Dentists, Dental Care Professionals, Nurses, Nursing Associates and Midwives (International Registrations) Order 2022
(1 year, 11 months ago)
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Lord Markham
That the Grand Committee do consider the Dentists, Dental Care Professionals, Nurses, Nursing Associates and Midwives (International Registrations) Order 2022.
Relevant document: 15th Report from the Secondary Legislation Scrutiny Committee
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
I thank noble Lords, and declare what is a kind of interest, in that my wife, as many noble Lords have heard me mention before, is an international dentist. For my sins, I had the joy of helping her to fill out one of these international GDC registrations—so I have a little bit of knowledge in this space. It was not the most riveting exercise of my life, but I do have some knowledge.
I beg to move that the order be approved. International dental care and nursing professionals form a vital part of the NHS workforce and make an important contribution to the delivery of healthcare in the UK. The GDC and the Nursing and Midwifery Council are the independent statutory regulators for the dental and nursing and midwifery professions in the UK, and nursing associate professionals in England, respectively. They set registration standards for healthcare professionals who wish to practise in the UK.
International professionals who wish to practise here must meet the same rigorous standards that we expect of UK-trained professionals. We believe that it is in everyone’s interests that such professionals can use registration processes that are a fair test of their professional competence and that provide them with a clear route to registration. We are reforming the legislative framework for the regulation of healthcare professionals to better protect patients, to support our health services and to help the workforce to meet future challenges. Ahead of this, action is required to provide the GDC and NMC with greater flexibility to amend their international registration processes. This will help the regulators ensure that future international registration pathways are proportionate and streamlined, while continuing to robustly protect patient safety.
We plan to take forward all the proposals we consulted on and have made one small amendment to the order in the interests of patient safety. This relates to the requirement that a qualification relied on by international applicants to the dental care professionals register can no longer be a diploma in dentistry. This change introduces fairness and consistency between the UK and international routes, as UK-qualified dentists cannot apply to join the DCP register using their dentistry qualification. The GDC also expects that increasing the capacity of the ORE exam will support international dentists applying to join the GDC’s register. The amendment will allow the GDC to process applications from dentists to join the register as DCPs that are received up to the day before the order comes into force. This guarantees that any live DCP title applications submitted before the legislation is passed will be processed.
I draw the Committee’s attention to an issue raised by the Secondary Legislation Scrutiny Committee, which noted that the Committee may wish to seek reassurance on how appropriate safety standards will be maintained. The primary purpose of professional regulation is to protect patients and the public from harm. Any new or amended registration pathways will be based on applicants meeting the same standards of training and knowledge as UK-trained professionals. These standards are set by the independent regulators in consultation with the professions, the public and education providers.
The order provides the GDC with greater flexibility to apply a range of assessment options for international dentists and dental care professionals. The GDC will have much greater freedom to update its overseas assessment fee, content and structure, now and in the future, as these will no longer be set in legislation that requires Privy Council approval to be changed. The requirement that dental authorities provide the ORE is removed, allowing the GDC to explore alternative providers. Candidates who were affected by the suspension of the exam during the Covid pandemic will be provided with extra time to sit it.
I understand that the GDC will first consult on the new rules in its international registration processes, which will come into force 12 months after this order is in force. It plans to increase the capacity of the ORE exam and support greater numbers of international dentists to join the register more quickly.
The order also includes a charging power, so that fees can be charged to international institutions for the cost of recognising their qualifications. This will support the GDC in registering individuals either based on an assessment of their qualifications, skills and training or by recognising the qualifications they hold.
On changes to the Nursing and Midwifery Order 2001, the NMC will have the flexibility to use two pathways in addition to its test of competence, which will remain its primary registration assessment. The first is recognition of an international programme of education. The second is qualification comparison, whereby the NMC may ascertain whether an international qualification is of a comparable standard to a UK one. The draft order also clarifies the NMC good health and good character declaration requirements. I commend this order to the Committee.
Lord Hunt of Kings Heath (Lab)
My Lords, I first declare an interest as a member of the General Medical Council. I welcome this order and pay tribute to the NMC and the General Dental Council for their work—and particularly to my noble friend Lord Harris, who so eminently chairs the GDC.
As the Explanatory Memorandum makes clear, this is in a sense an overture for a suite of orders that the Minister will bring in relation to all the registering bodies, essentially to streamline the fitness-to-practise processes—in the case of the GMC, to enable the statutory registration of physician associates and anaesthetist associates—and to update the governance of these bodies.
