General Dental Council

Paul Beresford Excerpts

Tuesday 9th December 2014 Westminster Hall

[Sir Paul Beresford (Mole Valley) (Con)]

I am delighted to have the opportunity to air my concerns—although, because of the time restrictions, only some of them—about the General Dental Council. I am particularly delighted to see the Health Minister who is responsible for, among other things, regulation. I fear that, due to a quirk in the law, he may not be able to help me too much today, but any general hints will be gratefully received.

I must commence with a small selection of declarations of interest. First, as a registered dentist, I am subject to the dental regulators. Like other dentists in my position, I pay their annual fees and I am subject to their regulation. Secondly, I have a link with Lockton, an insurance broker specialising in professional indemnity, including insurance, for a growing number of dentists. Thirdly, I chair the all-party group on dentistry. Finally, as one can imagine, because of all that, I am under considerable pressure from a number of dental groups, some of which I am a member of, numerous dentists—the e-mails flooded in when this debate was announced—and dentistry-related organisations that wish this debate to take place.

As the Minister is aware—although you may not be, Mr Hollobone—the two main regulators of registered dental practitioners are the Care Quality Commission and the General Dental Council. They serve slightly different functions, although there is a feeling among the profession that they overlap. Both are funded by fees paid by dental professionals.

Virtually every registered dental professional, along with their organisations and registered staff, accepts and believes—as do I—in the need for dental regulation. On arrival as inspector of dental surgery, the CQC, although initially feared, spent some time finding its way. Many practitioners may not agree, but my personal feeling is that the CQC has become progressively more proportionate and tends to encourage the raising of standards, rather than riding in on practices in a heavy-handed way. In comparison with the GDC, the annual fee that I paid to the CQC for the next financial year dropped by 20%.

Also in contrast to the CQC, the reputation of the GDC has drastically deteriorated among the profession over the last year or so. The situation was foreseen in 2009, when Rick Haythornewaite, the then highly respected chairman of the Risk and Regulatory Advisory Council, gave a lecture to the GDC entitled “A practical approach to risk for 21st century regulators”. It is worth quoting a fairly long paragraph from that speech:

“When regulators get it right the customer and the public enjoy the advantage of choice, feel the benefit of unseen protections; when they get it right these people who serve the customer and public, whether they be company employees or they be professional service providers such as yourselves or whoever else, feel motivated, they feel empowered to perform, to innovate, to adapt. When they get it wrong though, the customer and the public feel the straitjacket of unnecessary regulation, the weight of disproportionate interventions and the frustration of curtailed civil liberties.”

That last sentence should be printed in a large font, framed and placed on every wall in every room at the GDC.

The Professional Standards Authority regularly reviews the GDC. Its most recent report stated that the GDC failed to meet two out of five standards for registration and six or seven standards out of 10 for fitness to practise procedures. Although I have not delved deeply into this, it would appear that the report indicated that the independence of the GDC investigating committee was in danger of being compromised. If so, that could reflect both on public protection and on fair consideration for referred dental practitioners. Among the profession at least, and to some degree outside it, there is a feeling that the GDC is—to use a hackneyed phrase—not fit for purpose.

Concerns were bought to a head when on 30 June the GDC embarked on a consultation concerning the proposal to raise its annual retention fee by 64%—and this in an atmosphere throughout the nation of financial restraint, with enormous pressure by Government to restrain fee rises among public bodies and organisations. As someone with considerable interest in the efficiency of local authorities, so as to keep local taxes down—which, incidentally, most have managed to do in the current environment—I believe that any increase over 1% is irresponsible. The outcry among the profession was considerable, particularly as many registrants do not normally criticise the GDC because their vocational life or death depends on it. The vast majority of complainants asked the GDC to justify the increase, as did leading dental organisations, including the British Dental Association.

At the last minute, the GDC postponed its decision and announced that it had commissioned KPMG to prepare an independent and “full review” of the assumptions underlying the suggested fee increase in the consultation. On behalf of its members, the BDA sought sight of the instructions to KPMG and a list of documents provided for its assessment—not an unreasonable request, bearing in mind that the BDA represents dentists who have to pay the fee. They were not forthcoming and freedom of information requests were refused.

