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APR
22
0

Corporate Bullying

By Chris Tapper

 

One working day in April 2018, precisely at 4.50pm, ten minutes before the unseemly scramble by the dentists to get out the door to avoid the dry-retching of the nurse’s as they clean the filters out, I was presented with a sheet of paper.

A nurse delivered the A4 sheet with a flourish and the warning that our corporate practice manager required my signature before five, since she was going away for a few days.

A space had been left for me to make my mark and I noticed all my colleagues had already signed the sheet, with that day’s date. My colleagues had all apparently attested to the fact that they had completed in-house training in needlestick injuries, they had all read the practice policy on needlestick injuries, and they had then participated in a ‘facilitated practice discussion’ about needlestick injuries. The top of the sheet stated that all the training and accompanying requirements had to be completed by the end of January 2015.

I certainly hadn’t completed the in-house training in question personally and definitely hadn’t noticed a facilitated practice discussion, unless I missed it because I was engrossed in Facebook at the time, doing a fun quiz on ‘is your line manager a homicidal psychopath?’ (My answers were probably of great value to Cambridge Analytica and the ‘Leave’ campaign).

More interestingly, three of my colleagues hadn’t even been employed by the corporate around the date mentioned and I figured that two of them couldn’t possibly have done the training since they are new trainees, though they MAY have read the policy during induction. One of them admitted they had only signed the policy sheet “To avoid a lot of hassle.”

I dismissed the nurse with an “I can’t sign it since I haven’t done the training,” to be met a few minutes later by a text from the head nurse with a link to a video on, presumably, needlestick injuries.

The upshot was that I actually went online and found the subject on the website of a training organization I occasionally use, and produced a CPD certificate before six and signed the form anyway.

Yup, I wimped out rather than be met with the ‘I’ve Been Bagging Angry Wasps Into A Sack With My Bare Hands Face’ of my corporate practice manager.

Of course, the nub of the above was that someone in management (I don’t know at what level) had fouled up and had realised that CQC requirements had not been met. In order to meet requirements, staff had been browbeaten into fraudulently signing a statement that would give the authorities the impression the company was complying with regulations.


And the reason I have outlined the above?

 

Corporate Bullying

 

At this time of year, independent dental providers are bidding for contracts against the corporates and increasingly, they are being undercut by the latter, who use their low wage, high trainee workforce ratio and dubious interpretation of NHS regulations to undercut independent practices.

Corporate Bullying


NHS commissioners are desperate people. They need to secure services at the lowest possible rate and the corporates present them with exactly what they need to satisfy the number-crunchers at the Department of Health - high numbers at low prices. To quote from a popular 70’s sitcom, “Never Mind The Quality, Feel The Width.”

It’s a subtle form of bullying, but it’s bullying nonetheless. The Independent practices cannot possibly hope to compete on an equal footing with companies that run their practices on trainee nurses and (largely) EU dentists willing to work for £8 to £9 per UDA until Brexit is put into effect.

It’s the equivalent of being elbowed in the face by the school thug as he pushed into the lunch queue.

I have worked for a corporate for over five years after selling my own practice, and during that time we have had a huge turnover of nursing staff. As nurses qualify, they leave within months for the independent sector - not once has a qualified nurse been replaced with a qualified nurse. The company just takes on another trainee, and often the £9-per-UDA associate finds him/herself providing the in-surgery training.

The playing field is definitely not level. Low quality materials, poorly maintained equipment and restrictions on which laboratories can be used all contribute to the ‘Poundstretcher’ mentality. At one point last year, we had absolutely no x-ray facilities while head office sourced the cheapest scanner possible.

Unfortunately the commissioning Area NHS Teams are either oblivious to what is happening in the corporates, or are turning a blind eye. And by no means is my corporate the worst offender - I’ve seen worse with my own eyes. As corporates go, mine is considered to be one of the ‘good guys.’

So what is to be done? Your guess is as good as, although I would LOVE to see widespread and coordinated unannounced CQC inspections nationwide at 9.00am. Or else a mass walkout of the Nash by the independents? The corporates definitely wouldn’t cope - few of them hit their contracts annually anyway.