I noted in paragraph 10.4 of the Explanatory Memorandum the statement:
“The Department’s view is that it is for the regulators as independent bodies”.
I ask the Minister to assure me that in those new arrangements and governance processes the Government are as committed to these bodies continuing as independent entities as they have said during the consultation process.
I also raise with the Minister the one area in which I think the consultation produced disagreement in relation to the proposals, which is in regard to the DCP register and the fact that, as I understand it, dentists qualifying overseas are not to be allowed to come on to the DCP register. This was raised in Committee in the Commons. The Minister said:
“The change introduces fairness and consistency between UK and international routes because UK dentists cannot qualify or apply to join the DCP register using their dentistry qualification in other countries.”—[Official Report, Commons, Delegated Legislation Committee, 6/12/22; cols. 7-8.]
The point I want to put, which has been put to me by a dental practitioner, is that we are biting off our nose. We are disallowing future working by dentists from overseas in the professions covered by the DPC. The dentist said to me:
“I am working alongside four experienced dentists, three in the UK under the Homes for Ukraine scheme and one under the Afghan resettlement scheme.”
If this change occurs in the future, I think that they may be covered by the current grandparenting provisions. However, if this were to happen in the future,
“their livelihoods and contributions that they could make to our society would be severely constrained. Even with excellent English, overseas dentists are waiting some time … to sit the overseas registration exam”,
which allows them to practise as dentists, although I know that the GDC is considerably improving their performance to allow them to. The dentist went on to say:
“In the meantime, if the GDC implements this restrictive measure, overseas dentists could then take employment only as trainee dental nurses”,
which is really wasteful of their abilities.
I would like further clarification from the Minister about why this is taking place. Given the workforce challenges in the dental profession at the moment, I question whether this is the time to implement a new provision simply because dentists in the UK cannot be recognised in other countries. Perhaps the Minister would be prepared to look at this again.
Lord Harris of Haringey (Lab)
My Lords, the noble Lord, Lord Hunt, has effectively declared my interest for me. However, just for the record, I declare that I am chair of the General Dental Council and have been for the last 15 months or so. I am grateful to the Minister for introducing and bringing forward this order. I think we will all benefit from the fact that he has some familial insight into the issues that we are looking at here and in other matters.
I hope that the Minister will accept that this order has been quite a long time coming. It was already long awaited when I was appointed 15 months ago, and the discussion has been going on since at least 2017. This particular order has been introduced twice in the past few months, before the present order; it had to be withdrawn and introduced again, for various technical reasons.
I start by saying clearly that the General Dental Council welcomes this order. However, I want to take this opportunity, in Grand Committee, to make it clear what this order does and does not do. As I think has been said by all noble Lords who have spoken so far, internationally qualified dental professionals make a vital contribution to the UK dental workforce. In recent years, more than one-third of newly registered dentists have qualified overseas, and current workforce pressures would be immeasurably greater without the contribution that they make. However, the current processes for international registration are cumbersome and inefficient. Existing legislation imposes considerable constraints on the GDC’s ability effectively and efficiently to assess the skill and knowledge of internationally qualified dental professionals. For dentists, there is an overseas registration examination with a very rigid structure and, because of the statutory framework, a very limited range of providers. This results in places not always being available for candidates who want to sit the exam.
Quite properly, nothing in this order reduces the high standards required of international candidates seeking to join the UK register. I am sure that the Minister will want to reaffirm that that remains the Government’s priority. Certainly, public protection is, and remains, central to the purpose of the General Dental Council. The standard applied to international candidates is, and should be, equivalent to that applied to people who register based on UK qualifications. Nobody will want to see those standards compromised, least of all the GDC, and the changes made by this order protect those standards but will enable modernised and more flexible approaches for assessing whether candidates have met them.
The order brings in some immediate changes, 21 days after it has been made—so we are probably talking about March this year. From that point, a number of changes will happen immediately. At the moment, the overseas registration examination is in two parts: the first is effectively a written process, and the second a practical test of skills. It is a requirement of the existing legislation that the second part must be concluded within five years of the first part. During the Covid pandemic, part 2 exams had to be suspended and, through no fault of their own, some candidates missed the opportunity to take part 2 because the five-year time limit had expired and therefore lost the opportunity to be registered, because you cannot simply start again. Those affected will now have restored to them the opportunity to sit the second part of the ORE. That is welcome, and it addresses an injustice for those affected as a consequence of the pandemic.
