The phrase 'elephant in the room' is an English metaphorical idiom for an obvious problem or risk no-one wants to discuss, or a way of thinking no-one wants to challenge. It's not quite the same as burying your head in the sand, but it's not far off.
For too long society has left mental health to fester. That particular elephant in the room looms large. Yes, there are confounding factors – austerity for one has caused significant stress for many – but ultimately the environment we operate in has become a melting pot of issues.
Tim Newton and Brid Hendron have previously said stress is: "complex and difficult to define as it both ambiguous and context dependent. It is experienced by our profession as a whole, service providers both secondary and primary care (independent or corporate) and internally at the level of the individual professional. Individuals often choose their own words to describe stress such as anxiety, pressure or unhappiness but there is a general consensus that stress is something most of us would prefer to be without"
BDA research shows 39% of community dentists and almost half of GDPs have self-reported high levels of stress. Those are alarming statistics, even more so considering the average for all British workers stands at 15%.
A simple Google search shows you how prominent the topic is, and how far back people have been discussing it. Indeed one could argue the fundamentals of dentistry may well serve to cause and/or increase stress. A dental contract unfit for purpose, constant government change, financial pressures and the pressure to deliver customer service are all issues previously cited, but there is one that has the potential to cause more trouble than most.
In 2014, the GDC received 3,099 fitness to practise referrals. This also happened to be the year the BDA took the GDC to court over the unlawful raising of Annual Retention Fees. Make of that what you will.
Only four years prior to that, the number of fitness to practise referrals stood at 1,401, and in 2016 the figure showed signs of decline at 2,630.
According to a report published by Europe Economics, evidence suggests that male dentists in the UK are more likely to be referred to complaints or disciplinary bodies than female dentists. This is also supported by evidence from literature about other healthcare professions.
Stress can cause a number of repercussions, some more obvious than others. Everyone can understand money, so we'll start there. In 2015, Dentists' Provident paid £58,956 for 'work related stress'. In 2016 they paid £125,735 for the same reason.
In 2015, Dental Protection published the findings of a survey of their members who had been investigated by the GDC. In their response to the GDC's consultation on Voluntary Removal from the Register, they stated that 78% of dentists reported a detrimental effect upon their mental or physical health, 94% reported an impact upon their stress and anxiety, 76% said it had an impact on their personal life and 67% reported an adverse effect on their confidence.
A staggering 34% of dentists considered leaving the profession after having been investigated by the GDC. There is little doubt that as an investigation can take years to conclude, dental professionals' mental and physical health might suffer as a result.
Pertinently, the same response also stated: 'Unfortunately in these situations suicide is a very real risk'.
Let that sink in for a minute. A Fitness to Practise case could potentially lead to suicide.
Unfortunately for medical colleagues, that potential has become a reality. During 2005-2013, the GMC reported 28 cases of suicide or suspected suicide while the doctor in question was under investigation for fitness to practise.
Rory O'Connor, a co-ordinator at the Dentists' Health Support Programme, told BDJ In Practice he wasn't particularly surprised:
"There is little doubt fitness to practise cases brought against an individual can induce significant problems in their lives', he said. 'In my experience, besides the anxiety caused by cases that go to hearing, there's an element of guilt and shame involved too. It doesn't matter if there's no case to answer, calling someone's professionalism into question is going to cause a ripple effect.
"The biggest issue I see in the process is the time span between being notified of a case and the outcome. In our opinion it is totally unnecessary and causes more harm than good. I understand there is a process to go through and the GDC need to gather evidence, but too often it is a process drawn out way beyond what we consider reasonable. Perhaps in the past there has been a 'one size fits all' approach to cases, and that is no way for a regulator to approach such a delicate process. Furthermore, signposting to where and how the individuals in question can seek support throughout the duration of these cases is severely lacking.
"You are entitled to support throughout the process. It isn't an easy time, there's no getting away from that. The problem is people do not know where to go, where to look, who to turn to. This is when problems start to mount. The GDC pop a line or two at the end of the fitness to practise notification, but by halfway through the letter you're understandably concerned about the content, it gets overlooked.
"We have long suggested that the GDC should follow the same model as their veterinary colleagues, the RCVS. They send out the support programme in a separate letter detailing what the help and support protocol is. It's clear, definitive and no doubt helps the practitioner involved throughout.'
The right approach?
In July 2014, the GDC placed a number of advertisements – one of which appeared in the Telegraph – encouraging patients to contact the Dental Complaints Service (DCS) if they were not completely satisfied with their private dental care.
The advert neglected to mention local resolution, and instead advised patients to contact the DCS.
