Law and ethics
As members of a healing profession, dental surgeons are expected not only just to obey the law of the land, but also to abide by ethical principles in their professional and personal life. Ethics are moral principles or rules of conduct expected in the professional and personal conduct of someone practising a profession. To assist dental surgeons in ethical matters, the General Dental Council (GDC) regularly issues guidance booklets.
In 2004, the GDC issued new guidance entitled ‘Standards for Dental Professionals’. Subsequently, it has produced advice booklets on specific topics, such as Raising Concerns, Dental Team Working and Complaints Handling. These booklets were sent to all dentists on the Dental Register of the United Kingdom and distributed to the dental schools to be given to dental students during their course on ethics and jurisprudence. As all GDC advice documents are now available online (www.gdc-uk.org), printed versions are only supplied on request.
(Note: For an explanation of the acronyms used throughout this chapter, please refer to the Acronyms section at the end of the chapter.)
Several organisations have issued principles of ethical guidance for the professions including the General Medical Council (GMC) in their booklet Good Medical Practice published in 2001 with revision in 2006 when it was re-named Duties of a doctor, and the FDI World Dental Federation at its 1997 General Assembly approved a statement on ‘International Principles of Ethics for the Dental Profession’, which is still available on the FDI Website (www.fdiworldental.org). The GMC’s principles are very comprehensive and put the patient first. As they can equally apply to the dental profession, they are set out here.
Patients must be able to trust doctors (dentists) with their lives and wellbeing. To justify that trust, you must show respect for human life and you must:
You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.
(Note: The GMC is currently consulting on the above advice, and expect to issue a further revision in 2012. When this revision has been accepted, it will be available on the GMC Website (www.gmc-uk.org).)
In 2005, the GDC produced a sturdy plastic ‘credit card’ with its contact details. On the back of this is printed:
The principles of practice in dentistry
As a dental professional, you are responsible for doing the following:
12.2 The General Dental Council
The first attempt to control the practice of dentistry in the UK was the Dentists’ Act of 1878 which created the first official Dentists’ Register. Only a registered person was able to use the title ‘Dentist’ or ‘Dental Practitioner’. In the late nineteenth and early twentieth centuries, there were two ways to become a dentist; either by serving an apprenticeship as a dental technician followed by being apprenticed to a dentist, or by studying at a university or college and obtaining either a degree or a diploma in dentistry.
Up to 2006, the Dentists’ Register was produced annually in book form. Also, it has been accessible on the GDC Website for several years, although dentists’ full addresses were not included. From 2007, the Dentists’ Register became only available electronically, with full addresses, which means that it can now be updated continually rather than annually. Only fully registered dentists’ names appear on the register; the GDC needs to be contacted individually for information on dentists holding only temporary registration.
The 1921 Dentists’ Act prohibited the practice of dentistry by unregistered persons. It set up the Dental Board of UK, which was administered by the GMC. After that date, only persons with a degree or diploma in dentistry from a recognised university or college could apply to join the register. However, anyone who had completed apprenticeship dental training, and was over 21 years of age when the register was formed, was admitted to that register.
The Dental Board of UK was dissolved by the Dentists’ Act of 1956 and it established the independent GDC to take over the role of governing the dental profession. This Act also permitted the use of the additional title of ‘Dental Surgeon’ and permitted the introduction of registered ancillary dental workers. All previous laws relating to the practice of dentistry were consolidated into one Act by the Dentists’ Act 1957.
The Dentists’ Act 1983 altered the composition of the GDC by increasing the numbers of elected dentists to 18 and Privy Council nominated lay members to six. However, the 17 nominated dental members from the universities and colleges giving dental degrees and diplomas plus the four UK Chief Dental Officers still made up over 40% of the membership. This Act also strengthened the disciplinary procedures undertaken by the Professional Conduct Committee and introduced a Health Committee to deal with dentists who had health rather than disciplinary problems. The Dentists’ Act 1984 consolidated the 1957 and 1983 Acts into a single piece of legislation.
In 2005, the Dentists’ Act 1984 was amended by the Dentists’ Act 1984 (Amendment) Order 2005 (a Section 60 Order). This Order updated several aspects of the Act to allow for changes the GDC wished to make. The most important provision of this Order is that it allows for future amendments to the Dentists’ Act 1984 to be made as ‘Orders in Council’ by the Privy Council. This method of making any amendments that may prove necessary in the future is much simpler and involves very little legislative time. The 2005 Order also allowed for the registration of dental care professionals (DCPs).
