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Dear Mr Brack,

I have previously been a harsh critic of the GDC, especially in the days of the previous registrar. Indeed, I wrote many blogs that were well received by the profession. With the departure of the previous registrar, there was an opportunity for the GDC to begin to repair the damage it had done to the profession by the draconian and inefficient manner in which it had been led.

There appeared to be a time when the new team seemed to be developing a far more appropriate attitude to regulation, and I therefore felt it appropriate to perhaps watch the situation without commenting further. It was disappointing when Jonathan Green left, although I did feel that with you at the head of the Organisation (for indeed it is NOT a business but a QUANGO I think you will find) then there would be a continuation of the bridge building that was sorely needed.

However, whilst there seem to have been some minor improvements, fundamentally there seems to be no real change in the way the GDC wishes to be perceived by the profession and how it executes its statutory duty. Under the aegis of protecting the public, it is actually doing more to negatively affect the public it serves to protect by continuing to prosecute its role in a draconian and often arrogant manner. There is still huge a lack of insight into the damage it is doing to the morale and the well being of its registrants; damage that can be squarely blamed on the actions of the GDC itself.

Because when a profession is so scared of its very shadow that it can no longer function as it is supposed to, then the ONLY thing that will happen is harm to the public. That these professionals are so scared of virtually every treatment they do, every comment they make (including ones like this), and every action they take is a sad indictment of the way that the GDC is systematically destroying the very profession it regulates.

By retaining the ARF at the same level again, with yet another different reason than before, is symptomatic of the disdain and the contempt with which the profession perceive the GDC have for them. The profession are happy to be regulated, but by a fair, just, and right touch regulator. The continued heavy touch that the GDC continues to use cannot continue if the profession is to survive to be allowed to serve its patients as there will come a tipping point where we will no longer be willing to accept the duress of just turning up to work. If we placed a colleague under this type of stress in our workplace then WE would rightly fear being reported to our regulator.

We are human beings who set ourselves out to care for other human beings. There is no higher privilege than to care for another. However, we make mistakes, we are fallible. You are the same as us, a fellow of the Human race.

We rarely do things wrong deliberately, but we shouldn’t live in fear that the next thing we do both privately or in our jobs could end our careers and destroy our lives.

Please think of the damage that is being done to our profession by this apparent continued lack of insight displayed by the GDC.

Kind Regards,

Simon Thackeray

Image credit - Rakka_pl under CC licence - not modified.

Once again the new patient charges have been announced for the NHS, and once again they have gone up far more than the amount dentists will get for their UDA’s. The third consecutive inflation-busting rise in patient charges means that an ever increasing number of dentists will find themselves as unpaid tax collectors for the government, with the added pleasure of having to continue to practice in a hostile environment where the threat of litigation and GDC involvement is ever present.

So what will it actually take for dentists to wake up and smell the coffee? Patients are paying an increasing amount for their care, and as they do so, direct their annoyance as ever to the dentists. Its unlikely that they will understand or accept the explanation given that the charges are in effect a taxation, as they are too closely linked to the provision of a service.

Why do many of the dental practices seem to forget that they are in truth independent contractors within the NHS, and as such only have to refuse to contract to the NHS in order to retake a degree of control of their own future once again? It can’t be that working within an NHS contract is too easy; we increasingly hear of the demands on the practitioner’s time to fulfil the contract requirements. This time of year is full of comments on social media about the increased flurry of activity in order to hit the UDA’s targets once again or suffer claw-back.

By raising the patient charges, the government is contributing less and less each year to the cost of dental provision. The population of the UK isn’t reducing, and the cost of providing dentistry isn’t either. But for less and less contribution the government is still dictating the terms of the contract, and dentists continue to accept it.

Will it actually take the government to raise the patient charge to £30 for an exam (whilst still paying £25 for the UDA) for dentists to realise that they would be better off just charging the patient £30 and sticking two fingers up at the government? Or is it the NHS pension that people are holding out for? Or the continued chance to pay an associate £10 per UDA when they are really getting £30?

Practice owners (and particularly the bigger practices and corporates) definitely have the whip hand here. I can remember the times when associates were few and far between. It appears that the reverse is now true in many areas of the UK (particularly in metropolitan areas), which allows the principal to reduce the unit price of a UDA paid to an associate. An increase in patient charges will likely bring a drop in the number of patients visiting practices, and in one fell stroke this will reduce the PCR, and reduce the chances of the UDA targets being met, and therefore a claw-back occurring. I know of many associates that are made liable for the gross amount of any claw-back due to their individual underperformance (rather than the net amount they have been paid per UDA). Add this to the NHS pension of the principal that is effectively enhanced by paying a smaller percentage of the UDA value, this hardly puts the principal under any immediate pressure to withdraw from the NHS system they are still aligned with. However, I suggest that it is now causing a much greater ‘Us and Them’ situation with associates than ever before.

So why is it ok to make money out of the associates and not charge the patients a decent amount for their care? Whilst a business has a duty to its shareholders and owners to keep its costs low, with the introduction of the minimum wage this means they don’t tend to be propping up their bottom line by charging their staff for the privilege. They tend to charge their customers for it with the increase in the charge for the product.

Unless you happen to be in a fixed price system…so the only way money can be made (let’s forget upselling to patients using the NHS as a way to get them in the practice for now) is by reducing the costs of the workforce and investment in the business. However the government expect more and more for less and less (look at the next round of orthodontic commissioning that is going on) and it becomes impossible to square the circle unless someone actually pays for it. That certainly isn’t going to be the government.

Given that some patients will not be able to afford the hike in charges does not mean that many others would not pay for a decent service if they had to. Surely having fewer patients (but of the sort that don’t sue and complain) that are being charged a fair amount for the service provided, with no third party dictating targets has to be better for the stress levels of both dentists and patients under their care?

Will it take associates to actually walk away from the profession and retrain? With the current environment of stress due to the GDC, threat of litigation, and the real time reduction in associate income, then this has never been more possible than it is now. And that will lead to a reverse in the associate market again, especially if the (currently unknown) effect of Brexit results in European dentists returning to their home countries – and who wouldn’t if it meant avoiding the GDC and Litigation!

So what will it take for the profession to see the light? That we need to realise the government would still wish to control us if they only contributed £1 in every £100 charged and only then will we react? Or do we need to remember that everyone who owns a practice is a private practitioner already and they should just tell the government:

‘No More’.

Image credit - Pascal under CC licence - not modified.

No one can deny that modern technology has been a revelation in recent years. The use of it to improve diagnostic yields in radiography, to allow mainstream imaging in practice of aspects of dental tissues that we couldn’t previously visualise the same way  can only benefit our patients. Computerisation of dental notes and management systems, (whilst restricted in the choice of manufacturers) have probably improved the efficiency of most dental practices far beyond that of the old paper systems. Digital marketing tools, online presence through websites and blogs, and social media are all here to stay, and have driven the profile of the profession upwards. All in all, I think most of us would agree, technology has been largely a good thing for the profession

But one thing that I am REALLY struggling with that has come about as a result of this type of technology is the increase in Referral Portals for NHS referrals. On the face of it is would seem to be a streamlining of the process needed to refer into secondary care, and reduce the costs and problems with paper referrals. Entering the data via a computer linked to the patient database and directly into the referral systems would seem on the face of it far more efficient that writing a letter and posting it.

So why do I have an issue with it? This sort of advanced technology is right up my street normally. However, because of the way these systems seem to be implemented, I can see potential problems for registrants falling foul of the GDC Standards when they are forced to use them. The GDC standards that I personally think relate to this type of system are :

Standard 1.7 – Put patients interests first before your own or those of any colleague, business or ORGANISATION – these systems tend to be imposed unilateral decisions that don’t seem to have any guarantee that they are better for the patient (or indeed tested fully).

Standard 4.2.6 - If a patient allows you to share information about them, you should ensure that anyone you share it with understands that it is confidential – How does a faceless system with no identification of who receives the data comply with this standard?

Standard 6.3 – Delegate and refer appropriately and effectively. However, someone else often choses where the patient goes and who they see, with the clinician often having no idea of the degree of expertise that clinician actually has. Referrals are even rejected if often irrelevant (but required) tickboxes are not filled in.

Standard 6.1.5 – You must ensure that all patients are fully informed of the names and roles of the dental professionals involved in their care - How does a portal allow us to do this? Do we give all our patients Bill Gates’ name as its done on a PC?

Standard 6.3.1 - You can delegate the responsibility for a task but not the accountability. This means that, although you can ask someone to carry out a task for you, you could still be held accountable if something goes wrong. You should only delegate or refer to another member of the team if you are confident that they have been trained and are both competent and indemnified to do what you are asking.

For me this is the big problem. This alone is where the entire concept falls down unless we are indemnified for the errors of the system. What if this is a life changing referral such as a tumour? You are going to be ultimately responsible as you have to make the referral, and you can guarantee the powers that be who thought it was a good idea to impose the portal will NOT indemnify you against the failure of the referral in some way, nor will the GDC.  If the referral is rejected because of some missing tickbox that is largely irrelevant to the immediate urgency but required because some software engineer hasn’t allowed any flexibility in implementation then I personally cant see how this should ever be the responsibility of the clinician. The fact I might for example omit the patients GP because I’m more interested in the speed of the referral is a pedantic bureaucratic issue and not one of patient care.

I can’t comprehend how we as a profession have allowed this type of loss of control of patient care to creep into our referral systems. I am fairly sure there are practices that are on referral pathways that our patients will be allocated to that many of us would not be happy for them being treated in. Part of being a professional means that you take on the ultimate responsibility for the care of a patient, and the GDC standards means that includes ensuring they are referred to an appropriate colleague. Unless every single one of these referrals is triaged by a clinician then there will be mistakes made. And this pre-assumes the system actually works like it should…..

I have had the misfortune recently of being forced onto a pilot in my local area of just one of these systems. Due to the obviously more knowledgeable people in charge of procurement in my area, they foisted a system onto practitioners without actually discussing anything with them first. To say I experienced problems was an understatement, and I know many others did too (despite the LAT saying the response to their questionnaires about it was overwhelmingly favourable – presumably because the portal lost as many bad responses as it did referrals). To be quite honest, I would have been better served learning how to send smoke signal referrals rather than use the system that was imposed. I did some research into the actual system and found that it had been dropped by at least one area as it was unsatisfactory, and another region have accepted that the same system isn’t good, but it’s the best they’ve seen. Hardly a glowing endorsement is it?

For example, in the 2 months I used it, we experienced a plethora of problems. I don’t think it is particularly useful to have to spend over TWO HOURS trying to upload a Periapical radiograph, knowing that if it wasn’t sent the referral would have been rejected. This was a compressed file of just 103kb. I don’t think it is particularly helpful to have half the tick boxes missing for medical histories, or dropdowns that you can’t fill in because they are incorrectly populated. A spell check that allows only the incorrect spelling of a drug is also pretty useless. It’s not useful that the system doesn’t tell you if the referral has gone correctly, or instead forever been lost in the ether of the internet. It’s not professional to have no idea who you have just referred the patient to or who is going to read the information. Not particularly useful if your patient who doesn’t have an email address (like many of my elderly patients) can’t even be referred at all as the system refuses to accept the referral without their email address. It also falls foul of my data security policy of allowing an unknown (to me) commercial third party installing software onto my system (which is massively firewalled both by hardware and software – which would appear to more than can be said for the NHS system if the recent Cryptolocker problem is anything to go by).

But having the system obviously ticks another box for those who confuse boxticking with patient care. By having a system that once again means all the responsibility still lies with the registrant even though they have no control of it is highly convenient for the powers that be. They get to have a load of committee meetings about the procurement, knowing full well that if and when it fails, and if and when patients suffer from it, it will be the clinicians who will get the blame for it. Having a system imposed from above without actually making sure it works is nothing new: lets face it the NHS hardly have a great track record in getting IT infrastructure correct out do they? Heaven help us if our friends at Capita get involved with implementing one of these systems; patients will probably end up with an 18 month wait instead of an 18 week wait. Still, at least losing patients in the system will make the waiting lists look good for the managers and they can get their bonuses for being so successful…..

So unless we get some form of indemnification from those who perpetually get to wash their hands of responsibility, I can’t see how we can use these portals and still adhere to our required standards. Please correct me if I’m wrong.