As for me, I’m off to Poundland.

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© Chris Tapper, GDPUK Ltd, 2018.

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APR
05
0

Easy Pickings – UK Dentistry And Dental Litigators

By Chris Tapper

 

Six years ago, I attended a two-day residential course. It was a CPD course I hasten to add, not the usual anger management or ‘appropriate behaviour in the workplace’ type of thing I used to have to attend before they found the right tablets for me.

Anyway, it was very interesting, although I freely admit I never put a single thing I learned into practice – mainly because the dental corporate I work for wouldn’t shell out for the equipment I needed unless I could produce a business plan that proved I could earn them at least a tenner for every quid they invested. But that is by the by.

On the evening of the first day (a Friday if I recall correctly), the ten participants plus the lecturer and two representatives of the sponsoring company, enjoyed a meal in the hotel where the course was being held. After a very pleasant starter and main course, I moved to where a gaggle of four youthful dentists were sitting and enquired as to where they were in terms of their careers. It transpired that all four had graduated from the same Northern dental school and had all been qualified roughly two years. They were all general dental practitioners and had all taken up associateships in NHS practices.

As the most experienced dentist on the course – actually, why mince words, the oldest – I was interested to see if the youngsters were enjoying their chosen profession so far. I think I was trying to vicariously re-establish myself with my early enthusiasm for dentistry.

I posed, what I felt, was a fairly innocuous question to the group:

 

"How’s it going?"

 

One female dentist confessed that she cried every night when she arrived home from work, and sometimes did it during surgery sessions. One of the males said he was so anxious about work that he threw up most mornings and that brushing the lingual aspects of his teeth was impossible, while the other female said she had trouble sleeping and had been put on antidepressants six months earlier.

Perhaps the most troubling response was from the other male, who confessed that he had on a number of occasions, thought of ‘ending it,’ having realised that he had made a dreadful mistake in going into dentistry, and couldn’t see any way out. My concern for him diminished a little when I saw that he had an incredibly healthy appetite, demolishing his own rhubarb crumble and a female colleague’s lemon sorbet in less than three minutes.

When I questioned them more closely, the reason for their universal despair was not down to the pursuit of ridiculous UDA targets or the student debts they were saddled with, but the fear of dental litigation.

All four were constantly worried that they would see their careers end either in a GDC meeting, or more likely, through the bad publicity and financial ruin brought about as a result of a civil action facilitated by a dental litigation firm. They felt that the chances of those events happening to them were high, since one of their fellow students had already found himself in the middle of litigation as a result of an NHS root-filling having not worked.

Now that was six years ago, and I would argue that since then, the UK dental profession has slipped into a febrile anxiety that I have never previously witnessed in the 30 years or so that I have been working in dentistry.

Never have I seen dental colleagues (and even strangers) so jaded and so preoccupied with fears of dental complaints and ‘the dreaded letter’ from a certain Northern dental litigation firm.

I will freely accept that I have no scientific evidence for my observations and that my views are based purely on the empirical, but I personally know of no dentist who has not recently entertained thoughts that a patient might ‘turn legal’ if the wind blows the wrong way.

Over the past 18 months, I have been offering support to a close young colleague, being pursued by an extremely aggressive young solicitor (she IS young, I looked her up) who is alleging ‘negligence’ after her client developed dry socket after a routine extraction of an upper first molar. Rightly or wrongly, my colleague decided she did not want to consult her defence organisation and so I have been (rightly or wrongly) equally aggressive in demanding expert witness or consultant reports in support of their absurd claim. So far, the solicitor has failed to provide any evidence of negligence or give any reason why an expert assessor’s report has not been provided. All I know is, it has been fun ‘having a go’ back, but it to me illustrates a sad fact – nobody in the UK-based dental profession is safe from opportunistic punts from patients who want to make a quick quid from the no-win-no-fee mob.

A few months ago, a solicitor I know told me that during a local meeting of his legal colleagues, a speaker said that a lucrative and growing new source of business was dental litigation and that it was “something to think about” since the clampdown on spurious ‘whiplash’ claims and ‘Benidorm Belly’ – where package holiday tourists claim compensation for stomach upsets caused by dubious calamari and fries - had resulted in less opportunity for successful claims.