Another important part of this Order made it compulsory for dentists to have ‘adequate and appropriate insurance’ to remain on the Dentists’ Register. This insurance must indemnify the dentist by providing sufficient insurance cover for liabilities that may be incurred in carrying out work as a dentist.
In 2003, the GDC was reconstituted, and comprised of:
• four elected from the professions complementary to dentistry (PCDs) elected by registered PCDs (note: in September 2005, in line with new legislation, the GDC agreed to use the term ‘Dental Care Professionals’ (DCPs) instead of PCDs)
In 2009, in line with government plans for health care regulation, the membership of the GDC and the way that membership will be appointed changed. The new GDC is smaller, comprising:
This means that from 2009, the GDC no longer has a majority of dentists in its membership. Following national advertisements, all members of the GDC will now be appointed by the government’s Appointments Commission within the parameters set down by the GDC. The purpose of this change is to remove any perception by the public that professional members of the GDC, and of other health care regulatory bodies, are representing those who elected them, rather than being purely responsible for the effective regulation of that profession.
The new GDC retains the power to elect its chairman/president from within the membership of the Council.
The GDC is the regulatory body of the dental profession. It exists to protect the general public by ensuring that only qualified, competent and ethical people practise dentistry. It protects the public by means of its statutory responsibilities for dental education, registration, professional conduct and health.
The GDC supports dentists and dental auxiliaries (DCPs) in the practice of dentistry and encourages their continuing professional development (CPD) (GDC’s Mission Statement).
Registration with the GDC
Only dental surgeons registered with the GDC and medical practitioners registered with the GMC are entitled to practise dentistry. Graduates and licentiates in dentistry of universities and Royal Surgical Colleges of the UK may be registered on completion of the appropriate form and payment of the prescribed registration fee. The universities and Royal Colleges in the UK provide the GDC with lists of their dental graduates or licentiates. Registration has to be renewed annually as long as a dentist wishes to practise in the UK.
Holders of an appropriate European Dental Diploma who are nationals of member states of the European Union (EU) are also entitled to register, as are Icelandic and Norwegian graduates, since Norway and Iceland are members of the European Economic Association (EEA), as are dentists who qualified in Switzerland. Any European dentist applying for registration requires documentary evidence of:
Disqualification from practice in any EU/EEA member state automatically bars a dentist from registering with the GDC.
Up to 2001, dentists holding a primary dental diploma from certain overseas universities that the GDC has visited to check educational standards could also be fully registered with the GDC and are still able to continue to be registered. These universities are in Commonwealth or former Commonwealth countries where dental education is similar to that in the UK. No other qualifications are automatically accepted by the GDC for full registration and, therefore, the right of undertaking independent dental practice in the UK.
There are several ways by which dentists with qualifications that do not fit into the above categories can register with the GDC.
Temporary registration is available to allow such dentists to teach, do research work or obtain postgraduate instruction in certain approved hospital posts for a limited period. Temporary registration only lasts for the period of a particular post or employment and can be renewed normally up to a maximum of 4 years. This maximum period was extended to 5 years for those beginning temporary registration from 2004. Applicants for temporary registration must personally attend the GDC offices with:
People with temporary registration can only practise dentistry under the supervision of a named, fully registered dentist of consultant status in the UK.
After 2 years of temporary registration and subject to satisfactory reports from the consultant(s) supervising the temporary registrant, a ‘Temporary Registration with Limited Supervision’ status may be granted. This will allow, for example, the temporary registered dentist to undertake out-of-hours on-call duty when the supervising consultant will probably not be on the premises but only available by telephone or some form of paging. Also, since 2006, the GDC has granted temporary registration for 25 supervised posts for up to 12 months in primary dental care for dentists preparing for Part C of the International Qualifying Examination.
International Qualifying Examination
The International Qualifying Examination (IQE) replaced the Statutory Examination in 2001. At the same time, the GDC has ceased to recognise the primary dental diplomas from certain universities overseas. From 2001, all dental surgeons who do not have a primary dental qualification gained through a dental school or Royal Surgical College in the UK, the EU or the EEA will have to sit the IQE. Some of the dental courses in newer member countries of the EU do not meet European standards; also dentists from these countries who have obtained their qualification from a non-EU country (e.g. the former Soviet Union or Yugoslavia) will need to enquire at the GDC whether they are eligible for full registration on an individual basis and demonstrate that they are of good character and in good health.