Image by Benjamin White

It has been a little while since I last wrote this blog. Various things have taken over as they tend to do in life, and the blog unfortunately was something that seemed to never quite get done. However, I’ve now found myself back in the writing frame of mind, and I still seem to have opinions that some will agree with and no doubt others will disagree with, so here we go with some more ramblings of a Yorkshireman.

I have still been keenly observing what has been going on with regards to the profession over the last few months, and there still seem to be the same old problems surfaces that always have. I shall be writing about all of these issues in the near future.

The GDC seems to still be a problem to many, and personally whilst it seems to be to have become more aware of its previous problems, I don’t think it can truly move on whilst the current chair is still at the helm. It is time for a registrant to be in charge again, and for Dr Moyes to be moved to some other Quango where he can’t oversee damage to the morale of an entire profession.

Social media is also still a hot topic, and the GDC have now issued a case study on this. Some of the profession are obviously of the opinion that social media is the real world, and seemingly lack the ability to see it in its true context. There is a lack of humility in the profession where social media is concerned, and huge damage can occur to people when they believe that all they see on their iPhone is the unadulterated truth. It isn’t.

The lack of a new NHS contract, or anything really concrete is also concerning. However, I have a fairly simple view on this. We must be deluded as a profession if we think for one moment that there is suddenly going to be a fantastic new contract that will give the patients and us everything we ask for. I will guarantee that any new contract will primarily be worded to the benefit of the DoH so that the dentists can be held responsible for whatever goes wrong with it.

I’ll write more on these subjects in the coming weeks. But for this blog I though I would concentrate on something that has seemed to be brewing for quite a time, and might actually be reaching a tipping point.

Indemnity.

Now, I can remember when my indemnity was about £1200 a year, and didn’t particularly change by much annually. But now, as a principal dentist working full time, it is £5800. This increase is over the period of about 10 years. We have seen an increase in both the activity of the GDC and especially negligence solicitors in this time, which it is claimed to account for the increase in our costs.

Indemnity is a little bit like car insurance in that you hope you will never need it, but it is a necessary evil to have. With the costs of legal representation being what they are, and the increase in the amount of cases being brought, it is not really surprising that costs rise year on year.

But how do we know how these costs are calculated individually? If you are a young driver with a fast car (which you will no doubt be flaunting on Facebook!) then you are likely to be a higher risk than an older person in a more sedate family saloon. This doesn’t necessarily translate to your dental indemnity though. It seems that the longer you are in the profession, the more likelihood you are to be sued and thus have higher premiums. Perhaps the reason for this is that when these practitioners retire, often the patients are found to have large amounts of remedial dentistry to be done. This may be the case, and I am aware of some dentists who have built up a good practice on rectifying this type of problem, especially when they perhaps encourage the patient to take some form of action against the previous dentist.

I’m not saying a wrong shouldn’t be corrected in that situation, but there do seem to be some dentists who are quite happy to throw colleagues under the bus in order to ensure they get the benefit of the patient charges to rectify the problems. Perhaps ‘There but for the grace of god go I’ would be an apt phrase to remind those considering this course of action. In addition, they will also find that their indemnity is going to increase also when this happens.

Because that’s how this kind of indemnity really works; the current members are paying for the claims that are currently being made and are going to be made in the future. In much the same way as the state pension works.  We can’t have an indemnity company suddenly have empty coffers, so they have a duty to ensure they assess the needs of the society to actively have the funds to cover their expenses. All of this is paid for by the membership.

However, this is where I spot a problem. There are some dentists who for what ever reason have higher indemnity costs. Whilst it always seems unclear why this is (as there is no apparent transparency in the fee structure when applied to an individual member), it is not unreasonable to consider that there might be an increased risk identified by the indemnifier. So they are basically saying there may be claims likely to be made against this person in the future. I have no problem with that in principle, but the issue comes when this person then leaves the society because the costs of indemnity have risen so high it is fundamentally unaffordable for them to keep paying.

What happens then? The costs of these future claims will be potentially met by the rest of the members who are maybe NOT doing the same sort of high risk dentistry as the member who has left. One can argue that this is a socially responsible and indeed professional manner in which a wronged patient can claim recompense. The problem occurs when there are more of the lower risk members paying for the expenses of the higher risk. Add into this situation that the societies offer ‘discretionary cover’, meaning that your claim only has the right to be considered by the society (and not actually guaranteed to be supported), then some people feel that they are paying an increasing amount of money for less than guaranteed and continued support in their time of need.

It seems to me that many of the members of the traditional membership societies are becoming increasingly worried about the inexorable rise in costs, and the discretionary nature of the support offered. I am aware of much conversation about the pros and cons of moving between the societies, and I’m also aware of the increase in membership of the Insurance based companies as a result of the concerns about this. One of the advantages of insurance based cover is the presence of a written contract, and the ability to make a complaint to the Insurance Ombudsman, which doesn’t exist with the discretionary membership. In addition, the insurance companies are also heavily regulated by the likes of the Financial Services Authority; the traditional indemnifiers however seem to have no regulator at all. The counter to this argument is that with discretionary cover the traditional indemnifiers can cover those who are not indeed members at the time of a claim, and for the benefit of the profession. I can recall this publically happening at some point in the past, and if I am not mistaken it was a human rights issue that became clarified as a result. However, just how many times has the discretionary cover been used in that manner, and not just to refuse cover?

The way I see it, we will reach a tipping point if something is not done soon to clarify more robustly the stance of the traditional indemnifiers, especially where their discretionary powers are concerned. I want to know that I have the support of the indemnifier in assisting me in my time of need, and not that at some point they decide to pull the plug due to a disagreement or just because it is easier and cheaper to settle (despite it being morally, ethically, and clinically wrong to do so). Does writing a blog of this nature give them grounds to refuse cover? Your guess is as good as mine since there is no real published criteria to know where you actually stand.

I can see there becoming a tipping point at some time in the future where all the good clients of the protection societies are no longer willing to put up with the uncertainty and the lack of transparency about the decisions made about any individuals’ costs and especially the discretionary element of support. These clients will leave, and since it is a requirement to have appropriate indemnity, there will be no shortage of new style companies happy to disrupt the market place and offer an alternative.

For example, what if the indemnifier needed a million pounds to cover its expenses and it had 10,000 clients? The cost per client is obviously £100 per client. But what if this indemnifier then starts to haemorrhage clients until it only has 1000? The cost per client is then £1000. These remaining clients are not necessarily going to be the high risk ones either, as it’s probably the case that those higher risk clients will have changed society much sooner in order to keep their costs down.

This is probably a gross oversimplification, and I’d actually welcome someone putting me right over this, especially from any of the defence societies. However, fundamentally what I see is an ever increasing demand on the resources of these societies, with a potentially decreasing number of members footing the bill, and those members not actually knowing if they will be fully supported by the society due to the discretionary nature of the membership. This is a prime situation for a tipping point to occur that changes significantly the whole model this operates under. This might be practitioners leaving, or it might be a re-evaluation of the business model to take things into account. However it is not something that can remain the unchanged as it appears to me unsustainable in the long term.

Before anyone says this couldn’t happen as the societies are so big and have so many customers, all I have to remind you of is Kodak not identifying the digital camera revolution, Encyclopaedia Britannica not recognising the  threat of the internet, and finally the inexorable rise of Uber in its disruption of how we utilise taxis.

All indemnifiers are also reliant on the need for legal cases to continue. By this I mean there is a symbiotic relationship between the defence and prosecution of dental cases, as without one side the other cant really exist the in the same way. Once a case is begun, then costs accumulate on both sides, and the legal profession feeds from this accordingly. These adversarial sides become dependent on one another, and in particular the defence side of negligence does not necessarily work under a no-win, no-fee basis in my experience and gets paid regardless of winning or losing (by our indemnifiers). Cynically, one would say it is therefore in the financial interests of those in the legal profession to have the current highly litigious situation in dentistry to continue, because there appears to be no shortage of work for them. The practice of dentistry becomes the raison d’etre for the existence of both the societies and those legal firms feeding it until we do something to stop it.

There may be protests from the indemnifiers of the tome of this blog; certainly I have taken no account of some of the truly awful issues that result in harm befalling patients by some practitioners. I am definitely of the opinion that we as a profession most certainly still need to put our house in order, and there is probably no room within it for some of the practices that some of our colleagues routinely feel are acceptable. However, unless you are part of the solution, then you are actually part of the problem, and I feel that there should be much more clarity evident in the world of indemnity, so that the profession can practice with the confidence that our patients need us to have when caring from them.

Otherwise, what’s the point in us continuing to serve our patients? That may well create a further tipping point…..of no one in the profession left to care.

Image credit - Guiseppe Milo under CC licence - not modified.

Political leaders are often said to have a honeymoon period at the very beginning of their new post. At a time where their political capital as at its highest, there tends to be a degree of ‘benefit of the doubt’ given and political opponents treat them well. I get the impression that due to the lack of political opponents to currently wrestle with means that Theresa May has had less of a honeymoon, and more like a ‘swift registry office wedding and straight back to work on Monday’ type of period. There has been no particular need to allow her into the post gently, and indeed she hit the ground running it appears.

It wasn’t quite the same with the new Chief Dental Officer. An initial period of cautious approval and hope that the new incumbent might be a less dogmatic and more approachable one than previously was supported initially by in increase in visibility, and the right kinds of sound bites the made many think this could be someone who is more in tune with dentists than was previously the case.

Well, it certainly looks like the honeymoon is over for our new Chief Dental Officer after the comments this week about routine examinations is anything to go by. Once again it appears the CDO has trotted out the underlying political message desired by the paymasters at DoH. What appeared to start out as a marriage that could work with the profession now appears to be heading for a divorce already.

The comments that were published in the Telegraph and the Daily Mail appear to rehash of those made in 2004 by Raman Bedi, and again in 2011 by Barry Cockcroft, both gleefully published by the Daily Mail, and no doubt trying to reinforce the opinion that the majority of the profession are money grabbing charlatans. The same old mantra is being rolled out by yet another incumbent of the CDO post, which despite its downgrade by government now to a junior supporting role, is nonetheless listened to by the press and therefore the public in order to give more ammunition to the incessant deprofessionalisation of dentistry as a whole. (Or so it seems to me).

In addition, the comments by former NHS Trust Chairman Roy Lilley in the same article that dentistry has become ‘a rich mans hobby’ provided in ‘lavish environments’ would be quite frankly laughable if it weren’t for the fact that they are so offensive. I’m sure he didn’t sit in an office furnished from a secondhand furniture store in a cold draughty office block, so why the hell should we? I could wax lyrical for a long time about my opinions of such people in NHS high office, but I’m sure much of it would give the legal profession many hours of extra work. Suffice to say the ignorance of comments such as this are what I would expect from a member of the ‘profession’ that continually commissioned excessive amounts of UDA’s year on year from D’Mello, and oversaw the disasters at Stafford amongst other things. Perhaps Mr. Lilley would be happier receiving his routine dentistry in the kind of environment that charities such as Bridge2Aid find they have to work in? Perhaps then he might be grateful for the small luxuries his salary allows him to experience. I would suggest he puts some of his money where his mouth is and donates to such deserving causes so they could ever hope to achieve a level of care that even the worse off in our society take for granted.

But I am more concerned the comments made by Col. Hurley seem to go deeper and are potentially more damaging to the profession than any crass comments made by an NHS apparatchik. Comparing the profession to garage mechanics is crude and whilst part of me can always find parallels with any other industry, it is highly disingenuous to make that comparison without thinking more closely. The analogy can be torn apart so easily on many levels.

With the GDC and CQC breathing down the necks of professionals all the time, I’m sure many of them would wish to have a working environment more akin to the relaxed nature (comparatively) of working in a garage. I can’t quite remember the last time the General Garage Council struck a mechanic off for using the wrong oil, or not explaining the different kinds of windscreen washer fluid before servicing a car. In addition, Col Hurley seems to forget that likening the situation to an MOT is also a bit silly, since it is a legal requirement that you have to submit your car for that test every year. Her comparison fails hugely at this point. Perhaps the situation with dental problems (especially that of the huge number of children admitted for GA’s) wouldn’t be as bad if people were compelled by legislation to see a dentist yearly as part of their responsibility to the others contributing to the cost of state run care? But then of course the state wouldn’t be able to afford it and would have to admit as such.

