Ask Dental Protection

After each inspection the Care Quality Commission (CQC) produces a report.  This is a legal obligation under Section 61 (3) of the Health and Social Care Act 2008.  The report focuses on their findings and whether a provider is meeting the regulations and is structured to reflect the five key questions that CQC asks; are the services safe, effective, caring, responsive and well-led?  The report will also set out any evidence about breaches of the regulations.

CQC send the draft report to the provider for comment in relation to factual accuracy.  There is a deadline for providing comments or challenging the report and it is important to meet it. 

The report is normally emailed to the registered provider (or nominated individual and the registered manager).  If those people are likely to be absent at the time this report is expected, alternative arrangements should be made for accessing the CQC communication in a timely fashion.

It is important to understand the grounds upon which a challenge can be made and whether CQC have followed their own guidance and reported accurately, as well as acted proportionately and obtained evidence to support their statements.  It is also important to provide documentary evidence to support any challenge you wish to make.  If you feel that the report is factually incorrect and the inspector does not agree with your challenge then you are able to escalate your concerns within CQC to the national professional adviser for dentistry.

Take care not to confuse factual inaccuracies with any errors that you have made within the practice or gaps which you have in your systems as those would normally be addressed in your action plan.

You have one chance to affect change within the draft report particularly if incorrect, imprecise, unreasonable, unsupported or misleading statements have been made.  This enables CQC to make appropriate changes to your report prior to finalising it. The process of altering the document also assists CQC to standardise their methodology across their workforce. 

Access further advice about CQC

It is becoming common for patients to ask to record discussions about their dental treatment using a mobile phone. Dental Protection is also aware of cases where the patient has made a covert recording without telling the dentist. In a recent case in the USA, a clinician was sued after a patient’s mobile phone recorded him making unprofessional comments about the patient whilst he was under anaesthesia.

It is common courtesy that somebody wishing to make a recording should ask permission. If you feel uncomfortable at the prospect then you should express that discomfort and tell the patient that you would prefer your conversation not to be recorded.

If you would prefer not to be recorded, but the patient is insistent, it would be inadvisable for you to refuse to proceed with a consultation simply because the patient wishes to record it. A patient may have their own reasons for wishing to record a consultation and it would be worth exploring this further with them. Reasons could relate to the complexity of the consultation, the significance of the diagnosis, the patient’s memory, or the patient’s potential dissatisfaction. A little careful questioning could be helpful in discovering the patient’s thought process. Often patients simply wish to record consultations to ensure that they do not forget important information and/or because they want to share it with a friend or relative. There may be other ways of communicating this information (for example, by writing down the relevant information, or recording a summary of the relevant points at the end).

If your consultation is recorded, it would be sensible to ask for a copy so that it can be placed in the patient’s notes to form a permanent record. Medical records already incorporate a variety of formats, including text messages and emails to and from patients, and recordings could become part of this mix.

Secret recordings

Technology makes it increasingly easy for patients to secretly record conversations. Most mobile phones and smartphones have record functions which can easily be activated without the dentist or dental nurse realising. Even hand-held games consoles can record conversations.

A patient does not require your permission to record a consultation. The content of the recording is confidential to the patient, not the dentist so the patient can do what they wish with it. This could include disclosing it to third parties, or even posting the recording on the internet. So what does this mean for dentists?

The content of the recording is confidential to the patient, not the dentist so the patient can do what they wish with it.

Protection

Smartphone use in the dental surgery should not affect the way you deliver treatment. Dentists and hygienists should always behave in a responsible and professional manner when working with a patient and consequently, any recording will provide concrete evidence of that. Such a record would inevitably be more complete than a traditional note and Dental Protection’s experience is that detailed record keeping is an invaluable tool in protecting the dental team against unsubstantiated complaints or legal action.

A recording would potentially provide even more detail to demonstrate the professional management of your patients. There should be no reason therefore why you should have anything to fear from such a recording.

Whilst you may understandably feel that being recorded may impair the professional relationship, this may well simply be a matter of adapting to current cultural and societal norms where it is becoming commonplace for the public to record and publish on the internet all sorts of pictures, recordings, etc, relating to their private lives.

The future?

Technological advances will undoubtedly bring further changes and it may well be that in 20 years’ time, recording of consultations, with copies being held by both doctor and patient, will be commonplace.

The short answer is that there is no legal or regulatory requirement to record individual local anaesthetic batch numbers and members can rely on Dental Protection to support them in the event of a challenge to the contrary.

To learn how confusion has arisen about this subject see the briefing document

To a large extent the problems you have are a contractual matter between you and the practice and therefore very much depend upon the associate agreement you were provided with when you started work.

Assuming this is a standard associate agreement, you should find there is a clause within that agreement indicating that the practice is required to provide you with the services of a dental nurse on a day-to-day basis. The only time when this would not be the case is when exceptional circumstances exist (sudden illness, etc).

The General Dental Council’s guidance clearly indicates that all clinicians should work alongside another team member (preferably a registered dental nurse) at all times. This is not necessarily a matter of chaperonage, but in fact relates to the provision of medical emergency care to patients.

If one of your patients was taken ill during a treatment session and perhaps lost consciousness, you might find yourself facing the dilemma of either looking after the patient or going for help. You could not do both if you were working alone. If a dental nurse was working with you, this would not be the case.