Being a Dentist

 

Recent experience has taught me that dental litigators are a tenacious and avaricious species and are unlikely to give up easily on an area of medical law that they consider to be easy pickings. Certainly, according to my legal friend, lawyers see it as a much easier area to be successful in than medical litigation.

Soon, the cost of dental defence subscriptions will be prohibitive to viable practice, and the profession, once all our European colleagues go back home, will find itself unable to cope with patient demand. What is the answer? Your guess is as good as mine.

Until then, I am going to have a rhubarb crumble and some sorbet.

 

 

 

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NOV
28
0

We Did Not Sign Up For This

We Did Not Sign Up For This

I thought I'd share this latest opinion piece by a young dentist in the latest BDJ, entitled:
"Defensive dentistry and the young dentist- this isn't what we signed up for."

Read it here 

 




So what are THE main problems here in Dentistry in England worst of all, but relevant to all the UK too?

My shortlist would be:

1. An impossible UDA NHS contract that publicly promises unlimited care for needs, in a very limited system

2. Onerous regulation using the slide-rule of 'perfection' instead of 'seriously below' reasonable standards.

3. An increasing Claim/Blame culture that takes little or no SELF responsibility for prevention or resolution in the first place. It's like they are given an 'exemption' ticket and thus can claim/blame/complain with impunity, even when fraudulent.

4. A CLAIMS culture driven by some enhanced-fees Lawyers selfishly, resulting in the UK having the worst reputation in the World for FALSE or exaggerated claims, just to get free easy money, from car whiplash claims to holiday insurance etc.

5. Some very Poor Expert witnesses who seem to readily use a yardstick of perfection, without the experience or TRUE NEUTRALITY to act in the public interest first, regardless of WHO engaged/paid them and not applying No.2 above properly.
The trouble is those prosecuting/claiming are only too happy to send MORE work to those who seem to write the worst reports - this may be SO bad that it needs a lookback exercise - if it's good enough for our dental records then why not ?

5. Some indemnity organisations feeling vulnerable because of the above and/or struggling to put up a timely/full defence, make a Corporate decision to minimise THEIR future liabilities in years to come and payout early. It's a tough call for them I know, but many now want to see more pushback and earlier payouts may be just pouring petrol on the fire and thus encouraging more claims, fishing and efforts to get more payouts. It's like a feeding frenzie and that's bad for all.

6. Due to pressures and cuts from the DH and HEE on the undergraduate curriculums, clinical teaching is downrated and research and other targets get all the qudos/funding, so our Undergraduates are getting less clinical exposure, training and preparation for the 'real' world = more like walking into a Gladiator ring and surviving the first few years, but with early scars already from the above. Increasingly even after FT/VT not all are surviving those first few years after qualifying and already experiencing GDC, Lawyers letters, Complaints, Compromises from systems and Corporate limitations and high stress etc - certainly not looking forward to a happy Career!

7. Our Profession - yes we must take some of the blame, but currently we are taking ALL OF THE BLAME whilst Society is overlooking or even encouraging further the above 5 aspects for short-term gain and anyway those Dentists have it easy so let's see them suffer, right ?!? 

So at what stage do we reach breaking point - at what point do we say enough is enough and start acting together in Unity.???

UNLESS we start making it someone else's problem, this will continue and in 10 years when our Profession is decimated and dental care is so defensive it's do nothing or refer for extractions, the population suffers greatly.

Read that article again in the BDJ - our young graduates are rightly saying, this is NOT what I signed up for .

Tony Kilcoyne.

 

 

Image credit - hierher under CC licence modified

 
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© Anthony Kilcoyne, GDPUK Ltd 2017

4087 Hits
AUG
21
0

Is the GDC supertanker turning? by Keith Hayes

Is the GDC supertanker turning? by Keith Hayes

Last Monday 14th August 2017, I had another meeting with Jonathan Green (Head of FtP) and Matthew Hill (Head of GDC Strategy). 
It was a no holds barred meeting and I was free to ask any questions. I wasn't locked in dungeons under 37 Wimpole Street at any point! 
Here is the agenda of the 90-minute meeting, along with the GDC answers in blue. 

