, while the other female said she had trouble sleeping and had been put on antidepressants six months earlier.

Perhaps the most troubling response was from the other male, who confessed that he had on a number of occasions, thought of ‘ending it,’ having realised that he had made a dreadful mistake in going into dentistry, and couldn’t see any way out. My concern for him diminished a little when I saw that he had an incredibly healthy appetite, demolishing his own rhubarb crumble and a female colleague’s lemon sorbet in less than three minutes.

When I questioned them more closely, the reason for their universal despair was not down to the pursuit of ridiculous UDA targets or the student debts they were saddled with, but the fear of dental litigation.

All four were constantly worried that they would see their careers end either in a GDC meeting, or more likely, through the bad publicity and financial ruin brought about as a result of a civil action facilitated by a dental litigation firm. They felt that the chances of those events happening to them were high, since one of their fellow students had already found himself in the middle of litigation as a result of an NHS root-filling having not worked.

Now that was six years ago, and I would argue that since then, the UK dental profession has slipped into a febrile anxiety that I have never previously witnessed in the 30 years or so that I have been working in dentistry.

Never have I seen dental colleagues (and even strangers) so jaded and so preoccupied with fears of dental complaints and ‘the dreaded letter’ from a certain Northern dental litigation firm.

I will freely accept that I have no scientific evidence for my observations and that my views are based purely on the empirical, but I personally know of no dentist who has not recently entertained thoughts that a patient might ‘turn legal’ if the wind blows the wrong way.

Over the past 18 months, I have been offering support to a close young colleague, being pursued by an extremely aggressive young solicitor (she IS young, I looked her up) who is alleging ‘negligence’ after her client developed dry socket after a routine extraction of an upper first molar. Rightly or wrongly, my colleague decided she did not want to consult her defence organisation and so I have been (rightly or wrongly) equally aggressive in demanding expert witness or consultant reports in support of their absurd claim. So far, the solicitor has failed to provide any evidence of negligence or give any reason why an expert assessor’s report has not been provided. All I know is, it has been fun ‘having a go’ back, but it to me illustrates a sad fact – nobody in the UK-based dental profession is safe from opportunistic punts from patients who want to make a quick quid from the no-win-no-fee mob.

A few months ago, a solicitor I know told me that during a local meeting of his legal colleagues, a speaker said that a lucrative and growing new source of business was dental litigation and that it was “something to think about” since the clampdown on spurious ‘whiplash’ claims and ‘Benidorm Belly’ – where package holiday tourists claim compensation for stomach upsets caused by dubious calamari and fries - had resulted in less opportunity for successful claims.

Recent experience has taught me that dental litigators are a tenacious and avaricious species and are unlikely to give up easily on an area of medical law that they consider to be easy pickings. Certainly, according to my legal friend, lawyers see it as a much easier area to be successful in than medical litigation.

Soon, the cost of dental defence subscriptions will be prohibitive to viable practice, and the profession, once all our European colleagues go back home, will find itself unable to cope with patient demand. What is the answer? Your guess is as good as mine.

Until then, I am going to have a rhubarb crumble and some sorbet.

I thought I'd share this latest opinion piece by a young dentist in the latest BDJ, entitled:
"Defensive dentistry and the young dentist- this isn't what we signed up for."

Read it here 

So what are THE main problems here in Dentistry in England worst of all, but relevant to all the UK too?

My shortlist would be:

1. An impossible UDA NHS contract that publicly promises unlimited care for needs, in a very limited system

2. Onerous regulation using the slide-rule of 'perfection' instead of 'seriously below' reasonable standards.

3. An increasing Claim/Blame culture that takes little or no SELF responsibility for prevention or resolution in the first place. It's like they are given an 'exemption' ticket and thus can claim/blame/complain with impunity, even when fraudulent.

4. A CLAIMS culture driven by some enhanced-fees Lawyers selfishly, resulting in the UK having the worst reputation in the World for FALSE or exaggerated claims, just to get free easy money, from car whiplash claims to holiday insurance etc.

5. Some very Poor Expert witnesses who seem to readily use a yardstick of perfection, without the experience or TRUE NEUTRALITY to act in the public interest first, regardless of WHO engaged/paid them and not applying No.2 above properly.
The trouble is those prosecuting/claiming are only too happy to send MORE work to those who seem to write the worst reports - this may be SO bad that it needs a lookback exercise - if it's good enough for our dental records then why not ?

5. Some indemnity organisations feeling vulnerable because of the above and/or struggling to put up a timely/full defence, make a Corporate decision to minimise THEIR future liabilities in years to come and payout early. It's a tough call for them I know, but many now want to see more pushback and earlier payouts may be just pouring petrol on the fire and thus encouraging more claims, fishing and efforts to get more payouts. It's like a feeding frenzie and that's bad for all.

6. Due to pressures and cuts from the DH and HEE on the undergraduate curriculums, clinical teaching is downrated and research and other targets get all the qudos/funding, so our Undergraduates are getting less clinical exposure, training and preparation for the 'real' world = more like walking into a Gladiator ring and surviving the first few years, but with early scars already from the above. Increasingly even after FT/VT not all are surviving those first few years after qualifying and already experiencing GDC, Lawyers letters, Complaints, Compromises from systems and Corporate limitations and high stress etc - certainly not looking forward to a happy Career!

7. Our Profession - yes we must take some of the blame, but currently we are taking ALL OF THE BLAME whilst Society is overlooking or even encouraging further the above 5 aspects for short-term gain and anyway those Dentists have it easy so let's see them suffer, right ?!? 

So at what stage do we reach breaking point - at what point do we say enough is enough and start acting together in Unity.???

UNLESS we start making it someone else's problem, this will continue and in 10 years when our Profession is decimated and dental care is so defensive it's do nothing or refer for extractions, the population suffers greatly.

Read that article again in the BDJ - our young graduates are rightly saying, this is NOT what I signed up for .

Tony Kilcoyne.

1. A. Al Hassan.  Defensive dentistry and the young dentist – this isn't what we signed up for. BDJ 223, 757–758 (24 November 2017)
2. M Kelleher. State-sponsored dental terrorism? BDJ 223, 759–764 (24 November 2017)
3. Discussion on GDPUK forum 

Image credit - hierher under CC licence modified

Last Monday 14th August 2017, I had another meeting with Jonathan Green (Head of FtP) and Matthew Hill (Head of GDC Strategy). 
It was a no holds barred meeting and I was free to ask any questions. I wasn't locked in dungeons under 37 Wimpole Street at any point! 
Here is the agenda of the 90-minute meeting, along with the GDC answers in blue. 

It raises some important considerations about what we need to do as a Profession. I think we need to think about the answers and discuss a strategy for the Profession. 

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The fog is burning off.  The focus is clear.  And so it should be for you.

On balance the case swings clearly.  We are part of Europe. We are European. And yet we should not be part of the political and fiscal force majeure that is the EU.

So I urge you to vote, and if you are open to simple argument, I urge you to vote Leave.

The time has come to lead Europe from outside the EU, not from within.

This Thursday is the most important in the political life of this nation to date. Please make use of your democratic right, to maintain those same rights.

?

Tony Jacobs BDS, dentist, publisher of GDPUK.com

Image credit -Fernando Butcher under CC licence - not modified.

It’s no secret that I’m firmly in the Remain camp.

Until recently, the EU was a largely irrelevant part of my life; something that is there, that I don’t need to worry about, that was barely noticed in the background. But the claims by those wishing to leave have turned passing indifference into passionate support.

I am strongly pro-free market, I believe in personal liberty, and in economic liberalism, but with fairness for all, meaning the removal of artificial barriers and monopoly trading. The EU has delivered this in spades; we know that if we buy Romanian pork, it is made (or rather should be) to the same standards as pork produced in the UK; we know that if we travel abroad, we will be treated according to over-arching laws.

The EU provides regulatory framework; it makes sense that where trans-national trade is concerned, the rules are arrived at through trans-national organisations. But we must also place human rights into the fray – it is not right that a company in one country can produce an item using labour that is forced to work 60 hours a week whereas another country can only allow 35 hours. Trade is increasingly globalised and our companies compete with companies from all over the world. What the EU promotes is a level playing field for all companies, allowing survival of the fittest, while ensuring that competitive advantage is not derived by transferring the costs from company to workers. If we all play by the same rules, only the strongest company will survive. If the rules are different, then one country can make their workers’ pay for the success of their businesses.

We also have harmonisation of regulations. This means that our companies have access to other countries’ internal markets that could otherwise be blocked through unnecessary or discriminatory legislation – perhaps the best example being the German purity laws, which created an artificial barrier for non-German beer to be sold in Germany. The EU forced Germany to remove these barriers for imports, and as a result, you can buy a can of Tennent’s Super in a supermarket in Bremen, should your fortunes be so unkind.

Britain has always been a trading nation, from the tea clippers in the days of empire, to the financial trading of the 80s and the digital marketplace of the naughties. We must remain relevant. We must modernise as life changes around us. We are better placed to trade as part of the EU, we are stronger in the EU and we share a bright future trading with our European brethren.

I have already voted to stay in the EU, not because of what I fear we will lose if we leave, but because of what we stand to gain by remaining part of the EU.  

Duncan Scorgie is a dentist practising in Midlothian

Image credit -Abi Begum under CC licence - not modified.

“Patriotism is the last refuge of a scoundrel,” stated Samuel Johnson.

We have seen England football fans with their aggressive displays of false patriotism, Nigel Farage with his “blokey” 1950s English image, both suggesting that the past was some sort of rosy era that we can head back to. The whole Brexit campaign smacks of a distasteful arrogance that the British are better than the continentals.

I am a Special Care dentist, and I remember being startled and gratified in equal measure to find that a profoundly autistic non verbal man presents exactly the same dental treatment challenges in Ireland as in France as in Greece.

Your non verbal autistic man has no concept of Brexit and Patriotism, but maybe he can teach us how shallow, ignorant and superficial our debate and thinking has become on this issue. 