It follows that if such a situation was to arise, you might have to explain perhaps to the coroner, the courts or the GDC why a dental nurse was not present with you in the surgery, in accordance with GDC guidance. This would not be easy, particularly if it could be shown that the patient had suffered harm through lack of emergency care.

You should discuss your concerns with the practice owner and practice manager and ask them what action they feel they can take to be of assistance to you. Your associate agreement likely contains a contractual obligation (to say nothing of an ethical obligation) on behalf of the practice to try to ensure a good working environment.

If the problem continues or shows no signs of resolving, you may have to consider your position at the practice.

As with any other referral, it is the responsibility of the referring dentist to establish the suitability of the person/service to whom/which the referral is made. Even though teledentistry relies on digital files being exchanged between colleagues, the principle is the same. It is important for you to know who will be responsible for interpreting the patient’s records, as well as establishing that they are registered and what qualifications they have to provide this service.

To protect the patient, it is also important to know that the distant colleague is suitably indemnified. Dental Protection recommends that members should contact us first if they are considering using a teledentistry service situated outside the UK.

In addition, Dental Protection recommends that:

• All patients are made fully aware of the involvement of any other named person(s) in their care and treatment, through teledentistry, and also that they properly understand any constraints, limitations or risks introduced as a result
• You establish written protocols between yourself and any other clinician/organisation with whom/which you have any kind of teledentistry relationship. These protocols should specify the parameters of the relationship, the role and responsibility of each party, the arrangements in place for data protection, and quality assurance

Generally speaking, the ownership of any item of dental treatment passes to the patient at the time the appliance is fitted. This is, however, not always the same time as the treatment is completed. It follows then that during the various stages of denture construction, a denture itself still belongs to the clinician.

Once it is fitted, however, the patient then owns that denture, irrespective of whether or not a fee has been paid. Before demanding the outstanding fee, it is wise to check that the patient is happy with the denture. Allow them to express any dissatisfaction they may have and deal with this before deciding if you want to pursue the fee.

If the situation cannot be resolved, you may want to acknowledge that no fee has been charged and leave the denture with the patient as gesture of goodwill, to potentially mitigate an escalation of the patient’s dissatisfactions.

Removing teeth for orthodontic purposes is very much part of what a referring dentist would be expected to do. Whether it is fair or not, the patient’s own dentist would normally be expected to provide any extractions requested within an orthodontic treatment plan.

It may well be that you have a colleague who would be happy to carry out the extractions on your behalf. To expect the patient to see another practitioner simply because you are refusing to provide this service may be considered an inconvenience and could possibly even stretch to being a breach of contract if the extractions were associated with NHS treatment.

To withdraw from providing a particular form of routine treatment may not be considered reasonable and in any of your patients’ best interests. Extractions would be considered part of mainstream dentistry and you should not decline to provide this element of treatment that is also in the best interests of the patient you originally referred.

If you are uncertain about the reason for the extractions, you may wish to clarify this with the orthodontist.

Limited Indemnity is available at no cost to a dental nurse when he or she is working as an employee, of a full-subscription Dental Protection member who is in the appropriate membership category. As a benefit of membership, an unlimited number of named employee dental nurses can be included per member subscription. All you need to do is to ask your dentist to contact us.

That employee indemnity however only extends to claims in negligence and will not provide assistance for any GDC or disciplinary matters or for the provision of individual written or telephone advice.

Indemnity, offering the full range of member benefits is available to all registered dental nurses either as direct members (following the payment of the appropriate subscription) or (free of charge) where the practice is part of the Dental Protection Xtra practice scheme.

An adverse comment placed on a website, be it NHS Choices or the practice’s own website can be upsetting, especially as it sits in the public domain for anyone to see.

With regard to an adverse post left on NHS Choices, the website does have the advantage of allowing the practice to post a response. Whilst there is no requirement to respond to posts on this website and indeed it would be inappropriate to respond to a complaint in this way, it is advisable that a practice responds to such posts with a simple acknowledgment of the comments made and an invitation to the patient to make contact with a named person to discuss their concerns directly. This reassures both the patient who made the post and any other patients, potential patients and any others reading it that the practice takes patient feedback seriously and is keen to learn from patient experiences and to improve the service they offer. A suggested response is:

Many practices have protocols for routinely reviewing posts left on NHS Choices and see them as an opportunity to improve services. Some practitioners also wish to thank those who have left positive feedback.

A similar approach could be taken to comments placed on practice owned websites which have facilities for this, and sites such as Facebook. Practitioners could also consider inviting satisfied patients to leave positive reviews. These may be helpful in themselves and can also have the effect of balancing out and indeed outweighing any negative comments.

It is clearly easier to look after a patient’s care when all the practitioners are located at the same address.

However, there is no legal reason why you should not allow the patient to see her existing hygienist and indeed prescribe to a hygienist at another practice if you can satisfy yourself that the hygienist works in a way which is acceptable to you and they will co-operate with you in the patient’s overall treatment plan.

It is possible that the patient has an issue with the dentist who was treating her at the old practice. Your prescriptions to the hygienist at the old practice could be criticised by the dentist there and of course that would be in nobody’s interest.

It might be a good idea for you to write a gentle letter to the patient explaining why you would prefer the hygienist at your practice to carry out the treatment in accordance with your established team approach.