Dentists, Dental Care Professionals, Nurses, Nursing Associates and Midwives (International Registrations) Order 2022

Debate between Lord Patel and Lord Harris of Haringey

Monday 9th January 2023 Grand Committee

[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 This particular order has been introduced twice in the past few months, before the present order; it had to be withdrawn and introduced again, for various technical reasons.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.