I have many friends as dentists whose origin is from countries such as Bangladesh, India, Spain, Ireland, Italy and Greece. We have far more in common being dentists than our national and cultural differences divide us.

My late father landed in Normandy on D-day plus six, and often told me he never wanted to experience war again. The EU has many failings, but has kept the major players in Europe from warring with each other. That is why I would vote to stay in.

Neil Martin is a Special Care Dentist in Northamptonshire.

Image credit -Abi Begum under CC licence - not modified.

We must stay in!
We are the civilised and ancient democracy!
We must strive to exert change from within.
Our mistake was not joining at the beginning and before you start I know it was personal politics De Gaulle etc!

The whole argument has horrified me because...there are NO Facts just subjection!!!

I feel we are in a smaller world with more connections..why do I want to leave and become smaller??
I like my European family and think they have so much to teach US!!
We should be paying MORE because we are so lucky!
We should be caring for the less fortunate!
In fact I think that we should STAY BECAUSE IT IS RIGHT!!

Dr Alisdair McKendrick is a GDP in Northamptonshire.

Image credit -Abi Begum under CC licence - not modified.

Regardless of the outcome on this very important choice presented to the British public, it is unlikely that a seismic shift will happen. The UK will not collapse if it leaves the EU or decides to stay within. I fear a large amount of campaigning already underway and yet to come, is riddled with slick speeches oiled with dubious premises and unsubstantiated claims. Exaggeration and obfuscation are rife and even an alert and politically savvy observer will struggle to separate the wheat from the chaff.  

Image credit -Abi Begum under CC licence - not modified.

Do you need the penetration test?

Don’t worry, I’m not about to delve into the wet fingers stuff – this is a different penetration test (no smirking at the back). The idea came to me after hearing a radio programme about cyber crime. They interviewed someone who had been employed as a Penetration Tester. A penetration test (a.k.a. pentest, intrusion detection and red teaming) is, it seems, a well-known and recognised process in the worlds of cyber security and IT governance. Essentially, it is an evaluation of the security of IT systems by trying to exploit vulnerabilities before hackers and criminals can. It goes beyond looking at operating systems and software to include improper configurations and risky operator or end-user actions.

A dentest?

My idea is that dental practices should evaluate their governance vulnerabilities by what I’m calling a ‘dentest’. In other words, before CQC inspectors mark you down, the GDC writes a disapproving letter or a patient uses your complaints procedure you should check whether your systems or staff can be faulted. There might be several ways to do this. In the wider world reformed hackers and fraudsters are often employed for such tasks. However, I don’t recommend scouring the GDC’s list of erased dentists. Much more sensible to keep it in-practice.

This is where that irritating team member who is always finding fault and asking endless questions comes into their own. Divide activities in the practice into manageable chunks and set them the task of ‘penetrating’ them one at a time. In theory, they need expertise in an area to be able to exploit any vulnerabilities. Otherwise, how will they know whether, for example, decontamination procedures are being followed correctly?

A journalistic trick

Fortunately, such in-depth knowledge is not required. How do you think Jeremy Paxman managed to get politicians to squirm night after night? How does the team on Channel Four News report on a variety of different topics with apparent authority? The answer lies in what journalists and reporters learn on their first day at university – the ‘5 W’s’ – Who? What? When? Where? Why? and How? (yes, I know there’s also an ‘H’). Ask these questions persistently enough and you’re bound to get the answers (or not) on virtually every topic.

For example

Take decontamination procedures. Your ‘dentester’ needs to be given half an hour during which they ask the 5 W (and 1 H) questions of, initially, virtually anyone in the practice. Anyone? Yes, because they might start by asking the practice manager: “Who is responsible for decontamination?” With that answer, they could ask the person or persons named: “What is the decontamination procedure?” Then follow up with: “Where is it done? Why? How?”

Any “I don’t know”, “I’m not sure”, “I’d have to ask”, “I can’t remember”, replies suggest a vulnerability.

If they began with a receptionist, they might get the answer: “I don’t know”, which they can follow up by asking: “Who will know?”. If the receptionist says the practice manager, the dentester is off and running. If the receptionist doesn’t know, that suggests a vulnerability – each member of the team should know what roles and responsibilities other members, especially senior staff, have.

Another example

Now the dentester, or another member of staff with an equally enquiring mind, could play at being a patient. They could ask any team member: “How do I make an appointment?”, “How do I make a complaint?”, “When is the hygienist available?”, “Where is the nearest car park”, “How much do implants cost?” Depending on whether they questioned the part-time Associate or a receptionist, they should be given either the name of the person who will know or the actual answer. The dentester proceeds to ask more questions, as before.

The learning points

The dentester’s work is, of course, wasted unless you ensure the vulnerabilities he or she uncovers are shared with the team and corrections discussed and implemented. Also, a dentest is neither a one-off exercise or a standalone one. With new compliance requirements coming on stream all the time, new systems being introduced and new staff joining the team, vulnerabilities may surface again – so regular dentesting is required.

Also, you may wish to enlist a ‘secret shopper’ to check for vulnerabilities. Obviously it needs to be a person your can trust and who will respect confidentiality. Perhaps someone from your plan provider or the dental lab you use or, better still, your favourite dental business management consultant…

Image credit -Andy Maguire under CC licence -  modified.

We all know what fight or flight means. We all know the situations where you feel the rush of tension before you panic and go one way or the other.

The third response, freeze, is often overlooked. But freeze is exactly what I did, day in, day out, for years.

I froze. Standing, at the counter in my local big name coffee shop, for what felt like an hour. In reality it was only a second. What had caused this rush of fright?

The barista repeated. “Do you have a busy day?”.

That was it.

This wasn’t in my mentally rehearsed plan. I was ordering a cappuccino, the same as I did every Thursday in the morning, part of my weekly coping strategy. Going out of the house, doing SOMETHING, was better than sitting at home, waiting for the afternoon shift to start. I had become accustomed to going to the coffee shop, ordering the same thing every week, and gradually became more and more comfortable with my surroundings. And then this happened. I couldn’t go back. Well, at least not for a long time. I was comfortable, and she had ruined it by asking a straightforward question that any reasonable person would have answered without hesitation.

Social anxiety is a problem I’ve had since I was 8. I don’t remember exactly how it happened, but I was never really comfortable around people. Having someone who was obviously uncomfortable around other children drew the bullies out like flies to a turd. So I was a very obvious target of bullying. I froze, all the time. I couldn’t do anything. It got worse and worse, every time I was asked anything by an authority figure, I ground to a mental halt, unable to answer and unable to move. Rabbit in the headlights.

I was pushed into social events by my parents, who were clearly at their wits end and thought that forcing me to go to interact with other people would help. It didn’t. It made things worse.

As a teenager I got great solace in music. The louder the better. By putting earphones in, I could block out the cacophony of the outside world, and if anybody tried to talk to me, the brief time it took to take the earphones out gave me a fraction of a second to steady my nerves.

And then I discovered alcohol. I went to university, unable to feel comfortable when surrounded by anybody, and I found that at first beer took the edge off, then it became whisky. At the same time, I started smoking cannabis. Cannabis was wonderful. My anxiety was gone, I could be much more “myself” and it even allowed me to sit in a room and have no nerves at all.

But illicit drugs and alcohol soon took their toll and were starting to take over my life, as I descended down the path of alcoholism, and being so anxious of normal life that I couldn’t function without the instant and total relief brought on by cannabis.

I decided to stop everything. I stopped drinking, I stopped smoking cannabis. I was left (briefly) with the one drug that provided any form of relief, nicotine, although I stopped that fairly soon after.

Meeting new people was always very tough after that. It went back to how it was when I had been at school. I completely froze. When you freeze and struggle with conversation, people make all kinds of assumptions, with the stories sometimes making their way back to me through friends. If only they had known the truth, I don’t think people would have been so judgemental. The worst experiences were when people talked ABOUT me, to a third party, when I was right in front of them, on one occasion telling the third party that I was “the weirdest person I’ve ever met”, and the other, that I had “zero personality”. That was a trigger for a complete meltdown, and when it happened I struggled to leave my flat for a couple of weeks afterwards on each occasion.

And so on to the world of work. Eye contact became increasingly difficult. I somehow managed to develop a different persona for dealing with patients, and could blag my way through. I was able to talk to patients with comparative ease, but I always kept it very informal. Staff, however, were almost impossible to deal with. The more people tried to assert themselves as an “authority figure”, the worse it became. I once again got labelled as “weird”, got left out of social events, and then told that I made no effort to socialise. I do wonder if they knew how much effort it was to smile and say “Hi” to somebody in the morning, whether the same judgement would be made.

I recently decided to get treatment for this as I was incapable of living a normal life. It’s a lonely existence, plodding through life without any real social interaction. Social media has equally helped and hindered me at the same time, in that while providing an outlet for at least some socialising, it has also acted as a crutch, and got in the way of normal social interaction.

I had 8 sessions with a psychotherapist to try to overcome the social anxiety, and while progress is slow, the realisation that nobody looks or cares about me or what I say, was actually a huge relief. My GMP prescribed some antidepressants that unfortunately made my anxiety worse. However, after nearly a year of pushing myself into more and more uncomfortable situations, I’m much better. I can finally look somebody in the eye, and I don’t freeze when the conversation goes “off script”. I don’t take any medicines and I am no longer receiving any psychotherapy.

My only regret is that I hadn’t been able to access the treatment earlier. 

Image credit -PracticalCures under CC licence - not modified.

Walk down any high street and you’ll likely witness a cornucopia of contrasts and contradictions. Overweight people, painfully thin people. Healthy looking pensioners, teenagers who couldn’t run for a bus. Naturally wrinkly old people, unnaturally smooth-skinned middle-aged people. Adults with bright shining teeth, children with a mouth full of decay.

It’s deeply ironic that in an age when many of us could live to a 100 and all but the most serious diseases can be treated, some people are clearly missing out. As a mother of two and former practice manager it particularly disturbs me to see children with bad teeth. The numbers are staggering. According to the Health & Social Care Information Centre recent report NHS Outcomes Framework for England, tooth extractions due to decay in children admitted as inpatients to hospital, aged 10 years and under were at the rate of 462.2 per 100,000 population in 2014/15. That’s about one in every 216 children.