On the other hand, whilst continuing the garage comparison, preventative maintenance is the responsibility of the driver, and there is indeed a whole host of legislation in place to ensure this happens.  So if my garage (ethical and professionally run) recommend I get something rechecked in a period because the vehicle might be dangerous, then I would be foolish to ignore that advice both from a safety and legal point of view. I’m also not likely to blame the mechanic if my car breaks down because I haven’t looked after it.

That there are dodgy garages will be no surprise, but then we all know there are dodgy dental practitioners who, amongst other things, blatantly game the system because the lack of clarity in the current contract makes it possible for them to do so. I suggest however that there are a higher proportion of mechanics that are not ethically guided than dentists due to their lack of professional regulation, and to make an analogy between them therefore is somewhat clumsy and misguided.

Comments like these have more than likely damaged the working relationship between the CDO and the profession in my opinion, and shown that her

Honeymoon period is well and truly over

The open letter to the profession published in January in Dentistry from Col. Hurley suggested that budgeting the NHS funds appropriately was at the forefront of all the planned changes that she would suggest. No one would argue that this is appropriate and should be the way forward. In an era of austerity we have to look at how the finite funding is spent, and I personally agree that much of the NHS budget could be better spent than recycling the same healthy patients.

However, these are often those patients who take an interest in their dental care. When we have 50% of the population not attending a dentist at all, then the budget is going to be spent on those that do. Couple this to the failed UDA system that makes it a financial risk to take on too many high needs patients (who are often those who don’t value the service and miss appointments), then is it any wonder that the small businesses of dental practices need the repeat business of regulars to survive? The screaming lack of clarity that is present in the current contract, and in my opinion will remain in any new contract (purely because of the benefit to the Government and no-one else) is not likely to be addressed anytime soon. There is no appetite for the Government to officially admit dentistry is rationed, yet we all know it is, and instead a press release such as this could have helped both the patients and the profession by being honest about the amount of money the NHS has to spend on routine examinations.

For the first time, it appears an NHS manager (Chris Hopson writing in the Observer) has this weekend finally admitted that that aspirational wishes of the NHS are not met by the funding needed to provide them and rationing is likely in the future. Perhaps the ‘worried well’ that Col. Hurley is referring to as being seen so regularly should actually make way for those who cannot access treatment. Perhaps by publically endorsing a core service that is equitable for all would go a long way to meeting her desire to target the resources of the NHS more appropriately rather than once again making it the dentists fault as usual for the perpetual lack of funding to provide ‘world class’ healthcare for everyone.

So, instead of therefore criticising the dentists for seeing patients more often ‘than needed’, why didn’t she take the opportunity to actually say that the NHS can’t actually afford to fund this type of regular recall, and that it only has the funds to see patients once every two years? A comment such as this is more likely to get the support of the profession since we all know how poorly funded the system is, and yet it doesn’t alienate the profession so much. Suggesting then that the patients are still free to see their dentist 6 monthly, but under a private arrangement, would both inform the public of the truth about the parlous state of NHS funding, and gain the support from the vast majority of dental professionals by talking it out of their hands. Instead of encouraging the patients to question the integrity of the professional caring for them this would be more appropriate surely? It is a chance for her to stand together with the profession she is part of whilst still fulfilling the government need to obtain value for money with its funding.

What is amusing is the same papers ran a story only the week before stating that soldiers face a week in jail for missing dental appointments in a bid to reduce the amount of personnel unavailable for military deployment due to dental disease. Is this a not double standard? Coming from the military back ground she does, I’m sure Col. Hurley was aware of this issue before she became CDO. So when the public read these conflicting stories, how are they to make a decision? Is it that dental problems can be so bad that the army punishes offenders who don’t take responsibility for their dental care with jail; or that you don’t actually need to go to the dentist for 2 years? Which is the message about dental health that is correct?

We all have cases to robustly shoot down the 2-year interval theory. For instance, I have a low risk patient who I have been seeing for many years now. Probably one restoration every 6 or 7 years, good oral hygiene etc., and is in the early 40’s. At a routine 6 monthly I spotted a lesion under the tongue. This turned out to be a squamous cell carcinoma. It wasn’t there 6 months previously. They would be one of the patients that fit in the criteria of a biennial examination. I’m sure that would be of great help to a spouse and children if the patient had listened to the advice. Fortunately for the patient we expedited the referral appropriately. However, at the next 6 monthly, there was still some nodal involvement that we picked up. This fell between the review appointments at oncology, was pointed out to them, and now a neck dissection has been performed. Once again, the DENTAL problems were minimal.

What about the increase in the HPV+ types of Oral Cancer that are now being seen in younger lower (traditional) risk patients? Or subtle diet changes that misguided approaches to a healthier lifestyle involve that create more dental problems and more long term cost to the state? I can go on, and I’m sure there are many other examples that people can give.

I can think of NONE of my patients that I would be confident leaving for 2 years without some form of assessment. When you ‘get out of the mouth’ and look at patients as a whole it is astounding how many things can impact their oral health in so many ways, and 24 months is a long time indeed…Whilst I admit there are those patients who never seen to need anything doing, how do we know they won’t suddenly suffer a need for medication or have health issues that change their dental risk? Since the Government seem to fail to take responsibility for educating the population about the risks of the links between health and dental issues then many patients will not automatically seek our advice. When they then return with a mouthful of problems because of some misguided attempt to save the state money because we’ve had to accept the demand for a longer interval between assessments, then I know that we are going to get the blame, and the GDC and ambulance chasers are going to be rubbing their hands together in glee, whilst the DoH wash their hands of the responsibility.

I unfortunately have to keep hammering out to many of my local GMP colleagues that we are not blacksmiths any more, but highly trained medical and surgical colleagues who take a full view of the patient in a holistic manner, but concentrating on the head and neck. It would appear that solely concentrating on just the teeth and gums is what even our CDO feels we are doing given the tone of the comments in the press. I wonder when the last time she actually fully assessed and treated a patient from start to finish, and whether of not the pressure of a real (and not with an institutionalized cohort of patients) dental practice has been experienced.

The BDA press release the same day was suitably pithy; but in reality the message wont be important to the public given they usually jump on any chance to further hate our profession.

But if the headlines actually said something like ‘Dental Trade Union refuse to negotiate with Government’s ‘Top’ Dentist’ then this might allow us to start to get our message across. The DoH is perfectly happy to sensationalise headlines to further their own ends, so it’s about time we did.

Calm Down, Calm Down, Calm Down

The words of Harry Enfield’s bubble permed Scouse's of the 1990’s are perhaps the most apt at the moment to describe how I feel about the outpouring of angst on the result of the EU Referendum.

Alternatively, to plagiarise somewhat Winston Churchill,

            "Never has so little sense been spoken by so many in so few hours"

I am probably about to join that increasing pile of rubbish, but thought rather than add fuel to what appears to be some as a bonfire of Liberalism and Tolerance I’d try to get a bit of perspective back. I’m certainly no political commentator, (and once you read this you’ll probably agree!!) but I do feel quite strongly how this has developed over the weekend. The sheer vitriol that has been produced in such a short time has been nothing short of shocking, but at least we now have got some real political debate and possibly change on our hands. However, we all need to calm down and stop falling out, because BOTH sides have valid points in my opinion and the only way to move forward now is if we calmly look at the big picture once again.

Because we haven’t actually left Europe. Not yet, and we will not in the next few weeks, months, or years. The referendum was a non-binding one, and merely the biggest opinion poll that has been run in this country for years, albeit with slightly more weight than most have. Unlike the Alternative Voting referendum in 2011, which had a legally binding result, there is no legal duty for a Government to act upon the result of Thursday’s result.

That’s right, Government has no obligation at all to actually heed the result.

It’s certainly monumental that the UK has voted in the way that it has, and there are a multitude of reasons why individuals will have done so. Many of them will have been misguided in other’s eyes, but all of them were personally valid ones to the person who was actually entitled to put their cross in the box. But we have seen the biggest turnout for years that has galvanised the electorate in way that I thought would never happen (now if only we could mobilise dentistry the same way…). This was always going to be a subject dear to the hearts and minds of the populous. It’s a shame that many of the most vocal of those who now feel betrayed by the decision were the ones with the lowest percentage turn out (the 18-24’s having less than 40% turnout). Perhaps there should have been a button on Facebook, or Text your Vote to allow that sector to vote? After all, many of them expect instant and easy solutions without having to actually physically get up and do something…. In addition, a democracy can keep continuing to vote and vote and vote until it gets the answer it wants.

Politically, I am of the opinion that David Cameron has played a political masterstroke. Unlike many, I was not shocked at all when I heard of his resignation. This is a man with an exceptionally astute political mind, and the outcome (although unexpected by many) will have been modelled by advisors. If we read into what he has said in the past, he had only alluded to the fact that a leave vote would result in the British public ‘expecting’ the process to leave the EU to be started straightaway.

An expectation by the public is not the same has an obligation by a politician though, and with his resignation, he has delivered what can only be described as a Hospital Pass to his successor as Prime Minister. For the formal process of leaving the EU to begin, Article 50 of the EU agreement relating to departure has to be formally invoked. Now, it is unclear if the invocation of this can be made by only the Prime Minister, or whether (more likely in my opinion) it has to have been voted on by Parliament in order to become formal. However, the result of the referendum, DID NOT invoke this process, and no matter what the EU Bureaucrats say, the UK is the only entity that can start this process.

So, a political hot potato has been deftly delivered by David Cameron as his last act in office. A new Tory Leader from the Leave side will have to either go against the referendum result, which will immediately destroy their personal credibility and therefore the faith of many people in their suitability to be Prime Minister, or they will have to activate Article 50, which then will probably have to go through parliament to be voted on. If they don’t do this immediately, then doubts about the suitability of the new leader to govern will set in as well. Is this not a most beautiful revenge on his once close allies Boris and Michael? In one fell swoop Cameron has called their bluff magnificently. ‘Leave’ now has to put up or shut up, and either enter into negotiations with the EU saying it was all a ploy to get further concessions, or activate the Article 50 clause, which might be their own political suicide if they don’t truly believe in what they have achieved.

I think we will then have the prospect of a snap General Election that could once again change the political face of the UK and re-establish a new political balance. One that might have Remaining in the EU as one of its fundamental promises. That’ll give the electorate who are currently appealing for a ‘best of 3’ approach to democracy to have another go at influencing the decision. However, quite as possibly with be a further endorsement of the desire to leave, but then there becomes a true mandate for a new Government to act upon. It’s like pressing the Reboot switch.

We have now heard that the Scottish MPs under Sturgeon will actively block the departure of the UK from the EU if this goes through parliament for a vote. So nothing at the moment is a given for the UK actually managing to leave the United States of Europe. The majority of the political commentators will know all this but cynically I’m of the opinion it serves the purpose of the media to keep all the froth and agitation going at the moment to confuse the populous even more and influence how they think whilst selling papers.

And the leaders of country with such political ability in the world didn’t see this outcome as possible?????

I suppose I should have a few opinions on what this means in Dentistry then. Well, for a start the GDC isn’t going to be affected by it at all. The Dentists Act 1984 is a piece of UK legislation and whilst it has EU aspects covered by such as the Human Rights Act and Data Protection Act, and has to be compatible with EU tenets of law, nothing within the day to day interpretation of the Act is likely to be affected by what happened last week. The same is true with the CQC. The UK is wonderful at developing infrastructure like this, and certainly doesn’t need the EU to make a business out of bureaucracy. There certainly won’t be a bonfire of the dental Quangos whether we stay in or out is my prediction.

There are a significant number of EU graduates working in the UK, and I don’t see any evidence that coachloads will be shipped back through the Channel Tunnel before it is bricked up overnight. What might actually happen though is that the corporates might find their supply of naïve EU dentists dries up due to the uncertainty of the future direction of the UK, and they might actually have to pay a competitive income to get people to work for them. This will no doubt affect their bottom line somewhat, and they might actually find they are now susceptible to the same pressures that normal practices are under and have to adapt the same way as we have all done. This can only be a good thing in order to restore the competitive balance in our profession.