Since 2004, in certain circumstances, EEA citizens who qualified outside the EEA can apply for full registration on an individual basis; the GDC will take account of that dentist’s qualifications and previous dental experience in deciding whether or not that person is entitled to full registration.
Any dentist who has previously passed the Statutory Examination or the IQE, or entered the register before 2001 with a previously recognised degree or diploma (e.g. from a Commonwealth country) is entitled to full registration with the GDC.
The IQE is in three parts:
Part C comprises written examinations; an oral examination in general dentistry; clinical examination of a child and an adult patient; a practical clinical examination involving patient treatment; and an examination in medical emergencies.
Exemption from Part A is granted to holders of MFDS; or primary/Part 1 FDS examination or equivalent from one of the UK Royal Surgical Colleges; or have passed Part A of the UK Intercollegiate LDS. Non-EEA passport holders cannot be accepted for the IQE unless they have achieved a minimum score or 7 in each individual section of the Academic International English Language Testing System.
Unless Part C of the IQE is passed within 18 months of Part B, it will be necessary to retake Part B of the examination.
The IQE was closed to new applicants in 2007, but remains open for candidates to have up to two attempts each at Parts B and C of the examination. Alternatively, candidates who have passed Part A can transfer to the new examination detailed below with a reduced fee for Part 1 of that examination.
Overseas Registration Examination
In 2007, the Overseas Registration Examination (ORE) became the new statutory examination to permit overseas dental graduates to apply for admission to the Dentist’s Register.
Additionally, since October 2011, before applying to sit the ORE, prospective candidates need to demonstrate that their dental course and qualification is comparable to EU training and assessment requirements. A statement to this effect has to be obtained from the National Recognition Information Centre for the United Kingdom (UKNARIC). This organisation, and similar organisations in other EU countries, has been set up by the UK government to check comparability of all professional qualifications. A NARIC Statement/Certificate of Comparability has to be submitted with the application to sit the ORE. Also, prospective candidates need to have taken an IELTS English Language Test and scored a minimum 0f 7.0, with no section scoring less than 6.5, to be eligible to sit the ORE. No other English language test is acceptable.
The ORE is a more streamlined system comprising two parts:
Up to four attempts each are allowed for Part 1 and Part 2 of the ORE. Also, Part 2 has to be passed within 5 years of the first attempt at Part 1 of this examination.
Additionally, to register with the GDC, candidates will need to provide evidence of good standing.
The GDC has advised that prior to being able to work in NHS dental practice, those who have passed the ORE may also be required to undertake up to a year of vocational training in the UK.
It should also be noted that dentists from outside the EU require a work permit to undertake any form of employment in the UK. It is recommended that the application for a work permit is made in the country of residence and is available to be shown to an immigration officer on arrival in the UK.
Continuing professional development
The GDC has made continuing professional development (CPD) compulsory since 1 January 2002. To remain on the Dentists’ Register, it is necessary to show that 250 hours of CPD have been completed over a 5-year period, 75 hours of which must be verifiable. Verifiable CPD comprises formal teaching with concise and appropriate educational aims and objectives, plus a quality control mechanism.
The 5-year CPD cycle was phased in over a period of 3 years depending on the date of first registration with the GDC:
These first 5-year cycles therefore ended on 31 December in 2006, 2007 and 2008 respectively.
Dentists whose first registration date is on or after 1 January 2002 commence their 5-year cycle on 1 January of the year following their first registration. Also, dentists applying to rejoin the register will have to show that they have met CPD requirements prior to being readmitted to the Dentists’ Register.
From 2006, all registered dentists have certain core subjects that must be included in their second and subsequent CPD cycles. Dentists who first register in or after 2006 must include the core subjects in their first CPD cycle as well. These core subjects are:
The GDC also recommends the use of a personal development plan to ensure that both dentists and their patients benefit as much as possible from the CPD that is undertaken. Specifically, the GDC recommends that those working in a clinical environment undertake CPD to ensure that they are up-to-date in:
The CPD for DCPs is 150 hours in every 5-year cycle, of which 50 hours must be verifiable, and to include the same core subjects as dentists for the same number of hours. As dental technicians are not involved with radiography, they can substitute 5 hours covering materials and equipment. The GDC also recommends that DCPs include legal and ethical issues and complaints handling as part of their CPD.
