Mike RidlerHead of Hearings

General Dental CouncilAn overview of Fitness to Practise

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THE FIVE BASIC STEPS FOR STAYING OUT OF TROUBLE

• Keep your registered address up to date• Set up a Direct Debit for your ARF• Always have professional indemnity• Never ignore the GDC if we write to you (we

don’t forget and we won’t go away !) • Do your CPD and submit the returns

Referrals

• 2013: 2990 complaints (almost double the number for 2011)

• 2014 : 3099• 2015 : predict 3,300

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FTP OverviewNew complaint

Triage

Assessment

Investigating Committee

Practice Committee

Resumed Hearing

Triage - overview

• Test – “is the allegation capable of forming an allegation that the Registrants FTP impaired”?

• Complaints are ‘triaged’ and cases that cannot or should not be pursued are closed

• In 2014, 888 cases were closed at Triage • The remaining complaints continue on to

casework for investigation and assessment

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Triage – case examplesExamples of cases closed at Triage:• Registrant’s profession is entirely incidental

to the case i.e. no indication that patients are at risk or evidence of a risk of detriment to the profession e.g. a registrant in dispute with neighbour or registrant registered on internet dating site.

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Triage – case examplesFurther examples of cases closed at Triage:• Dispute re clinical judgment provided in clinical

dental report e.g. in civil claims where a dentist’s interpretation of a patient’s treatment is contradicted by a second expert

• Customer service issues which do not impact on care• Level or quality of service where there is no

suggestion that a registrant is directly responsible e.g. complaints relating to waiting time

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Triage – case examplesExamples of cases closed at Triage:• Complaints where the GDC has simply been copied in

to correspondence and there is no suggestion that patients are at risk

• Anonymous complaints where there is no suggestion that patients are at risk

• Contractual or employment disputes where there is no suggestion that patients are at risk and there is an appropriate recourse available through the courts

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Assessment• Caseworkers are allocated & investigate cases until

sufficient information for assessment• Casework Managers test – “Does the information

provided amount to an allegation that the registrant’s fitness to practice is impaired?”

• Managers close cases that cannot be pursued • In 2014, 1298 cases were closed at assessment • Cases with a prospect of success are referred to the

Investigating Committee

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Investigating Committee (IC)• The IC test:• Is there a reasonable prospect of the allegations being found

proven?• If yes, is there a real prospect of a Practice Comm finding the

registrant’s FTP impaired? • Investigating Committee can: Close a case with no further action Give advice or issue a warning (published or unpublished) Adjourn a case for further information Or if the case is sufficiently serious, they will refer it on to a

practice committee.

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Investigating Committee (IC)• If there is a serious risk to patients, the public or the

registrant themselves, the IC can refer the case to the Interim Orders Committee (IOC) at the same time as referring it to Professional Conduct (PCC), Health (HC) or Professional Performance Committees (PPC)

• In 2014, the IC decided 1012 cases and referred 321 registrants to the PCC

• In 2014, the IC and Registrar together referred 264 cases for Interim Orders

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Interim Orders Committee (IOC)• The IOC does not make findings of fact – it can only make an

assessment of risk• An IO can only be imposed for a maximum of 18 months and

must be reviewed every 6 months• The High Court can extend orders on application• The IOC can only impose a suspension or conditions • Grounds for making an IO - public protection, in the public

interest and in the registrant’s own interests• The Registrar can also make referrals to the IOC• In 2014, out of 264 referrals, 144 IOs were made and 104 were

not made. 25 were adjourned for various reasons

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Practice Committees [1]

• 3 committees – Health Committee (HC), Professional Performance Committee (PPC) and Professional Conduct Committee (PCC)

• 129 cases heard by PCC in 2013• 187 cases heard by PCC in 2014

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After Referral by the IC (KPI: 9 months to the hearing)

• Legal activities• Prosecution investigate• Hearings - Case

Management actions, set date and length

• Service and notification• Defence prepare case

• Hearings activities• Assemble panels• Arrange venue• Book LA, Steno etc.• Cttee Sec, Usher• Programme of business

and other documents

• Composition: usually 3, max 5 (Dentists, DCPs, Lay) • Legal Adviser• Supported by Hearings Team (Cttee Sec and Usher)• Separation of functions inside the GDC: Fitness To Practise Team: complaints handling, IC,

prosecution (want to win their case) Hearings Team: listings, Panels, arrange and support

sessions (neutral, want case to be heard fairly and efficiently with no grounds for appeal)

Professional Conduct Committee

What does the Practice Committee do?