What also might be beneficial to dentistry from leaving is the restoration of parity to our own graduates. Those who graduate from the UK have to complete foundation training before being allowed to work in the NHS, yet those from the EU don’t. Not only that, because the EU training is seen as equivalent to the UK, we cannot impose requirements like the ORE on them. Are all the EU Dental training courses the same quality? I think some of us might disagree that every single course is.  Surely this has benefitted those from the EU more than our homegrown graduates, and this potential discrimination can be possibly now be addressed in the future.

We still don’t really know what will happen with the prices of dental goods in the long term. Much of it is indeed made in the EU, but the USA and Asia are also vast markets, and not necessarily unified like the EU. China as an emerging market has already rocked the world of the dental technicians, and there is no reason why that cannot happen in the rest of dentistry. Admittedly controlling quality is going to be the issue, which worries me, but there are also some highly ethical businesses there that would work well within dentistry. There will be inevitably be some adjustments of prices because of the strength of the pound, but equally there is now an opportunity for entrepreneurs within the dental supply chain to start ‘disrupting’ the usual model.

The one thing we are unsure of is the overall effect on the general public and their incomes. Potentially this is huge, and the instability that is coming will affect them to an unknown degree. It is notable that the professional advice from the likes of the Bank Of England is to keep calm, whereas those who have a self interest, either towards the EU, or financially, in keeping the markets volatile is to Panic and Run Away. I know what I shall be doing. At times like this speculators usually manage to be the overall winners anyhow, so it’s in their interest to keep earning their money how they always have done.

But all this pre-assumes we will actually leave. I’m afraid I don’t believe the upper echelons of political power (and by that I don’t mean government but the high level civil servants who are in post despite what political flag is flying over Westminster) haven’t already worked out what their long game is and planned their chess moves accordingly.

So, we need to keep calm, because we haven’t actually left yet, and I personally don’t think we were ever going to….

Though the real question is can we trust any of them anymore?

Image credit - Muffinn under CC licence - not modified.

Ever since humans started to trade with themselves there has always been the need for them to feel that have got a bargain in some way. It’s human nature to actually feel like you got something worth more for less than you needed or intended to pay, and as such that drives many businesses in a constant battle to attract customers by offering bargains.

There’s a simple explanation for value in any transaction.

• If you pay a lot for something that’s poor quality it then it’s a rip off.
• If you pay a lot for something that is high quality then that is acceptable (and even possibly exclusive)
• If you get something that is poor quality for a low price then that’s called cheap.
• If you get something that is high quality for a low price then that’s a bargain.

Everybody loves a bargain. That’s why sales are so popular all the time, trying to get people to spend money they don’t have on products they don’t need. You only have to look at Groupon and Wowcher to see the type of offers that are touted on there. This is not necessarily a problem in the consumer driven world that supermarkets and retail stores operate in, but caveat emptor is the mantra that we should all employ when looking at this type of trading. Its also the way that our Beloved Chairman would probably like to see in his Red Book of ‘How the Dental market should evolve’, at least according to his now infamous Pendlebury Lecture.

The problem with this of course is that there isn’t a particular need to have ethics in those kind of industries that can price cut and offer heavy loss leading deals in order to get people through the doors and then upsell. It also usually involves already cheap products, or those with artificially hiked prices then given a huge discount, to con the buying into thinking they are getting a bargain.  

The reason for this is if it appears too good to be true, then it probably is (for someone). There stories galore of businesses that have almost or actually imploded due to a demand that they didn’t foresee when offering a ‘too good to be true’ deal. One of the most famous was the Hoover free flights promotion in 1992. Due to a huge surplus of electrical products they needed to sell, they came up with the offer of 2 free round trip tickets to destinations such as America. Somehow they failed to realize that offering tickets that were worth well in excess of the product they were trying to sell (the qualifying purchase only needed to be over £100) would result in an overwhelming demand for their products and hence the tickets. The court cases took until 1998 to settle, and cost Hoover an estimated £50million pounds. It would probably have been less costly for Hoover to scrap the products they needed to sell rather than to retain their market share. They were big enough to survive, but not everyone would be so lucky in a similar situation.

So what has this got to do with dentistry? Well, there has been an increasing trend to offer these kind of deals to entice patients into practices which are probably too good to be true. It’s a matter of contention that this is how some mixed practices operate, by offering certain NHS items to patients and then upselling the options that ‘aren’t available’ on the NHS. Even after 10 years of the new contract I am still struggling to understand the concept of how offering an NHS exam but having to see the hygienist privately works within the contract, and no one at all has yet presented an argument to me that convinces me this isn’t just a form of upselling by getting the patient in on the pretext of NHS treatment and then providing a private upgrade. Whilst business survival is paramount in dentistry in the same way as any other business, some often seem to forget there is a higher ethical plane that dentistry must lie on when running our businesses.

People outside dentistry don’t often get this, and one of those appears to be Mr Moyes, but also there is an increasing amount of people within the profession itself who have, shall we say, ‘flexible’ ethics when it comes to the upselling game and marketing in general, and who seem to forget what it means to be part of a caring profession. Is it any wonder that some GDC cases have an accusation that the financial motivation of the registrant one of the reasons the case is being heard?

Marketing is vital to the survival of dental business, but not at the expense of our professionalism, which is inextricably linked to our ethical compass. Something those who sit on the outside of our profession seem to forget. With the increase in non-registrant owned corporate practices, we have some people who see dentistry as just another business and apply the same rules to it as would be more appropriate for a supermarket. They however don’t run the same risks as those who are regulated do. 

A recent example would be that of the clinics in Manchester and London offering deals on limited outcome orthodontics through Groupon. These clinics now appear to have gone to the wall leaving patients who have paid for treatment up front out of pocket and a significant number of them now facing the prospect of paying more for the completion of their treatment. What their perception of the profession will now be can only be guessed, but it isn’t likely to be good.

And then we wonder why as a profession we get bad press, and are labelled greedy dentists. Even the GDC have got something right recently in the warnings about the use of things like Groupon to promote dentistry. That does actually seem at odds with the beliefs of their consumer-rights driven Chairman. It will be interesting to see how this situation develops, since there is likely to be little or no regulatory comeback against the owner of these clinics, but the full weight of the GDC may be felt by the registrants who were involved with the treatment of those affected.

Selling a product for a price far less than it costs elsewhere will attract people who are after a bargain. Restored implants for £795? Orthodontics for £995? Is it all part of a mechanism to draw people in and then upsell using crass pseudo ‘ethical’ selling (that potentially doesn’t even meet with the requirements of Montgomery let alone those of the GDC) to actually get the purchaser to buy something that actually profitable rather than the offer? But this isn’t a pocket money purchase, and these patients are likely to be attracted by the ability to have something they thought they couldn’t afford. So the business model of upselling is not necessarily going to work, as these patients might not be able to afford a bigger investment. There is then an exceptionally fine line between your bargain purchase becoming a rip off because it doesn’t turn out to be what it was promised to be. Anecdotally, purchasers like these are often the ones who have no particular loyalty to a practice and are shopping on price alone. The same ones who are usually well aware of how to use social media to destroy a reputation, and then take further legal action….

It doesn’t matter that these people will now maybe only end up paying roughly the same as it would have cost to have the treatment provided by a different practitioner in the first place; they have been misled into thinking they could afford something that they wouldn’t normally be able to and their bargain has now become a rip-off. The point is these people have suffered at the hands of our profession and we will all pay the price for that eventually. The owner of the clinic involved appears not to be a registrant, and the business model used to draw people in means that both the clinic and Groupon are likely to have been paid up front which improves their cashflow. But surely the ethics of this type of business are not those of a caring professional? Pile ‘em high and sell them cheap whilst upselling to a customer might work in some industries, but dentistry has the subtle difference of being driven by a core ethical requirement to do the right thing FOR THE PATIENT. With the change in the rules that allowed the increase in corporate dentistry and non-registrant ownership that had been restricted since the 1920’s, one could argue that the good old days were actually better for both the patients and the profession. Were ethics and professionalism more in the forefront of the profession those days?

Whilst all this is an example of what has happened in a case where a non-registrant is involved, I think there are probably registrants who should be taking a long hard look at themselves, possibly both individually and as members of corporate organisations.

I’m afraid that I for once agree with the GDC over their warnings of involvement with this kind of marketing practice.

This is a race for the bottom financially, but more importantly ethically, that I for one am not going to compete in.

Image credit -Gordon Joly under CC licence

I could basically repeat this mantra for the whole of this blog and I don’t think many would disagree with it (except of course Bill himself). However, I think my readers are more used to having a bit more to get their teeth into, so I’ll pad this out a little more. It won’t run to the 306 pages of the Professional Standards Authority report (here) into the GDC, but the sentiment is the same…

As well as reading my ramblings, I would strongly urge you read two blogs by a couple of fellow colleagues whom I have the utmost respect for. This blog was not originally going to be about Ghosts of Christmases Past, Present, and Future, but it is quite an appropriate analogy.

These are our perspectives on what has gone before, what is still happening, and what we need to do. Three views for the price of one.

http://dominicohooley.svbtle.com/a-christmas-tale

http://campbellacademy.co.uk/blog/short-gdc-update/

I am very aware of the warnings by Dental Protection not to be too critical of the GDC in public. However, I think the publication of the recent report allows me to point out some factual issues in that report, and exercise my right to free speech about a public body without too much fear.

The PSA’s whistleblower report makes fascinating, and at times unbelievable reading. What is clear from it is that the GDC at both Executive and Council level is not only a failed organisation, but a completely and utterly incompetent, insensitive, and dare I say it, corrupt (in the ethical and moral sense) edifice that now needs to be put out of OUR misery.

The report is probably the reason that Ms. Gilvarry has decided the time is right to move on. We can only hope that other regulators do not suffer in the same way as we have in the recent past; I would certainly hope any organisation thinking of engaging her in a similar position is made aware of this damning report and the role she quite obviously played. It’s really not something I’d want on my CV.

From the writing of policies by untrained and unknowledgeable staff who then went on to train more untrained and unknowledgeable staff in the process of discipline (via the Investigating Committee), the lack of scrutiny of the IC’s work, the failure to correct the problems outlined in the previous PSA report, having an ineffectual whistleblowing policy, rewriting it and it still being useless, to the utter lack of oversight by the very Council whose duty it is to ensure the Executive do not go off on a tangent, there can be no doubt the GDC has become a derided regulator both by the profession and the PSA.

So how on earth then can the Chair feel he can remain in post too? Not only that, are the other members of the Council so isolated from the real world situation everyone else can clearly see, that they somehow feel they have no responsibility for this disaster of an organisation that they are at the head of?

Having a regulator that uses untrained staff, described by their own director as just ‘bums on seats’ and ‘clones’, to be responsible for an entire section of a professional disciplinary process is nothing short of negligent. It is admitted in the PSA report that they were under pressure from the Executive to ‘Get the Job Done’, which implies the rulebook went out of the window. When people’s careers, livelihoods, wellbeing and indeed their personal lives are being held in the hands of people quite obviously out of their depth and unaware of their duty, then that attitude by the Executive is utterly reprehensible. Not only that, there still has to be the accountability that is sadly lacking. These members of staff are not specifically blamed by the PSA for the problems, as it was recognized the responsibility was entirely that of those in overall charge of the systems (and some of them are no longer in post thankfully), but one would hope that the moral compass of anybody involved would direct them to make the right decision and now leave.

Whilst the influence of these people was seemingly only on the members of the Investigating Committee, one would hope that the integrity of those on that committee was such as to not be influenced by them. However, by a simple process of extrapolation it makes one worry that other committees were under pressure of being influenced in the same way. The evidence for this isn’t in the PSA report because they didn’t specifically look for it, but we all know the GDC have acted unlawfully before in setting the ARF, which isn’t exactly a great track record. Not only that, but the findings suggest that the situation the PSA investigated with the Investigating Committee leaves the GDC open to further legal challenges via Judicial Review over the decisions it made. I would therefore suggest that EVERY SINGLE case that falls within the dates the report encompasses is reviewed and looked at independently, at the GDC’s own cost. If that bankrupts it, good. Perhaps the Government might take notice when it has to bail out the GDC.

It’s a bit like a parent dealing with a delinquent child; it tends to ignore it hoping things will get better, then gives it a stern talking too, but when it finally has to go down to the police station and bail it out for a serious offence the realisation that there is probably something perhaps seriously wrong with its offspring begins to dawn.

