British Dental Association. Response to. The General Dental Council s consultation. revalidation for dentists

Transcription

1 British Dental Association Response to The General Dental Council s consultation on revalidation for dentists

2 Who are you? To help us to understand the context of your response, please indicate the perspective from which you are replying. I am replying as a ( please tick the boxes that apply to you) Dental Professional (please tick the box which applies to you below) Clinical Dental Technician Dental Hygienist Dental Nurse Dental Technician Dental Therapist General Dental Practitioner Orthodontic Therapist Specialist Dually qualified On behalf of an organisation On behalf of an education provider On behalf of a regulatory body On behalf of a professional association Other (Please specify) (Please specify) (Please specify) (Please specify) British Dental Association (Please specify) 2

3 British Dental Association Response to The General Dental Council s consultation on revalidation for dentists Introduction and summary 1. The British Dental Association is the representative organisation for dentists in the UK, with over 19,000 dentist members and nearly 4,000 student members. We have widely consulted with our representative committees in developing our response to this consultation. We have a number of specific comments and will also deal with the Council s questions. 2. The BDA has been part of a number of working groups on the development of revalidation and has provided feedback over the last few years, including through the open consultation in We were also members of the Working Group for non-medical Revalidation which reported in November We have supported the idea of revalidation that is professionally-led by the General Dental Council. We have also said that revalidation should not be employment-dependent and have stressed that any system would have to be proportionate and cost-effective. 4. The government intends to consult further about regulation of the professions in 2011 and we believe that this could lead to a complete review of the current revalidation proposals. We understand that any revalidation system will now not come into effect until 2015 at the earliest. 5. We also understand that the GDC plans to undertake a cost-risk-benefit analysis as a priority now. We have repeatedly asked the GDC for this information and are pleased that there is now progress on this issue. 6. We note that the report on principles for revalidation of the Working Group on Non-Medical Revalidation (November 2008) affirmed that the intensity and frequency of revalidation needs to be proportionate to the risks inherent in the work in which each practitioner is involved. We support this. 7. As the consultation is being conducted despite the possibility of a complete change to the proposals, we are basing our response below on the current consultation document. We feel, however, that under these circumstances the current consultation should have been withdrawn until the government review and the cost-risk-benefit analysis had been completed. Proportionality 8. In earlier consultations and workshops, the GDC has repeatedly reaffirmed its wish to develop a system which is proportionate to the problem it wishes to address and not place unnecessary burdens on registrants. 3

4 9. We believe that the proposed approach, particularly the issue of third-party verification, departs from these earlier reassurances. It is onerous and bureaucratic, is not based on evidence of need and is inappropriate per se but most particularly in the current economic circumstances. It is not clear to us why third-party verification is necessary at all. A system based on self- and peer review, for example through a portfolio, appraisal/one-to-one meetings and observation, would be much more effective in ensuring that the arrangements are profession-led. Portfolios and personal development plans are now increasingly in use. With regard to appraisal/peer assessment, dentists work to ethical standards which include professionalism, honesty and an obligation to raise concerns, and, as long as appropriate training, protected time and the necessary funding are made available for all dentists to undertake such reviews, this approach would be much more practical. 10. In contrast, the need to sign up to yet another verification scheme will make the system very costly and unnecessarily repetitive. The Care Quality Commission will be responsible for assuring the quality of the service and the compliance of the service provider and those working for them with a wide range of standards, many of which duplicate GDC standards. It is important that the standards against which the individual revalidates are professionalspecific and not service-specific and add value. The area that is missing in all the current arrangements is clinical skills and it is this area that is the most challenging and of most interest to patients. We believe the GDC should concentrate on this aspect and support the four individual elements that will be relevant to GDP revalidation. It will be important to ensure that the distinction is clear. 11. The profession is therefore concerned that the proposals as currently defined would be yet another layer of regulation which would duplicate some requirements but not dovetail sufficiently for the relevant organisations to work with the GDC to one standard process. It would result in more paperwork and stress for dentists and fewer patients treated. 12. Any revalidation arrangements will need to reflect the reality of service provision, particularly the structure of the NHS, and commercial realities. How would dentists comply with revalidation if, mid-cycle, their recommended thirdparty verifier was decommissioned or went out of business? Would more time be allocated for compliance under such circumstances, and without penalty to the registrants? Flexibility 13. As we pointed out in our last consultation response, it is important to ensure that any revalidation system is as flexible as possible, as dentists and other members of the dental team work in so many very different settings. We are aware that the current proposals have been developed with general dental practice in mind, but even in this one setting, the ways of working vary widely. It is important that any system is flexible enough to enable its implementation across the diversity of work environments and roles within the profession. 4