Looking past the legitimacies, the nuances and the timing of the ad, Rory believes it was another line in the ad that could do the most damage:
"In it there was a line about the GDC 'protecting the public', and I asked myself from what? The message there is completely wrong. The regulator is not a barrier or a line of defence between the public and the profession. Around one in four adults already have dental anxiety, and if our own regulator is suggesting they're protecting the public from the profession, what sort of message does that give out?
"It was an unnecessary thing for the regulator to do, as it provoked fear. It was little wonder the profession reacted in the way they did. If, as a practitioner, you are constantly practising in fear of having a complaint made about you, then it is highly likely someone will complain about you.
"If you practise without fear, with confidence in your abilities, the chances are greatly reduced. It is like playing not to lose and playing to win; you often find those playing not to lose will be on the wrong end of a score.'
John Makin, head of the DDU said: "The already significant workload that dental professionals have to cope with, the need to meet patient demand and the large amounts of information to absorb, make dentistry a high-pressure profession at the best of times. This can be further increased by the duty to cooperate with GDC investigations. While responding to investigations is part and parcel of being a dental professional they can be the source of significant personal stress.
"A DDU survey of just under two hundred dental professionals who had faced a GDC investigation or negligence claim in the previous five years, found that over 50% worry about being sued or complained about again. Roughly 33% of respondents said the experience meant they no longer trusted patients or treated them differently, while 14% suffered health problems following the complaint or claim."
MDDUS Head of Dental Division Aubrey Craig added: "Being on the receiving end of a GDC complaint can be extremely stressful and it is natural for dentists to fear the worst, even though few of these cases make it beyond written correspondence.
"The often unjustified threat of regulatory action can destroy careers and reputations and lessen public confidence. That serves neither patient nor dentist.
"We strongly believe that the GDC fitness to practise process needs to be more sensitive to the needs of dentists. The current dental complaints system is slow, disproportionate, outdated and cumbersome. As a result, many dentists face unnecessary stress and anxiety. Resolving more complaints at local level would benefit patients and reduce stress on dentists."
A renewed focus?
With the GDC seeking feedback on its future plans, and government understood to be contemplating wide-ranging reform of health regulators, the BDA is preparing to reach out to its members and seek their views on shaping the future of regulation.
While change is clearly needed – and to some extent underway – BDA Chair Mick Armstrong believes the reappointment of his GDC counterpart is a missed opportunity:
"The GDC Chair's term in office has been defined by a total collapse in trust in professional regulation among this profession, and the question remains whether such a figure can ever deliver the change we need', Mick said.
"While this reappointment represents a missed opportunity, our priority remains clear. Patients and practitioners deserve a regulator and a chair that really understand dentists and dentistry."
Raj Rattan, Dental Director at Dental Protection welcomed the GDC's willingness to reform, but believes there are a number of areas that still require attention:
"Firstly, the length of time taken by the GDC to carry out initial investigations needs to be addressed. Long investigation times can be detrimental to dental practitioners' health and wellbeing.
"Secondly, Interim Orders Committee (IOC) referrals continue to be made far too freely and this is concerning. In our experience a significant number of cases do not meet the necessary legal test for an interim order and should not have been referred to IOC in the first place. Referrals can be made late into the process, even when the GDC has had the papers for months, if not years during the initial investigation phase suggesting that there is no real urgency or perhaps even necessity. These delayed cases undermine the reputation of the GDC in the eyes of the profession and the public.
"Thirdly, the GDC must make clear that 'misconduct' is very serious, so an ordinary registrant and/or member of the public understand that an investigation is necessary to protect the public.
"Finally, whilst undertakings are used as a quick and effective way of ensuring public protection, they must be proportionate and manageable to be acceptable.
"The suggestion that undertakings be offered and agreed as an alternative to a Practice Committee Hearing is a sensible alternative – both from a public protection perspective and a cost perspective - and is a welcome proportionate proposal in the context of achieving 'right touch' regulation.
"The procedures the GDC have already put in place to deal with cases at a local level, when there is no realistic prospect or likelihood of a finding of current impairment, are a positive step forward. However, reducing the number of unnecessary Fitness to Practise hearings is also vital and something we have consistently called for.
"While safeguarding the public is vital, it is also important that dental professionals are not put through stressful and preventable inquiries by the regulator. A review of dental regulation is necessary and we welcome the opportunity to join the debate."
Commenting on the GDC's recent activity, John added: 'The GDC has acknowledged the need for change and, after discussion with the DDU and others, has already made some welcome changes to its Fitness to Practise processes.