The BDA had definite suspicions that there was a paucity of clear figures and that misleading data had been included. It maintained that no clear business case had been made for any increase. It was not alone in those suspicions, which were later compounded when the KPMG report apparently—although I have not had access to it—assessed that many of the key assumptions contained

“high levels of estimation uncertainty”.

The Australians have a short, sharp phrase to cover that English expression. In the event, the GDC lowered the increase from 64% to 55%. The bill is sitting on my desk at the moment.

KPMG’s advice alone leads to questions about the original proposal and the thinking behind it. I understand that the main reason given by the GDC for the rise is that it is because of the substantial rise in patient complaints and the immense cost of fitness to practise investigations and procedures. To my horror, I discovered that many investigations take 18 months, leaving the patient and dentist hung out to dry for the whole period.

In case the public were unaware, the GDC took out a full-page advertisement in one of the national papers encouraging complaints—or, perhaps I should say, “advising patients how to complain”—to the GDC. From my years of experience in indemnity protection, I know that the first and most successful avenue of complaint from a patient is the dentist or dental professional. Most, if not all, dental and medical indemnity providers assist practitioners in resolving complaints. They are exceptionally competent at that, and resolution covers many of the complaints, which therefore do not need to progress to the GDC, unless it is encouraged. As any MP will understand from their experience of constituency complainants, dental professional complaints vary from the deeply serious to the vexatious and the frivolous.

Many years ago, when I used a purple-coloured impression material, one of my lady patients claimed the next morning that the whole of her mouth and lips had turned purple overnight. I immediately asked her to return to the surgery. Approximately an hour later, she telephoned to tell me that it had all gone away as she drove from the heights of Hampstead towards central London. She put it down to the change of air pressure as she came down from her elevated Hampstead home. Needless to say, on completion of her work and after submitting an account, she replied with a writ. With the assistance of my then indemnifying organisation, we arranged for a senior consultant to review her situation. The problem was resolved when the consultant referred her to Guy’s hospital for dental and psychiatric treatment. The bill remains unpaid.

The resolution approach is implicitly encouraged by the CQC, which requires practices to keep a complaints file setting out complaints and how they are dealt with by the practice. Complaints to the GDC about private dentistry go through a triage and resolution system. As a result, many do not progress further. In particular, they do not progress to fitness to practise hearings. However, it appears that national health service complaints to the GDC almost certainly plough straight into the full procedure, leading to fitness to practise hearings. For the patient and the practitioner, these are generally long, drawn out and draining. For the dentist and his or her indemnifier, the costs can be ghastly, adding to the professional’s fear and emotional trauma.

Particularly in these days of complicated dental procedures, I have severe doubts on occasions that the committee members, whether lay or professional, have sufficient knowledge to make a decision without help. That help is drawn by the GDC from experts—or, should I say, so-called experts. In a few cases, the so-called experts are making a career professional career out of producing condemnatory reports for the GDC.

One practitioner I know well, who has considerable postgraduate expertise combined with the appropriate degrees from that postgraduate work, was taken apart by a so-called expert who did not appear to have the appropriate degrees or experience. I looked at that expert’s website, which contained considerable references to the large numbers of reports that he undertook for the GDC. He appeared to be making a side career out of aggressive reports on behalf of the GDC against the professionals. After a protest to the GDC, it accepted a second expert report, which was dramatically different and was to the benefit of my colleague.

I accept that, at last, the GDC is taking, or seeking to take, steps to reduce costs. It claims that it needs legal changes to be able to use the same service for private dentists as it does for to the NHS. I find that a little wrong; nevertheless, the Government have accepted that to some degree and are introducing a section 60 order that will legalise that change. That does not seem to be reflected in the GDC estimate and predictions. It claims that the increase in complaints will require an additional £18 million.