5 Individual versus practice 14. The GDC notes that the existing recognition systems tend to focus on the practice as an entity rather than the individual professional. Despite reassurances that much of the evidence under these systems can be brought forward by individuals for the purpose of revalidation, we are concerned that this might not be as straightforward as proposed. 15. It becomes a particular issue for dentists who might move practice once or more during a revalidation cycle. They may not have access to documents of the practices they have left, particularly those relating to patients. A similar situation could arise if a practice owner retired or a practice closed, resulting in important evidence possibly being lost to individual dentists who would then be without the necessary documents. Problems can also arise as a result of a breakdown of a working relationship. There must therefore be an obligation enshrined in the system for all professionals to share the necessary information with all who need it for revalidation purposes. Validation 16. The BDA s Education Committee noted that, although there is currently no clear policy decision on validation or provisional registration, a question on this issue was raised in the consultation on training outcomes. The Committee felt that an alternative to revalidation could be one set of validation for all, after an initial five years on the register, for example. This might address competence better than regular cycles of revalidation. Costs 17. There is considerable concern about the potential cost of revalidation and we look forward to a full economic evaluation from the GDC. The concern is exacerbated by a view that the proposed system should avoid duplication with other regimes and concentrate solely on clinical competence. 18. The cost to the individual in complying and to the Council in administering the scheme will be significant and this, coupled with the cost of CQC (and equivalent) regulation, must call into question the proportionality of the proposals. 19. We reiterate a point we made in the previous consultation response. We agree in general that registrants should make a contribution to the costs at Stages 2 and 3 where they have clearly failed to revalidate at Stage 1 but this must be in the context of an appropriate and proportionate system which avoids duplication and is targeted. We are particularly concerned about the costs and the implications for those who have been on career breaks or working abroad. We comment on this issue in our answer to question 9. Revalidation of dentists who are returning to the register 20. We welcome the possibility that dentists who have stayed on the register whilst working abroad may use overseas evidence in their revalidation. We also welcome the option of the GDC verifying portfolios of evidence in some cases where revalidation under these circumstances is otherwise impracticable. We have said that we consider third party verification to be inappropriate for 5

6 general practice in any event and the practicalities for this group are even more open to question and need further consideration, should the proposal go ahead. Specific GDC questions 21. Question 1a: The GDC envisages that all dentists will have their compliance checked at Stage 1 by an approved external verifier. For GDPs, we expect that this verification will normally take place through a practice inspection. Are there any other ways an approved external verifier might check a GDP s compliance? We do not agree with the proposal of external verification and would prefer a system based on self- and peer verification. 22. Question 1b: What are the ways in which an approved external verifier might check the compliance of other groups of dentists, e.g. specialists, dentists in salaried services? We believe that, within the salaried services, management practices such as appraisal combined with self- and peer verification will adequately cover the revalidation requirements. Those working in the hospital service have an annual appraisal which will change as part of medical revalidation. It would make sense for this system to be recognised for dental revalidation, but the new NHS appraisal would need modification to reflect dentistry. We would hope the GDC would look into this and work with the relevant authorities. It must be noted that, under a third-party verification system, a conflict of interest may exist if employers are required to act as external verifiers. Specialists in the hospital or salaried service sector should be covered by their employers systems. Those in high street practice would use the same system as general dental practitioners, using relevant clinical standards. A system to revalidate those who share their time between practice and salaried environment would need to take into account evidence from both settings as appropriate. 23. Question 2: A lot of the evidence that GDPs currently collect is practice-based. The main individual evidential elements within the framework we are proposing for GDPs are set out on page 15 and are CPD, patient feedback, colleague feedback and patient records checks/clinical outcomes indicators. Are there any additional items of evidence of individual performance that we should require approved external verifiers to check at Stage 1 of revalidation for GDPs? If so, what are they? The list seems appropriate. The BDA still has concerns that any system of patient feedback must be robust and objective. 6

