“This is a very important lesson. You must never confuse faith that you will prevail in the end – which you can never afford to lose – with the discipline to confront the most brutal facts of your current reality, whatever they might be.”
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Why should a “law” described first in 1908 be relevant to everyday Dentistry (and more)?
Robert Yerkes and John Dillingham Dodson described their tests with rats that could be encouraged to complete a maze when stimulated with slight electrical shocks. When the strength of the shocks was increased however the rats just ran about looking for an escape. They concluded that arousal levels helped to focus attention and motivation on the task at hand but only up to an optimum point and after that point fatigue appeared and performance declined.
Research has found that different tasks require different levels of arousal for optimal performance. For example, difficult or intellectually demanding tasks may require a lower level of arousal (to facilitate concentration), whereas tasks demanding stamina or persistence may be performed better with higher levels of arousal (to increase motivation).
The first image shows the classic inverted ‘U’ shape of a difficult task (placing implants, molar endo, treating some children are examples that come to mind). It also shows a continuation without decline of more simple tasks which can be maintained for longer without reaching a point influenced by fatigue (examinations, routine restorations on well adjusted patients).
The second image shows the typical “stress curve” where performance takes a while to peak if we are under too little stress, then goes through a short period of optimum stress before reaching too much and heading down through exhaustion to burn out.
The reason that I have written about this is that we need to look at the time periods that these curves represent from the short (an hour say) to long (months or even years). There are different challenges that dentists face with differing solutions.
Firstly of course there is the fatigue that comes from trying to do too much challenging work in a short period of time. This results in high stress levels and possibly poor performance on a daily basis. Often there are time management issues where we are obliged to match our performance to the patients availability. This can see a clinician “coasting” by dealing with the relatively straightforward whilst at their peak in terms of readiness and responsiveness but then having to find reserves of energy when the patient “demands” treatment at later times in the day. I have never understood why dentists are reluctant to tell the patient exactly when and why they would like to see them. My own experience in a practice with large numbers of children was to insist on seeing under 11s for any treatment (examinations excepted) first thing in the morning. For the most part when people have reasons explained to them and can understand that it is for their benefit then they will comply with your wishes.
Also to consider are the long term problems of fatigue that arise from the day after day, just doing it without time off. Even in the best time managed (at a relatively micro level) practice if there is often not enough time spent away to unwind, recharge the batteries and recover, then burn out will creep up on you. The prodromal signs are a lack of efficiency and, more importantly, effectiveness.
Dentistry is still a macho occupation for many who seem to get a perverse enjoyment from overwork. It’s sad but true that for many there is an opportunity to build the life they want but put obstacles in their own way as if frightened of taking control.
Time management on both micro and macro levels is hugely important, ignore it at your peril. Get help if you need it.
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The 500th Monday Morning Quote and a very personal one.
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I found out recently that a copy of this lecture had been removed from its “place” on the GDC website, there is only a summary on FGDP(UK), I am happy to produce it here because I believe it is important. If you would like a PDF copy then please contact me through my website.
INTRODUCTION
Thank you very much for inviting me to give this lecture.
I – obviously – didn’t know Malcolm Pendlebury. Since I had no connection to dentistry before taking on the chairmanship of the GDC, and have had no professional reason to spend much time in the East Midlands, our paths never crossed.
However, I have read the obituary of him that the British Dental Journal printed in April 2005. It paints a picture of a man immersed in dentistry – not just treating patients, although clearly he did a lot of that in general practice and as a specialist at Queen’s in Nottingham, but also a leader in developing education and vocational training, in setting standards and quality assurance systems and generally spreading the message that constant improvement is a key element of professionalism. The obituary concluded: “….he sought to raise the status of general dental practitioners, provide them with standards they could aspire to and thereby to raise the quality of patient care.”
The challenges that Malcolm Pendlebury identified and tried to tackle have become more pressing in the ten years since his death. How to define service quality and clinical outcome, how to regulate the providers of services and who should do so, how to meet the legitimate expectation of patients that they will be treated with respect and not be damaged by the care they receive – all these questions and more are now at the forefront of the debate about healthcare.
As a relative newcomer to both the dental sector and professional regulation, four things seem clear to me:
WHY WILL THE EXPOSURE OF FAILURE GROW?
Why do I say that the exposure of failure will continue to grow? The main reason is a change in attitude on the part of politicians and the public.
Since the creation of the NHS successive governments have tried to find ways to improve efficiency and productivity across the NHS. Beveridge’s assumption that the NHS would be increasingly affordable as a healthier population required less care quickly proved to be completely false. The demand for all forms of healthcare has grown well beyond anything that might have been expected and shows no sign of slackening. Different forms of central planning and direction have made no real impact.