It’s one thing Ms. Gilvarry falling on her sword (or was she pushed?), but the supervisory role of the council during this period was non-existent. In addition, the judgment of the chair has also been called into question over decisions that he made. The sort of important decisions we take for granted will be made correctly by someone in his position. The sort of decisions that if we made incorrectly would see us in front of the regulators fearing for our careers….

There is NO way that Dr Moyes has the respect of the profession as a result. He has shown his lack of understanding of the profession on so many occasions, starting with the infamous Pendebury lecture where he likened us to the supermarket sector. That’s all well and good in this increasingly consumerist world, but you don’t get people losing their careers if they give you the wrong shape carrot or your tin of beans is past the sell by date.

So I address the final part of this blog to those people involved in the whole sorry affair.

To the Investigating Committee Secretariat, you must ensure nothing like this is ever allowed to happen again. The overwhelming majority of people in dentistry are good people, and they are not numbers that need processing despite your instructions to ‘get the job done’ by what appears to be a bunch of Dentist Haters. There is no defence to the excuse of ‘we were just following orders’; Nuremberg in 1947 saw to that. Whilst the GDC whistleblowing policy has been shown to be pretty useless, please bear in mind the need to do the right thing if there are things you are not comfortable with. Please remember, you are not the judge and jury.

To the members of the council; you might have thought that being part of the GDC would be altruistic and for the greater benefit of our profession. It should be. You might even have thought it looked good on the CV. At one time it would have conveyed respect and deference. But given the utter failings and lack of detailed, focussed, professional management that has occurred, you might be better admitting you were unwittingly coerced by the members of a ruling Politburo, which might go some way to rescuing both your CV and your own professional reputation. The Council’s oversight has been so lacking, not even Specsavers could help it.

Finally, wake up and smell the coffee Dr. Moyes. You seem to have absolutely no idea what being part of a profession is, and the members of the council have obviously not educated you properly (or been allowed to). The insight that you rightly demand of your registrants has been sadly lacking by your entire organisation, and given the tone of your emails to us particularly by yourself. I’m just waiting the email from you saying what a resounding endorsement of the GDC the PSA report is, since that’s the usual spin that is put on things at Wimpole Street. Your oversight of the Executive has been completely ineffectual. Your part in this whole debacle cannot be brushed under the table; it happened on your watch so you must bear responsibility at least in part. It’s quite ironic that some of your previous posts have been with the Office of Fair Trading and Monitor. Because there has been absolutely nothing fair about this organisation whilst you have been at the head, and your monitoring of what was going on around you appears to have been non-existent. Dentists might be in the minority of whom you regulate; but believe me without us the profession couldn’t exist. Ignore us at your peril.

For that reason your fitness to regulate has been found impaired and you must face the sanctions.

Dr. Moyes, you must resign.

You must all resign.

When an oppressive situation arises develops over the years as the one we have with our current regulator, it is natural initially, to think this won’t directly affect me. Gradually, though, it becomes apparent from the people you hear of who are affected, and then those you personally know that becoming involved, you start to think a little differently.  When its people the calibre of Colin Campbell and ‘Microdentist’ (to name a couple whom I know personally) then as I’ve said before in my previous ramblings, there’s no hope for any of us.

So if this happens to us, we need to know we’ve got the support and help of organisations that can back us to the hilt. The backing of our indemnifiers is our lifejacket; they take our money and promise to help us keep afloat.

But it is becoming apparent that the support we need to rely on might not always be a given. An increasing number of colleagues seem to be being told by their indemnifier that they wont be supported, or they are supported up to a point and then dropped. No smoke without fire? In reality I’m sure there is a degree of this in these situations. Social media is often full of discussions involving this subject, with some of the participants almost wearing a badge of pride that they’ve used their indemnifier multiple times. I’m left thinking in those cases that the problem here isn’t the indemnifier, but the way these individuals are practicing dentistry and not learning from what appears obvious to others. After all, if you keep on crashing your car into the same wall every time you drove to work, perhaps its about time you either drove a different route, learnt where the wall was, buy a slower car you can control, or just give up driving. In these cases the indemnifier is probably absolutely right to start loading the costs of representation.

Is this always the case though? There seem to be so many rumours flying around that suggest if you ring for advice this counts against you, or that if you settle a certain number of times you’ll see your premiums loaded or even cover withdrawn. There is a definite lack of public clarification from the indemnifiers about the decision processes involved in these situations. One of the indemnifiers has said that ringing for advice does NOT load the premium or count towards a risk analysis. But what about a letter that immediately closes a case or offers a refund (which is usually out of the pocket of the practitioner and not the indemnifier). We don’t know what their process of risk assessment is. We need to.

I’ve been aware for a long time of the discretionary nature of much of the indemnity, and the fact it can be withdrawn, and I’m surprised more dentists aren’t. But I’ve never heard of so much of this discretionary withdrawal actually happening as recently. A good part of this is probably due to the unprecedented increase in complaints, but is this the only reason? There isn’t any public explanation usually as to what discretionary cover is, because it’s at their discretion, which is a fantastic catch all, but that doesn’t help us. We don’t actually know what the criteria are, so we don’t actually know if we are going to be helped when we need to be. Some practitioners will be higher risk that others, but that is not necessarily their fault either. Some of those will work in environments that are naturally more hostile than others, such as prisons, and it is not their practicing style that brings the risk to them or the indemnifier but the nature of the patients they treat. I would also strongly argue that there are certain demographics of patients and even geographic hotspots that increase the risk of complaint and claims, and perhaps we should be made more aware of that in order to mitigate the risk to us. We need to know.

I can see the point that if we don’t know what the reasoning is we wont construct our practice around it. A sort of Indemnity Gaming if you like; if you know the criteria that are used then you know what you can get away with and just stay within the margins (if you are a dodgy practitioner that is). But this is what risk assessment should be about. I’m talking about the risk to our livelihood and careers here. We can lose our home due to a regulator that we accept is not fit for purpose, so we need the security that our indemnifier is going to be transparent and fair with us.

I don’t see any profits warning or indications that their membership reserves are running terminally low from any of the indemnifiers which suggests that they are in reasonable financial health. Given the beautiful offices that many of then operate out of confirms that indemnity is big business. Which leads me to where I think part of the problem lies.

The bigger a business, the more it loses its personal touch. There is a immediate personal contact with the advisors who do so much valued work, but they are not going to be the party that decides if support is withdrawn or not. That is likely to be made at a higher level, lacking in the emotive connection with the dentist. There is so much litigation going on now that the indemnifiers have to be large, and have to have the resources necessary to run such organisations. The costs of the support network in order to run the core business are huge. The cost of the legal representation for its clients is also huge, and shows no apparent sign of getting any less. As more patients complain via the medium of ‘No Win No fee’, or direct through the GDC, then the need for the indemnifier grows symbiotically as does the drain on its resources. With the demand to stay in business, then the indemnifier needs to ensure it is financially solid enough to survive to protect its clients. Its survival then becomes the prime reason for its existence, and it becomes even more risk averse. Thus affecting the very clients it is there to protect. Is this why some dentists are finding themselves without a lifejacket? Will there eventually be a multi million pound business protecting the one or two clients who are so risk averse themselves they will never need the indemnifier as they never see a patient?

This symbiosis is no different to any other supply and demand industry. The more the GDC presses ahead with what appears to be the UK’s largest complaints handling business, the more the indemnifiers will grow on the back of the legislative need for us to protect ourselves. The more they need to protect the finances of the business it becomes.

But we need to know they will be there for us when we are walking the plank. Perhaps the indemnifiers should publically reconnect with us, be more transparent, and show us their human side once more. After all, it’s not all about the money….

It’s about saving lives.

Did you read Part 1 of this blog? If not, click here

Image credit -Ian Armstrong under CC licence - not modified.

Readers may or may not have experienced the delights of going on a cruise. So how does a voyage on a Dental Cruise sound?

You join your ship with lots of other passengers and set sail. What is vitally important though is that you’ve been told before you sail you have to provide your own lifejacket. You notice that there are quite a few different sorts and colours. Some are ones that only inflate whilst you have them with you, and some are inflated all the time, even when you get off the ship at the end of your journey. Some passengers even have special coloured expensive ones that some of the lifejacket manufacturers don’t even supply. We’ll come back to those later. The industry is getting bigger and bigger, so more and more life belts have to be made for all those going cruising.

Initially it’s all really nice, the food’s ok, and the accommodation is too. However, there’s something not quite right. The crew seem to be openly hostile to you, and the officers never seem to speak. The captain of the ship and the 1^st officer never come down to speak to the passengers. You’re actually suspicious that the direction the ship is headed isn’t the one you signed up for. Not all the islands you visit are as welcoming as others. After a couple of ports you also start to see the numbers of passengers dwindling a bit and you hear a lot of splashes at night.

You do a little research and you find out that the crew is in better quarters than you are, and your money has gone to pay for that. You have to tip the crew more and more even though the service is rubbish, and then you find out the way they worked out the tips was illegal. More worryingly you hear that the captain orders the crew to round up passengers who might be a danger to those who live on the islands the ship has visited or might visit yet. The captain orders the islanders to report anything they don’t like about the passengers to the bridge. The captain also allows spies to be put ashore to trap some passengers if the locals themselves don’t report the things that are done ashore. Passengers who have committed some sort of infraction are invited to visit the Bridge for a tour. Its not an option. You hear rumours that some of the officers don’t speak as the 1^st officer has ordered their tongues cut out, possibly to prevent mutiny. You laugh at this, but you start to get a bit worried. You realize the crew doesn’t trust the passengers at all. Some of the passengers even report other passengers, or get the islanders to report them, or even join the crew.

Then you see why the passenger numbers are dwindling. Every night, the crew makes those passengers who’ve had the bridge visit walk the plank. They are allowed to take their lifejackets though. Sometimes the crew let the passengers off before they get to the plank, although there isn’t always consistency as to who will be let off or not. Some even get halfway down the plank before they are allowed to come back. Usually that’s because the lifejacket manufacturers send their best machinists and repairers to make sure of the buoyancy of the jacket whilst its owner is on the plank. This costs the manufacturers lots of money, so it’s better if the lifebelts never get used in the first place. But you’ve already paid for the service when you bought the lifejacket.

Most of those that do fall off the plank therefore obviously have their lifejackets to help them. These keep them afloat until the rescue boat picks them up and puts them back on the ship. Sometimes some are thrown overboard before the captain has heard the case and they might be allowed back on board, or they might be put ashore until the case has been heard, then they get to walk the plank all over again.

However, there’s a problem with some of the lifejackets. Not all of them are going to work. Most do, but not all. Any you might be wearing one that isn’t going to work when you need it.

Now some of this is because the passenger has done something so bad that Mercenaries employed by the crew are allowed to puncture the lifebelt. Some of these passengers drown or swim to shore, but either way they never get back on board. Occasionally the crew or even a mercenary punctures a lifebelt through their own incompetence and hope they don’t get found out. The lifejacket repairers sometimes throw a spare lifejacket to them. But sometimes the sharks get them first.

But sometimes its because the maker of the lifebelt has decided not to put the flotation device in a lifebelt because of something you’ve told them or you’ve walked the plank before. It looks the same, and you certainly paid the same for it, but its only when you try to use it that you realize its not working. Remember those with the special coloured expensive lifebelts? They’re really expensive because the normal lifejacket makers wont supply normal ones to these passengers because they keep being made to walk the plank, or just keep jumping overboard because they do stupid things and don’t seem to learn from it. In fact, some of the lifejacket makers wont supply them at all but don’t always say why. Strangely, some of these passengers seem to arrive at the ship in fast cars and occupy the biggest and best passenger suites.

Occasionally there are times when a passenger is walking the plank and the manufacturer of the lifebelt actually takes it off them, either just before they walk, when they’re in the water, or when they get back on board having survived the ordeal. The rules say passengers can’t stay on the ship without a lifejacket, but they now can’t get one to fit, the manufacturer wont sell them another, or they don’t have enough holiday cash left to buy another one. They either have to stowaway for which the penalty is immediate plank walking, or they have to get off at the next port.

The captain no longer answers to the ships owners, but they don’t seem bothered, and the captain and 1^st officer decide they’re going to expand their little seafaring enterprise as a result. There’s a ship right behind with loads of passengers that go ashore and always paint the islands white and harm the natives, and occasionally the captain makes one of them walk a plank, but doesn’t seem that bothered by the harm they’re doing. They don’t have any lifebelts on that ship either.