My experience of cost-cutting in the public service tells me that some lateral thinking on expenditure, by looking at small as well as large costs for efficiency improvements, can be productive. On small costs, this example may not apply now, but a few years ago I helped to organise a reception for an international oral surgery cancer symposium. I was offered the opportunity to attend for free, but on looking at the agenda, I realised that, in spite of my not inconsiderable understanding of oral cancer, the proceedings were beyond my education. Imagine my surprise to hear that two or three lay members of the GDC were attending the two or three-day conference. The likelihood of their education on the microscopic structure of various oral cancers being of any use to their role on the GDC was, to say the least, remote. However, I assume that the GDC paid for their not inexpensive hotel rooms, plus travel and two or three meals a day, as well as the cost of attending the conference.

In a more substantial area, I understand—again I am a little cautious, because I may be wrong—that the GDC is undertaking a total review and refurbishment of its property. The funding for that, I understand, has come from balances rather than through a loan or mortgaging system, which would have spread the costs and allowed its balances to be used to buffer expenditure as new procedures and cost savings, which it claims to be looking for, were installed.

I am interested the GDC’s involvement in allowing—I use that word carefully—the Department of Health and the Minister to look at its finances, savings and its justification for the proposed increase in the annual retention fee. That interest extends to whether the legislation on health regulators, which has been drawn up for possible implementation after the election, will for the first time allow direct Government and ministerial influence on the GDC and, in particular, its fees. I fail to be convinced that it has really looked sufficiently at its costs and procedures in seeking savings. It appears to me that, under attack, the GDC has started to become reclusive and adopted a bunker mentality. I understand that hearings and council meetings are increasingly held in private, which is all the more alarming when its chairman, in delivering the annual Malcolm Pendlebury lecture, appeared to be seeking to expand its areas of operational interest.

Good professional dentistry and medicine is built on good relationships with patients and on trust and confidence between the professional and their patients. This has improved dramatically over the last few years. The GDC should have a role in that, but its image in the eyes of the profession—and, I believe, as consequence of its procedures, patients—has reached an all-time low. The dental profession’s trust in this regulator has gone. I suspect that the patients’ trust will follow in due course.

--- Later in debate ---

[Dr Poulter]

As I said, under legislation, I am unfortunately powerless to intervene directly on fee setting. We recognise the independence of health care regulators and would not want them to be micro-managed by Government; that would be wrong. However, my view is very clearly, as I have outlined, that a strong evidence base is needed to justify a fee rise. Given that other health care regulators faced with similar challenges have not raised their fees to the same unprecedented degree, I have not myself been convinced that the evidence base is strong enough to justify this fee rise. I hope that that answers the hon. Gentleman’s question.

In that context, it is worth drawing attention to the section 60 order currently in progress in the House, and to the consultation process that has been taking place. The fee rise is perhaps all the more surprising as we are making good progress with the GDC on bringing in the legislative changes that will reform the way that it operates. Those changes, in the form of a section 60 order, will assist with reducing its operational costs by an estimated £2 million a year through potential efficiency savings. My hon. Friend the Member for Mole Valley made the point that all regulators need to look at better ways of working and efficiency savings in their own practice. Of course, that, as well as patient protection, is a benefit of introducing a section 60 order: it will help to reduce the running costs, potentially, of the GDC and streamline processes.

The public consultation on the GDC-related section 60 order recently closed, and the vast majority of respondents were supportive of the proposals. We therefore intend to proceed with the measures and will publish our response to the consultation in due course. My hon. Friend may be surprised to learn, as I was, that the GDC did not wait for the outcome of the section 60 order consultation before announcing the fee rise.

The changes proposed in the section 60 order will: enable the GDC to delegate the decision-making functions currently exercised by its investigating committee to officers of the GDC, known as case examiners; enable both case examiners and the investigating committee to address concerns about a registrant’s practice by agreeing undertakings with that registrant, which have the same effect as conditions on practice, without the need for a practice committee hearing; introduce a power to review cases closed following an investigation—rules to be made under that power will provide that a review can be undertaken by the registrar if she considers that the decision is materially flawed, or new information has come to light that might have altered the decision and a review is in the public interest—introduce a power to allow the registrar to decide that a complaint or information received did not amount to an allegation of impairment of fitness to practise; introduce a power to enable the investigating committee and the case examiners to review their determination to issue a warning; and ensure that registrants can be referred to the interim orders committee at any time during the fitness to practise process.