Most recently the Blair and Cameron reforms to the organisation and functioning of the NHS in England have been designed to bring market pressures to bear by:
The main focus has been on hospitals, especially acute hospitals. Dentistry has not been centre stage. Indeed dentistry already operates in a market. Patients are free to choose their dentist. Roughly half of the dental sector’s income comes from private payments, not general taxation. To a reasonably large extent the success or failure of a dental practice depends on it serving its patients well. I know that not everyone likes or accepts the proposition that dental service providers compete in a market place, but that is the reality and increasingly it is the viewpoint of patients.
However, dentistry has not been unaffected by the development of a quasi- market in the wider healthcare system and will not be in the future. Why?
Markets produce failures as well as successes. Indeed, for a market to function properly customers have to be aware of whether a provider is good or bad. So, it was, and remains, a central objective of policy that the customers for different healthcare services should be able to make rational choices, based on reliable information about the quality of performance of different providers. In other words, for the policy to work Ministers have had to acknowledge – indeed, publicise – failings in clinical and service quality – some of which were highlighted by the targets set by government.
Simon Stevens, in his recent speech to the NHS Confederation’s annual conference highlighted the importance of publishing reliable and easily- accessible data on clinical performance. Not for the first time most effort is focussed on acute hospital care. But, in time this will become routine in every part of the English healthcare system, I believe. Already there are several social media sites where patients offer their own, often highly-subjective, assessment of the quality of care they have received. So, it would be foolish to think that the information revolution will pass by dentistry.
Even today the exposure of failure has had an impact on dentistry as well as on teaching hospitals and DGHs. Today media stories about healthcare, including dentistry, are as likely to be about failings as successes. Politicians and the media are prepared to criticise the healthcare system in a way that would have been unthinkable a decade ago.
This pressure to expose failure in all its forms will not reduce in the future. Indeed, the financial pressures that lie ahead for the healthcare sector may well increase the risk of bad practice and poor treatment.
The case for protecting the funding of the NHS is increasingly questioned. As the economy grows, so too will the funding of the healthcare system……probably. However, we won’t see repeated the scale of increase in funding of the early part of this century.
If additional funding is forthcoming, acute hospitals are likely to continue to absorb a growing proportion of the available money. There will also be new priorities to accommodate. For example, ministers are increasingly emphasising the need to support the funding of social care from the NHS budget, and to give mental health a degree of protection.
Somewhere in the system funding will be squeezed. It seems unlikely that dentistry will escape. But a squeeze on funding can create unforeseen incentives to take risks – to cut corners in diagnosis or treatment, to use cheaper materials, to spend less time per patient, to avoid investing in new equipment or in maintaining premises, and so on. These are precisely the kinds of behaviour that generate complaints to the GDC and other regulators about fitness to practise.
DEMAND FOR DENTISTRY IS GROWING…AND SO ARE COMPLAINTS
Public attitudes have also changed. The users of dental services are now much more consumerist in their attitude. Dentists and dental care professionals now have customers, not clients ………or, indeed, patients. Part of a consumerist attitude is an expectation that services will be organised around my needs and preferences, that quality will be good and the price fair. And if the service is poor or the quality unacceptable, consumers are willing to complain and to seek whatever form of redress seems appropriate to the circumstances of the case.
These consumer pressures are compounded by the increase in demand for dental treatment, and in the volume of complaints. 1.4 million more people have been seen by an NHS dentist since 2010. Not all of this is traditional oral healthcare work. Demand for cosmetic treatments continues to rise – there has been a 50% rise in cosmetic dentistry in the past 5 years
So, this increase in demand for services coupled with changing attitudes have together generated an unforeseen level of complaints. There has been a 110% increase in complaints to the GDC between 2010 and 2014. Well over half of our budget is spent on fitness to practise.
And it’s not just the GDC that is getting more complaints about dentists and dental care professionals.
It is extremely difficult to get a completely accurate picture of dental complaints across the UK as it isn’t centrally recorded. But in 2012-13:-
Add to these figures the 2972 complaints made direct to the GDC.
In 2013 there were just over 38500 dentists and 62500 dental care professionals on the GDC’s register. So very crudely – and I stress that caveat – these very rough figures could mean that 17 per cent of the profession were the subject of some form of complaint. Even allowing for some overlap between the referrals to different agencies, this is staggeringly high.
It also undermines somewhat the proposition that there is a high level of patient satisfaction with dentistry.
Bear in mind that the GDC doesn’t aggressively market its disciplinary role………we don’t behave like a claims management company! However, the Francis report said regulators should raise their profile with patients and engage in more pro-active regulation. The GDC can’t ignore that.