The second immediate change, which my noble friend Lord Hunt of Kings Heath has referred to, is that new applications to the dental care professional register must be based on the primary qualification appropriate for the professional title being applied for. That stops a loophole whereby applicants who are qualified only as dentists have been seeking to register as a DCP. The Committee needs to know that there has been a flood of such applications in the last year: some 1,075 international candidates for registration as DCPs have been approved, which is more than the total number currently on the DCP register from any source. That enables them to practise in this country without going through the more appropriate ORE process for registration as a dentist. There is also now a considerable backlog of applications all seeking to make use of the loophole before it is closed to new applicants 21 days after the order is made. This change is important and overdue. The lack of clarity about what individuals are qualified to carry out in terms of their professional duties is not helpful, and therefore the loophole needs to be closed. The delays and the flood of applications to try to avoid the deadline are causing considerable operational issues for the GDC in managing all overseas registration, and indeed registrations of UK-qualified dentists.
At the same time, the order is going to give the GDC some new powers, although they will take some time to have practical effect. The requirement for assessments of international dentist applications to be conducted by a dental authority—effectively, a dental school—will be removed. Over time, that will give the GDC much greater flexibility in procuring providers and potentially in designing new assessment models. For example, it might be possible to look at the question of whether the first stage of the overseas registration examination has to be taken in this country or whether it could be taken overseas. That flexibility will be sensible, given the current problems in finding suitable providers. However, it is important to stress that this will not have an immediate effect while current contracts remain in place.
The GDC will also gain the power to make detailed rules about how applicants should be assessed. There will be a requirement to consult on these rules and, critically, the current requirement for Privy Council approval will be removed. The practical effect is that the rules can be more flexible and responsive to changing environments, not the least of which is that the fee can reflect the cost, which at the moment is not necessarily the case until it has received Privy Council approval.
The point is that the order is a vital enabler of reform but does not in itself deliver it. Removing the overly prescriptive constraints is a vital first step towards creating a more effective system but it does not and cannot provide an immediate increase in the dental workforce. The rule-making powers in the order do not come fully into effect for 12 months, and even then it will take time to develop new approaches, consult on new draft rules and procure the supply of the necessary services. Alongside that we have the continuing uncertainty about the different provisions that currently apply to people who can currently benefit from the continuing recognition of EU qualifications. If the Government choose to close that route as a result of the review that they are required to undertake this year, significant additional capacity will be required in the GDC’s assessment processes. Any indication today from the Minister as to whether the existing arrangements for applicants from the EEA will continue would be most welcome.
The order provides provisions for the GDC to explore alternative processes for the recognition of international qualifications. Incidentally, it should not be confused with the powers included in the Professional Qualifications Act that allow for the mutual recognition of qualifications through international agreements: they are outside the scope of this order.
Enabling the recognition of international qualifications is not as straightforward as it might at first appear—and there is certainly no quick solution. New processes for the quality assurance of education and training to secure public protection will be needed, alongside new fee structures. This type of recognition may need to be specific to an institution and qualification. It is not, therefore, a quick solution to workforce challenges. The approach taken would have to be fair to those who undertake the UK qualifications, and indeed to the institutions providing them. Also, any route to recognition would need to be applicable globally and take into account the very different standards and approaches to qualifications around the world.
The key point is that none of these changes will solve the wider problems of access to NHS dentistry. The role of the GDC is to register dentists and dental care professionals who are fit to practise in the UK. But there is a separate process before they can work in the NHS. They still need to go through the performers list validation by experience process to practise in the NHS for each UK nation in which they want to practise. So streamlining the ORE process does not in itself deliver more NHS dentistry. I appreciate that the Minister did not assert that that would be the case, but I have heard that view expressed in various quarters, perhaps by former Ministers, which makes it necessary to reinforce the point.
More significantly, if the NHS dental contract fails sufficiently to incentivise UK-qualified dentists to provide NHS dental services, it is not immediately obvious that overseas-qualified individuals faced with the same set of incentives will choose differently from their UK-qualified counterparts. The BDA in a recent briefing warned that
“NHS dentistry is facing existential threat”,
that even before the pandemic
“only enough dentistry was commissioned for half the population in England”
and that the proposed package of changes to the NHS contract announced by the Government in November was “modest” and “marginal” and would
“do little to arrest the exodus of dentists from the service, or address the crisis in patient access.”