In addition to the current CPD requirements, the GDC is planning to introduce revalidation. This process is not expected to start before 2014 for dentists, and sometime after this for DCPs. The frequency of revalidation is yet to be decided. Revalidation will require all dental professionals to demonstrate that they meet the standards for registration with the GDC in four main areas:
It is proposed that this will affect those in primary care in the first instance, and that there will be three steps or stages to this process
1. This is likely to be a paper exercise, where the registrant collects evidence to demonstrate their abilities in the key areas. This will be evaluated, and the majority are expected to be revalidated at this stage.
2. Those who have not met the required standards will be given further time to provide evidence that they have met the standards or fixed any concerns. This stage has been referred to as remediation or targeted assessment and would be undertaken by trained peers, probably within the practice setting. Random peer assessments may also be undertaken.
3. Those who do not revalidate in stage 2 will be subjected to an in-depth assessment and, if this is unsatisfactory, removal from the register would be possible. This stage is expected to only apply to a small number of registrants, and it is realised that the system much be sufficiently robust to justify proceeding to stage 3.
Council for the Regulation of Healthcare Excellence (CRHE)
The government set the Council for the Regulation of Healthcare Professionals (CHRP) in April 2003 and it consists of 10 lay members and nine members nominated by health care professions regulators, including a GDC nominee. In the Health and Social Care Act (2008), the name of the council was changed to the Council for the Regulation of Healthcare Excellence. Its main role is to encourage co-operation and greater consistency in the work of health care regulators, and promote good practice. One of the CRHP’s powers is the ability to appeal to the appropriate court of law against a decision of a health care regulator where it considers that such a decision has been over-lenient.
Care Quality Commission (CQC)
This body is not for the registration of individual health care professionals, so is not involved with the GDC. It is discussed here as it was also set up as a result of the Health and Social Care Act (2008). However, its purpose is the regulation of organisation and the premises where health and social care is undertaken. The CQC became active in April 2009 and currently registers and regulates:
Medical practices will also have to be registered by 2013, or 2012 if they undertake certain invasive procedures.
Independent Safeguarding Authority
This authority was established in 2010. Any individual treating or caring for children or vulnerable adults has to be vetted by and registered with this authority, who will check whether the applicant has any criminal record that might make them unsuitable to have contact with vulnerable persons. This process was previously called Criminal Records Bureau Enhanced Disclosure (CRB.ED). However, the UK government decided in 2011 to review the cumbersome procedures originally required for registration, and the outcome of this review is still awaited. Meanwhile, CRB.ED is still valid.
In Scotland, there is a separate, but similar, scheme called the Protecting Vulnerable Groups (PVG) Scheme.
12.3 Titles and descriptions
Registration with the GDC allows the use of the titles Dentist, Dental Practitioner or Dental Surgeon. Also, since November 1995, the GDC has accepted the use of the courtesy title Doctor, provided that it is not used in a way to suggest that the user is anything other than a dentist. Before 1998, no other title was permitted, but the GDC is now empowered to set up and maintain specialist lists of practitioners who can show they have received sufficient postgraduate training to be considered specialists in a particular field. Practitioners on these lists are permitted to use the appropriate titles (e.g. ‘Specialist in Endodontics’).
There are two methods of entry to these specialist lists:
2. By virtue of current specialist practice and previous training. This pathway was open for 2 years following the establishment of each individual specialist list only and is referred to as transitional arrangements.
The GDC originally established 13 specialist lists. These are:
|Specialty||End of transitional entry period|
|Dental and maxillofacial radiology||31 May 2002|
|Dental public health||15 April 2000|
|Endodontics||31 May 2000|
|Oral medicine||30 June 2001|
|Oral microbiology||31 May 2002|
|Oral pathology||31 May 2002|
|Oral surgery||15 April 2000|
|Orthodontics||30 June 2000|
|Paediatric dentistry||30 June 2000|
|Periodontics||31 May 2000|
|Prosthodontics||31 May 2000|
|Restorative dentistry||15 April 2000|
|Surgical dentistry||31 May 2000|
The specialty of restorative dentistry involves training in endodontics, periodontics and prosthodontics; it therefore involves a longer training period than that required for specialisation in only one of the three recognised restorative specialties.
