Ask Dental Protection

Throughout a professional career there will inevitably be times of personal stress which may, for example, involve financial difficulties, relationship or family concerns (bereavement, marital breakdown) that could have an impact or bearing on day to day decision making and in the short term on mental wellbeing. Such factors may, albeit subconsciously distract a registrant from the challenges of patient care.

Paragraph 7.2.3 stipulates ‘You must only work within your mental and physical capabilities’ and these capabilities will vary at times for us all. Hence there is now an imperative to self-assess and not to work with patients if you are particularly stressed or physically unwell.

The guidance reminds me that I need to update and develop my professional knowledge and skills throughout my working life. Am I right in thinking that the GDC is going to change the CPD arrangements that currently apply?

The GDC intend to increase the verifiable CPD requirements for each registrant group to be ready for the introduction of Revalidation but to do so this will require a change in the law called a Section 60 order. There is currently no indication as to when this will take place.

Dental Protection responded to the GDC’s consultation of CPD and our response document gives further information on what is being proposed.

The GP’s Guide to Personal Development by Amar Rughani (Radcliffe Publishing, 2001) is available from Amazon. This text offers a simple guide to the process of formulating a PDP, with exercises and advice on how to write and develop a PDP. It shows the reader how to demonstrate that they have engaged in appropriate educational activity, essential for revalidation. Some postgraduate deaneries are also able to provide advice about formulating a PDP.

The Royal College of Surgeons also has guidance and templates on PDPs as well as other organisations such as the former Deaneries.

Members are advised to get in touch with our Membership Services team prior to carrying out treatment to ensure they have adequate and appropriate indemnity for the particular treatment being planned.

Looking to the future when revalidation commences, each registrant is likely to require a Personal Development Plan (PDP). Each learning event and episode of formal training should be anticipated, documented and a reflection on the learning experience kept in the PDP. This provides invaluable evidence of a commitment to lifelong learning.

In the meantime, any in-house training offered to team members needs to be properly documented, with aims and objectives together with the learning outcomes clearly listed. Evidence of attendance should be kept with certification where appropriate (CPR training, for example).

Where practical training is being undertaken, a log should be kept of the number of tasks undertaken in the three following categories:

• Directly observed
• Carried out under close supervision
• Carried out unsupervised, but checked. This checking stage should be documented.

Similarly with any course attended, certification and ideally a reflective record compiled by the participant should be kept.

Standard 6.2 simply says; you must be appropriately supported when treating patients. The word ‘must’ indicates that this is an absolute requirement rather than a suggestion. But this clarity is diluted by the use of the word ‘appropriate’ which introduces an element of judgement and creates a degree of ambiguity. Although ‘appropriate support’ is not defined in the guidance, there are four very good reasons why it might be sensible for a dental hygienist to be supported by a dental nurse when treating patients:

• Response to a medical emergency
• Managing infection control
• Chaperonage
• Chair side assistance with patient care and note-taking

Clearly there are cost implications associated with the employment of additional manpower in any business and the GDC recognises (in a personal communication about interpretation) that although the permanent support of a dental nurse might be desirable, if only to make the treatment session run more efficiently, situations will arise where the patient can be safely treated by a hygienist without chair side support but where assistance can readily be summoned in an emergency.

Standard 6.2.2 says: You should work with another appropriately trained member of the dental team at all times when treating patients in a dental setting.

• By adopting the use of the word ‘should’, this indicates that the duty does not apply in all circumstances. When deciding whether the duty should apply (there is reference to the circumstances in the guidance), it is necessary to consider the other standards in the guidance in order to decide whether or not the hygienist can work on the patient without a dental nurse in a specific set of circumstances. Patient safety is paramount amongst these. Standard 6.2.1 requires that registrants must not provide treatment if they feel that the circumstances make it unsafe for patients

If the hygienist feels trained, competent and confident to treat patients in the absence of a dental nurse and that the absence of a dental nurse would not put the patient at risk, and would be able to justify the decision if challenged, then that would be acceptable. Many factors could affect this assessment – not least, the specific patient involved, the nature of the treatment being provided, and so on. It would be important to be able to show that these factors had been properly taken into account. Naturally, there would have to be another competent person available in the practice to deal with a medical emergency.

It is for the clinician treating the patient to undertake the risk assessment and to decide what would be in the best interests of the individual patient.