Those were the BDA’s words, but I hope that the Minister will be able to give us some assurance on the nature of the discussions that will take place on the future of NHS dentistry and the NHS contract.
To conclude, these changes in the international registrations order are welcome, but they will not address the fundamental issues.
Lord Patel (CB)
My Lords, I will be very brief, because many of the points I might have made were more eloquently made by the noble Lord who just spoke.
The only thing I will say is that, from my experience when I chaired the previous assessor of postgraduate medical training, the Specialist Training Authority, which was established following the EU rules, the same problems occur in recognising equivalence of training. It is easier to recognise a qualification, but when you recognise equivalence of training, it has to take into account, as already elucidated, not just the knowledge but the experience and skills that practitioners can have.
It is even more difficult when you try to certify somebody or accredit somebody with a qualification that is highly specialised—including in dentistry. For instance, they might not be a general dentist but you might want to recruit them because they have specific, high-quality training in a very specialised area. Assessing their equivalence is then made that much more difficult. So the points are well made about an order that I welcome for its simplicity—but it does have drawbacks that need to be addressed, and one way to do that would be to give the General Dental Council more authority to implement its own processes to assess qualifications, experience and training.
I turn now to the nursing and midwifery side, which is a slightly different issue. We should distinguish between qualifications and certifications. While we train nurses as graduate nurses—and that applies to midwives too—not all countries have graduate programmes in nursing and midwifery. They are trained and certified to be fully trained midwives, and having the Nursing and Midwifery Council to assess qualifications, experience and training makes it that much more difficult.
Lord Allan of Hallam (LD)
My Lords, I do not have any direct professional interest in the subject at hand, but as somebody who lives in London and needs dental care, and as a parent, I am grateful to those dentists and midwives from all over the world who have provided me with excellent service through the years. We should be grateful to them all.
From these Benches we also broadly welcome the order the Minister is putting forward. It is clear that we should make it possible for all suitably qualified healthcare professionals to practise in the UK and it is, frankly, a waste of an individual’s talent and a detriment to public interest if there are unnecessary delays or barriers to registration. The noble Lord, Lord Hunt of Kings Heath, described dentists coming here from countries such as Ukraine and Afghanistan who can make a significant contribution, and we need to enable them to do so rather than disabling them from doing so.
Of course, there are necessary checks to protect patient safety, but what we are saying with this statutory instrument is that we believe that the professional bodies, such as the General Dental Council and the Nursing and Midwifery Council, are the bodies most competent to determine what those checks should be and to set out the right testing and assessment processes to allow applicants with overseas training and experience to apply their skills here. In this debate I have learned a lot from the detailed experiences of the noble Lords, Lord Hunt of Kings Heath, Lord Harris of Haringey and Lord Patel, about what this means in practice. It seems to me to be the right decision that we should empower those bodies even further and give them the flexibility that they need to be able to adapt over time as circumstances allow, balancing out the need for safety but also the need to get people on to the register as quickly and reasonably as possible. We agree with the Government on the broad thrust of these provisions and that the additional flexibility is important.
I raise one question with the Minister. Do the Government have any criteria in mind for assessing whether this change has been successful? For example, have they looked at the cost and speed of applying to register before and after the additional flexibility is granted and after the new processes are brought in? The noble Lord, Lord Harris, correctly reminds us that this will not be immediately, but certainly over this multiyear process, if we are to make this change, it would make sense to look at the situation before and after. I note that paragraph 14.1 of the Explanatory Memorandum points out that the instrument itself has no monitoring provisions, but with any legislative change it is helpful for that to be the case, and I hope that the Minister will be able to describe some criteria that the Government have internally for deciding whether this has been successful.
Finally, I end on a note of caution about the safety standards. Sadly, something will go wrong; somebody will be registered in future who should not be registered. When that happens, the fact that we are all supportive of this today means that we will all own that decision, and we should not say that this is wrong because of a single bad case. Overall, we are making the correct decision. The correct risk assessment is that we trust bodies such as the General Dental Council and the Nursing and Midwifery Council to make decisions.
As the noble Lord, Lord Hunt, correctly pointed out, this is part of a process; we will be going further, and other professional bodies will be given similar flexibility. That is the right decision now and will be the right decision in future. Even if and when something sadly goes wrong under the new procedures, as I said, we will need to remember that, overall, we took this decision because we wanted to see more of those people—the kinds of people from whom I have certainly benefited—on the registers in the UK providing the professional services that they can.