Surgical dentistry was confined to dento-alveolar surgery, whereas oral surgery encompassed surgery to surrounding structures and the treatment of maxillofacial injuries. At the December 2005 meeting, the GDC decided to merge the surgical dentistry list into the oral surgery list. Current surgical dentistry trainees and future trainees would have to train to the oral surgery core competences. Those previously admitted to the surgical dentistry list are reminded that the professional duty is to practise only within the limits of their competence. This change will bring the UK in line with the situation in the EU and in many other countries. This merger took place in April 2007.
In 2008, the GDC added another specialty, ‘Special Care Dentistry’, again with a 2-year transitional period for those already competent in that specialty.
Maxillofacial surgery is considered to be a medical specialty by the EU, and maxillofacial surgeons are registered with the GMC.
Professions complementary to dentistry (formerly dental auxiliaries)
Since 1956, the GDC has been responsible for maintaining a register of dental hygienists and dental therapists. These auxiliaries can undertake a limited form of dental practice under the supervision of a registered dentist. Also, the 2005 amendments to the Dentists’ Act of 1984 have allowed for the registration of other groups of dental care workers. In 2005, the title Professions Complementary to Dentistry (PCDs) was changed to Dental Care Professionals (DCPs).
Dental hygienists are permitted to scale, clean and polish teeth and also to apply certain prophylactic materials to the surface of teeth. They may only provide treatment when under the direction of a registered dentist who has examined the patient and prescribed the course of treatment to be provided. If the hygienist is not under the personal supervision of the dentist when carrying out prescribed treatment, the dentist must be satisfied that the hygienist is competent to carry out that treatment. Hygienists who qualified prior to 1992 and who administer local anaesthetic infiltration analgesia must have attended a course and received a certificate in administration of local infiltration analgesia, or hold the Diploma of Dental Therapy.
Dental therapists are permitted to extract primary teeth, undertake simple fillings, scale, clean and polish teeth and apply certain prophylactic materials to the surface of teeth. They are also permitted to give advice on dental matters within the limits of the treatments mentioned above and to administer local infiltration analgesia. They are also able to carry out work under regional block analgesia that has been administered by a registered dentist. Before 2002, dental therapists were only allowed to work in the community dental service or in the hospital service, but they are now free to work in a general dental practice that wishes to use their skills. They can only provide treatment that has been authorised and prescribed in writing by a registered dentist who has examined the patient. A registered dentist does not have to be on the premises but should be readily available should an emergency arise.
Dental hygienists and dental therapists were not permitted to treat patients under conscious sedation before July 2002, but can now do so provided a registered dentist remains in the room throughout treatment. Also, since that date, both groups have been permitted to:
If, in the future, dental auxiliaries/DCPs are allowed to perform additional duties, it is essential that they attend for appropriate courses of instruction on these additional duties and techniques before undertaking them.
New classes of dental care professionals
The Dental Auxiliaries Review Group of the GDC published a report in November 1996. This report recommended that, in future, dental auxiliaries should be known as ‘Professionals Complementary to Dentistry’ (PCD) and that all classes should be statutorily registered with the GDC. Only those in training and with appropriate qualifications would be eligible for registration. In 2005, the GDC changed the title of these groups to ‘Dental Care Professionals’ (DCPs). Several new classes of DCPs are eligible for registration, and ‘grand parenting’ arrangements have been agreed for dental nurses and dental technicians, but only for the first 2 years of this register.
The GDC Dental Care Professionals’ Register opened in July 2006 and is separate from the Dentists’ Register. Registration for dental nurses and dental technicians became compulsory in July 2008. Also, it became illegal for a non-registered person to use any of the recognised DCP titles as they are protected by law. For two of the new classes of DCPs, clinical dental technicians and orthodontic therapists, registration has been compulsory since this register opened.
All classes of DCPs who work in a clinical environment will need to provide a certificate of good health signed either by their doctor or the dentist employing them if they have been in his/her employment for at least 12 months and have provided evidence of appropriate and up-to-date immunisation.
The new groups are:
Only qualified dental nurses will be allowed to register and undertake additional duties such as removing sutures and packs and taking impressions for study models on the written instruction of a dentist who is on the premises. Following appropriate additional instruction, dental nurses will also be allowed to take radiographs and give oral hygiene advice.