Makes decisions on cases in a 2 stage process:

• Listens to evidence, decides on facts, announces its findings on each allegation

• Listens to explanations, mitigation, submissions; decides on impairment and sanction

Powers of Practice Committees

• Decides if Fitness to Practise impaired • If FTP impaired, imposes sanction • Reprimand• Conditions• Suspension for up to 12 months• Erasure (not less than 5 years)• Sanctions must be considered in

ascending order of seriousness

Practice CommitteesPCC Outcomes 2014 Erasure [33]

Suspension [37]

Conditions [41]

Reprimand [14]

Not impaired [24]

No misconduct [11] 11

No case to answer [2] 2

Resumed Cases

• Suspended or conditional registration that requires review from any Practice Committee

• Sanctions are slightly different – panel cannot erase on review. Instead they can vary, revoke or extend the existing order or substitute the order.

• They can also suspend indefinitely after a period of 2 years continual suspension

• A dedicated Case Review Team are responsible for monitoring registrants’ compliance with these orders

• In 2013, 52 resumed cases heard resulting in the continuation of 21 suspension orders and 31 condition orders

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Other reasons for case closure…

• Voluntary Removal (VR) - a registrant can apply for VR at any part of the FTP process

• Rule 10 application – the IC can be asked to review a decision of a previous IC if appropriate, to reassess what allegation(s) ought to be considered by a Practice Committee – this can lead to cases being closed post reassessment

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Issues* in Conduct Cases 2014 (1)• Poor treatment 94• Fraud/dishonesty 47• Poor practice management 15• Failure to obtain consent/explain treatment 37• No professional indemnity/insurance 5• Conviction/caution (alcohol, drugs, theft, fraud, assault…) 27• Conviction (possessing indecent or pornographic images) 2

• Personal behaviour 15 • Indecent assault, inappropriate sexual behaviour 6 • Other (miscellaneous) 8

* Cases often involve multiple issues: these figures cover the main ones but not every element which has been raised in Charges.

Issues* in Conduct Cases 2014 (2)• Failure to take appropriate radiographs 41• Missing oral cancers 2• Failure to inform patient of adverse incident 4• Prescribing issues 21• Basis of treatment not clear (NHS/private) 5• Hygiene, Cross-infection control, Hazardous waste 10• No medical/dental history taken 14• Failure to co-operate with GDC or disclose convictions 16

• Misleading advertising 6• Working outside scope of practice 12• Making racially offensive comments 2

* Cases often involve multiple issues: these figures cover the main ones but not every element which has been raised in Charges.

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View from the other regulators•Some seeing significant rises in referrals Optical Council + 48% Pharmaceutical Council + 54% Chiropractors – 25% Nursing Council + 10% GMC / GDC – 0%

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What does our caseload contain?

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Treatment issues

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Patients Interests

What would it be like for you ?

• Long drawn out (15 months +)• Uncertain • Worrying, pre-occupying • Very stressful – for you, family, others • Best avoided if at all possible

Importance of Communications Skills

• Probably 50% of cases involve communications issues of some sort• Get those right and your risk of appearing at the GDC falls sharply• Treatment plans: copies to patient, amend if plans change• Explain options, details of treatment, benefits and risks • Explain the basis of treatment (NHS or private), and costs • Surgery and sedation: written pre- and post-operative instructions • Obtain proper consent, document it, get signatures • Keep good notes – could the next treating dentist understand them ?• Handle complaints well and they most probably will not go further • Keep in touch professionally: LDC, BDA, FGDP etc; do your CPD

The not too distant future…..

• Case Examiners to be introduced in 2016• Role of case examiners• Effective from late summer 2016• Investigating Committee not abolished but scaled back• Begin advertisement for case examiners posts – before

end 2015 • Interviews in early Spring 2016• Recruits train and work up from early Summer 2016

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Fitness to Practise Improvements – 2015 Initiatives

• Dedicated Screening Team – focus solely on triage (2 day KPI) and faster Interim Orders referrals (28 day KPI)

• Lean review of FTP process with added focus on quality/timeliness

• Customer Satisfaction – online feedback for Registrants/ Informants/ Witnesses

• Introduction of case examiners with powers to agree undertakings

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Other New Initiatives

• New Research• Regulation of Dental Services

Programme Board• Online Patient Panel

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New Research

Complaints Analysis

• Statistical analysis of GDC complaints data; • Nature and trends of Fitness to Practise complaints to the GDC;• Limitations of data;• Potential similar analysis of data from external organisations

and whether valid and meaningful comparisons or trends could be identified;

• Further research the GDC can take to continue to build our knowledge base in the coming years.

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Regulation of Dental Services Board

Members: • GDC, the CQC and NHSE (and now includes the NHS Business

Services Authority) Aims:• Better understanding of how the overall system of dental

regulation in England works and what can be done to improve it. • Identify areas of overlap between the GDC, CQC and NHSE and

whether the right part of the system deals with issues about performance in the most cost effective way.