Very similar section 60 orders have been laid before Parliament in conjunction and consultation with other regulators, and a great benefit of those orders is that they are about not just protecting the public but supporting the regulators to have more streamlined processes and reducing costs. Of course, when costs are reduced, we would always expect the savings to be passed on to the people who pay the annual fee.

[Sir Paul Beresford]

Is there evidence that the other registering organisations have reduced their fees, or keep them down, in the light of the anticipated savings, which would be sensible?

[Dr Poulter]

If we look at similar organisations, we see that the GMC, for example, has similar practices and processes. The Nursing and Midwifery Council has a very small fee rise, but has seen a similar section 60 process take place. All those regulators, in my view, have taken every step possible to look at their annual fee in the context of the section 60 orders, and with the mindset that any fee rise needs to be fully evidence based and appropriately proportionate. From my conversations, and from the practice of other health care regulators, I think that there is very good evidence that that is a consistent pattern of behaviour. As I said, the GDC’s fee rise is unprecedentedly large, and its behaviour is not consistent or in keeping with that of any of the other health care regulators, from what I can see.

In addition to the GDC-related section 60 order, the Government are taking forward a number of key pieces of secondary legislation in this Parliament to address priority areas that we have identified after discussion with the regulatory bodies and other stakeholders; I mentioned other section 60 orders. We are also working on a response to the Law Commission’s valuable work on proposals for more wide-ranging reforms.

I am aware that the decision not to progress a professional regulation Bill in the current Session has come as a disappointment to interested parties. However, that decision provides an opportunity to invest time in ensuring that that important legislative change is got right, for the benefit of those who will ultimately be affected by it. My hon. Friend outlined very articulately some of the challenges that need to be considered in putting together the Bill. We are committed—I would like to put this on the record again—to bringing forward primary legislation to address wider reforms to the system of professional regulation when parliamentary time allows, but in the meantime, working with the regulators, we have put in place, or have in train, a number of section 60 orders. They are about streamlining processes, providing efficiencies to the regulators and, most important of all, protecting patients and the public.

Let me say a quick word about the GDC’s general performance. It is very important that the GDC manages its rising volumes of complaints as well as the other issues raised by the Professional Standards Authority as part of its annual performance review. In due course, the GDC will need to demonstrate what it has done to address the recommendations made.

Hon. Members may be aware that the Professional Standards Authority is also conducting an investigation of the GDC after claims were made by a whistleblower about the management and support processes of the GDC’s investigating committee. I understand that the Professional Standards Authority has concluded the evidence-gathering phase of the investigation, is in the process of compiling the investigation report, and will provide that report to the Select Committee on Health and publish it on its website in due course.

I have outlined a number of issues and concerns about the unprecedentedly high rise in the GDC fee. As we have discussed, it is out of keeping and inconsistent with the behaviour of many other health care regulators. I am not convinced, from the evidence that I have been presented with, that there is a strongly evidenced case to support that fee rise, and it goes against Government policy, which is to encourage regulators to set appropriate and proportionate fee rises, to show restraint where appropriate and to be mindful of the effects of fees on registrants.

I want to make it clear, in drawing to a conclusion, that I am not raising any doubt about the fact that the GDC continues to fulfil its statutory duties. However, it will need to make significant improvements to meet the challenges set out in the annual performance review undertaken by the Professional Standards Authority. Registrants, patients and the public need to be able to have confidence in the performance of the GDC and to see improvements in its operation, effectiveness and efficiency. I hope that I have answered all the points raised in the debate, and I again thank my hon. Friend the Member for Mole Valley for raising a very important issue that I am sure is filling many MPs’ postbags.