That’s an average for England, in Yorkshire and The Humber the figure was about one in every 112. The report also showed that: ‘Nationally, there is a strong correlation between area deprivation and the rate of tooth extraction. As deprivation increases so does the rate of tooth extraction. The rate of tooth extraction in the most deprived decile is almost 5 times that in the least deprived decile (808.7 compared to 167.5 per 100,000 population).’

What does Google say?

To attempt to answer the question posed in the title of this blog I decided to post it into Google. The result was many references to information on children’s oral health and an article in the Daily Mail with the headline: ‘The lazy middle-class parents who don’t teach children to brush their teeth: By a teacher who’s seen the horrific consequences’.

The article claimed that parents were too busy to show the children how to brush their teeth and when the teacher opened a pack of tiny toothbrushes and tubes of toothpaste in her class of four-year-olds ‘the children were saucer-eyed with curiosity.’

An article on parents.com claims: ‘Many parents are surprised to learn that kids need help brushing their teeth until at least age 6. Young children simply don't have the manual dexterity to do the job well.’

In October 2014, in guidance aimed at local authorities, NICE said: “Schools and nurseries should run tooth brushing schemes to help standardise the oral health of younger children.”

In an article about this guidance in The Telegraph, Joyce Robins from Patient Concern was quoted as saying: “Nice has often been accused of pushing nanny state measures but this is more like a ‘supernanny state’.

“What will they suggest next, that parents can drop their children off at school naked and unwashed, and leave the state to step in and do the rest?”

Oh dear.

There is an answer

So if parents are too lazy, too ignorant, too impoverished, living in area of deprivation or are combination of some of these factors, what is to be done? The answer comes from the USA. Tegwyn H Brickhouse D.D.S., Ph.D. Department chair, research director and associate professor in Pediatric Dentistry at the Virginia Commonwealth University was the lead author of a paper presented to the IADR/AADR/CADR conference in March 2013. In it she wrote about a study into a scheme to decrease the number of low-income children in the Roanoke Valley with long term dental disease. The Child Health Investment Partnership of Roanoke Valley (CHIP) provides in-home preventive oral health services designated as the Begin with a Grin Program. The paper states: ‘In the context of a home visit, Community Health Nurses (CHNs) and Pediatric Nurse Practitioner (PNP) apply fluoride dental varnish (FV) to the teeth of CHIP-enrolled children from tooth eruption to 36 months. They educate the caregiver in preventing tooth decay and the importance of a dental home.’

The study found that: ‘Two applications of FV to the child’s teeth significantly reduced the likelihood of having any decay.’ The conclusions were: ‘Home visiting programs such as CHIP’s Begin with a Grin serves as a model to improve the oral health of high-risk children. The CHIP program provides an innovative solution for providing oral health care to the nation’s medically underserved populations.’

NHS Choices states: ‘From the age of three, children should be offered fluoride varnish application at least twice a year. Younger children may also be offered this treatment if your dentist thinks they need it.’

That presupposes a parent takes their child to a dentist. The CHIP Begin with a Grin programme avoids that requirement. However, dental practices would need to be informed when children are born in their area.

Is this something the GDC and NMC (Nursing & Midwifery Council) should be liaising about? Another question seeking an answer…

Image credit -Tiffany Terry under CC licence - not modified.

My previous post about stress was posted here on 28 January. This time, I’m attacking (more accurately, sneaking up on) stress from a different angle. And I’m starting by going back in time. Way, way back to pre-CQC. It seems prehistoric man suffered stress, would you believe? And guess what – we know it from their teeth! In 2010, George Armelagos, an anthropologist from Emory University in the USA, discovered enamel defects in teeth dating back one million years indicating that, ‘During prehistory, the stresses of infectious disease, poor nutrition and psychological trauma were likely extreme.’ This stress reduced life expectancy – remains from Dickson Mounds, Illinois, showed that individuals with teeth marked by early life stress lived 15.4 years less than those without the defects.

So is stress bad then?

Not necessarily; read on. According to the Mental Health Foundation: ‘Some stress can be positive. Research shows that a moderate level of stress makes us perform better. It also makes us more alert and can help us perform better in situations such as job interviews or public speaking. Stressful situations can also be exhilarating and some people actually thrive on the excitement that comes with dangerous sports or other high-risk activities.’ The Foundation does point out that stress is only healthy if it is short-lived.

Stress causes a surge of hormones to better help you deal with ‘fight or flight’ situations. According to NHS Choices: ‘Once the pressure or threat has passed, your stress hormone levels will usually return to normal. However, if you're constantly under stress, these hormones will remain in your body, leading to the symptoms of stress.’

How much stress is normal?

Now we come to the science – specifically the Depression, Anxiety and Stress Scale (DASS). This is a self-report questionnaire whereby you answer questions, add up the score and convert these to severity ratings for depression, anxiety and stress. There are two versions – DASS and DASS 21. The former has 42 questions, the latter 21 (so you multiply the scores by two). Ignoring depression and anxiety for the purposes of this article, the severity scores for stress are:

·        Normal 0-14

·        Mild 15-18

·        Moderate 19-25

·        Severe 26-33

·        Extremely severe 34+

DASS is not a diagnostic tool. If you are feeling anxious, depressed or stressed, you should see your GP – even if you get low DASS scores. However, if you wish to get some idea of how stressed you are and so gauge whether it could be considered healthy, go to https://www.cesphn.org.au/images/mental_health/Frequently_Used/Outcome_Tools/Dass21.pdf for DASS 21 (remember to double your scores for the full DASS severity ratings.

No added stress

In my previous post, I urged you to stop putting stress on others – particularly colleagues and staff in your practice. Now we see that some stress is normal and may well be beneficial. So does that contradict what I wrote before? Not at all. Yes, some stress is normal and healthy but so very few of us lead completely stress-free lives that we need added stress at work. Relationships, health, family obligations, household maintenance, cars, money worries all cause stress. Many of us are also good at getting stressed about things that haven’t even happened yet! So who are you to add to the stress of your colleagues or staff and maybe move them from normal to mild, moderate or severe on DASS?

Stress as a management tool?

Excuse me? Think twice (or more) before you decided to ‘push’ members of your team to make a greater effort. It is far more effective to motivate people to work more effectively or efficiently. People work best through their lunch hour when they don’t hold a grudge at you demanding it but because they genuinely want to get the patient records up to date.

As a manager you should be familiar with the theory of psychological type as introduced by Jung and the Myers-Briggs Type Indicator – so you know how to get the best out of each member of your staff.

This is a topic covered on my courses – come and find out.

Image credit -Bottled_Void under CC licence - not modified.

What a day! Traffic jams, a flat battery in my mobile, a parents’ meeting tonight and I’ve still got to write this blog about being stressed.

Ah, that’s better. It’s another day and instead of writing the blog when I was tired and grumpy, I wisely left it until now. If only all stress would dissipate so easily.

This is not an examination of stress in dental practice. For that, I recommend an excellent study on the Yorks and Humber Deanery website.

And this is not about managing stress because I agree with dentist and communication coach, Brid Hendron, who says we need to be eliminating stress.

This is also not a guide to stress relief. There are plenty of those available and the Stress Management How to Reduce, Prevent, and Cope with Stress article here is better than many.

So what is this blog about?

Oh dear, I can sense you’re become a bit stressed reading this, so I need to get to the point. Which is to ask: are you the source of stress in your practice?

Can you honestly say you don’t ever put stress on your subordinates/superiors/equals? Think carefully, do you bang on endlessly about problems that cannot be solved within the practice (government policy, for example)? Do you set your staff unnecessarily tight deadlines to complete work? Are you careless about returning equipment so that colleagues can’t find it? Do you leave an empty loo roll in the toilet and a dirty mug in the sink?

#LoveYourImperfections (not)

Such behavior may, according to the online dating service TV advertisement, result in you finding true love but that won’t be in your practice. Instead, it will result in stress, which will have consequences. According to the HSE, 9.9 million working days were lost to work-related stress, depression or anxiety in Great Britain in 2014/15.

Just stop

Like ceasing smoking or the consumption of alcohol in too large quantities or (as in my case) pigging out on cream buns, stopping causing stress is easier written than acted upon. Here’s what you should do. Suffers of stress are advised to keep a stress journal. Do likewise but instead of recording stressors on a daily basis, you should identify ‘stressees’ (the colleagues to whom you’ve caused stress). This won’t be easy. Not everybody reacts to stress by pigging out on cream buns or bursting into tears. Quite probably, you won’t witness the effects of your stressful action within the practice. So here comes the clever bit.

Stress balls

At a team meeting, explain you’ve read an article about stress in the workplace and want to learn how many people in the practice feel it. Now place a bowl of marbles, walnuts or (if you are in an upmarket practice) Ferro Rocher chocolates in the tea room (staff lounge) with a mug (porcelain cup) beside them. Ask your staff to place one of the items in the mug (cup) at the end of each week if they’ve felt stressed.

Self-regulating stress reduction

Once this has been done for a few weeks (so that staff have become comfortable with it), explain that you’re keeping a stress journal and would like others to do likewise (anonymously, of course). While there is no direct correlation between what people note in their stress journals and the weekly marbles/walnuts/chocolates ‘score’, it is in everybody’s interest to reduce the stress they place on colleagues in order to decrease how many ‘stress balls’ are in the mug (cup) at the end of the week.

Let me know how you get on with this exercise (and perhaps you can come up with a name for it).

GDC hearings: The imbalance of probabilities

Can we make the Regulators serve the Public and the Profession in foro conscientiae (the court of the conscience), rather than just a notion of what the regulations might say?

I have attended and been asked to make some input into a variety of cases recently involving several different Regulators.

It has become clear that there is a real danger that rules and regulations which may have been drafted for the protection of the Public and the guidance of the Profession are sometimes widely misinterpreted at best and occasionally deliberately corrupted and applied at worst.

How does this occur?

