Tricky questions

05 March 2013
Volume 29 · Issue 3

Last month’s Francis Enquiry Report into Mid-Staffs Hospital, and particularly its management and systems, made for uncomfortable reading, at least for the public.

Writing in The Times, Dr Phil Hammond, hospital doctor and speaker at the BDA conference two years ago, had some even more forthright words, saying: “The Department of Health exists to ‘manage’ bad news, protect reputations, suppress dissent and deliver only good news.”

That attitude, says Hammond, goes to the heart of the NHS organisation. We have all heard or read in the media of whistle-blowers being victimised and even dismissed for having the temerity to report instances of sub-standard care.

In dentistry, the situation is little better. Whilst, as the CQC’s report on the State of Care showed unequivocally, the vast majority of dental patients are treated safely, appropriately and efficiently, there are, as we all know, a small fraction of practitioners and professionals who more or less consistently fail to meet acceptable standards.

Of course, as registrants we all know we have a duty to report any such instances of which we become aware. ‘Raising concerns’ it’s called and the GDC has a very good guide to the process on its website.

That is where the problems can begin. Initially, concerns should be raised with your employer or locally, which could be a career-limiting move for an associate or a dental nurse. If victimisation is believed likely (hard to prove, I’d say) then, after seeking advice from your professional organisation (hmm) or defence organisation, you should consider telling the GDC itself, as well as the CQC (or whichever flavour of regulator happens to govern your patch).

Be prepared for lots of form filling. Starting with your full name, partly because anonymous concerns are probably treated somewhat less seriously (and more easily brushed off, perhaps), and partly because it enables the concern-raiser to obtain protection under PIDA. Not to be confused with PeedOff, this is the Public Interest Disclosure Act, and contains some worrying loopholes.

Essentially PIDA will protect you against recriminations only if the matter concerns law-breaking, health and safety, or environmental terrorism (such as pollution). Poorly crafted amalgams, or a post crown with no root filling? I’m not sure you’d be protected there.

So you see a couple of poor treatments from a practice across town, or spot the dentist you work for re-using a turbine handpiece on a second patient. What then? If you go to the GDC, you’ll have to provide evidence to support your contentions. If they follow up and find a case to answer, you’ll be required to attend a hearing, for which you’ll get a travel allowance but not much more for your day off work.

Plus the hearing date may change at the last minute, or it could turn out at the last minute that you’re not needed after all so why did you cancel a whole day’s patients?

Most dentists, we all agree, offer a good or excellent service, certainly so far as clinical care is concerned. At least they have demonstrated that their ‘patient experience’, safeguarding and infection control satisfy the (mostly non-dental, to date) CQC inspectorate. So why, they can legitimately argue, does everyone have to go through a regulatory inspection every other year at a cumulative cost of up to £1,600 (in England)?

Judging from recent statements, the CQC feels the same way. But the only way to identify the ‘non-compliant’ is by the sort of process I’ve just outlined. There’s no doubt that a ‘duty of candour’ which the NHS is about to adopt (supposedly) is truly politically correct and in the over-riding interest of patients. “I’m so sorry Mrs Jones, the final periapical shows that your root filling is actually 3mm short of the apex and this may lead to a reduced long-term prognosis” is actually quite a difficult route to follow – especially when the receptionist is going to ask for £350 downstairs.

Equally dangerous to criticise others, tempting as it may be. “Mrs Jones, do you realise that your last dentist missed the well-established interproximal caries on three of your back teeth?” But I suspect for many that’s the easy way out, unprofessional as it may be. Easier that than the unpaid trip to a Fitness to Practise hearing?

All this is cruel and unfashionably blunt. Not for nothing was this column called Tricky Questions. The truth is that if we really want an open, transparent and caring healthcare system, these are some of the issues we have to contend with in our own, relatively fatality-free corner of medicine. How must it feel in A&E or a high dependency unit?

The only answer has to come back to ourselves as individuals. We have to embrace open discussions and communication within teams, to be prepared to admit that none of us is perfect and that we can all improve our practice. And that (I’m afraid) takes two things: reflection and audit. We’ve got to review what we do, and to enable us to do that, we’ve got to put metrics on our history.

Great, I hear you say, not only have I got to put up with regulation, standards, compliance and all the rest, and treat the patients, now I’ve got to spend half my life looking back at the other half. The answer is “yes you have – and moreover, when you look in the mirror, you have to be honest about what you see”. If we only could all do that (including the managers and staff at all the healthcare premises across the UK), the Daily Mail would have to write about something else.