Orthodontic therapists will be trained to carry out orthodontic duties to a previously agreed treatment plan and under the direct supervision of the dentist. In the first instance, only dental hygienists and therapists will be able to undertake additional training in orthodontics. Their duties will include taking impressions, fitting removable appliances and headgear, fitting separators and orthodontic bands, placement of direct bonded orthodontic attachments and the ligation and removal of archwires previously fitted by a dentist and the removal of orthodontic bands and excess cement.
Only qualified technicians will be allowed to register and to call themselves dental technicians. In addition to the construction of appliances, they will be able to take tooth shades of patients for the construction of prostheses and impressions for study models on a written prescription, but only on the dentist’s premises.
Clinical dental technicians
Clinical dental technicians will be limited to the fitting and insertion of complete upper and/or lower dentures. They will only be able to treat patients referred to them by a dentist who has examined the patient. Clinical dental technicians working within a dental practice will also be allowed to provide partial dentures. As this is a completely new class of PCD, it will require new training programmes and examinations that will have to be approved by the GDC. The Dentists’ Act needs to be amended for this group to be recognised as it is currently illegal for dental technicians to insert dentures into patients’ mouths. Also, the resistance of the dental profession will need to be overcome before clinical dental technicians are generally accepted.
Maxillofacial prosthestists and technologists were originally included in the GDC’s list of PCDs, but as much of their work is non-dental, the Institute of Maxillofacial Prosthetists and Technologists, on the recommendation of the Department of Health, has elected to be registered with the Health Professions Council rather than the GDC.
The GDC has proposed three new boards that will be responsible for registration, standards of education and training, health and conduct of DCPs. These are:
12.4 Requirements for the practice of dentistry
Regulation by the General Dental Council
It is the GDC’s duty to maintain the Dentists’ Register and the Dental Care Professionals’ Register. The Registrar and Chief Executive of the GDC is responsible for ensuring the accuracy of these registers. The Registrar must remove the name of any dentist or DCP who fails to pay the annual retention fee. A name can only be restored to the register by formal application and the payment of a restoration fee in addition to the annual retention fee. If an applicant is refused restoration, has been removed for non-payment of the registration fee or has been removed from the register for a reason other than via a Fitness to Practice Committee, that applicant can appeal to the Registration Appeals Committee. This committee must comprise of at least three members of the Fitness to Practice Panel.
The Dentists’ Act (1984) gives the GDC the responsibility to supervise all stages of dental education, postgraduate as well as undergraduate. The GDC determines minimum standards and sends visitors to dental schools and other training establishments to check on standards of teaching and of examination of students. It has the power to recommend that the recognition of a dental qualification by the GDC is withdrawn should the council consider that the training or examination no longer secures sufficient knowledge and skill to practise dentistry.
The 2005 Amendment Order requires the GDC to determine the appropriate standard of proficiency required, and to specify the content and standard of education and training required for the registration of PCDs.
The GDC also has a duty to remove from the Dentists’ Register or the Dental Care Professionals’ Register any member who is shown to have behaved in a manner unsuitable for continued registration. The GDC has regularly issued written advice on the standards required by the professions it regulates. The latest series of booklets, under the title of Standards Guidance, were updated in 2005 and 2006, and have been sent to all on the registers and new registrants. These booklets are also available to download from the GDC Website. In 2011, the GDC reviewed its guidance documents, but the revision had not been published by the time of writing. It is expected that revised documents will be available on the GDC Website as soon as they have been approved.
At all times, the dentist’s and dental care professional’s conduct must be of the high standard that the public and the profession expect. The dentist’s first priority is a responsibility to patients. If a dentist’s conduct falls below this high standard, the GDC has the power to suspend or remove the dentist’s name from the register. Conviction for a criminal offence or serious professional misconduct can be grounds for refusal of admission, erasure or suspension from the register. Conduct or behaviour prior to qualification is also considered by the GDC; therefore, this power also applies to students. Any dentist or DCP who is found guilty of serious professional misconduct in another country is not entitled to register with the GDC.