The passengers frequently get together and talk to one another, but no-one ever has the bravery to arrange a passenger mutiny even though they keep having the cost of the planks added to their tips. Most of the passengers are too busy trying to protect themselves to look out for the others. The senior officers of the crew don’t talk to one another as they haven’t any tongues, and those passengers that become part of the crew and can still talk don’t want to resign as they say they’re the ones that keep the bridge visits and plank walking fair. The happiest are the mercenaries that get to puncture the lifebelts as they get a bonus especially if they can make it take longer. The manufacturers seem to want to really only give the lifebelts to those that will never use them as they don’t have to spend money readying them for plank walking or repairing the punctures. But their top repairers are happy because they get paid more when they have a puncture to repair.

What a silly story…. No one in their right mind would get on that ship if they read that, or stay on it a moment longer than they possibly could once they found out what was happening.

Read Part 2 of this blog by clicking here.

The Hired Gun with a smoking gun….

We all know the GDC has spent the last few years on its own little self-righteous planet, and even given its recent pitiful showing in front of the Health Select Committee there appears to be no sign they are planning to return to normality in the near future.

Indeed, this week, what can only really be described as damning evidence of the GDC’s utter and complete contempt for the process of Justice in its most fundamental form has been revealed.

A case in front of the Professional Conduct Committee this week has revealed that it is not only the initial stages of the disciplinary process that are woefully inadequate which resulted in their huge backlog of cases; but that the basic legal requirement of full disclosure of the case against a registrant may be riddled with horrific inefficiency and contempt for the fundamental tenets of justice. Not only that, the GDC is not following the rules set out for its registrants and flagrantly flouting them in order to pursue its own agenda of what now appears to be a persecution of the profession via its individual registrants. The PCC themselves described it as an ‘Offence to Justice’.

In this particular case, amongst other things, the GDC had 9 different versions of its expert witness report, and failed to submit many of them in a timely manner for the defence case to be prepared. It was still submitting them to the defence on the day of the scheduled hearing. Not only that, but it would appear that evidence the GDC held was not submitted to the defence at all, which may have helped the defence case. Thankfully the outcome has been for justice and propriety to be upheld by the members of the PCC. (who have for some reason remained anonymous)

With the facts that have come out about the way this case has been handled, the GDC has now plumbed new depths it seems. I didn’t think we could be treated with any more contempt that we already were; but this is jaw-droppingly bad. By what definition do the GDC expect us to have fair trial if they don’t submit the evidence as per the rules? They fail by their own standards throughout this case. Where is their duty of candour? Where is their transparency in their dealings with the registrant?  Have they actually read the Human Rights act? I refer them particularly to Article 6, the right to a fair hearing, which quite obviously would not have occurred in this case had it not been for the integrity and the strength of the members of the PCC.

For the PCC to accuse the GDC of being egregious (or outstandingly bad) is an extremely strong and unusual stance for them to take. Whilst this occasionally happens in the criminal and civil courts when a judge or jury might take exception to the conduct of one of the sides, for a committee funded by one of the sides to effectively take a swipe at its paymaster is highly unusual. I know the PCC is made up of independent members, but don’t forget, despite this independence, they are funded by the prosecuting side, the GDC. I am not for one minute casting any doubt on the integrity of any of the members of these panels, and in this particular case nothing could be further from the truth. But one has to wonder how much of a culture of fear is being instilled that pervades throughout any process the GDC is remotely associated with including these committees. How many other cases have been similarly dealt with by the GDC and the PCC not spoken up in the same way? We know now that this is an organization that doesn’t seem to apply the rules of law and justice properly to those it pursues, and even think these rules don’t apply to itself, and then show no insight whatsoever into its failings. Even the GDC solicitor involved in the case appeared to have had an inappropriate contact (not contemporaneously noted incidentally!) with the patient witness in order to ask leading questions and to coach them which also a big no-no.

Just as strident but more worryingly to my eye is the criticism the GDC’s expert witness comes in for at the hands of the committee. I have not seen this amount of criticism of the expert in any case before. It almost seems like he has gone out of his way to act as some sort of private investigator in order to help the GDC secure its desired conviction. There have been a couple of cases recently where the GDC’s expert witness has come in for criticism, but not to this degree.

Expert Witnesses are required to be independent and objective. It is an enormously privileged position to be in as they alone are allowed to give opinion-based evidence to a court and not just statements of fact. They are not and should never be seen as a Hired Gun to destroy the defendant. For whatever reason it would appear that in this case the expert has gone beyond his remit in such a way that one could seriously question that if this were a civil or criminal case whether serious charges against him would be the result of such a deviation from the accepted role. All the expert witness training I’ve done (and I’ve done a lot) has stressed the importance of never being a Hired Gun. I’ve had solicitors request I change parts of my reports to better serve their cases; and the answer has always been an immediate refusal. An expert witness has a duty to the court and to no-one else. We are not Magnum PI no matter how much we might want to be.

But by acting as a hired gun, this expert has now turned this case into a smoking gun.

Experts are no longer immune from prosecution, and given the evidence in this case, one has to wonder if the abuse of process by the GDC and its expert means that this should now be taken further by the defence team in order to recoup their costs. Ironically, the expert could well be professionally covered by the same indemnifier involved in the defence, but then I’d have thought that might be an appropriate time for any discretionary support for the expert to be withdrawn since it appears he acted in such an unusual manner. Its also rather hypocritical of an expert who appears to be acting far outside his remit to feel he can stand in judgment of a practitioner who may or may not be acting outside his sphere of expertise. Unfortunately Expert Witnesses are not regulated in any way other than by their profession; but this behavior has to be close to bringing the ‘profession’ of expert witnesses into disrepute. I know a good many experts who are aghast at the revelations in this case.

I’m sure the acquitted practitioner will probably now want the whole thing to go away, but I really hope that he doesn’t take this lying down; the GDC should be massively on the back foot with this revelation, and the profession’s moral (and legal) advantage should be well and truly rammed home now.

The BDA should also now get very vocally involved again, and if they don’t they are going to miss a huge opportunity. If they approach it through lobbying MP’s they should broadcast this loudly to the profession so we can hear their voice.  Some have said they should call for a complete halt to the GDC investigating process; but this would leave the public open to the risk of any truly dangerous individual being left free to practice. However, in my opinion they should press for every case both this expert and this particular GDC team been involved in to now be independently reopened, re-examined and all at the cost of the GDC. The costs of this should then be made exceptional from the annual GDC budget so they cannot then charge the profession for this. I’m sure they’ve got some indemnity insurance kicking around somewhere they can use. In addition, every pending case that involves just a single patient complaint should be now be suspended until a full independent inquiry (and I don’t mean by some equally flawed organisation like KPMG) into the above cases has been completed. There should be full and complete disclosure, and compensation paid to any registrants if the GDC are found to be in the wrong. Any employees of the GDC found to be in breach should feel the full weight of any legal process, and not be allowed to hide behind the corporate protection of Wimpole Street.

The GDC are quite obviously in breach of the Human Rights Act. There was no way this registrant was going to get a fair trial, and the GDC were quite obviously unconcerned by that. How many times they have done this before now needs to be made public. If we persistently did the same to our patients we would lose our careers, our livelihood, and our professional integrity. They should pay the same price and their executive should now be held vicariously liable if the law has been found to be broken (again…)

Resignations of individuals at the GDC are no longer enough for confidence to be restored in our regulator. The profession should demand the highest powers possible now decide their fate. Whether this should be up to individuals crowd sourcing an opinion from a barrister as to whether the GDC are breaching our human rights; or our indemnifiers taking their own legal action to seek redress for the expenses incurred in cases like the above;  and whether the Health Select Committee recall the GDC Executive to be given the coup de grace; or the BDA continue their lobbying of MPs whilst we keep filling those same MP’s mail sacks with letters. It needs to be all of the above and simultaneously. We need to unleash a veritable storm that cannot be ignored.

Enough is enough. We need to keep taking firm action.  Is the entire profession listening? It’s time to hit back again.

The one thing that has been a constant in my entire career so far, and has been the fundamental guiding force to everything I do, has been my ethical compass.

Where it came from originally I suppose was my upbringing, but then further refined by exposure to teaching (particularly clinical) of such a style it helped me to understand what an important position we as professionals hold, and the huge responsibilities we have to other people, primarily our patients.

Whilst clinical experience and techniques have doubtless changed through my practicing career as it does for all of us, the ethics of how and what I do have remained a fundamental baseline that cannot be compromised in my opinion.

I’m sure for the majority of the profession this rings happily true. So much so I have wrestled with even submitting this blog for publication. After all, none of us know anyone in the profession who could do with taking a good look at themselves and thinking about what I’ve written here…..

There are times when I have had to wrestle with what the right course of action is clinically, but these dilemmas have always been fairly straightforward when put in the perspective of how other medical professionals might have to act, and I’m actually quite grateful that for the vast majority of us our day to day decisions are rarely likely to have life changing impacts on our patients, especially when compared to the huge responsibilities of cardiac surgeons or oncologists for example.

But….

If our ethical compasses have become somehow magnetized by a malign influence that we fail to see, ignore, or indeed we positively allow to affect us in some way, then our actions will have potentially life changing impacts on our patients. Ok, so maybe not as severe as for the medical professionals mentioned above; but certainly at odds with the ‘First do No Harm’ principle we swear an oath to.

I am purposely NOT going to go into the potential malign influences of the NHS contract and how it might be abused or gamed; I leave readers to draw their own conclusions about this after reading this piece. What I will say is that my examples below probably only scratch the surface of what might be happening in our profession.

There is huge increase in the cost of indemnity, and whilst we have a GDC that is not fit for purpose causing at least part of this increase, it surely cannot be solely due to that alone. We can blame no win-no fee solicitors to a degree, but don’t forget that cases have to have some merit to be paid out, even if only on the balance of probabilities. Otherwise, they are defensible.

So, consider the parallel increase in availability of orthodontics and implants in recent years. This blog incidentally is NOT aimed solely at the orthodontic aspect although it may seem so; it is purely written from my personal experience of one aspect of our profession that I have experience in so feel able to comment on a bit more.

These treatments are by their very nature high value items, and potentially have a higher profit margin that some of the more routine treatments offered. The courses maybe expensive, as is the equipment needed to carry out the treatment. Being the principal of a practice that offers both these treatments, I am pretty well placed to know the financial aspects of them. What is worrying is that there seems to be a section of the profession that immediately has a new direction on their ethical compass when they start to offer these services, sometimes after only a weekend course. Admittedly this might apply more to the orthodontic side of things as I think it is now more recognized that implants are not quite as simple as Meccano to install.

But with the increase in availability (or is it an increase in higher pressure marketing and selling??) we see the parallel, and often steeper rise in litigation and Fitness to Practice associated with these treatments. Personally, I think a good chunk of this is due to the magnetism that potentially affects the compass of some of the profession after being exposed to these treatment modalities.

It’s one thing coming away from a weekend composite course having learnt what is likely to be a refinement of an existing technique, to actually introducing a whole new treatment modality to your patient base that wasn’t taught at all at undergraduate level. The ethics of such a situation are different in my eyes. When at least some of the course is given over to how to sell the new treatment to your patients on some courses (rather than spending it further exploring the ethics, assessment, case selection etc) it is not surprising that magnetism is already starting to alter the direction of the needle on your compass…

There is nothing wrong with a return on investment, but it’s how you go about getting that return that might be the problem.

Let me give you some background with regard to my orthodontic experience to put into perspective where I am coming from.

I was fortunate to work as a clinical assistant in the mid 90’s in orthodontics. One morning per week I treated patients under the supervision of a consultant in a regional hospital, and this continued for about 4 or 5 years. By that time I had seen and indeed treated some pretty advanced cases under very close supervision. I was also treating simpler cases in practice as an associate. Along with another general practitioner, we estimated this experience prepared us to treat perhaps 30% more of our orthodontic patients in practice, but more importantly it had taught us how to identify what we definitely couldn’t or shouldn’t treat. The ethics of what we could now do was drilled home all the time since we often got to see the slightly more ‘random’ orthodontic treatments that had failed in the hands of practitioners with experience only of removable appliances at undergraduate level.