Whilst it might be considered that most regulation has been drafted to improve standards and reduce the risk of poor practice continuing; it is quite obvious that it can be applied in a manner to exert control or ‘manage’ the Profession. Sometimes this may occur deliberately and because it broadly serves the purpose of a government administration, it is allowed to continue at least as long as it serves a purpose. Sometimes it occurs at a much lower level and whilst not serving any particular purpose, it is allowed to continue because there is nobody at that level who is prepared to question it.

I’ve got nothing against shop assistants, however I wouldn’t be wanting them to draft the GDC Charge Sheet which might end a Professional career. There is a high turnover of staff at the GDC which I suggest leads to a poor understanding and there appears to be a low level of dental knowledge.

What this might mean if you are in the dock

One of the cases to which I refer involved a young colleague, and for whom funds were raised at very short notice thanks to the excellent GDPUK membership.

If you read the Charge Sheet, you would be forgiven in believing this dentist was a real danger to the Public. However I’m sure that you will all remember me reminding you to read between the lines whenever you are dealing with a Regulator. That is certainly necessary in this case.

Example appearing on a Charge Sheet

(i)            The use of a double cantilever (the bridge was fixed-fixed)

(ii)           Not adequately assess that a RCT was required (the tooth was root treated and had been a symptom free bridge abutment for 20 years)

(iii)          Fitted an inadequate post which was a) short of the apex, b) not extending to the apical third and c) was inadequate in width. (The post was temporary and deemed too wide).

If the Charge sheet is a nonsense, the solution is simple. The Panel changes it, strikes it out or substitutes different wording. In other words, it moves the goalposts. The Panel, which is independent by hearing both parties then asks its own questions of the witnesses. It is advised by experts and can choose which expert it ‘prefers’. The expert appearing on behalf of a registrant might then be warned by the Prosecution barrister that the GDC may take action against them. The prosecuting barrister is instructed by the GDC and regularly prompted by their expert witness.

In one of the cases to which I refer, four patient witnesses who had made a complaint were called. One of the witnesses was travelling to London and it was found that she intended to speak in favour of the Defendant and it was agreed therefore that this patient would not be heard.  

The Panel seemed to have some ability to read between the lines, but in the end ‘prefers’ the testimony of two patients. One of these patients produces a hand annotated diary of the treatment dates containing some dates that the defendant was actually not in the practice (a screen shot of practice diary was produced as evidence). The patient was receiving treatment from more than one dentist at two different practices simultaneously, but on the ‘balance of probability’ is to be believed. This patient was heard to say that she was seeking ‘redress’ on at least four occasions.

Our young colleague describes how he always uses rubber dam for RCT and yet on his last day in the practice he finds there is no rubber dam available. He admits that on this single solitary occasion, rubber dam was not used. The patient has pleaded that a temporary post crown be placed (the same inadequate temporary post that was short of the apex) and he accedes to the request of RCT and temporary post, since the broken tooth was within the patients smile. He uses rotary RCT instrumentation, floss on hand instruments and high volume aspiration. The patient is the same one who was not given the opportunity to give further evidence in support or denial of the registrant. Our young colleague is guilty therefore of serious clinical failures and therefore misconduct.       

Another patient gives evidence about never having received treatment he has paid for, but the Panel agrees that this evidence is just not credible, which it isn’t.

A fourth patient was having a long and complex treatment plan part of which had been incomplete and following a tooth fracture needed to be modified. The patient didn’t clearly understand the new treatment plan and for that our colleague was criticised.

It’s worth mentioning that there were NO PATIENT RECORDS available because there had been a burglary declared immediately following the practice change of ownership. This was highlighted to the Panel. 

Communication was a big word in this Hearing. Other significant words are ‘insight’ and whether or not the Panel consider that this is ‘embedded’ sufficiently. Our young colleague was supported by Sir Peter Bottomley in person who made a statement and also by the testimonials of 47 patients.

The GDC however do not need to give weight to the above in making their determination, although I noted that the prosecution barrister frequently returned to the GDC to ask for further instructions. I think it worthy of note that the Panel describe our young colleague within the Determination as follows ‘It is clear from all of this evidence that you are viewed as a competent and caring dentist, who will go out of his way to assist his patients.’

Do the GDC therefore need to apply Conditions, because that’s what they did? 

Please read the GDC Determination when it is published.

So what?

If you recognise any of the issues above, you are guilty of misconduct and your standards will be deemed serious failings. Approximately 1 in 7 dentists in the UK currently face some form of investigation which could result in imposition of sanctions either through the GDC, CQC or NHS and this number is growing constantly. This might mean that we have the worst performing Dental Profession in the World bar none or that we have the most disproportionate Regulators.

You may consider yourself lucky and are happy to cross the bridge with your indemnity organisation when your time comes; or you may be sufficiently confident to wade across the raging torrent alone when your indemnity organisation makes an unexpected discretionary decision against you.  

What type of indemnity organisation are you currently paying for?

How can it be legal?

You are required to have professional indemnity and it is considered a serious failure if you have ANY gaps in your cover period. Indemnity providers however do not guarantee to provide legal representation to you and if they exercise their discretion in favour of their balance sheet (or dressed up as other members interests) you will find yourself alone or facing a huge legal bill.

A recent Hearing which I attended over 7 days starts at £32,000 and it’s uphill from there.

Does anything need to be done about this?

You read the PSA report published 21^st Dec, I hope.  https://www.professionalstandards.org.uk/docs/default-source/psa-library/investigation-report---general-dental-council.pdf?sfvrsn=6

What exactly have we learned about whistleblowing from the Sir Robert Francis Report (Mid Staffs)?

And you can see how the whistleblower was treated, you can see what the PSA thinks about it and you have seen how the GDC are going to be dealing with your ‘serious failings.’

You tell me, do you need to do something about this?

So where are we now?

From a variety of recent cases we can conclude:

·         The GDC consider failure to use a rubber dam in endodontics to fall seriously below the required standards and therefore to represent IMPAIRMENT and worthy of sanctions.

·         In my view neither the CQC nor the GDC have a currently correct understanding of CONSENT which conforms with the recent Supreme Court judgement of Montgomery – v Lanarkshire Health Board. This needs to be challenged in the High Court.

·         The GDC will always use the ‘balance of probability’ in forming an opinion on which evidence it prefers. 

So where are we going in 2016?

The Profession must for once in its life join together. The issues regarding Consent and use of rubber dam will need to be challenged and this requires more than a well-intentioned individual or some crowd funding. It requires a strongly actioned move being taken by the BDA and the indemnity providers.

Image credit -Michael Coghlan under CC licence - not modified.   

‘Hope got me through…..’ Terry Waite CBE

A warming Xmas story to boost practice manager’s morale

I have been to many a Christmas carol concert over the years but this festive season I attended one that I will never forget! The concert was held in aid of Emmaus, a UK charity that helps homeless people off the streets and of which Terry Waite CBE is president. For those young readers who may not know, Terry was an envoy for the Church of England in the late 1980’s. He travelled to Lebanon to try to secure the release of four hostages but was kidnapped himself and held captive from 1987 to 1991. Terry spent almost five years, including four Christmases, in solitary confinement without any news of his family, his friends or the outside world. Torture and mock executions were a regular occurrence.

Terry was invited to be a guest reader at the concert and he relayed a story to us of his fourth Christmas in solitary confinement……the room was dark, damp and cold. There was no source of heating and only a single blanket to keep him warm. Terry was forced to sit on the floor in the tailor’s position whilst shackled to a radiator which for a very tall man must have been torture in itself. His only source of light was a single candle; his only company, a bible. One day, after many attempts, Terry managed to encourage his guard to tell him the time and date. He was surprised to find that it was late afternoon on Christmas Eve. Terry decided to celebrate Christmas by holding his own, personal Holy Communion so saved a small piece of bread and drop of water from his meagre rations. His candle was burning low but he wanted to wait as long as possible to be sure that his celebration was as near to Christmas Day as possible. In the dying light of his candle, Terry took the morsel of bread and water, blessed it and savoured it whilst reading a passage from his bible. The moment passed as the light finally died.

When asked how he survived these lonely, unbearable years, Terry’s answer was ‘hope’!

I think in the world of the practice manager there is much hope that can be taken from this message and many synergies too. I work with many practice managers who feel lonely and isolated incarcerated in their cold offices in the rafters of their practices. Communication with busy staff can be scarce increasing the sense of segregation. On the rare occasion that a staff meeting is held, everyone wants a ‘piece of flesh’ or demands answers about something. The practice principal is generally focused on the clinical workload leaving the burden of renewed CQC inspections, financial management and human resource issues to the overloaded practice manager. The pressure to perform is sometimes torturous. On top of the internal workload scrutiny is increasing from the outside world. A week rarely goes by without dentistry featuring in media headlines and public observation of the dental profession being heavily influenced by this bad press. The weight of complaints handling and demands from patients also falls on a practice manager’s shoulders and sometimes ‘giving blood’ is still not enough in some cases!

So, where can a practice manager find ‘hope’ in such difficult circumstances? How can they release the burden, shake off the shackles and find freedom and enlightenment as Terry did? One definition of hope is ‘a feeling of expectation and desire for a particular thing to happen’. This is all well and good, but in business, hope sometimes needs to be accompanied by a ‘mental shift’ to allow change and escapism to happen.

Here are my ten top tips for seeing your hopes come to fruition:-

1.      Define your purpose – be clear as to what kind of manager you wish to be. Take responsibility for shaping the future.

2.      Embrace change – be proud of what you have achieved to date but embrace change and make improvements.

3.      Keep moving forward – view failures and disappointments as an opportunity to improve, evolve and succeed.

4.      Communicate – plan, organise and review communications with your team and patients to be effective.

5.      Lead authentically - be sensitive, open, firm and fair. Learn to listen. Be you!

6.      Believe in yourself – be prepared, have faith in yourself and be true to your inner beliefs.

7.      Make everyday count – give 100% to everything you do.

8.      Act now – deal with situations as they arise. Don’t leave things to fester.

9.      Keep a positive attitude – do not tolerate negativity or poor attitudes. Stay focused on steering a buoyant ship!