Serious professional misconduct by a dentist cannot be precisely defined. However, it is considered to be conduct by a dentist that falls short of the standards of conduct expected among dentists and that this should be a serious omission/commission. Specifically, the GDC has to decide upon a dentist’s Fitness to Practise (FtP) if a complaint is made. In the case of DCPs, the GDC uses the more general term of ‘misconduct’ for matters that may be investigated and be subject to disciplinary action. The GDC regularly sends out information to all registered persons, giving clear guidance on standards expected of a practising dentist and a DCP; failure to maintain these standards could lead to a charge of serious professional misconduct. Also, any criminal conviction in the UK of a person on a GDC register is automatically forwarded to the council by the police, who may also inform the GDC of formal cautions and other matters of concern. The GDC accepts a court conviction as conclusive proof. A later claim of innocence to the GDC cannot, therefore, be made in mitigation!
In addition to criminal convictions, a patient, a member of the public, another dentist or a DCP may make a formal complaint to the GDC. The GDC’s solicitors or a person acting in a public capacity (e.g. an officer of a health authority or similar body) can inform the council of any matter that they feel should be considered under the GDC’s disciplinary procedure.
In its current publications, the GDC states that its FtP procedures are not there to punish registrants; they are there to protect patients by ensuring that those providing their dental care are fit to do so. Also these procedures provide opportunities for registrants to remediate any issues that may be affecting their fitness to practise.
Until 2004, disciplinary hearings were conducted by various committees made up of GDC members. The GDC started discussing major reforms in 2000 to update its functions and membership to make the organisation fit and appropriate for the twenty-first century. One of the reforms was to set up an independent Fitness to Practise Panel made up of people who are not members of the council, to form a pool from which the membership of the disciplinary committees would be formed, thus allowing the council to concentrate on strategy, such as setting standards, and also ensuring that there was no risk of compromising the integrity and impartiality of conduct hearings. This pool originally consisted of 15 dentists, five DCPs and 15 lay people. By 2006, these numbers had increased to 20 dentists, six DCPs and 22 lay people. By Order of Council in 2009, the maximum numbers of members on the statutory committees of the GDC was increased again.
The maximum numbers now are:
The members of the panel were appointed by a Special Appointments Committee of four lay, two dental and one DCP appointed by, but not members of, the GDC.
Panel members are initially appointed for 5 years, and have been given appropriate training for their task. As has always been the case, appropriate legal advice is always available for all conduct hearings.
Since 2004, this new system has been kept under review and was revised in 2006, several additions and changes being introduced into the FtP framework:
• Requiring only a civil standard of proof (balance of probabilities) in conduct cases, which is less than the criminal standard of proof (beyond reasonable doubt) that was used previously in conduct cases.
Fitness to practise investigations
The current system was instituted in 2006 and comprises one or more of the following stages:
Initial assessment of complaint or received information
An initial assessment is undertaken by a FtP case officer, who will decide whether the information received raises any issues that need to be looked into. If the answer is ‘yes’, the investigating officer must:
All legitimate complaints received by the GDC concerning FtP are initially assessed by the Investigating Committee, which is made up of GDC members, who consider the allegation and determine whether it ought to be taken further and deliberated by a Practice Committee at a full public hearing. Meetings of this committee are held in private and consider matters only on the basis of documentation received; neither the registrant concerned nor witnesses are called. This committee can:
• refer the case to a Professional Practice Committee for a full inquiry and, if necessary, refer the case immediately to the Interim Orders Committee to consider if action is required before a full inquiry by a practice committee.
The remaining committees are drawn from the FtP Panel:
The Interim Orders Committee
At any stage in the investigation, a case may be referred to this committee. This committee has the power when necessary to protect the public, the public interest or the registrant themselves pending the outcome of the case. It does not investigate allegations or conduct a fact-finding exercise. If necessary, this committee can:
The Practice Committees
There are three Practice Committees whose role is to determine whether a registrant’s fitness to practise is impaired and, if so, what action has to be taken to protect patients. Also, these committees have the direct power to impose interim suspension, or conditions limiting the field of practice, if it is considered that immediate action to protect the public is needed pending the final outcome of a particular case. If one of these committees considers it appropriate, it can refer a case directly to another practice committee.
These committees are:
The Professional Conduct Committee
This committee investigates cases involving conduct issues. It has the power to:
• erase a registrant from the register, which recently became for a compulsory minimum of 5 years. Refer the case back to the Investigating Committee, the Interim Orders Committee or to one of the other practice committees.