7 24. Question 3: What evidence of the individual performance of other groups of dentists should be collected for Stage 1? The existing salaried services appraisal system covers all the domains of dental practice required for the proposed revalidation scheme. Each salaried dentist produces a personal portfolio of evidence against each standard in these domains. Using these portfolios, dentists are appraised annually by a senior colleague. Where no senior colleague with appropriate clinical knowledge or skills is available locally, an external appraiser is identified from another service. This system has been developed in conjunction with NHS Employers. Satisfactory completion of this appraisal system should be sufficient to meet the requirements for revalidation. If the GDC wished to spot check compliance it would be relatively simple to check a sample of portfolios, as is now the case with CPD portfolios. The appraisal process for hospital and academic clinical dental staff also covers not only quality of clinical activity but also all aspects of well-being, fitness to practise, communication, management of complaints and probity. 25. Question 4: Should a dentist be subject to any additional requirements at Stage 2, to differentiate it from Stage 1? If so, what should they be? No. We have an additional point on stage 2 remediation phase. It will only work if there is sufficient infrastructure to underpin it. We note that the GDC will not be responsible for remediating registrants and that the Council anticipates that dentists will be able to make use of existing support mechanisms. The problem is that such mechanisms are undeveloped and patchy, and lack a consistent funding infrastructure. They are also under greater threat now that there are such significant funding constraints in the NHS. 26. Question 5: The GDC has identified two options for in-depth assessment of GDPs at Stage 3. These are an examination or a defined period of continuous assessment akin to the model used for vocational training. Which of these options do you prefer? Please state the reasons for your answer. The comments below must be seen in the context of our concern about the financial implications of the entire proposals for revalidation and in particular the cost and practicalities of remediation, particularly in the current economic circumstances and the lack of a risk assessment, for which there is no detail at this stage. We would welcome the availability of two options. An examination may be practical and may suit those who can approach this issue in a pragmatic way. On the other hand, many of those who have to go through Stage 3 may already be under high levels of stress due to failing the earlier process of Stages 1 and 2 and be better suited to continuous assessment. We nevertheless have major concerns about both options. The reference to an examination similar to the Overseas Registration Exam (ORE) has been removed from the consultation document, but from earlier versions and discussions we are aware that the GDC s proposal was essentially based on 7