"One example is the introduction of Case Examiners with a view to reducing the number of protracted cases leading to stressful and costly Fitness to Practise hearings. However there is still more work to do to improve the process so that the Fitness to Practise process is proportionate and fair to registrants while maintaining public protection.
"The GDC's recent publication Shifting the Balance discusses further potential measures and we welcome the increased focus on prevention as there are still too many complaints going to the GDC that fall outside its powers and should be made more appropriately elsewhere. We will be scrutinising the proposals in detail on behalf of members and responding to them."
MDDUS has also welcomed the 'ambitious and radical plan' from the GDC to shift the priority to upstream prevention from downstream punishment, to refocus fitness to practise work and to make the complaints process more transparent, consistent, fair and responsive.
Aubrey said: "We fully support any steps that will make the complaints and regulatory processes less stressful for dentists and reduce the number of unjustified final hearings.
"As John has previously alluded to, early local action is key to defuse complaints. In our experience, patient complaints that are dealt with quickly and efficiently between the patient and the practice are far more likely to be resolved.
"Wider reform is needed to achieve this. So, we welcome work on a profession-wide complaints handling initiative that strengthens first-tier complaint resolution and the steps being taken to improve efficiency, transparency and decision making in the fitness to practise process.
"We believe focus should only be on the most serious allegations, usually where there is an apparent immediate risk of harm to the patients. The GDC's challenge now is to turn aspiration into credible and effective action."
According to Rory, there have been instances whereby individuals have struggled to get indemnity, even if they have been through a Fitness to Practise case and the decision was no case to answer:
"That is a distinct barrier to your professional life", he said. "On most occasions the indemnity is significantly – and potentially in the thousands – more expensive, but we have also spoken with dentists who cannot get indemnity at all, even if there is no case to answer. The whole process is wrong, and simply does not look after its own."
MDDUS stated that 'Risk sharing across the profession is at the heart of what we do. Only where a dentist's risk profile falls seriously out of line with others, will we consider restricting the benefits of membership or very rarely declining to offer renewal.
"All individuals who are interested in joining MDDUS must undergo a careful risk assessment process that is implemented fairly and consistently. Such a process is necessary as due to the fact that we are a mutual indemnity organisation and have a responsibility to protect our members' interests by ensuring the decisions we make do not incur any inappropriate risk – this can sometimes mean refusing applications for membership.
"The combination of our mutual status, lifetime protection and flexible use of discretion in our members' interests gives greater protection than the commercial alternatives available."
John told BDJ In Practice: "The DDU is part of a mutual not-for-profit organisation owned by its members and as such, we must act in the interests of all those members. This includes monitoring for and managing risks to which the organisation may be exposed.
"When considering new applications for membership from colleagues who want to join the DDU, we take in to consideration the interests of our existing members and the risk any new applicant may pose to the mutual fund. Each application is, therefore, carefully considered on its merits. However we do recognise that in recent times no colleague has been immune to the potential risk of a complaint to the GDC and we are mindful of this."
Raj said: "Our approach to risk carefully balances the needs of the individual member with those of the membership as a whole. We are well aware of the potential impact that claims and regulatory proceedings can have on a member's career, and believe that prevention is better than cure. We aim to alert members when their risk profile differs from that of their peers, and work with them to reduce their risk, although this may not always be possible.
"Our focus is to protect and support the professional interests of over 300,000 members around the world. We believe that the majority of members should not be compromised by the small minority who receive a comparatively high volume of claims, and in these instances we will act to ensure that their actions do not adversely affect the mutual fund.
'When making any decision on future membership, we take into account the whole history of a member, which may include information that the GDC does not hold and is not aware of."
There is little doubt surrounding the appetite to change. In an ideal world groups like the Dentists' Health Support Programme would cease to exist. We would look after our own better than we do now. Confounding issues such as the contract and a challenging economic climate have and will continue to take their toll, but, as Rory points out, it is – or at least it should be – the role of the regulator to ensure the welfare of its members are at the forefront of policy moving forward. The consultation process will no doubt shed some light on what BDA members think of the GDC's appetite for change. For the sake of their mental and physical wellbeing, it is one we all hope will satisfy their hunger.
Why we need change
This letter published in the British Dental Journal and is the type of situation that can cause any healthcare professional – let alone a dentist – cause for concern.
BDJ Portfolio Associate Editor
This article was orginally published in BDJ in Practice in March 2017.
BDJ in Practice magazine
BDJ in Practice magazine is part of the BDJ portfolio, and is posted out to BDA members monthly, covering the latest issues, trends and information relevant to practising in dentistry today.