Regulation in the spotlight

30 June, 2011 / editorial

The thorny topic of regulation, and in particular whether dentistry is over-regulated, was top of the agenda for the dentists who attended the recent Scottish Dental round table event.

The latest evening of dental discussion and debate was chaired by Roger Matthews, Chief Dental Officer of Denplan, and he wasted no time in getting down to brass tacks, asking: “Are we over-regulated? And is regulation proportional to the risk?”

Irene Black, GDP from Glasgow as well as being an Assistant Director in NHS Education for Scotland’s National Decontamination Support Team and a Dental Practice Advisor for NHS Greater Glasgow and Clyde, was the first to comment on the new era of regulation. She said: “There is a difference between regulation of a service provider and regulation of the individual. Problems could arise when an individual practitioner with difficulties impacts on continuance of the service and vice versa.”

Aubrey Craig, Head of Dental Division at MDDUS, was in agreement and pointed out that dentistry in 2011 is now more than simply treating patients. “Of course the patient is the central hub to all this,” he said. “But from that are numerous spokes that feed into various different elements that you as a dentist have to carry responsibility for, both personally and if you are running a practice, as the provider.”

Irene Black then pointed out that any regulation has to have the patients’ best interests at the centre. “I think we are in danger of losing sight of that,” she said. “Every aspect that is scrutinised as part of an inspection has to be underpinned by the question: ’Is what we’re being asked to demonstrate always going to improve patient care?’”

With the advent of the Care Quality Commission (CQC) in England and the newly-founded Healthcare Improvement Scotland (HIS) north of the border, Aubrey Craig called for simplification of the whole process. He said: “It would be great to have one document, one inspection, one process that would tick all of the boxes.”

Margie Taylor, Chief Dental Officer for Scotland, argued that steps are being taken to simplify the whole area of practice inspections. She said: “It seems to me that we have to avoid inspection fatigue. You have vocational training inspection, practice inspection, and potentially whatever HIS agrees to introduce. So it is a good opportunity just to try and bring them all together. We’ve done the first bit of doing the VT and health board inspections and trying to bring them together. We just have to, now that HIS has formed, work with them.”

Janet Clarke, GDP from South Queensferry, argued that private practices should be treated the same as NHS practices in terms of inspection. She said: “I think the danger is that if you are a purely private practice then nobody need go into your practice, and that is a concern. There are very few of those in Scotland but there are still some purely private practices.”

Margie Taylor then said: “Well we do have the opportunity, with HIS just beginning to have a look at it, to introduce something as sensible as we possibly can. I think they are willing to speak to us about it.”

But Hugh Harvie, Head of Dental Services Scotland for Dental Protection, highlighted the possibility that the standards recorded during an inspection might not be carried forward. He said: “It requires diligence, it requires effort by the practice owners and the dentists and staff working in the practice to ensure that everyone is aware of the importance of these issues and, more importantly, that they are trained in the techniques etc.

“But you will still encounter practices where the attitudes are a bit questionable.”

Aubrey Craig said he believed it was a training issue that practices needed to invest in, especially since the registration of DCPs. Irene Black argued: “This is about behavioural change. You can educate people until you are blue in the face but there has to be something that drives change. No matter how much you regulate or inspect, there will be some individuals who will not accept that change is necessary, for various reasons.”

Roger Matthews explained that at Denplan they came to the conclusion that observing clinical procedures wouldn’t add a great deal to the detailed clinical records audits and radiographic audits that they carried out.

Irene Black agreed that you can learn a great deal from dentists’ record keeping but said: “I think the experience from vocational training, where people are watching each other on a regular basis, an element of peer review raises the stakes and makes you think more about what you are doing.”

The conversation then turned to the pros and cons of peer review with Hugh Harvie arguing that he believes communication between colleagues can be very beneficial but that: “I think it is very difficult for people to raise these issues within practices and that’s unfortunately where relationships break down, because it can lead to suspicion, uncertainty and unhappiness. Instead of opening up and talking about it, resentment grows and communication stops.”

And Irene Black then pointed out: “We’ve identified a specific problem with the whole of dentistry here, in that we don’t communicate with each other particularly well. It may be because we feel we are in competition with our neighbouring practices and other colleagues. There is always that psychological issue about hanging on to your own patients. We take it as a personal slight if they decide to move down the road.

“So there’s a strange kind of attitude of not opening up to our colleagues and that is perhaps the market place we work in.”

However, Janet Clarke revealed that she is a great advocate of peer review. She said: “We’ve recently implemented in the practice team meetings with the dentists once a month. Just getting the dentists together on a regular basis to talk clinically about cases is such a big deal. I just think it’s great to be able to do that.”

Asked if she would do the same with the practice down the road, she replied that she would be more than happy to. “I’ve always done that, but whether everybody else would is a different matter,” she said.

The conversation then turned to the competitiveness that seems to be ingrained into many dental students to be the best at specific procedures at undergraduate level and then, once graduated, to be more successful than your peers – making the most money in year one, etc. There was general agreement that this is a particularly destructive mindset.

Margie Taylor asked if that mindset was down to feeling threatened and, if peer review was in a non-threatening environment, might it be more widely adopted? John Gall, GDP from Edinburgh, replied by saying: “I think peer review can be that though. I’ve been in a peer review group for about 17 years and it is exactly like that. Maybe the five or six people in that group have worked particularly well together, but we talk totally openly about our practices and our clinical work as well.

“I’m a huge advocate of peer review. I think it was put aside for audit when audit became the big thing and I think peer review was sadly neglected, or has been.”

“But audit is something you can do on your own,” countered Hugh Harvie. “There is no reason whatsoever that you can’t audit your own work. Peer review is something you do with someone else and that requires building confidence. But both audit and peer review are powerful engines for driving up standards individually and collectively.”