10.  Stay healthy – sleep, eat and exercise well. It has a direct impact on your mental wellbeing as well as your body.

Happy Christmas everyone and here’s to a New Year full of hope!

Image credit Mararie under CC licence - not modified.

Are you giving your patients what they want this Mouth Cancer Action Month?

A recent survey highlighted by the British Dental Health Foundation (www.dentalhealth.org) found that 9 out of 10 dental patients want to be screened for oral cancer but only 14% of those surveyed were aware that they had been whilst visiting the dentist. An estimated 90% of dentists are screening for oral cancer during a dental examination but do not talk to the patient about what they are doing!

Why is the dental profession so reluctant to talk about the ‘C’ word when patients want to hear it? Is this due to our fear of litigious activity if patients know too much or is it because dentists lack knowledge, confidence and experience in dealing with oral cancer management? It seems irrational when we hear about skin, cervical, breast and testicular cancer all the time. The public is exposed to messages about these types of cancer on the television, through other media and even in GP’s waiting rooms. At certain ages we are invited to be screened for a variety of cancers and given advice about screening ourselves regularly too. People are generally well informed about prevalent cancers and aware of Government initiatives to tackle the problems.

Why is oral cancer any different? Why is our profession so fearful of talking to our public about this developing epidemic? Why is there no Government initiative to combat this hidden killer? Why are girls not informed that the HPV vaccine will safeguard them against oral cancer as well as cervical cancer? Oral cancer is not just a hidden killer but also a silent one as nobody seems to be talking about it!

So, this Mouth Cancer Action Month (https://www.dentalhealth.org/our-work/mouth-cancer-action-month) give your patients what they want! Train your team to talk to patients in a confident, knowledgeable and appropriate way particularly during screening. Teach patients to self-screen on a monthly basis and arm them with the information that they need to look out for the early signs of the disease. Self-screening is particularly important as NHS recall intervals continue to be unreasonably stretched. The way I see it, if patients are given joint responsibility to screen themselves for oral cancer, this may help to counteract the barrage of litigation we are experiencing. As a profession, if we screen for, talk to and educate our patients about oral cancer, we will be meeting our professional obligation to do so as well as keeping the CQC happy when they come knocking at our door.

Talking to patients about oral cancer not only raises their awareness but it also helps to spread the word about the disease. Give people what they want and they will also tell their friends and family about the fantastic job that you are doing. ‘Word of mouth’ is the most effective marketing tool at your fingertips, so go ahead and use it!

"Squamous papilloma -- very low mag" by Nephron - Own work. Licensed under CC BY-SA 3.0 via Commons.

The FCA is more than just the OFT with a new name . . .

by Martin Gilbert 

Offering credit to your patients used to be so simple. All you needed was a Consumer Credit Licence and that was it. When a patient wanted to spread the cost of the treatment, you forwarded an application to the lender, they sorted out the paperwork, you did the work and you got paid.

Then the credit crunch came along, and in the aftermath it was decreed that the Office of Fair Trading wasn’t the best organisation to supervise consumer credit (think about the unfettered antics of payday lenders and home reversion scheme providers) and responsibility was transferred to the Financial Conduct Authority.

And they are a different animal altogether. They started gently enough, by writing to all CCL holders and telling them that if they wanted to continue to be credit brokers, they just needed to register for Interim Permission.

Then all IP holders were notified of the Allocation Period in which they have to apply for Authorisation. The last ones finish in February 2016. Applying for authorisation (which for most dentists, who just need to act as Secondary Credit Brokers, will be for Limited Permission) is not too difficult, as long as you have the time and understand the terminology (who knew that ‘agreeing to carry on a regulated activity’ was itself a regulated activity, and one which you have to have).

So you complete the online application and pay the fee. The letter arrives (within their 6 month’s SLA) with your Authorisation, your Firm Reference Number and information about your ongoing obligations. You skim through it, and then file it.

But this is only the start of your relationship with the FCA.

Next you get an email telling you that a Return is due. So you phone the FCA Helpline, who tell you that you should have registered for GABRIEL. Which you didn’t bother with, because you hadn’t really read the letter, and the OFT never used to ask you for any returns, so it hadn’t occurred to you that the FCA would. (CCR008 is required quarterly, CCR007 is annual, and there are fines if you miss the deadlines).

Then you get an email telling you that your Periodic Fee is due. So you phone the FCA Helpline, who tell you that you should have registered for online invoicing. And when you do so, and find the invoice, you’ll see that you also have to pay a Money Service Advice Fee and a Financial Service Ombudsman Levy.

So then you think, I can’t be bothered with this, I’m going to cancel my authorisation. So you phone the FCA Helpline, who tell you that you should have registered for CONNECT (not the one you used for your original application, but the one that was mentioned in that letter) to enable you to make any changes to your standing data. And when you do eventually manage to login, you have to find your way through ‘Start a new application’ to get to the cancellation option.

If you’ve got more money than time, there are plenty of firms out there who’ve made a business out of managing the authorisation for you – typically charging £600 to submit your application and £25 a month for ongoing compliance.

Or you could become an Appointed Representative of a specialist such as Chrysalis Finance, who look after the compliance and the reporting, and provide you with a state of the art online portal to process applications simply and easily. So you can not only get on with giving your patients the best treatments, but you also make them affordable for them. 

Martin Gilbert, a chartered accountant,  is a Director of Chrysalis Finance.

Thursday 16th April 2015 is the day I will never forget.  I was in surgery with Amy.  Bea was at reception.  It was a life changing moment for me and I am sure, for all of us, by Dr Chris Tavares BDS

THE CARDIAC ARREST

We were ready to get the patient in.  At around 3:45 pm,  Amy went out to get him in.  As the surgery door opened I could hear him having a laugh with Bea.  He came in, we exchanged the usual superficial pleasantries, had a laugh.  Asked him how he was. He said “Fine, very well thank you”.   Soon, was this to change.

He told me he had fractured a tooth in the upper right area this morning. There was no pain but it was sharp.  I turned round to type this into the clinical notes.  I could see that his ASA rating was 1.  Nothing medically to worry about.  As I was typing, I heard heavy breathing behind me.  I turned round and saw his eyes had closed, his right leg was hanging off the side of the dental chair and as I faced him, calling his name and shaking him and lightly slapping his face, the breathing became more laboured.   I lowered the chair back right down and called him again.  Suddenly he came round and said: “Yes, yes I’m ok”…and then….he was ‘gone’ again. The breathing became more laboured to an alarming level. 

I asked for the emergency kit and Amy came back with it.  He was still breathing heavily.  As I attached the pulse oximeter to his finger, his head suddenly came forward, tongue protruded and his breathing become a desperate stridor.   His face then went completely purple / ashen. 

Immediately I instructed Amy to let reception know “Medical Emergency.  Cardiac Arrest. Call an Ambulance.”  She went straight outside.  I noted the time and started CPR immediately.  30 compressions to 2 breaths.   At one stage, I vaguely remember thinking part consciously, that If I don’t do this, he will die. It was a battle between death and I and death was not going to take him, not on my watch.  I pumped like mad.

I heard Bea, shout, if he was breathing. I shouted back: “No. Cardiac arrest. Not breathing.”  

Amy came back in and brought the AED in. We connected it up and followed the instructions.  Bea stayed on the phone in, in case 999 needed to speak to her.

The AED spoke in an incredibly loud ‘voice’:

“Stand back. Do not touch the patient.  Assessing rhythm…..Shock advised…….Press the red button and shock.”  I did this and the whole chest arched and lifted off the chair with part of his body.  The AED assessed the rhythm again and instructed us to continue to carry out CPR. 

Meanwhile as Bea had more training in Med Emergency, she came in and Amy went outside to wait for the ambulance.  As I carried out compressions, the pulse oximeter showed a pulse of 110  and oxygen content of 70%.   This little bit of information was reassuring as our AED did not have a screen with the ECG tracing. 

The AED instructed again:  “Stand back. Do not touch the patient.  Assessing rhythm…..Shock advised…….Press the red button and shock.”  I followed the instructions.

The first paramedic arrived. This was about 11 minutes from the time the patient went into cardiac arrest.   I continued CPR.  He took over immediately to check the back of the chair was firm enough and immediately said ‘yes’, good.  I then took over again as he got his gear out.

The AED instructed again:

“Stand back. Do not touch the patient.  Assessing rhythm…..Shock advised…….Press the red button and shock.”  I did this and the chest arched and lifted off the chair.  The AED assessed the rhythm again and instructed us to continue to carry out CPR. 

Suddenly the patient responded and pushed my hands off his chest!  Then went still again.

The paramedic was in no hurry to attach his AED.  He asked if our AED showed what was happening on a screen.  I said no.  He seemed happy to continue with our AED at the moment.

The AED instructed again:  “Stand back. Do not touch the patient.  Assessing rhythm…..Shock advised…….Press the red button and shock.”  I did this and the chest arched and lifted off the chair.  The AED assessed the rhythm again and instructed us to continue to carry out CPR. 

By now two more paramedic vehicles and the ambulance had arrived.  Literally minutes if not seconds, 4 more paramedics came into the surgery.   The lead paramedic, the first one who arrived, switched over to his AED which had an ECG tracing.   The second lead asked about the medical history of the patient and I informed him it wall all clear. 

The third paramedic took over external cardiac massage as the second put an IV line in.  Sugar level was tested. Negative.

It is difficult to recall exactly what happened when and what was done when and in what order.  An airway was put in.   A drip was set up.  At some time I think they also injected something.  They did other things I am not sure what.  They also attached a contraption that carried out external cardiac massage.

As they looked at the ECG I heard the second paramedic say to the lead, “That’s VT” (I think that’s what he said. There was definitely a ‘V’ in his sentence) and this was confirmed by the first.  Everyone was instructed to stand away from the patient, they pressed a button, you could hear a ‘whine’ as the defibrillator charged and they shocked the heart again. 