We had begun to Know what we Didn’t Know.

Since then I have also been on the courses for commercially available appliances of different types, and had the advantage of my previous experience in looking at the systems and the teaching a little more objectively than perhaps some of the other delegates.

The problem comes when some of our profession don’t have these limiting factors in their internal ethical system. Some are possibly not enough motivated by the desire to always only do the right thing by their patient, but by their own financial and even egotistical drives. There have always been those in our profession who seem to have a sliding scale of principles, and are more driven for their own gains (and the patients may or may not gain as a result). I actually don’t feel that there are any more truly ‘bad guys’ in dentistry now as a percentage than in the past despite what the GDC think; but I think the potential for damage to our patients has increased because perhaps the fundamental ethics we should all have in place, in some are allowed to erode.

Combine this with the further issue now that with a lack of experience at undergraduate level for some aspects of dentistry, the starting point for not knowing what you don’t know is now much lower than perhaps it was in the past. This is where the ethics should come in to play, and whilst I applaud the efforts to fill a gap in the treatment needs by offering training in fields not covered by the undergraduate training, there doesn’t seem to be an ethical ‘lock’ in place with some practitioners to prevent them seeking their financial gain over that of the patient.

More controversially with regards to their ethical direction, perhaps they Don’t (want to) know what they Don’t Know about ethics?

So when the treatment goes awry because of not knowing enough about what wasn’t known, and the ethical direction was slightly (or massively) off, the profession has a HUGE potential for life changing impacts on both patients and its members.

This brings me on to the thorny subject of ‘selling’ in dentistry. Now, I have absolutely NO issues with dentistry as a retail environment, offering services to patients. Indeed, in order to keep a viable business in this ever competitive age, you have to consider how best to let your patients know the services you can offer them. I certainly do, and I feel it is another method of protecting ourselves from criticism that we are not offering a full range of options to our patients.

But ‘selling’ has to be fundamentally and overwhelmingly in the patient’s benefit, and not ours. I worry about some of the techniques I know can be used by some industries that if (or should that be when?) used in ours would exert an influence on the patient designed to get them to agree to treatment whether that is the right thing for them or not, or even more worryingly, whether the practitioner is truly capable of providing the treatment correctly or not. The pound signs appear, the ethics can get completely switched off, and it becomes a one sided benefit.

But what if you actually CAN’T solve those issues? (and are either aware you can’t, or just bite off more than you can chew?). The classical ‘Over Promising and Under Delivering’ is a guaranteed route to problems for patients and the reputation of the profession.

This is where the huge problem occurs. The practitioner that doesn’t know ENOUGH about what he/she doesn’t know, having been blinded by clinical and other courses that seem to offer all the answers to patients problems and get them to agree to treatment, with an underlying anaesthesia of the ethical values (if they ever had one in some cases) for what ever reason is not doing the best for their patient.

At all.

Without the ethical compass pointing in the correct direction, then there are those in the profession who cannot with their hands on the hearts say that they are truly driven by doing the right thing for patients. Take the ego and the financial aspect out, and their direction is quite possibly completely lost.

Until we make sure all our ethical compasses are calibrated properly, I’m afraid the GDC (in whatever guise it takes) will continue to be on our backs, and our Indemnity will continue to rise. The press will see us in the wrong light, and so will patients.

We need a return to the fundamental values of what we do and what that means to us and the patients.

And to do that, The Only Way is Ethics.

Image credit - Paul Downey  under CC licence - not modified.

When I qualified back in the early 1990’s, social media wasn’t exactly on the radar. The thought of being able to connect with a multitude of people instantly was the stuff of imagination. The Pub was our Facebook, and the only ‘likes’ we had were the various guest beers.

Now it’s such a part of our everyday lives that normal channels of communication are seemingly used in the minority. When you can connect with the entire world’s population from the comfort of your home, and carry on multiple conversations about multiple subjects simultaneously, the days of popping out for a beer and a chat with a mate seem numbered.

But what about the social etiquette, and more importantly the professional etiquette we employ when online? The GDC have standards that we should adhere too, and indeed GDPUk is actually specifically mentioned in them such is the impact social media has made on the profession. Specific specialist sites like GDPUk aren’t generally the issue, and whilst there are sometimes a few comments made that might get the GDC or lawyers a trifle interested, these sort of sites are generally appropriately populated and commented upon.

The problem are the wider platforms especially those such as Twitter and Facebook. Some users don’t seem to get the fact they are in no way whatsoever a place to remain private and anonymous despite what you might think.

Whilst the ‘more mature’ professionals seem to have the general hang of the way we should conduct ourselves, I worry that some of the younger members of the profession haven’t quite got the gist of what being a professional is yet and how they should present themselves in public to the public. Because no matter what steps they take, if they have a social and professional presence on media like that, they are well and truly exposed to public scrutiny.

There are a multitude of Facebook pages for Dental matters. Some are better than others, but all suffer from the same fundamental problem. They are not private. In order to use them you have some sort of visibility. For instance, if I wanted to discuss a case over a beer in the pub with a mate, I wouldn’t be doing it whilst posing in a mirror with oiled muscles. But that’s what communicating with some of the personas on social media is like. Some of the fairer sex seems to be somewhat less than modest in their attire on occasion, and one has to wonder if this is what the public expect of its professional classes. A couple of clicks and you generally have a range of private information about ‘friends’, particularly the more self-obsessed ones.

What about commenting into the perceived anonymity of an electronic device in such a way that you wouldn’t do in person? I’ve witnessed many an argument that would never happen in real life due to the social ethics the majority of us have; but once in the safety of the digital world the ‘keyboard warriors’ tend to lose all sense of propriety and the moral compass seems to have lost its direction.  And then there are the artists of self-promotion who feel every other comment has to be some form of pseudo advert for a business venture, or course you can’t possibly miss. I’m becoming guilty of the last one as my Twitter account now is used almost solely for the promotion of this blog and GDPUk. You see, the boundaries of who you are as a person, and who you are as a professional are becoming so grey with social media like Facebook that it feels safe to make that sort of comment, and think there is no comeback.

Finally, there are the vast numbers of photos of patients and cases that we see bandied around social media. The GDC is very clear on this,  in standard 4.2.3, where it states ‘You must not post any information or comments about patients on social networking or blogging sites’. Period. We can use ‘Professional Social Media’ but social networking sites are a no-no according to the exact wording. Personally, I think the GDC are possibly a little behind the times on this, as there are a good number of very good Facebook pages where some quite good discussions take place; however it remains to be seen if the GDC feels this is ‘professional social media’ when used in this way, as after all, they are the ones who get to decide….

The big problem though is that many people forget just what can happen to these comments and photos once they've been posted.

I’ve heard stories of people using screenshots of comments made on social media and then threatening to use them as evidence to send to the GDC. Screenshots can be shared outside the domain we think we are posting in, and as such can be disseminated far more than we might have considered when we posted. Unfortunately the self-righteous are rife on social media, and often mistake what is only free speech for something to get offended by, and take draconian steps.

I’ve seen the fallout when comments in a public section of a site then get even nastier privately; and I’ve seen wholesale bar-brawls break out in some places (although they’re usually involving musicians ? ). This is like taking a voice recorder or video camera to every meeting you have with a professional in case they say something that offends you so you have evidence and can report them. Since the GDC love nothing better than a good old Fitness to Practice case, we need to really be aware of what we put on social media, how we do it, and the persona we use on there. I think it is only a matter of time before there will be a full-blown case against a registrant involving some indiscretion or inappropriate comment on social media.

Now I’m no Luddite, prude, or some ‘holier than thou’ observer; as a forthright Yorkshireman I tend to say how it is and if you don’t like that then that’s your problem not mine. I’ve got patients as Facebook friends, and I tend to be exactly the same person online as I am in real life. I’m aware that anything I say there is something that I should be happy to share in a professional environment. I’m a real person and don’t have any airs and graces or chip on my shoulder that mean I think I’m some sort of superior being because I’m a dentist. But I can’t help thinking that some of the comments, personas, and attitudes we see as the public face of some of those in dentistry give the GDC every right to be concerned about the public perception of the profession, because if people can’t differentiate between a digital persona and a real one when they are posting then they really do deserve the attention of our regulator. The rationality and politeness filters seem to disappear from some of our profession when they get infant of some kind of keyboard. Couple all this with a competing bunch of the self-righteous, and the self-obsessed and we have a recipe for the profession to start imploding.

It certainly feels like it is one rule for the GDC and one for us where social media is concerned; the sheer fact you can ‘like’ the fact a colleague has been struck off, suspended etc, is not what I call professional. There’s also no associated comment when a colleague has been exonerated, like in the case of the Scottish dentist Keith Watson, who then attempted to take a vexatious patient with an apparent history of suing dentists, to court for defamation, which unfortunately he has had to abandon at great financial cost to himself.

But, this case shows there can be huge good come out of social media and its immediacy. In the space of less than 24 hours a fund had been created to support Dr Watson, a newly qualified member of our profession who would no doubt be financially challenged by a huge legal bill this early in his career.

http://www.gofundme.com/keithwatson Not only that, the messages of support for Keith have been flying around social media all day and latterly on GDPUK itself.  When used appropriately then, we have a fantastic medium to help people.

We need to embrace social media as its here to stay; it can be hugely useful, and massively informative; but we must use it appropriately, and think about the consequences of our presence in the virtual world. That’s what it means to be a professional.

The Health Select Committee will be holding an accountability meeting with the GDC on the 3^rd of March. It’s about time too, as they haven’t been asked to account at all to anyone but the judiciary recently (and they lost). It will be interesting to see if they try to spin that meeting in the same way as they did in the press release just after the decision in the high court in December.

It looks like the GDC have finally got to face the only people who they are answerable to. I wonder if they are going to try to wiggle out of the unavoidable truths?

I presume everyone reading this is going to submit his or her evidence to the HSC through this link before the deadline of 19^th February.

No?

Why not?

Are you scared?

Well actually, that is probably extremely close to the truth. I am personally quite worried these days that a GDC letter will arrive on my doorstep for some reason or another (and that is not because I know I have something to fear – my inherent belief structure tries to ensure I do the right thing by patients at all times, but I have also been openly critical of the GDC, which I’m sure they do not like – and they get to decide what is deemed as professional or not).  All someone these days has to say (even in jest) is “I’ll report you to the GDC for…” or ‘I bet the GDC have their eyes on you” and it feels like a letter from Wimpole Street is already winging its way to you starting the process of investigation and a potential loss of livelihood.

The lack of proportionality that has been written about previously means that a situation like this could be an increasing possibility for all of us. It’s why the ARF had to go up according to the GDC for goodness sake. To put a few figures on this, if you reckon on 40,000 dental registrants having about a 40 year career, and the current data from the GDC is that there were 1700 complaints in the first 6 months of 2014, then the maths shows that each registrant will have 3.4 complaints in a career. (3400 complaints x40 /40,000). Some of these complaints are against DCP’s, ok, and not all of them will go to the full Fitness to Practice hearing,  (but 40% of them currently do) but I’m sure you get the overall idea. Is it right that if this way of dealing with complaints continues, on average, every single dentist will have to face this career-wrenching possibility more than once? This alone tells the general reader that the regulator is going the wrong way about it.

Since the GDC are the initial arbiters of our standards and decide an investigation will run to see if there are any grounds to an allegation, and there is currently the interminable wait for a hearing, then I don’t honestly think I could mentally deal with that kind of pressure for that long with the fear of loosing all that I have put into patient care, this profession, and that of my livelihood and ability to provide for my family. Even if an investigation goes all the way to a hearing, is there any guarantee that there will be an understanding of the pressure we are now practicing daily under from the committee, especially when it is made up of so many lay persons?  Tony Jacobs wrote an excellent blog on this subject.

Some of you will have no doubt read the very eloquent and erudite blog written by Colin Campbell, a very well thought of colleague in my locality and indeed nationally. Colin is one of the most ethical and conscientious practitioners I have ever met. If you haven’t read it then it is a ‘must read’, because Colin is a person who wears his heart on his sleeve and this series of blogs are likely to be a wholly authentic and personal view of how HE felt during the process he went through.