It raises some important considerations about what we need to do as a Profession. I think we need to think about the answers and discuss a strategy for the Profession. 

Continue reading
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© GDPUK Ltd 2017

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JUL
10
0

Are you looking for ways to help improve your patients’ current oral care routines?

 

 

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SIGN UP TODAY

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JUN
21
0

Decision Day

Decision Day

The fog is burning off.  The focus is clear.  And so it should be for you.

On balance the case swings clearly.  We are part of Europe. We are European. And yet we should not be part of the political and fiscal force majeure that is the EU.

So I urge you to vote, and if you are open to simple argument, I urge you to vote Leave.

The time has come to lead Europe from outside the EU, not from within.

This Thursday is the most important in the political life of this nation to date. Please make use of your democratic right, to maintain those same rights.

 

 

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© Enamel Prism, GDPUK Ltd 2016

2256 Hits
JUN
20
2

Please don't vote for dictatorship

Please don't vote for dictatorship

?

The EU is behaving like a dictatorship
 
Unelected officials devise rules, laws and regulations. They have a Foreign Office, they plan an army. They tried to control our currency. They even affect our vacuum cleaners and light bulbs. And what about terrorists we wish to eject, terrorists who care nought for the human rights of their victims. We are stopped from deporting them.
 
Britain has a long proud history of both democracy that leads the world, as well as an even longer, prouder history of standing up and fighting against dictators
 
This vote, this week, allows the people of Britain the chance to vote against this non democratic organisation with which we have become unwittingly embroiled.
 
Thankfully . . . . No war will be needed, no blood will be spilt, no lives will be lost.
 
It needs you to place a small amount of graphite from the voting booth pencil in the LEAVE box.
 
Please vote LEAVE.
 
 

Tony Jacobs BDS, dentist, publisher of GDPUK.com

 

Image credit -Fernando Butcher under CC licence - not modified.

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© Tony Jacobs, GDPUK Ltd 2016

Recent Comments
Keith Hayes

Please don't vote for dictator...

I whole heartedly agree Tony. I will vote with my heart and my head on Thursday and I'm backing Britain as part of the World, not ... Read More
Monday, 20 June 2016 14:00
Tim Coates

For the good of future generat...

I'm with you all the way Tony. The remain camp are focusing on the short term economic hiccoughs that will follow Brexit. They a... Read More
Monday, 20 June 2016 15:08
4739 Hits
JUN
15
0

Its no secret I'm . . .

Its no secret I'm . . .

It’s no secret that I’m firmly in the Remain camp.

Until recently, the EU was a largely irrelevant part of my life; something that is there, that I don’t need to worry about, that was barely noticed in the background. But the claims by those wishing to leave have turned passing indifference into passionate support.

I am strongly pro-free market, I believe in personal liberty, and in economic liberalism, but with fairness for all, meaning the removal of artificial barriers and monopoly trading. The EU has delivered this in spades; we know that if we buy Romanian pork, it is made (or rather should be) to the same standards as pork produced in the UK; we know that if we travel abroad, we will be treated according to over-arching laws.

The EU provides regulatory framework; it makes sense that where trans-national trade is concerned, the rules are arrived at through trans-national organisations. But we must also place human rights into the fray – it is not right that a company in one country can produce an item using labour that is forced to work 60 hours a week whereas another country can only allow 35 hours. Trade is increasingly globalised and our companies compete with companies from all over the world. What the EU promotes is a level playing field for all companies, allowing survival of the fittest, while ensuring that competitive advantage is not derived by transferring the costs from company to workers. If we all play by the same rules, only the strongest company will survive. If the rules are different, then one country can make their workers’ pay for the success of their businesses.

We also have harmonisation of regulations. This means that our companies have access to other countries’ internal markets that could otherwise be blocked through unnecessary or discriminatory legislation – perhaps the best example being the German purity laws, which created an artificial barrier for non-German beer to be sold in Germany. The EU forced Germany to remove these barriers for imports, and as a result, you can buy a can of Tennent’s Super in a supermarket in Bremen, should your fortunes be so unkind.