Standard 1.7 reminds us that the patient’s interests must come before those of any, colleague, business or organisation. Clearly any attempt to justify a clinical decision based on financial considerations alone would be a breach of this standard.

• The use of the phrase ‘work with’ is not specifically defined in the guidance and as such it could reasonably be interpreted that in some situations a hygienist could ‘work with’ a dental nurse, even if the nurse was not continuously present in the surgery at all times. But such an interpretation should not be distorted to imply that a dental nurse would never need to be physically present in the treatment room/surgery.

The new Standards document requires dental practices to display:

• The GDC’s nine principles
• Details of all registered staff working at the practice, including names, job titles and registration numbers
• A reference to the GDC as the regulator
• A price list, including NHS patient charges (if applicable to the practice) and indicative price lists for private care for, as a minimum, basic items such as consultation, single filling, extraction, radiography, dental hygiene treatments. Items that may vary in cost can be described in a from-to scale
• You are also now required to give clear information on prices in your practice literature and on your website; patients should not have to ask for this information

It is impossible for any professional person to stop every complaint from arising. It is better to adopt a positive state of mind and accept that occasionally you will get a sub-optimal result or that for a variety of reasons (some beyond your control) that the patient is disappointed or unhappy with something that happened during their visit.

By encouraging patients to express themselves as they leave the treatment area you can often get them to tell you what could have been done better from their perspective.

There are many ways of identifying dissatisfaction:

• Prominently displaying your complaints procedure so that patients don’t have to ask for it and encouraging them to share any negative views with appropriate staff
• Train all staff to identify the ‘body language’ associated with dissatisfaction. The aim is to encourage patients to tell you if they have a problem, before they tell someone else
• Comment or feedback cards - usually only completed by patients who are particularly displeased or delighted with service. It is, of course, helpful to collect positive feedback as well as negative and neutral feedback

By handling this issue at a local level it may be possible to contain the issue and prevent it from escalating out of your control. It can also help to avoid the dissatisfied patient from bottling up a store of complaints.

Dental Protection’s Handling Complaints advice booklet offers lots more guidance on this subject. It can be found in the Risk Management section of the website.

The GDC doesn’t define specific timings for managing a complaint but it does expect you to respond to complaints within the time limits that the practice has set out in its own complaints procedure. The NHS has its own guidance on limitations for dealing with complaints and these can vary according to the country you work in.

Read our advice booklets on complaints handling

Sometimes things can take a little longer to investigate, particularly if key staff members are on leave or off sick. If you find that need extra time to investigate a complaint, you should tell the patient when you anticipate being able to respond. If there are exceptional circumstances which mean that the complaint cannot be resolved within the usual time scale, you should give the patient regular updates (at least every 10 days) on progress.

Patients should not feel intimidated, or that complaints are unwelcome. Many complainants are fearful or uncertain about the likely response from the dentist or his/her staff and this might encourage them to take their complaint elsewhere. It is better to eliminate any such potential barriers to patients, and make it clear to them that you are keen to resolve any complaints or dissatisfaction in-house.

It is counter-productive to view complaints in a negative light. Although it is not always easy, complaints can and should be seen as an opportunity to:

• resolve the patient’s dissatisfaction in-house, limiting the damage caused by the complaint;
• rebuild relationships with the patient, by showing them that you and your staff are truly professional, that you have their best interests at heart, and that you genuinely want them to be happy and satisfied with the treatment and care provided. Very often a patient, whose complaint has been satisfactorily resolved, can become the greatest and most vocal ambassador for the practice. A professional approach to a complaint bodes well for the practice’s approach to patient care and treatment generally;
• improve procedures so that the same problem doesn’t arise for other patients.

By offering patients a prompt and constructive response you can demonstrate that you have engaged with their complaint. A complainant who feels that they have been ignored or overlooked is very much more likely to take matters further into another forum. Showing that you care, exploring solutions and getting things done is the key to achieving an amicable resolution.

Practice owners should note that the new standards guidance places an emphasis on training the team to handle complaints from patients and the importance of being able to demonstrate that the training has happened. It is also a CQC requirement under the provisions of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 to bring the complaints system to the attention of service users.

The new guidance specifically states (para 4.2.3) ‘you must not post any information about patients on social networking or blogging sites’ such as Facebook and Twitter.