• Understand how risk is identified, how information is shared and how well co-ordinated the system is in the event of a significant incident.

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Online Patient Panel Results

• 93% very or fairly satisfied, while 6% were very or fairly dissatisfied;

• 31% of panel members said that they have some concerns about quality of dental care;

• 24% indicated that they have some concerns about the behaviour of dentists and DCPs - the main concerns for panel members were about poor quality of work, competence, costs and /or transparency of pricing.

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Future Engagement

• Stakeholder meetings to take place six times a year;

• Corporate Strategy Feedback;• New monthly email for dental professionals, plus

quarterly Gazette.

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Case examples……

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Case example 1 - Smith

• S referred by Nottinghamshire Police for 2 x minor motoring offences –

• Careless driving and speeding• Evidence suggests offences did not involve drugs,

alcohol or other aggravating factors • Offence 1 dealt with by way of Magistrates Court fine

(£400) and offence 2 by way of a fixed penalty

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Case example 1 - Smith

• Pass triage test?• Refer for Interim order – if yes, when?• Pass Assessment stage?• Investigation Committee refer? If yes, which

committee? • Final hearing – likely sanction?

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Case example 1 - Smith

• Closed at Triage• Reassured no alcohol or drugs involved• Registrant’s profession is entirely incidental to

the case i.e. no indication that patients are at risk or evidence of a risk of detriment to the profession

• Not capable of forming an allegation of impaired FTP.

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Case example 2 - Phillips • Clinical treatment provided to elderly patient in 2012• Patient claims P failed to assess, record or address pain in his

UL7 tooth – “severe pain on hot or cold”• No x-rays taken and no follow up advice given• P advised patient to use sensodyne toothpaste and applied

“Duraphat” varnish to UL7• Pain continued for further 7-10 days• Second dentist at practice identifies cavity after x-ray and fills

tooth• No FTP history and attended a training course following initial

complaint

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Case example 2 - Phillips

• Pass triage test?• Refer for Interim order – if yes, at what stage?• Pass Assessment stage?• Investigation Committee refer? If yes, which

committee? • Final hearing – likely sanction?

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Case example 2 - Phillips

• The Investigating Committee decided:• “the Committee considers that in order to sufficiently diagnose the cause of

the patient’s presenting symptoms, the Registrant should have carried out further investigations, such as taking radiographs. Consequently, the Committee is satisfied that there is a real prospect of allegations 1(a), 1(d) and 2(a) being found proven”

• Next step?• “In the circumstances (no FTP history/remedial CPD) , the Committee is

satisfied that there is no real prospect of a practice committee finding that the Registrant’s fitness to practise is currently impaired and that it would therefore be inappropriate to refer this matter to a practice committee”

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Case example 2 - Phillips • The Investigating Committee decided to conclude the case:• “To close this matter without action would fail to indicate to the Registrant the

seriousness of the alleged deficiencies, which cover fundamental areas of dentistry including assessments and record keeping. Having again taken into account the Registrant’s lack of previous fitness to practise history and the remediation demonstrated by the Registrant, the Committee is satisfied that it is both sufficient and proportionate to close this case with advice”

• Advice:• “Necessary to undertake thorough assessments and investigations of a

patient’s presenting dental condition; and• To maintain full, consistent and sufficiently detailed records which should

include full details of all assessments, investigation and treatment carried out.”

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Case example 3 - Bachada

• Defrauded NHS in excess of £80,000• Defrauded patients in sum of £3,000-4,000 – patients thought

receiving NHS treatment but charged private rates• Over 4 year period• Attempted to conceal by re-writing/destroying patient records• Pleaded guilty to 2 counts of conspiracy to defraud in 2010• 20 months imprisonment• Previous – 2004 suspended by GDC false claims against NHS/

providing unnecessary treatment

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Case example 3 - Bachada

• Pass triage test?• Refer for Interim order – if yes, when?• Pass Assessment stage?• Investigation Committee refer? If yes, which

committee? • Final hearing – likely sanction?

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Case example 3 - Bachada • FtP impaired by virtue of conviction• Erasure “exists because certain behaviours are so damaging to a registrant’s

fitness to practise and to public confidence in dental professionals that removal of their professional status is the appropriate outcome”

• Dishonesty – “Patients have a right to rely on registrants’ integrity. Important choices about treatment options and significant financial decisions can be made on the basis not only of registrants’ skill but also of their honesty. Dishonesty, particularly when associated with professional practice, is highly damaging to a registrant’s fitness to practise and to public confidence in dental professionals.”

• Ignored 2009 PCC warning• Erased – no appeal.

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Questions

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