Britain has always been a trading nation, from the tea clippers in the days of empire, to the financial trading of the 80s and the digital marketplace of the naughties. We must remain relevant. We must modernise as life changes around us. We are better placed to trade as part of the EU, we are stronger in the EU and we share a bright future trading with our European brethren.

I have already voted to stay in the EU, not because of what I fear we will lose if we leave, but because of what we stand to gain by remaining part of the EU.  

 

Duncan Scorgie is a dentist practising in Midlothian

 

Image credit -Abi Begum under CC licence - not modified.

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© Duncan Scorgie 2016

2499 Hits
JUN
15
0

Last refuge of a scoundrel?

Last refuge of a scoundrel?

“Patriotism is the last refuge of a scoundrel,” stated Samuel Johnson.

We have seen England football fans with their aggressive displays of false patriotism, Nigel Farage with his “blokey” 1950s English image, both suggesting that the past was some sort of rosy era that we can head back to. The whole Brexit campaign smacks of a distasteful arrogance that the British are better than the continentals.

I am a Special Care dentist, and I remember being startled and gratified in equal measure to find that a profoundly autistic non verbal man presents exactly the same dental treatment challenges in Ireland as in France as in Greece.

Your non verbal autistic man has no concept of Brexit and Patriotism, but maybe he can teach us how shallow, ignorant and superficial our debate and thinking has become on this issue. 

I have many friends as dentists whose origin is from countries such as Bangladesh, India, Spain, Ireland, Italy and Greece. We have far more in common being dentists than our national and cultural differences divide us.

My late father landed in Normandy on D-day plus six, and often told me he never wanted to experience war again. The EU has many failings, but has kept the major players in Europe from warring with each other. That is why I would vote to stay in.

 

Neil Martin is a Special Care Dentist in Northamptonshire.

 

Image credit -Abi Begum under CC licence - not modified.

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© Neil Martin 2016

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JUN
14
0

We must stay IN!

We must stay IN!

We must stay in!
We are the civilised and ancient democracy!
We must strive to exert change from within.
Our mistake was not joining at the beginning and before you start I know it was personal politics De Gaulle etc!

The whole argument has horrified me because...there are NO Facts just subjection!!!

I feel we are in a smaller world with more connections..why do I want to leave and become smaller??
I like my European family and think they have so much to teach US!!
We should be paying MORE because we are so lucky!
We should be caring for the less fortunate!
In fact I think that we should STAY BECAUSE IT IS RIGHT!!

 

Dr Alisdair McKendrick is a GDP in Northamptonshire.

 

Image credit -Abi Begum under CC licence - not modified.

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© Alisdair McKendrick 2016

2365 Hits
JUN
13
0

Stay connected with Europe - you fought for it

Stay connected with Europe - you fought for it
 
 

Regardless of the outcome on this very important choice presented to the British public, it is unlikely that a seismic shift will happen. The UK will not collapse if it leaves the EU or decides to stay within. I fear a large amount of campaigning already underway and yet to come, is riddled with slick speeches oiled with dubious premises and unsubstantiated claims. Exaggeration and obfuscation are rife and even an alert and politically savvy observer will struggle to separate the wheat from the chaff.  

It would be difficult for me to delve into projections, bureaucratic details, legal technicalities and number crunching as that is above my pay grade. To be fair, I feel many are probably in the same position - maybe even those in charge!
 
I do worry how an United Kingdom outside of an EU, instead of being leaders within it, would lose opportunities. I worry science and technology research and development would lose out, by not sharing knowledge, policies, objectives, infrastructure and freedom of movement being curtailed. Being out of EU would give us full control of our front door, however I worry that we would be less safe when knowing much less of what’s happening in the rest of the neighbourhood, let alone count on their help. I worry the British economic clout may be diminished when on its own, as well as more volatile. 
 
I abhor and despair with how the EU has become too complex and burdened with red tape, excessive running costs and obnoxious agendas some try to push. I don’t think Europe is ready for a true federalist solution. However, I believe the futures of the UK and Europe are inexorably linked, wether you like it or not. I would much rather see the UK leading from within, pushing for a 'leaner and meaner EU’, than staying aside without a say in it. You may say they’ve tried and failed, concomitantly it has not helped that anti-EU British MEPs keep getting voted in large numbers, when they only boycott and undermine proceedings whilst still taking advantage of their EU perks they claim to protest against. 
 