All of us – we and you and the other professional bodies – need to understand better what is causing this apparently high and growing level of complaint, and what can be done. Perhaps we should meet to pool intelligence and to identify areas for research or further analysis.
THE GOVERNMENT WANTS BETTER AND FASTER REGULATION…….THE GDC IS UNDER PRESSURE
My second theme tonight is the need to recognise that the regulators themselves are not immune from scrutiny. We are under pressure.
A big part of the focus of the Francis inquiry into Mid-Staffs was on actual and potential failings in the overall regulatory system – both professional and system regulators. The Healthcare Commission (now CQC), Monitor, the GMC, the NMC were all criticised to different extents.
And even before the Francis report was published and the Government started to think about its response, it was becoming increasingly clear that, despite a sophisticated system of commissioning and regulation, Mid-Staffs was not unique in mistreating patients and delivering care of an unacceptably poor standard. The Government realised with some shock that poor professional performance was being unearthed in many parts of the healthcare system. This was – and is – a bigger problem than just Mid-Staffs.
As a result the political and media focus was, and remains, as much on the performance of the regulators as on the performance of clinicians.
So, the Government wants better – tougher and faster – regulation. The following quote from the Government’s response to the Francis report in March 2013 illustrates this.
“……where standards are not met, the health and care system must be quick to detect problems, take robust action and hold those who are responsible, to account“
A regulator must be seen to act. Any delay or hesitation leads politicians to question whether the public can have confidence in the regulator…… which, of course tends to undermine public confidence!
But, there is, I think, confusion in the minds of politicians and the public – and certainly the media – about whether good professional regulation is intended to punish registrants for past failures, or to establish that registrants have changed their behaviour or improved their skills – or are willing and able to do so under supervision – so that they are fit to practice again either now or in the near future. That’s an issue that needs further exploration.
So, this is the era of conspicuous regulation, when rapid and tough intervention by a regulator, with maximum transparency and publicity, is the expected response to any failure in the healthcare system. And, of course, there are many occasions when that is a reasonable expectation.
THE IMPLICATIONS FOR THE REGULATION OF DENTAL SERVICES
What does this mean for dental regulation?
The GDC has to respond. Our system of regulation has to be, and be seen to be:
However, we operate in a complex regulatory environment, with different organisations policing different, but sometimes overlapping, parts of the healthcare system. For example, both CQC and the GDC regulate dentistry, and the MHRA regulates medical devices and the HSE can have a role in policing safety issues such as radiography. No doubt there are other bodies which might have roles in specific types of case – fraud, for example.
So, the GDC needs to be clear about its role and responsibilities, although these are nowhere defined very clearly so far as I can establish.
My current view is that the GDC’s responsibilities might be defined as:-
This isn’t very different to the obituarist’s summary of Malcolm Pendlebury’s professional ambitions, although perhaps more prosaically expressed.
If this is indeed a correct formulation of the mission of the GDC, everything we do should be determined by it, and we should do everything we reasonably can to achieve these purposes. I want to spend a few minutes summarising our current activities and future plans to discharge this remit.
However, we mustn’t lose sight of the fact that the GDC is only one of several actors on this stage. Dental care, like most sectors of healthcare, is part of a system in which different elements – policy makers, commissioners, regulators and service providers – have distinct but complementary parts to play in the organisation, delivery and oversight of good and improving care. The dental professions, and, indeed, patients, have big roles to play and I want to say more about this before I conclude.
Fitness to practise reforms
Returning for the moment to the GDC, undoubtedly the Council’s first priority for 2014 is to strengthen our fitness to practise regime. And we have already made a good start. While the decisions taken by the panels are judged by the Professional Standards Authority to be generally sound, we know from the audits undertaken by the Authority that our basic administration has been sloppy – poor communication, inadequate record keeping, deadlines missed etc. Part of the reason has been poor training and supervision of the staff. That is being sorted.
Part of the reason has been excessive caseloads. By investing in new teams to clear the growing backlog of cases, we have also managed to reduce caseloads to an efficient level. Already the benefits are clear. We are also using our technology better to manage processes – to ensure deadlines are met and communication happens.
Each of these is a small thing in itself, but in total they will create – are creating – better, more efficient processes that will enable us to offer a better service to patients and to registrants. The recruitment of an expanded pool of IC panel members and the creation of a much stronger support function for the panels will also play a big part in improving our performance in this area.
One consequence of this scale of investment is that fees will rise, probably substantially. And they need to keep pace with the increasing volume and cost of fitness to practise cases, although the GDC is no more immune to pressures on its costs than any other public body.