8 an amended version of that exam. There are many problems with this approach which have been demonstrated over time. Our concerns are outlined below. An examination The ORE, and the IQE before it, have had long waiting lists for many years. How would the GDC ensure that the new exam would have adequate places available? It would be completely unacceptable to ask dentists who are going through the revalidation process to be on a waiting list for the next available exam. There would have to be exam sittings each month for however many or few individuals might need them, and numbers would be variable. What assurance can be given that every dentist wishing to sit this exam can do so without major delay so as not to jeopardise their livelihood? If the GDC goes ahead with the proposal of including returners to the GDC register in Stage 3 (a proposal which we oppose), it will be impossible to know how many people will wish to sit this exam at any given time. The ORE is based on the UK s undergraduate degree level. The consultation document, however, mentions that all dentists should revalidate in accordance with their current practice. Will the GDC therefore prepare a variety of exams? If so, how would the various exams be allocated? Can the GDC ensure that any proposed exam is equally fair and proportionate to the dentist who has underperformed and to those who return to work from abroad or after a career break? There would also be a need for the GDC to provide information and preparatory support for those needing to sit the exam, and an assurance that necessary courses would be available at the time when exam candidates needed them. There have been issues with regard to feedback and an appeals procedure for the ORE for those who have failed. This issue has been raised many times, and, unless the procedures are fair and transparent, there would be a risk of future legal challenges. If the exam is to have more than one part, we would also like to see more detailed proposals and a reassurance that candidates would only need to resit the failed part of the exam, rather than the whole exam. Would there be only one exam for overseas graduates and those at Stage 3 of revalidation, or is the proposal to run two different exams? If there is to be only one, the implications for availability of places are even greater. The GDC currently operates a waiting list and first-come-first-served rule for the ORE. If there was only one exam, UK dentists currently running practices could be delayed by over a year until they were given a place. Supervised assessment Our preferred option is Option B (supervised assessment in practice, similar to vocational training), as the whole system of revalidation should be based on peer support. The Working Group on non-medical Revalidation also felt that there should be scope for remediation within the revalidation system, and that current best practice with regard to remediation should be taken into account. 8

9 We understand the difficulties in finding appropriate supervisors and the costs, and we believe that a central system should be in place, overseen by the GDC, to help with such issues. Which approach do you think would be the most effective in protecting patients? Please state the reasons for your answer. On balance, option B has higher potential to be more effective in protecting patients. This is because the registrant will spend time in a supported environment, taking away the learning gained from that experience and being able to use it in the future. An exam is a one-stop shop for which the individual prepares, with the danger to return to their old ways once revalidation is gained as the learning is not aimed at the future, but at the present time. 27. Question 6: What do you think Stage 3 should involve for other dentist groups? The arrangements for Stage 3 for other dentist groups should mirror those for general dental practitioners, with appropriate emphasis on each group s specific area of expertise. We believe, however, that this issue complicates the proposal of an exam even further, as all specialists are also on the general register. If they failed revalidation for reasons linked to their specialist involvement, would they have to revalidate at Stage 3 also for their general registration? Would they have to sit two different exams? There are serious implications for proportionality here. 28. Question 7 - Dentists who do not practise clinically. The GDC has put forward three options for the revalidation of non-clinical dentists. These are: a. Non-clinical dentists should revalidate against all four domains, in the same way as other dentists. b. Non-clinical dentists should revalidate under an adapted standards and evidence framework, placing greater emphasis on the Management and Leadership domain and less emphasis on the Clinical domain. c. Non-clinical dentists should not have to revalidate. We believe that there should be separate, new arrangements including a dedicated list - for dentists who are not practising but who still require or wish to be on the Register. This would achieve two things. Patient protection would be served as it would be clear which dentists were not permitted to practise. It would remove the current unrealistic compliance with CPD requirements that are not relevant to their work. A third benefit would be that it could include retired dentists who wished to remain listed. This could be in the context of option b or, if retired dentists are to be included, option c. 29. Question 8: Please state whether you agree or disagree with the following statement: The GDC proposals for dentists seeking to restore to the register after a career break of less than five years are reasonable. We agree with the proposals for dentists absent for less than a year, and for dentists absent for one to five years but within the same revalidation cycle. In the case of dentists who are absent for one to five years and who miss their revalidation point, we would generally agree with the option of revalidating under Stage 2 but would also like to see the option of revalidating under Stage 9