There are many (most of us?) out there that fear the GDC, and not for the correct reasons. We need to respect our regulator, and know that whilst it absolutely MUST act to protect the public, it is not effective ‘right touch’ regulation to do this by ruling the profession with that kind of fear. Using a methodology akin to continuing the beatings until the morale improves is not how it works these days.

Mistakes happen; I was once told right at the beginning of my dental career by an older practitioner the reason he was more experienced than me is because he had made more mistakes than me. Nobody is ever going to excuse the type of mistakes that are so dangerous they have to be dealt with swiftly and appropriately. But if we are to be perpetually living in the fear that one minor transgression will bring the full weight of our regulator down on our backs then that is wrong.

There are also bad people in our profession; nobody is denying that, and I will certainly make no excuses for them. But the climate of fear that pervades the profession at the moment is no way to prevent mistakes from happening, and it certainly wont do ANYTHING to stop that minority who are out to damage people because  they probably don’t have the emotional or ethical values to allow them to feel the fear those of us that practice ethically and responsibly (and fearfully) do.

So at the moment I remain scared. But I will still be submitting evidence to the Select Committee because I cannot, and will not be made to feel this way for the rest of my practicing career. We care for patients every day, but we also have to care about our future health for the sake of our families. After all, we too are human, just like the public the GDC must protect.

We have to stand up to the GDC and now show them the true and high calibre of the vast majority of Dental Professionals.

Blog image Edvard Munch [Public domain], via Wikimedia Commons 

I wasn’t going to write any more GDC related blogs for a while, as I don't want to be seen as a one trick pony, but the situation with the GDC is the singular most important thing to have affected our existence as a profession, and continues to have more twists and turns than a white knuckle roller coaster, so my apologies for writing about it again.

Seriously, was anyone surprised by the GDC’s decision to increase the ARF to £890 on the 30th October?

After the sham of a consultation, it’s not entirely surprising that this should be followed by what was probably a sham of a discussion at the Wimpole Street Lublyanka (for those unaware, that was the name of the HQ and prison of the KGB), and an ARF of £890 has been set.

Nothing has really changed though; despite now slightly reducing the amount for DCP’s (the majority being nurses who I suspect have that actually paid for by their practices), this would appear to have been the classic “give ‘em 3 choices and they’ll pick the middle one”.

The BDA is now set on its path for Judicial review; and this will be heard before the 17th December. The BDA stops short of recommending what its members can do up to this point, but If I may suggest the one thing that absolutely everyone can do now is cancel their direct debit, and write themselves a reminder to pay the GDC before the 31st December. That way they CANNOT take the money early, and whilst it may only be three or four weeks more before they can get it, at least if the BDA win the Judicial Review then people wont have to be waiting for a refund from a regulator that has no sense of respect for the profession. You will not be acting illegally, just stopping the GDC from getting its hands on your money sooner. Incidentally, according to a recent freedom of information request, the decision to engage KPMG was a decision taken by the Executive of the GDC and not by the council. One would have thought that engaging a company like KPMG with its associated costs would have been something put to the Council to vote on. Anyhow, the GDC will need even more money to pay for the services of KPMG, and guess what? We get to pay again.

This brings me to the point of this blog.

Civil Disobedience.

What would happen if every one of us rang the GDC between Christmas and New Year to pay? If a few thousand registrants rang over that 3 day period it means hundreds of calls would need to be taken every hour by the GDC if they had an 8 hour working day. What if their systems collapsed under the weight of having to take so many online or telephone payments? Apparently they are so arrogant they do not have the facility to take payment in cash, so the very press worthy images of a few hundred dentists turning up with buckets of £1 coins in order to pay are not going to hit the pages of the Daily Mail anytime in the future.

So what’s wrong with paying £10 on each of 89 cheques, and requesting a receipt for each one?  Or making multiple credit card payments of the same amount? Given that it is also legal to write a cheque on just about anything, may I suggest that a few 6’x4’ pieces of chipboard, properly filled out with sort codes etc delivered to the GDC in Mid-December from registrants wouldn't go amiss. How about arranging a mass payment in between Christmas and New Year, and on the days that the LAT’s insisted we should all be open for normal business? If just 100 of us turned up and wrote cheques out on pairs of boxer shorts (new ones obviously!) that might get some press attention. All at the same time as they're manning the phones taking the card payments above. One idea being floated on Facebook is getting the GDC’s bank account details and paying them directly by BACs. Its actually quite difficult for the GDC to trace who has paid at their end, but we will all have documentary proof at our end that it has been paid.

All a bit tongue in cheek admittedly, but with a serious side; if the judicial review fails, then we will have to pay this ARF. The BDA will continue the fight I know; but this particular avenue will then have closed, so a little bit of civil (legal) disobedience would show the GDC we are still up for a fight, but just looking for the next opportunity to open up a chink in their armour.

I also think that with Thursday’s decision the position of the remaining dental registrants on the GDC has now become untenable. I’ve stopped short in my past blogs of directly levelling any personal criticism at any members of the council, including the Chair and the Chief Executive. But with the emasculation of the profession so effectively by this council structure and those at its head, and the lack of any PUBLIC individual vocal defence of the profession by those who are members of it on the council, then they can no longer use the excuse of trying to change it from the inside. Thursday’s outcome should surely have delivered that message resoundingly to them. If they were against the ARF rise then they cannot now remain in the council; if they were for it, then they are not representatives of the profession. Either way, that makes their positions untenable. They look to be completely sidelined in the council processes that seem to be railroaded through at the whim of those who appear to be building a personal fiefdom with the seeming remit to destroy the entire profession it regulates. Indeed, they don't appear to write their own articles, as those published recently in the dental press which purported to be from them were 80% similar to one another when run through anti-plagiarism software. I also understand a large amount of the council business is now held behind closed doors, and only lip service is paid to the public aspect of the meetings these days which generally give the appearance of being stage managed for those observing.

As a Yorkshireman from the Loxley valley now living in Derbyshire, and working in Nottinghamshire, one legend that has been very close to me throughout my life is that of Robin Hood. I was brought up a stones throw from one of the reputed birthplaces of Robin of Loxley, am now living near the reputed burial place of Little John at Hathersage, and work close to the Major Oak near Mansfield, and I can see a huge analogy in this story.

We have a Sheriff of Nottingham, collecting taxes from the downtrodden masses, ruled over by a King John figure who’s got no real chance of a proper throne. The peasants don't like either of them but they don't care and keep finding more and more reasons to persecute the peasants whilst charging them for the privilege. This makes the remaining members of the GDC the barons at the table of the Sheriff with no real power whilst paying lip service to the Sheriff and King.

We've then got our Little John and Friar Tuck rolled into one, (ok, so its actually Fat Mick but the sentiment’s the same), and the BDA collectively as our Robin Hood (probably the Errol Flynn one rather than the Kevin Costner one given the size of its cojones recently!). That makes the profession the downtrodden peasants (metaphorically), some of whom became the Merry Men and Women. GDPUK is a collective Will Scarlett as the mouthpiece of a storyteller and bard. Hopefully the righteous King Richard is going to be the judiciary who will hear the BDA’s case.

Robbing the rich to give to the poor? How much money has the GDC had from us over the years? Having enough money to spend on QC’s and £78,000 Fitness to Practice cases over silly matters that should dealt with locally at lower cost to the profession shows it has no respect for the money it is given. It has become like a like a rich man who knows the cost of everything and value of nothing. Whilst its remit is to protect the public, this does not mean it should have the sort of reserves it wants. It should have enough to function effectively and no more.

Legend or not, every version of the story ends the same; good always triumphs over evil; a disorganised band of individuals becomes a force to be reckoned with after starting out with a bit of Civil disobedience and brings down a brutal Fiefdom that sees its subjects as legitimate source of money for its own ends, and for summary punishment at its whim.

At first the people can’t see how they will defeat the Sheriff. But up steps a leader and a small number of supporters. The impetus grows and grows until eventually a tipping point is reached. They eventually win by sticking together and keeping up the pressure. King Richard steps in and justice is restored.

Only we can decide if we let the Sheriff and King try to divide and conquer us. It’s still up to us to unite the profession against the GDC.

So to coin Moyes’ phrase of yesterday; ‘Are We Comfortable with that?’

I am.

* Image from Wikimedia Commons.

What happens when an Immovable Object meets an Irresistible Force?

Impasse. And so it would appear to have been for the last couple of weeks after the initial thrust of the BDA’s threats, and the parry and riposte of the GDC’s response.

However, I always thought it was going to be right at the end of the ‘consultation’ process that the BDA would make their next attack, and as we have seen yesterday, Mick Armstrong has told the GDC in no uncertain terms ‘ it’s 1 minute to midnight’. Waiting until the last minute has made sure the Judicial Review can’t be halted or paused to allow the consultation to finish, had it been launched prematurely and has made sure the GDC don’t get to see the BDA’s hand of cards early.

But this hasn’t actually seen the announcement of the BDA taking legal action to go to Judicial Review, and as such I bet a lot of people will be disappointed if they just look at this video superficially. I can see the posts on GDPUK forum that this is just BDA posturing again, and they haven’t the guts to carry out the threat.

But if you read the full press release as well as watching the video, and especially take time to look at the additional information within the release regarding the figures in the consultation, it is obvious the BDA are actually giving the GDC a final chance to back down. The GDC will suffer a humiliating loss of face if they do, but we as registrants and members won’t then have to foot both sets of legal bills.

I don’t get the impression Mick Armstrong is messing about when he says the BDA are committed to following this through. But as a fellow Yorkshireman I appreciate the sporting nature of letting your opponents know you’re going to hit them, hard, and give them a final chance to back down. But you only do that once you know you have the upper hand. The BDA might not have a Royal Flush, but it seems like the GDC only has a pair of Jokers at the moment. Reading the documents attached to the BDA’s submission leaves one in no doubt of the intention of the BDA to go to JR.

By engaging the services of a FORENSIC accountancy company the BDA appear to have pulled off a masterstroke; utilizing the skills of professionals specializing in detecting high level fraud, regulatory scrutiny and anti-corruption, and then publishing a précis of the findings publically must surely send the a big signal to the GDC that the BDA is not playing brinkmanship here, but actually means business. This is serious stuff now, and the BDA have now shown their cards to the GDC by revealing financial inconsistencies are what the JR will probably be based on.  

The forensic analysis of the accounts has apparently shown the GDC’s own published figures for the ARF hike are somewhat contradictory. These inconsistencies not only call into question the validity of the need for the ARF increase by questioning the basic level of evidence, but the inconsistency of the figures must surely now call into question the bigger picture of the integrity of the GDC in all of its financial matters. Whether this is part of the Judicial Review or not, the financial matters of the GDC must be impeccable, and they appear not to be.

The analysis of the figures would appear to go beyond the fact insufficient and inconsistent information has been given to registrants so they can’t actually make an informed response to the consultation. It seems to confirm the GDC is actually so contemptuous of us as intelligent people that they feel they can knowingly release confusing figures, expect us to then swallow the ARF rise, (after what we have all agreed is a sham consultation) and carry on as before. If a dentist were to confuse a patient in that manner, it would be cause for a registrant to be hauled before the GDC. Alternatively, it suggests incompetency and a lack of communication in the organizational structure of the GDC. Once again, they are grounds for a registrant to appear before the regulator. Whichever way you look at it (and it may be a combination of the two), our professional association appears to now have more robust evidence of the failings of the regulator and is prepared to act on it.

However since the GDC’s regulator is the PSA, and they seem to be about as threatening as a periodontally compromised 3 legged chihuahua with trismus and a sore throat, and as much use as a pair of waterproof sandals then you can’t really blame the GDC for not being too worried about the consequences of their actions.

Judging by the interview with Ms Gilvarry in Dentistry magazine, she doesn’t have appeared to understand what the profession is finding such a problem with. The penny certainly hasn’t dropped with her; perhaps this is because there aren’t actually any spare pennies left to drop at the GDC since their accounts seem to be in such a tangle.

But surely there must now be a realization by at least someone in power at the GDC that the BDA and the profession as a whole just might have a point. It would be useful if it dawned on them simultaneously that they have picked a fight with what seems to be a quickly developing Irresistible Force.

And they as the Immovable Object appear to have some ominous cracks developing, which wouldn’t do them a lot of good if they continue on the course they seem hell bent on taking…….

Image credit - James Cridland  under CC licence - not modified.