However, all that said, the legislative framework within which we currently operate is badly in need of a complete overhaul. It’s disappointing that the Government will not introduce in this session of Parliament the draft Bill produced at its request by the Law Commission. A huge amount of time and energy has gone into developing that draft legislation. I hope it hasn’t been wasted. But I am clear that the bulk of the reforms it would have created will not happen in my term of office in the GDC. We will lobby hard to rescue what we can from it. Any help you can offer will be gratefully received!
However, fitness to practise should not be the main means of tackling under- performance and patients’ dissatisfaction. In many cases a lengthy and complex process dominated by lawyers, over which the patient can exert almost no influence, is not what aggrieved patients want. They want an apology (probably) and they want deficient dentistry put right, which in some cases means funding to seek treatment from a different practitioner. This is what the Dental Complaints Service offers, and it does so remarkably successfully. It’s fast, it’s cheap and complaining patents and registrants are both very satisfied with the results it achieves.
But, it’s available only to private patients.
My aspiration is to extend the work of the DCS to include patients funded by the NHS. As well as giving a better service to patients who seek personal redress and to registrjants whose professional work is generally acceptable in quality but has failed in a specific incidence, making the simpler and faster and cheaper processes operated by the DCS much more available ought to reduce the current high level of expenditure on fitness to practise.
In addition to these internal process reforms the GDC is developing a strong working relationship with the CQC. Information is being exchanged, areas of risk are being identified and each regulator is gradually influencing the approach of the other. I am confident that this process will continue, to the benefit of both bodies. We aim to secure a similarly close relationship with NHS England, particularly under Simon Steven’s inspiring leadership. Securing close coordination of the specification and commissioning of services, system regulation and professional regulation will be beneficial to both the dental professions and also to the users of dental services. But, it’s work in progress.
Two other issues on our agenda deserve to be mentioned.
First, Continuing Professional Development. We attach importance to the registrants we regulate keeping up with developments in their fields, adding to their knowledge of their subject and related disciplines and learning new skills and techniques. But, it feels to me intellectually unsatisfactory for the regulator to focus on the volume of CPD undertaken by different dental professionals and not to pay some attention to the quality of the CPD products on offer and the effectiveness with which they are delivered. Can it really be left to individual registrants to assess the quality and relevance of the wide range of CPD now on offer? Shouldn’t the regulator, or the professional bodies, develop a better means of identifying CPD products that will genuinely improve the quality of dental care? I don’t pretend we have specific plans. But this feels to me an area where not everything that should be done has been done.
Second, standards. As someone new to the field, I find the GDC’s standards impressive – clear, pertinent, covering all the main issues, not over-prescriptive. We know that a majority of registrants are aware of the standards, and that they get referred to for guidance in dealing with specific issues that arise in practice. However, our research suggests that knowledge and use of the standards is by no means universal in the profession. That concerns me. It raises in my mind the question whether the GDC should make a more explicit link between securing registration – the right to practice dental care – and reliable evidence of knowledge and use of the standards.
Our registration system puts a lot of effort into establishing the qualifications of an applicant at the point of first registration, and rightly so. But, if we share Malcolm Pendlebury’s stated aim of a high-status, high-standards profession, shouldn’t we use the levers available to us to ensure that the standards we have developed are properly understood by all registrants? It a thought I leave with you tonight, but one I hope we might return to in the future.
A stronger focus on patients
A few moments ago when I was talking about the GDC’s responsibilities the first thing I mentioned was protecting patients from harm. We need to develop a better understanding of what those words mean in practice to patients. There is little point in us pursuing programmes of action that patients think are irrelevant to their needs and aspirations. So, in thinking about our future strategy, the GDC’s starting point will be to develop a better understanding of the perspective and priorities of patients.
The research we have done to date paints a confusing picture.
96% patients claim to be “satisfied” with their dental treatment. But they have no clear idea of what might constitute quality of service or of treatment. And, underneath the surface, there is evidence that the apparently high level of patient satisfaction is wide but not deep.
So what drives patient satisfaction with their care and treatment?
Patients described a good dentist as being one who had excellent communication skills, talked through the treatment that they are having, were polite and treated them with respect. Trust that the patients’ interest is put first is also key.
Qualitative research the GDC carried out in 2013 suggested that for many patients their satisfaction derives more from assumptions they have made rather than firm evidence.