The ECG tracing went flat and suddenly started up again and I could see what appeared as a more ‘normal’ tracing.  Then it took on another pattern again. 

They were in the surgery for about 1 hr to 1 hr 30 mins.  The tracing on the ECG was erratic and inconsistent in that time.  Every time they shocked him, the line went flat and then started again.

I had to help to deliver the oxygen for a few minutes.   In total the patient’s heart was shocked 6 - 7 times.

I am sure he had ‘come’ round a few times in that 90 minutes.

After the last shock, I cannot say exactly when but I suddenly realised they had stopped the compressions and delivery of oxygen.   They were moving around more relaxed. The lead paramedic asked one of the ambulance drivers to bring something in.  Then he asked her to bring the stretcher in.  I thought: “What, is he…dead?”. 

I had forgotten about the ECG.  I suddenly remembered it and looked over at it…..even though the patient was unconscious and no obvious signs of life, to me, ……… there was a ‘normal’ heart tracing on the ECG.   Very regular and steady.  I looked at his chest…he was breathing on his own!  I thought: “My God, there’s a normal rhythm!”  

They lifted him onto the stretcher with the airway and ‘automatic cardiac massage’ contraption still in place, I think. The airway was definitely in.   I suppose in case he needed it again.

3 of the paramedics went with the patient to the hospital, having taken the patient’s personal details.  2 stayed behind to pack up and clear up.  I asked the second paramedic if the patient was OK.  He looked at me, looked at our AED the oxygen cylinder and said pensively:

“He’s OK. Will have to see if he pulls through.  Hopefully there is no brain damage.  You got the oxygen,…. (he looked at the AED again, which was lying on the surgery floor) …….you had the defib…….you saved his life.” He said nodding.   It had not dawned on me at the time the significance of what he was saying.

The two remaining paramedics left, saying that they’ll be back to pick up the last remaining paramedic vehicle when they’ve finished at the hospital.

THE IMMEDIATE AFTERMATH

The three of us sat down, numb and started talking about the incident.  Bea made cups of tea and we sat in the staff room.  We agreed we could not have done anymore.  When he had been put into the ambulance, Amy said she heard one paramedics say to another that the patient had pulled the airway out.  This was put back in then the doors were closed. So it was good, it was reassuring to know that he was alive when he left the surgery to be taken to the hospital. 

There were no elation and shouts of joy. Just numbness.  The shock and disbelief that we had just be part of and witnesses to a full blown cardiac arrest in our dental chair.

As Amy and Bea were talking, I remember I had asked one of the paramedics if there was something we should do or someone we should report to. He said there was nothing.  If the patient dies, the police will be round to make their enquires and investigate.  If he pulls through, we probably won’t hear from anyone.

When I look back now, I cannot help but feel what a sad and unacceptable and ridiculous situation the profession has been put into by those who have the authority to ‘rule’ over us but really have been given or taken more authority that they deserve.  I have been told by a paramedic that we did the right things and possibly saved someone’s life, at the moment, but instead of elation at a professional stance of doing the right thing, unfortunately I started worrying about whether I had all the right ‘paperwork’, dotted all the ‘i’s and crossed all the ’t’s if there was an investigation!

When we finished our tea and I could see we were alright, we went down stairs to tidy up.  Bea put a note to order a new set of adult pads for the defibrillator.  I checked the oxygen content whilst Amy put the Medical Emergency things away.

It would have been about an hour to 90 mins when the door bell rang. Paramedics 1 and 2 were there.  We looked at them holding our breaths.  I asked how the patient was.  The lead said, looking at the ground:

“We have some news for you.  Looked up and smiled. We have him up and talking.  He’s actually up and talking.  He must have had a massive blood clot in the artery. They are thinking of discharging him in a few days. Well done” as he looked at each of us.

The relief from the three of us was palpable in the air.  He’s OK!

The 2nd paramedic looked at the three of us, then at me in the eyes and said something about CPR, getting the oxygen in then…..

“You had the defib…….YOU SAVED HIS LIFE””, nodding and repeated as he looked round at the three of us: “you saved his life, well done” and smiled.

I thanked them for delivering the good news, thanked them for getting here so quickly and for all they had done.

The two then left.

We shut the door and elation!  The total release of suppressed, involuntary tension.  Earlier on once the paramedics had arrived, Bea had cancelled the rest of the patients for the day and evening. I felt they deserved to have the rest of the day off!  Fortunately we weren’t seeing patients the next day.  They went home.

I stayed behind for a bit.

PERSONAL REFELECTION

Bea and Amy were just great.  I could not have asked for better support.  This was the first, and last I hope (!), medical emergency we had to deal with and, for all that, in at the deep end.    Amy just carried out unquestioning what she was asked to do.  Bea, calmly called the ambulance and handled the reception area.  In fact, as Bea was cancelling one of the patients’ appointment, he commended her on how calm she was when talking to him, given what she was in the midst of.

We were lucky there were no other patients in then.  No one ‘collapsed’ , broke down in tears or freaked out.  They both held it together.  Just amazing.

I will forever be grateful for the regulation that insisted we had Continual Professional Development (CPD) on “Medical Emergency” every year.  Every year we had a hands on 3 hours training session and I would also attend an additional lecture session.  I was never sure how much of this I actually retained in my head.

I made sure we held a medical emergency drill once a month. Only I knew when I would call one. I would always choose a time so we had a different number of staff around. We may miss a month at most but we held the drill regularly.

I am in no doubt this was one of five things that affected the outcome.

INSTINCT

When something like this happens, there is no time to think, no time to work your way through some mental venn diagrams or following the boxes of a mental flowchart.  It had to be instinct and what was already in your subconscious. 

Everyone just went into action. Everything just went so smoothly.  The call for the ambulance. Staying online with the 999 operator. Waiting outside for the ambulance.  Amy saw him and made a beeline for him.  CPR: 30 compressions to 2 breaths.

I have no doubts the regular drills helped us all.

STRIDOR & SUBSEQUENT LOSS OF COLOUR

I did not have to work out if he was breathing or his heart was beating. This just told me …negative.  I was lucky to have had these signs.

I just started immediate CPR and the ambulance was called. 

The rapid response I am sure contributed to the outcome.

CARDIAC COMPRESSIONS

One can never know if one is compressing chest deep enough.  You can’t measure the depth of compressions in such situations.In this case the colour of his face instructed me.  I could actually see the colour come back to his face.   This helped a lot when one is not consciously in a thinking mode and operating on instinct.

AUTOMATIC EXTERNAL DEFIBRILLATOR

The enemy to anything we do …….is ‘doubt’.  If you start asking yourself, doubting your actions, for anything, it is a recipe for disaster or failure.

He was, as I came to know, in VT/VF. I have no doubts the AED contributed to the positive outcome, directly and INDIRECTLY. 

Before the AED was connected, I was just pumping away but no idea if it was helping. 

The question always in the back of my mind is if I’m doing the right thing at the right time. 

When I connected the AED up, the minute I heard its “voice”, I was immediately aware of a sudden mental, physical and emotional relaxation. It was like having the consultant cardiologist in the surgery.

“Stand back…do not touch the patient…assessing rhythm….shock advised….press the red button and shock.”  I just thought: My God, his heart is being monitored now.  “Somebody” knew what was going on.  There is nothing more to do but follow the instructions.  It had an immediate calming effect on the whole process.

I had wondered if I should buy the AED.  I did. We’ve had it for 5 - 6 years now, every day checking the “green ready” light is on, never once thinking we will need it.  I have absolutely no regrets in buying it. 

I am well aware that there is still going on a major disagreement amongst professionals whether the AED is necessary in the dental surgery.  I will have no hesitation now to say YES.  I cannot be more appreciative of the AED.  It made the whole incident so much more easy to handle and I will forever be grateful we had one.  It actually helped to calm the room.   Was it ‘the thing’ that saved his life?  I don’t know.

I remember hearing at a lecture on Medical Emergencies.  I cannot remember who it was.  What he said was that we can never fully know exactly what is happening to the heart muscle and how it will respond to anything we do.  The patient, to all intents and purposes, is dying or nearly dead. If there is anything we can do that will remotely contribute to a positive outcome….DO IT.

Of course there is never absolute certainty in life.  The consequences of our actions can never be fully predictable.  If one will only act if one is always absolutely certain of the consequences of one’s actions, then one would just sit and do nothing.

The AED contributed in two major ways:

1    It really calmed the room whilst we waiting for the paramedics to arrive.

2    As I saw on the ECG screen later, it gave the heart a chance to re-establish a normal rhythm.

I HAVE ABSOLUTELY NO DOUBTS THE AED CONTRIBUTED TO THE POSITIVE OUTCOME in this case.

LUCK

Pure luck had a lot to do with it.  We were lucky the paramedics were able to arrive so quickly and there were so many.   They were just amazing.  They went about what they had to do in a calm, confident and controlled manner. 

We were lucky, before the paramedics arrived, none of us freaked out.  I have no doubts the regular drills we had played a large part.

One can never say for sure what exactly it is that brought about the positive outcome but I am sure luck played a part in it.

WHERE AM I NOW?

There is the disbelief that I was actually  deep in the middle of it all.  I actually looked at the face of someone who was clinically dead and he pulled through?   I came back from the Dentistry Show the day after ‘the event’ and went straight to the surgery, to call the hospital to see how he was. There was a slight eerie feeling going into that empty building, into the surgery. It was all clean, tidy and quiet. I could not help but wonder if 24 hours earlier, did all that really happen?

The suddenness of it all is what is so frightening. There were no medical history concerns.  One minute he was there, two minutes later he was gone. If he had been in his car, 5 minutes late for his appointment, he would have had it in the car and could have ploughed into a bus stop with men, women and children.

I value my life much more now.  An appreciation of what I have, life, wife and children,friends and who I am.  So much we take for granted. 

I was surprised how well we all were when we attended to patients two days later.  It will take some time for the slight apprehension to dissipate.  Is this person going to suddenly have a heart attack on me?