Baroness Merron (Lab)
My Lords, I thank the Minister for bringing this order before us. On these Benches, as across your Lordships’ House, these changes are welcomed as sensible and as part of a suite of measures that we will continue to consider. Certainly, the increased flexibility that they bring to the work of the General Dental Council and the Nursing and Midwifery Council by amending the registration and examination processes and procedures so that they are as effective and practical as possible is very welcome. This is about harnessing the capacity and meeting the standards that are needed so that we can ensure that we have the right professionals in place. The noble Lord, Lord Patel, raised important points that I hope the Minister will consider on how the practicalities of this need to be done.
I am grateful to my noble friend Lord Harris, who laid out what the order does but also what it does not do—in our deliberations it is important that we understand that. I noted his comment that there was no ministerial claim that this will solve a workforce crisis, but, as my noble friend Lord Hunt said, we have a challenge in getting a workforce in place to provide the services that we need. In that regard, it is important that we consider the changes today in the current context of the health system in the United Kingdom.
It is important to say that, sadly, in 2021 alone, 2,000 dentists and over 7,000 nurses quit the NHS. There are more than 46,000 empty nursing posts across hospitals, mental health, community care and other services, which means that one in 10 nursing roles is unfilled across the service overall. As we have spoken about many times in your Lordships’ House, the number of NHS dental practices fell by more than 1,200 in the five years before the pandemic, and there are 800 fewer midwives than just three years ago. That is the context in which we are discussing this.
I turn specifically to the order. If, as expected, the GDC begins recouping costs incurred around international registration, including charging applicants more to take the overseas registration exam, could the Minister give an indication of what effect this might have on the number of dentists operating in the UK? I am sure he understands that, given the number of dental deserts that we already face, we cannot afford to lose the capacity of any further dental professionals.
As well as the overseas registration exam, non-EEA dentists also have to go through the performers list validation by experience process to practise here. The Minister will be aware that stakeholders expressed concern about dentists’ PLVEs being disrupted—for example, by being endlessly rearranged or cancelled—and that that is acting as something of a deterrent to working here. Can the Minister confirm whether there is recognition of that difficulty, and whether the department is looking at what needs to be done to make the process as coherent and smoothly run as possible?
In the other place, the Minister of State committed to write further on the breakdown of positive and negative responses to the consultation that was carried out. Can the Minister of State’s response be made available to Members of your Lordships’ House so that we might also better know what stakeholders were thinking when they responded to the consultation on these changes?
The Government’s Explanatory Memorandum states that policy changes that the regulations make following this order
“may potentially impact international applicants and existing registrants with different protected characteristics, particularly with regards to age, sex and race”
but does not provide detail on what that impact might be. Can the Minister offer any insight into this, if the department has correctly forecast what the regulators are planning?
As we have discussed today, the intent of the order is that there will be changes to application processes and so on. Can the Minister indicate what plans there are to review and audit changes to ensure that there is consistency of decision-making, fair treatment of all applicants and the achievement of the right standards?
In conclusion, while we all support the substance of the order, I hope the Minister can give an assurance that its impact and implementation will not be beset with logistical hitches and unforeseen consequences, because we are keen to ensure that changes are made to deliver the right result to get the workforce more into place than it has been hitherto. I look forward to hearing what the Minister has to say about how the order may assist that, if not entirely cure it.
Lord Markham (Con)
I thank noble Lords for their contributions to the debate. I shall attempt to answer the questions set. As ever, I will happily follow up in detail afterwards.
I accept the premise that no one believes that this is a silver bullet that answers all the issues around recruitment and workforce needs. At the same time, I think there is a belief that this is one of many things that can, hopefully, help increase access at the end of the day. I reiterate our commitment to independence, in answer to the question from the noble Lord, Lord Hunt. That is fundamental to this issue and, hopefully, something that the noble Lord, Lord Harris, has recognised through this process.
Probably the point I would like to devote most time to is the one about the DCP register. I must admit that it is something I brought up specifically and wanted to go around the houses on. I absolutely understand the issue: are we cutting off our nose to spite our face? On the equivalence argument—our dentists cannot apply overseas—part of that, as it was described to me, was also the feeling that even in the UK our dentists cannot use the DCP route, so to speak, in that they might be a qualified dentist but want to use some other qualifications, rather than be a dentist. So it was felt that there was no consistency there either.