10 1 for those who can do so. Once again, these comments are in the context of our general concern about certain aspects of the proposals. 30. Question 9: Please state whether you agree or disagree with the following statement: To protect patients, a person who is off the register for five years or more should have to revalidate at Stage 3 in order to restore, whatever the reason for their erasure. We strongly disagree with this proposal. We would like to see on what evidence the GDC bases this assumption as we doubt that there is much of an evidence base gained from FTP cases on this issue. Dentists are professionals who put the interests of their patients first and who work only within their competence. Instead of putting them through a costly and stressful Stage 3 assessment, it would be more appropriate to provide mandatory courses of a getting-back-to-practice nature. Completion of such a course should be certified and lead to registration. They could then be asked to revalidate as normal. We are not convinced that dentists on long career breaks pose a risk to patients as they will show insight into their deskilling and will generally not wish to return to work without appropriate updating of skills. It is also possible that a returner has worked abroad and decided not to stay on the UK register during their absence; after all, the ARF is very high. There may be no deskilling under these circumstances, and a Stage 3 assessment would therefore be inappropriate and lead to unnecessary stress, cost and delay to start work. We believe that much more flexibility needs to be put into the system for this group so that the appropriate pathway is adopted depending upon the circumstances of the work undertaken abroad. A full assessment of the equality implications of this proposal is necessary. The assessment should be published. 31. Question 10: Do you agree or disagree with the GDC s approach to patient and public involvement in revalidation? We agree that there should be some form of patient involvement. But, as we have suggested above, there is concern about its potential for bias and lack of rationality, so it is essential that patient feedback should be objectively assessed and verified as it is too easy for feedback to be subjective and to lack understanding of the clinical and other circumstances in which care is delivered. It should therefore not be at the fore. 32. What other arrangements would you suggest? Question 11: How do you think the GDC should manage the patient feedback element of Stage 1 of revalidation? For example, should the process be managed centrally or locally? Because of the need for assessment and verification, patient feedback must be undertaken locally. 10

11 34. Should the GDC develop its own, required questionnaire, or accept other questionnaires which cover the standards required? A standard, validated questionnaire should be developed and agreed with stakeholders. 35. What are your suggestions for how the patient feedback process should be managed? See 31, 33 and 34. There must be a standard process agreed nationally and delivered locally so that it can be sensitive to the concerns expressed above. It also needs to be funded appropriately. 36. Can you identify any positive or negative impacts you perceive the GDC s policy proposals will have on different groups or communities, for example, particular ethnic groups, age groups, etc? Please explain your answer. We believe the cost implications for the current proposals are enormous and may cause increasing numbers of professionals to retire earlier than they might have done otherwise. In modern clinical practice, the proposals pose particular cost, time and compatibility issues with dentists who balance parenthood with working lives, or who may be on career breaks, for older dentists and those with limited and/or part-time practice. Summary 37. In the current times of ever-increasing regulation, we feel that the current proposals go much further than planned by the government and by the Working Group for Non-Medical Revalidation. As outlined earlier in this document, we have particular concerns about the issue of third-party verification. 38. The lack of a full economic, impact and risk assessment must be criticised. We are aware that this is now a priority for the GDC, but would seek assurances that such an assessment will be fully published. The assessment would also need to take into account the current economic situation and the financial burden brought on the profession by other regulatory regimes such as the CQC. Without it, it is impossible properly to consider the implications of the proposals. 39. While we are aware that the GDC has a Memorandum of Understanding with the CQC on each organisation s responsibilities, we are by no means convinced that the proposals contain an assurance that revalidation will not duplicate the efforts practitioners have to make for CQC registration. 40. The feedback we have had from our members in 2010 has shown overwhelmingly that the new levels of regulations constitute a considerable burden on resources and time. This results in fewer patients being treated as practitioners set more and more time aside for paperwork and inspections and therefore impacts negatively on patient care. 41. We feel that the proposals so far need much more piloting; the pilot projects in 2009 hardly covered a representative number of dentists. 11

12 42. We are still not convinced that an adequate evidence base for the current approach has been presented. A full review of fitness-to-practise cases is necessary to show that the current proposals - or even any subsequently modified address the problem they are trying to solve. 43. The issue of quality assurance of the revalidation process needs to be addressed in the near future rather than at a time when registrants will be nearing their first revalidation point. 44. We would welcome the opportunity to provide further detailed input into any future working groups and proposals. British Dental Association 64 Wimpole Street London W1G 8YS