The recent developments, all the nonsense, in the dental profession had really got me down.   All the effort in having to keep a surgery running with all the nonsense regulatory compliance and then having more piled on, unnecessarily.  I had been tired of putting so much effort into working as a dentist and getting so little back in return as the pressure of legislature piled on.  I was tired of legislature getting in the way of patient care. 

This ‘event’ has helped me to see things in perspective. This has been a good boost in morale as at least, all this effort came to fruition.  I am very proud of my staff and I hope they are of themselves too.

There is a mixture of emotions or feelings in myself.  Of course there is an immense feeling of gratefulness that we had a positive outcome.  Then, there is the feeling that one has been in a ‘privileged’ place, if that’s the word to use.  To have been involved in the thick of things and have a positive outcome.  Then there is something else I am aware of.   I am not sure how to describe it but it is a good feeling……….there is a deep seated feeling of stillness.

Every so often, the words that still ring in my ears:  “You had the defib……you saved his life.”

That inner stillness…..is….good.

Chris.

Dr Chris Tavares,

Dental Practitioner, Derby

April 2015

This blog was first published in April 2015, a few days after the event. In May 2016, after seeing more data, Dr Chris Tavares added the following:

I wanted to correct a few inaccuracies so as to be fair to the East Midlands Ambulance Service who did such a fantastic job on the day and to give credit when and where credit is due.

In the heat of things, a second can seem like a minute. A minute can seem like three minutes. I was able to download the data from the AED which records an ECG tracing every second. The AED analyses the rhythm every 2 minutes and advises to shock or not.  I was able to work out the exact timeline from this.

The heart was in VF.  CPR was started within 10 seconds of cardiac arrest.  The first shock to the heart was within two minutes of cardiac arrest.  The first paramedic arrived 5 minutes from the time we dialled 999. The five paramedics were in the surgery for about half an hour when a normal heart rhythm and spontaneous respiration were re-established and the gentleman was taken to the hospital. 

I have no doubts the rapid sequence of responses added to the positive outcome.

 The whole situation can best be summed up:

 “We did what we had to do ... the paramedics did their magic ... and the hospital staff performed the miracle.”

The gentleman is alive and leading a full life, no brain damage, no external scars.

Buy an Automated External Defibrillator and save a life.

Friends and Family Test [FFT]

The FFT will be introduced to dentistry in England on 1^st April 2015, which some might consider an appropriate date to introduce such a tool. David Cameron is an enthusiastic supporter and believes this simple test will provide “a single measure that looks at the quality of care across the country."

Others, including the Picker Institute, the Kings Fund and the British Medical Association are somewhat less impressed with the value of implementing such a tool. Chris Graham of the Picker Institute has stated that “the ‘simple, headline metric’ used for the test does not provide a reliable basis for comparing services or identifying those performing best.” Dr Kailash Chand, deputy Chair of the BMA, is slightly more direct in his criticism. He has described the FFT as a “political gimmick” and asserts that the last thing we need is to collect “more meaningless or misleading data”, a comment which I’m sure will resonant with many dentists.

Sadly this point is obviously lost on the Prime Minister, who continues to believe that the FFT will allow everyone to “have a really clear idea of where to get the best care”. It is hard to believe that such a simplistic tool could actually improve the quality of patient care in dentistry. (I refer to the FFT, and not the Prime Minister!) 

The only value would appear to be in the free text question, which we have naively been given freedom to design ourselves.

The simplest approach would be to ask …. “Why?”

As in, “why did you answer the previous question in the way which you did?” Rather than “WHY?” in the context of a dentist screaming at the moon, as another pile of ill-conceived bureaucracy is dumped on them from a great height courtesy of some narcissistic NHS manager.

Other suggestions for free text questions have included:

“How much of a waste of time do you think this is?”

“What three words best describe the people who developed this questionnaire?”

In the spirit of Patient and Public Involvement, it might also be worth considering the following as a suitable second question…..

“What question do you think we should include as our second question?!!!!”

It is tempting to treat the FFT with the respect which it deserves. NHS England appears to be resigned to this approach, judging by the fact that there is currently no target set for the number of responses required! The introduction of FFT is a contractual obligation and I can’t imagine that this laissez-faire attitude will persist. Perhaps they will include it within a future iteration of the DQOF as another measure of how well we complete our paperwork. The term “biro dentistry” is about to take on a whole new meaning!

So what should you do?

In our practice, we are fortunate to have a highly motivated, efficient practice manager, who seems to revel in the imposition of NHS bureaucracy. She obviously looks at the FFT as yet another challenge to be overcome, and failure to do so would be seen as a sign of weakness. She has organised strategy meetings, staff training, team discussions and already delegated duties. None of which involve me filling in a pile of FFT forms…… as yet!

There is unanimous agreement within our practice that the FFT question is a complete waste of time. It is not a reliable indicator of quality and provides inadequate information compared to our existing patient questionnaires. We see this as an additional burden on our staff, our patients and our practice, but will reluctantly comply and attempt to use the free text question properly to gather some feedback.

So what should the profession do?

As a profession, we need the BDA to take a strong stance and challenge NHS England on the introduction of additional bureaucracy, which quite clearly has limited patient benefit. It is correct that the BDA support the introduction of measures of quality, but such tools need to be valid, appropriate and worth the paper they are written on. 

Patient experience data is of considerable value in terms of improving the quality of patient care and there is obviously an increasing amount of data that is going to be collected, analysed and interpreted. This takes time and resources, but can only be justified if the data collected is robust, reliable and can ultimately be translated into improvements in patient care. If the data is not robust and reliable, the exercise will be a waste of time and simply add to the level of unnecessary bureaucracy and administration, which we have to deal with. It is not acceptable to measure what is easy to measure, rather than what is actually meaningful. This is ineffectual, burdensome and demoralising for staff.  

Jocelyn Cornwell of the Kings Fund states that “patient experience measures will only work if clinicians as well as managers take them seriously, and in general they don’t. Clinicians will reject measures they see as inappropriate or unreliable, and will not act on the results.”

We have an opportunity to put quality at the heart of the dental contract reforms, and Patient Reported Experience Measures are going to play an important role in the evaluation of quality. The current approach of NHS England does not instill confidence and it is therefore vital that the BDA, the FGDP and others influence how quality is measured within general dental practice.

1.    Department of Health. NHS dental services in England - An independent review led by Professor Jimmy Steele. In: Health Do, editor. London: The Stationery Office; 2009.

2.    Professor the Lord Darzi of Denham K. High Quality Care For All. NHS Next Stage Review Final Report. London2008.

3.    Kings College London and The Kings Fund. What matters to patients'? Coventry2011.

4.    Department of Health. Dental contract reform: Prototypes, Overview document. In: Legislation and Policy Unit DaES, editor. London: HMSO; 2015.

 Image credit - Glyn Lowe  under CC licence

Measuring patient experience in NHS Dentistry

A consistent criticism of NHS dentistry has been the continued focus on treatment and activity rather than prevention and oral health outcome; a pre-occupation with “quantity over quality.” Jimmy Steele acknowledged this in his 2009 report and highlighted the need to design a contract which provides “much clearer incentives for improving health, improving access and improving quality.”¹

We would all agree that dental care professionals should provide care of a sufficiently high quality for our patients, and it would not be unreasonable to expect to work within a system that supports this. Sadly, it is generally accepted that the current NHS contract does little to incentivise or reward high quality care, and I guess we should be encouraged by the fact that the contract reforms appear to be addressing this by developing a Dental Quality Outcomes Framework (DQOF).

The DQOF was initially based on three dimensions of quality as recommended by Darzi²: Clinical Effectiveness, Safety and Patient Experience. This has subsequently been refined with the introduction of two additional domains (Best Practice and Data Quality) within the prototype contracts. The addition of a domain which rewards dentists for submitting NHS claims on time perhaps gives some insight into the level of confusion which exists around the concepts of quality management and performance management. Submission of claims on time is certainly important for the smooth running of the system, but it is difficult to comprehend how this is related to the quality of patient care.

The Dental Quality and Outcomes Framework (DQOF)

This lack of understanding about quality in dentistry is further highlighted by the current design of the “patient experience” domain within the DQOF. Patient experience is recognised as a key component of assessing quality within the NHS, and the current DQOF includes seven questions purportedly related to experience. At first glance these questions may appear relevant “How satisfied are you with the NHS dentistry received?” or “Would you recommend this practice to a friend?” or “How satisfied were you with the cleanliness of the practice?”

They all seem quite reasonable questions, but do they provide an accurate assessment of patient experience?

You would certainly hope so, as the current intention is to assign 10% of your GDS contract to DQOF, and a failure to hit your target will result in financial penalty. When the QOF for GPs was introduced in 2004, significant investment was made to incentivise improvements in quality with a 25 – 30% increase in practice funding. Unsurprisingly, the situation is very different in 2015 for dentists. There will be no additional funding and no financial incentives – only financial penalties if we don’t hit our targets. They get the carrot, we get the stick!

When we look more closely at the questions within the “patient experience” domain it becomes apparent that the focus is primarily on patient satisfaction. This would seem strange as the NHS Patient Experience Framework actually states that “measures of satisfaction have a commonsense and political appeal, but they are the measures that experts, including experts in quality improvement, consider the least useful”.³

This all might seem a bit academic, and in practical terms not that relevant. Surely if you provide a good patient experience you will end up with a high level of satisfaction? This is possibly true, but definitely not the whole story.

Patient satisfaction surveys are widely used within healthcare and are a very useful way to obtain feedback and improve services at a local level. Dental practices regularly use patient satisfaction surveys to understand what their own patients want and respond accordingly. It is a fundamental strategy in developing and maintaining a successful dental practice. However, there is a subtle difference in using patient satisfaction to improve services and attempting to use the same approach to measure quality across a wide range of providers.

Patient satisfaction has been developed from consumer marketing and is based on disconfirmation theory where the quality of the service is measured against the expectations of the individual. The level of satisfaction expressed can therefore be as much about the patient’s expectations as it can about the quality of the service provided.