Patients assume that regulation is more extensive, unified and patient-centred than those of us involved may believe to be the case in practice. Patients are often poorly informed about the role of the GDC, but expect a proactive approach to regulation. They assume that we and other regulators actively search for consistent signs of poor care or malpractice, and expect evidence of problems to be proactively followed up without the need for a dis-satisfied patient to lodge a formal complaint. In our focus groups patients emphasised the importance of regular, unannounced OFSTED or mystery shopping-style inspections, which should focus on all aspects of quality dental care. And they were keen on star ratings being applied to dental practices.
Patients had specific views about the type of information that would support them in making choices and acting as informed consumers. They want to understand issues such as how good their treatment is and how safe their dental professional is.
Of course, not all patients had identical expectations and attitudes. There was a continuum. At one end were patients characterised as having a traditional outlook – they assumed that all dental services were of a similar quality and so they tended to base their choice of provider on convenience; they were unlikely to complain, except where they received very poor care.
At the other end were patients with a strong consumerist outlook who were likely to be more active and demanding. They would compare dental treatment and shop around. They were much more likely to complain and to provide feedback and they were consistently the most likely to be positive about increasing patient choice.
Many patients were in the middle of this continuum and exhibited attitudes and behaviour drawn from both types, but would be likely to be more demanding when circumstances changed (moving to a new area and choosing a new practice).
We will continue to research the attitudes of patients. In addition we are launching an online patients’ panel. The three main objectives of this are;
I hope that this will broaden and deepen our understanding of the perspectives of different types of patient, and guide us in developing strategies driven by what patients need and want.
I also hope that we, and NHS England and the devolved administrations, and perhaps the profession itself can develop sources of information that patients can use to make well-based choices. One sure way to reduce the growth in fitness to practise cases is for patients to be able to choose where and how they are treated based on reliable and easily-understood information about issues such as quality of service, appropriateness and effectiveness of clinical treatment, likely cost. Enabling potential service users to avoid weak practitioners before damage is done is surely a lot better – and cheaper – rather than prosecuting a fitness to practise case after the event.
THE CONTRIBUTION OF THE PROFESSION
I’ve talked in some detail about what the GDC is doing and what we aspire to do and achieve. And I’ve also talked a little about the role that patients can play in incentivising registrants to deliver high-quality care and treatment, given easy access to good and relevant information. What can the profession, and bodies like the Faculty do both to improve standards and prevent the continued growth in fitness to practise?
I don’t have a to-do list for you. That wouldn’t be inappropriate. But, taking as a starting point the aspirations of Malcolm Pendlebury, as his obituary summarised them, I think I can be expected to pose some questions for your consideration.
First, does the public, especially users of dental care services, understand what you do to protect them and to promote better and safer care? Is there more that you can do – in concert perhaps with us and others – to educate potential users of dental care services about what level of quality and safety they are entitled to expect? About what “good” and “excellent” mean?
Second, how can you help us prevent the growth in fitness to practise? How can you help to get our standards understood and used by all registrants? If that were achieved, if our standards were internalised and put fully into practice, many complaints would be dealt with in the practice and not in a GDC hearings suite.
Third, can we work together to understand better what patients want from dental care and why they feel it is necessary to complain? Can we, and other bodies, join forces to develop a common understanding of the reasons for different categories of complaint and to understand how the need for complaints might be prevented?
Finally, CPD. How can you help to ensure that what is on offer is of high- quality and genuinely improves the knowledge or skills of registrants? This seems to me a key issue for the profession to tackle, with every encouragement from the GDC.
CONCLUSION
Mr Chairman, once again my thanks for inviting me to give this address. If nothing else I have found it extremely helpful as a means of getting my own thoughts in some kind of order, although I would be the first to acknowledge that I have much to learn. I hope, however, it has been of some interest to you and your colleagues tonight. And I hope it has helped to illustrate that the agenda that Malcolm Pendlebury pursued throughout his professional life remains as relevant today as it was ten years ago.
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Sam Woolaston writing after 14 years as a TV reviewer.
“The Apprentice, maybe more than anything else, drives home that I have been doing this long enough; too long, some might say. I have written 20 – twenty – reviews of The Apprentice, and that’s not including The Young Apprentice, plus interviews with winners, with Lord Sugar and with Sugar’s sidekicks. I have nothing left of any interest to say about The Apprentice.
It’s not just the show that is tired – I am, too.”
I bailed out after series one having come to the same conclusion, so glad I didn’t waste any more of my life on it.
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I rarely comment on the quotes that I post, if they are worth reading then they should stand up on their own. This one is different because it falls into the “Sybil Fawlty” group of “bleedin obvious”. We have all been there and (sometimes) not done that. We have all stayed in a comfort zone that is increasing in discomfort but has not reached the tipping point. If my bringing these words from Bud’s book “You are in the right place” to your attention is a catalyst to help you do something different then my work is worthwhile.
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