Roger Matthews then asked whether “a team approach to dentistry, and successfully utilising the skill mix, could possibly provide
some kind of solution to this professional hubris that we have been talking about?”

Irene Black ascertained that part of the problem with utilising the skill mix is the protectiveness of dentists over their own patch. “But I think there is a bigger issue about not utilising them at all. In terms of therapists or other DCPs that could potentially be utilised, it could be fear of the unknown and how they can work for us effectively.”

And Janet Clarke said: “I think as dentists we are not very good at asking other people. You come back to thinking that everyone else knows what they are doing and perhaps I don’t. Actually most of us can learn from everybody else.”

Steve Anderson, Denplan Area Manager for Scotland, Northern Ireland and northern England, said: “I think it comes down to managing your own business. You’ve got these resources and it is about how you make the best use of these resources. It should also be about delegation, so you are not having to do everything yourself as a practice owner. “And that’s why I’m a great advocate of having practice managers. There are fewer practices with practice managers than I would like to see. A PM is very often a fantastic support to the practice owner.”

John Gall then said: “I would have thought that the natural way for things to go is that, as dentists become more and more trained at the higher end, that is what they should be doing.

“Dentists shouldn’t be doing scale and polish with a hygienist in the practice. In fact, the way things go, it should mean fewer dentists and a lot more hygienists and therapists. If we learn to use them properly.”

Chris Ross, GDP from Scone in Perthshire, pointed out that patient education also comes into it. She said: “It’s not just getting dentists used to how to incorporate therapists into practice. We’ve just spent many years getting our patients used to why they are actually seeing the hygienist and that the hygienist does do her job much better than we do, because she has had more training in it. That’s her speciality. It will probably take another few years for them to fully understand what the therapist does.”

“We live in an age of choice,” said Hugh Harvie. “If I go along to my dentist, am examined and found to require a restoration on one of my teeth, should I not be given the option of having that restoration placed by the dentist or by a therapist if one is working in the practice?”

Aiden McKenna, GDP from Westhill in Aberdeenshire, said: “I’m a great fan of hygienists, and we have four or five in the practice, but in a private dental practice setting I can’t see patients being happy with me passing the restorative treatment onto a therapist.”

And John Gall then said: “I think that is a problem in our heads. We managed it with hygienists 20 years ago and I just think it is only a matter of time with therapists. But I think it will happen.”

But Irene Black agreed by saying: “On the whole I believe that hygienists are far better at motivating patients and providing periodontal care than I am. At the moment most of us don’t have the intrinsic belief that the therapist provides a better level of service than dentists.”

And Chris Ross added: “Because we don’t have enough experience of what their abilities are.”

The question was then put to the table as to whether there should be a core service available on the NHS, with anything over and above that being charged for. Irene Black was the first to respond by saying: “Because we can’t do items such as posterior composites or bonded crowns on molars as part of NHS treatment, NHS practitioners run an element of core service already. When patients want these items provided, and if it is appropriate to their needs, we can say honestly: ’I’m sorry I can’t do that on the health service, but I can provide it privately and this is how much it would cost.’

“I wouldn’t wish to see us trying to provide a fully comprehensive NHS service that provided implants and the whole gambit. We could provide a good core service and give patients choice.”

Aiden McKenna signalled his scepticism by saying: “People have been talking about this for years. In my view it is too much of a political football, it will never happen.”

Roger Matthews indicated that Denplan has long considered a product that would complement public provision but that the definition would have to come from both sides of the fence, whether it would be a top-up service, grant in aid, voucher scheme or something else. He continued: “I wouldn’t say it is impossible, that’s just not true, because you just have to look around western Europe to see examples of how public provision and private insurance works.”

Rashmi Shah then said: “I would say that, in times of austerity, I think it probably makes sense for NHS dentistry to provide a core service. It would give patients the option of going to see their NHS practice for the bare essential, core service treatment, but if they want something more than just core service dentistry then they go to a private practitioner and the two things should be working together. As opposed to the NHS trying to provide everything and the funding not there for practices to do that.”

The table were then asked what could constitute a core service, to which Rashmi Shah proposed: “Maybe your core service should consist of examination, limited restorative work and periodontal work. Anything else the patient should pay for in full. You have your NHS treatment limited to a get-you-out-of-pain service and we’ll take your teeth out for you, but if you want a root treatment, then you will have to pay for that appropriately.

“I feel that the fee scale should be a very basic fee structure.”

Chris Ross argued that more emphasis needs to be put onto prevention, especially in the health service. And Hugh Harvie then said: “Maybe this provides the opportunity to look at it afresh and have a root and branch reform of the whole thing. What is it we are seeking to do? It is no longer a National Health Service as there are now variations in the various countries due to devolution. There is already rationing, if you like, within the system at the moment. Patients are opting to have teeth extracted rather than have root treatments done on grounds of costs. So we have got to recognise the realities of life and provide a system which meets patients’ needs and demands.”

And Irene Black responded by saying: “This is about patient education, but you have about 50 per cent of the population who don’t attend at the moment so do we have a two-tier system already? The care we provide depends on the patient base and perhaps where we work. Patients in different areas have different demands and can all be difficult in their own way.

“The difficulty in all of this lies in areas of real deprivation, where people have chaotic lifestyles and are not regular attenders. This is the patient base that has to have a safety net. The difficulty you have is excluding them from the opportunity to have something that is going to perhaps improve their life at the end of the day.

“So it has to be dealt with sympathetically. Most of us here are working in a population who are already educated as to the benefits of what we can provide and will seek our care regularly. Whereas a significant proportion of the population in Scotland still only actively seek dental care in emergency situations.”