This can perhaps be best illustrated by the example of two colleagues, let’s call them Eddie and Mick, who decide to go out for dinner at two separate eateries. Eddie decides to go to a Michelin star restaurant; Mick chooses McDonalds.

Eddie’s restaurant is very exclusive, with attentive staff and lovely surroundings. Unfortunately, Eddie has a bit of a weak stomach and he doesn’t particularly enjoy his grilled octopus. On completing his customer satisfaction form, Eddie considers himself to be “satisfied”, despite the disappointment of his main course.

Mick has fairly low expectations, but is pleasantly surprised with his ‘happy meal’ and the unlimited access to free ketchup. He is even more impressed when he receives a complimentary toy, which just happens to be ‘Olaf’, his favourite character from Frozen. On completing his customer satisfaction form, Mick considers himself to be “very satisfied”.

In analysing this data, one could conclude that both ‘customers’ were satisfied, although Mick was more satisfied than Eddie. We might therefore assume that the quality of the experience provided at McDonalds was superior to that of the restaurant. This may of course be entirely inaccurate, and could simply be an indication of the varying expectations of the two individuals.

I would not wish to repeat the same mistake as our beleaguered Chair of the GDC, by comparing dentistry to supermarkets, but hopefully this example might illustrate the dangers of using patient satisfaction as a measure of quality. In our world, the same situation applies where patients rate services based on their expectations and not on the quality of care provided. We all work in very different practices, in different communities with patients who have different backgrounds and very different expectations. It would therefore be inappropriate to use a measure of quality for dentistry based on patient satisfaction alone.   

There is extensive literature on measuring patient experience, which is closely aligned to the dimensions of “patient-centred care”. Various tools have been developed and validated, and it is disappointing, although perhaps not surprising, that NHS England have chosen to design their own non-evidenced approach. To be fair to NHS England, they have stated that they are developing new Patient Reported Experience Measures (PREMs) which they intend to validate before introducing them⁴. A refreshingly robust approach when compared to the imminent introduction of the Friends and Family Test.

Image credit -  Chance Projects  under CC licence - not modified.

Will there ever come a time in the dental profession when solidarity will create meaningful change?

Recently some bus drivers in London realized that some drivers were getting paid more than others, so they called a 24 hour strike last week, with less than a days notice.  Around 2.3 billion bus journeys are made in the capital in a year and on that day millions of people were affected as they were forced to use alternative transport. Clearly the knock on effect means that the underground and road traffic becomes clogged up. Cab drivers drove the capital to a halt when they realized that a US competitor was taking their lunch.

What is always clear when the press covers these stories is that the system itself is identified as the fault, not the actual providers of the service. Striking workers comes as no surprise for most of us. whereas health professionals standing up for their rights seems to be rare. It is unlikely the bus drivers that were getting above average pay would be so keen to raise the alarm. Akin to those contract holders with UDA values well above national averages.

In truth, the announcement of “evolution not revolution” by Earl Howe with the imminent roll out of the prototype contract scheduled over the next 3 years will mean it’s a long wait for those unhappy NHS contract holders. Indeed has anything really changed in the last 9 years ? Limited exposure from an ever-hostile press rarely highlights the disparate and confusion of what is literally affecting the vast majority of hard working and ethical health professionals every working day.

The cynic in me would say this is classic posturing from the commissioner of the service. After all “If the profession hasn’t responded firmly in the past, it is unlikely to do so in the future”.

When the doctors went on strike in 2012 , the press did not make out it was money focused doctors at fault rather a change in their pension structure at the core of the story.

If history teaches us anything about the department of Health then we know that it's going to a lot longer than planned to see real tangible change in the dental contract, which is intended to remain in place for 20-30 years.

The pricing transparency issue unveiled by a Which consumer review makes it even easier to point the finger at the “ money focused” dentist. What is left for the profession? How can we take real action to illustrate what causes the problem and that hard working NHS dentists cannot continue like this for years to come? (?)

Consider the facts for a moment

-       No increase in NHS dentistry budget planned for the next 5 years

-       Marked decrease in patient access across every existing pilot site ( speak to any pilot site and ask them how long their patients are waiting for an appointment)

-       Hygienists and less so therapists will take an increasingly larger role in prevention and health assessments 5 years from now.

So the question of solidarity, can it actually happen in dentistry? I sadly suspect not. Perhaps because every NHS contract holder has too much to loose if they were held to account. Perhaps successive governments only take real notice about dentistry when the press shows the long lines outside a new NHS dental practice opening up. Perhaps its fear of persecution in the press, or genuine concern for our patients well being and we are not prepared to leave our patient in the lurch? So maybe its time for dentistry to take stock and unite to take its part in controlling its destiny?

If not, the finger of blame will continue to point at the dentists who appear to be the bad guys.

We launched http://www.toothpick.com in 2013 with a clear objective. Make dentistry more consumer friendly for patients and provide an efficient way of building a patient list.

Having travelled and experienced different dental remuneration models around the globe I became acutely aware how different patients perceive dentistry. I suspect the combination here of the press portrayal and the rising patient expectation under a limited system has created a terrible reputation for the profession.

Its hard here as the NHS patient journey is far too short to form a positive opinion and a hostile press that is ready to dentist bash it becomes a downward spiral unless urgent action is taken from within to reverse this effect.

If it’s another rehash of the broken and failing system rather than a workable new contract formed then perhaps the new prototype signals the beginning of the end. Or could this be the trigger to start real action to identify the cause of the problem and have real inclusive dialogue for a solution that gives that gives a fair deal for the patients and the providers.

I feel only with this approach can we restore the professions reputation and trust with the public and the press, which takes years to build and seconds to destroy.

Sandeep Senghera

Image credit - Sludge Gulper   under CC licence - not modified.

Dr Sandeep Senghera BDS, CEO and Founder Toothpick   Sandeep combines his 12 years of experience and knowledge as a Dentist since 2002 with a passion for internet technology to create www.toothpick.com to help patients book a dentist online at over 3500 NHS and Private dentists in the UK. Drawing from a family heritage in business and start ups, his entrepreneurial nature and desire to improve patient experiences in Dentistry drives his business.

How is the CQC going to assess and inspect practices in 2015?

Here’s a check list that I have used BEFORE I plan a CQC visit:

·         Website for opening hours / NHS/private / services & treatment provided

·         Inspection history: Summary including date of last inspection, and including any breaches of regulation(s) or concerns identified at the visit. Date action plan completed.

·         Local Area Team (LAT) information return: Date sent and returned - any issues.

·         Provider information return: Notes re statement of purpose / compliments & complaints.

·         Feedback: A brief high level summary of any patient / other feedback from any other source.

·         Registration: Summary of changes to registration and registration issues, including details of the registered manager.

·         Notifications: Summary of notifications received at CQC, whether received when needed and within relevant timescales.

·         Concerns and enforcement: Summary of any concerns and/or enforcement not already covered above.

You have this information, so why not review it and decide what the CQC will make of it?

What does this mean in 2015?

CQC inspection in 2015 will be based on the following and in my opinion biased heavily towards Safe and Well-led. With this in mind, look down this check list and think about how exactly you could show me evidence that this is happening today in your practice.   I’ve put a few examples in each section.  

Safe

·         Lessons learnt and improvements made when things go wrong. Evidence? (risk assessments, RIDDOR, improvements made, changes planned etc.)

·         Care assessed to prevent unsafe care and treatment. Evidence? (Medical history checking system, treatment planning, record card audits, retrospective radiograph audit) 

·         There are systems, processes and practices in place to keep people safe and safeguard them from abuse.

·         There are systems, processes and practices in place to protect people from unsafe use of equipment, materials and medicines.

·         There are systems, processes and practices in place to prevent healthcare associated infections.

·         Potential risks to the service and individuals are anticipated and planned for in advance.

·         There are systems, processes and practices in place to ensure all treatment and care is carried out safely.

Effective

·         Patients are always involved in decisions about their treatment and the practice obtains valid consent and audits records of this. Evidence? (Record keeping audit, patient information in various formats, fees explained and written treatment plans, agreed practice wide system for recording treatment options understood by patient, pros and cons explained, time given for decisions, Mental Capacity Act understood)

·         Patients’ needs are assessed and care and treatment delivered in line with current legislation, standards and guidance. Evidence? (new patients survey considered, waiting time audit, opinion survey used, disability access audit performed, practice meeting minutes where GDC/CQC standards discussed, staff sign policy documents, system of governance operated)

·         There are effective arrangements in place for referring to other health professionals to ensure quality and continuity of care for the patient.

·         Patients’ oral health needs are assessed and care and treatment delivered, or referred, in line with current legislation, standards and guidance.

·         Staff have the right skills, knowledge and experience to enable the effective delivery of care and treatment.

·         Staff are recruited, inducted and appraised regularly and records are always available on the premises.

Caring

·       Patients are treated with kindness, dignity, respect and compassion while they receive care and treatment. Evidence? (Confidentiality always considered, patient survey acted upon, waiting times audited, comments book shows many patients are pleased with care, telephone answered promptly and politely with log kept, emergency spaces available every day, complaints tracker shows all complaints handled carefully, staff training logs, privacy and dignity respected).

·       Are people and those close to them involved as partners in their care.

·       Does the practice promote equality and diversity and recognise the needs of different groups.

Responsive

·         The practice staff routinely listen and learn from people’s concerns and complaints to improve the quality of care. Evidence? (Practice is growing, has plans for improvements, staff levels constant and staff encouraged to develop competencies, complaints handling regularly updated, everybody encouraged to participate, complaints tracker up to date and good comments in book, NHS Choices etc).

·         Patients receive an explanation of any need for referral with copy of letter and options/consequences.

Well-led

·         The governance arrangements ensure that responsibilities are clear, quality and performance are regularly considered and risks are identified, understood and managed. Evidence? (There is a written system of governance which is used in training and regularly updated, all staff are competent and have a personal development plan, there is a culture of openness and professionalism).

·         How does the practice engage, seek and act on feedback from people who use the service, public and staff.

·         How do the leadership and culture reflect vision and values, encourage openness and transparency and promote delivery of high quality care.

Let me ask you a few questions.