After July 2006, any new case reported to the GDC that is assessed by the Professional Conduct Committee is no longer judged as being guilty or not guilty of serious professional misconduct, but whether or not their fitness to practise is impaired. Also under these rules, the committee can sanction a suspension with review, which gives the committee the power to recall the suspended registrant before the end of the period of suspension to check whether or not the suspended person is fit to be returned to the register.
The Professional Performance Committee
This committee deals with cases where it appears that a registrant’s performance may consistently fall below an acceptable standard. Where necessary, this committee uses the National Clinical Assessment Service to undertake performance assessments of a referred registrant. This service is part of the national Patients Safety Agency. The nature of the assessment is case dependent; it will include a clinical assessment. Also, if necessary, it may involve behavioral issues and occupational health.
This committee can impose conditions or suspend registration in the same way as the Professional Conduct Committee. Where a local practitioner Advice and Support Scheme is available, this committee may recommend referral to such a scheme.
The Health Committee
The Investigating Committee refers cases to this committee where it appears that fitness to practise it due to a health problem. This committee may request appropriate medical advice to assist it in coming to a conclusion. Additionally, the dentist being investigated can arrange a report from his or her own medical examiner. This committee can impose the same sanctions as the other practice committees, including referral back to the Investigating Committee. It cannot, however, erase a dentist from the register if it determines that fitness to practise is impaired solely as a result of adverse physical or mental health.
If the CHRE considers that a ruling by any health care regulator, including the GDC, has been too lenient, it can appeal to the High Court for that ruling to be changed. Registrants can also appeal to the CHRE against decisions of the GDC’s Fitness to Practise Committees.
Also under the new rules introduced in July 2006, all applications for restoration to the register require the GDC case presenter to inform the appropriate practice committee of:
The respondent and/or their representative are entitled to:
However, the committee may take the view that any attempts by the respondent at this stage of refuse the original proven allegations could hamper their attempt to be restored to the register.
The CRHE has criticised the GDC’s current disciplinary procedures for being too cumbersome, thereby causing a backlog of cases. The GDC was able to make changes to improve the fitness to practise processes, including:
Draft proposals for more sweeping change are on the GDC Website for consultation; and, if approved, changes are expected in 2012. The main proposed changes are the following:
• That case adjudicators will have the power to agree and manage undertakings with a registrant in more minor misdemeanors, although still being able to refer cases on to the practice committee immediately or at a later date if necessary.
The changes already in place decreased the backlog of cases awaiting an initial decision by over one-third in the first part of 2011.
New guidance on ethical advertising has been issued by the GDC, which takes effect from March 2012. This incorporates important recommendations in the Code of Ethics for Dentists in the EU. The GDC clearly states that whenever the name of a registrant appears on any form of advertising, it remains the responsibility of that individual dental professional to ensure the accuracy of their personal information appearing.
It states specifically that:
All information and publicity regarding dental services should meet the following criteria:
In addition to the above, Websites should include:
Websites should be regularly updated to accurately reflect the current personnel and the services offered. No comparative information comparing the skills or the qualifications of one dental professional with another should ever be displayed. Listing memberships of professional associations and societies, or honorary degrees, can be misleading and imply additional skills, so should not be included.
Other requirements for the practice of dentistry
Following qualification, a dental surgeon is immediately eligible for full registration with the GDC. Before commencing the practice of dentistry, however, there are several requirements or recommendations that should be carried out in addition to registering with the GDC.
There are three organisations in the UK that provide indemnity for dentists and doctors. These are mutual organisations, which mean that the organisation belongs to the members and all profits made by these organisations have to go to the benefit of the members (unlike a limited company where owners or shareholders reap the benefit of any profits). These organisations are:
These organisations provide members with indemnity against any legal action brought by patients; advice and assistance on medicolegal matters; legal representation at courts, tribunals or professional committee hearings on disciplinary matters; and general advice on professional conduct. Hospital trusts and health authorities as employers of salaried practitioners have corporate indemnity should a patient sue the organisation or individual employees. However, this cover does not include representation of a practitioner at tribunals or disciplinary hearings of any sort. Therefore, it is advisable to belong to one of the professional protection organisations; these organisations offer lower rates of subscription for those practitioners who have indemnity from their employers.
Professional indemnity is also available on the commercial market, but this normally has a maximum limit of indemnity and only provides cover within the time of the insurance contract. This is an important factor, which is recognised and covered by the professional protection organisations, as there may be a delay of several />