Finally, the eligible voter will decide. I hope whatever the result, things will go well for the country which I have made my own for over 10 years now and intend to continue contributing to. I would feel better if the UK stayed and fought for a prosperous and safe Europe from a position of influence, after all Brits having been doing that for quite a while. At times, let us not forget, with great human cost. Would be a shame to turn our backs now. 
 
 
Eurico Martins is a GDP, who qualified in his home country of Portugal, he has been working as an associate in the south of England for the last 10 years.
 
Image credit -Abi Begum under CC licence - not modified.
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© Eurico Martins, 2016

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APR
26
0

Do you need the penetration test?

Do you need the penetration test?

Do you need the penetration test?

 

Don’t worry, I’m not about to delve into the wet fingers stuff – this is a different penetration test (no smirking at the back). The idea came to me after hearing a radio programme about cyber crime. They interviewed someone who had been employed as a Penetration Tester. A penetration test (a.k.a. pentest, intrusion detection and red teaming) is, it seems, a well-known and recognised process in the worlds of cyber security and IT governance. Essentially, it is an evaluation of the security of IT systems by trying to exploit vulnerabilities before hackers and criminals can. It goes beyond looking at operating systems and software to include improper configurations and risky operator or end-user actions.

 

A dentest?

My idea is that dental practices should evaluate their governance vulnerabilities by what I’m calling a ‘dentest’. In other words, before CQC inspectors mark you down, the GDC writes a disapproving letter or a patient uses your complaints procedure you should check whether your systems or staff can be faulted. There might be several ways to do this. In the wider world reformed hackers and fraudsters are often employed for such tasks. However, I don’t recommend scouring the GDC’s list of erased dentists. Much more sensible to keep it in-practice.

This is where that irritating team member who is always finding fault and asking endless questions comes into their own. Divide activities in the practice into manageable chunks and set them the task of ‘penetrating’ them one at a time. In theory, they need expertise in an area to be able to exploit any vulnerabilities. Otherwise, how will they know whether, for example, decontamination procedures are being followed correctly?

 

A journalistic trick

Fortunately, such in-depth knowledge is not required. How do you think Jeremy Paxman managed to get politicians to squirm night after night? How does the team on Channel Four News report on a variety of different topics with apparent authority? The answer lies in what journalists and reporters learn on their first day at university – the ‘5 W’s’ – Who? What? When? Where? Why? and How? (yes, I know there’s also an ‘H’). Ask these questions persistently enough and you’re bound to get the answers (or not) on virtually every topic.

 

 

For example

Take decontamination procedures. Your ‘dentester’ needs to be given half an hour during which they ask the 5 W (and 1 H) questions of, initially, virtually anyone in the practice. Anyone? Yes, because they might start by asking the practice manager: “Who is responsible for decontamination?” With that answer, they could ask the person or persons named: “What is the decontamination procedure?” Then follow up with: “Where is it done? Why? How?”

Any “I don’t know”, “I’m not sure”, “I’d have to ask”, “I can’t remember”, replies suggest a vulnerability.

If they began with a receptionist, they might get the answer: “I don’t know”, which they can follow up by asking: “Who will know?”. If the receptionist says the practice manager, the dentester is off and running. If the receptionist doesn’t know, that suggests a vulnerability – each member of the team should know what roles and responsibilities other members, especially senior staff, have.

 

Another example

Now the dentester, or another member of staff with an equally enquiring mind, could play at being a patient. They could ask any team member: “How do I make an appointment?”, “How do I make a complaint?”, “When is the hygienist available?”, “Where is the nearest car park”, “How much do implants cost?” Depending on whether they questioned the part-time Associate or a receptionist, they should be given either the name of the person who will know or the actual answer. The dentester proceeds to ask more questions, as before.

 

The learning points

The dentester’s work is, of course, wasted unless you ensure the vulnerabilities he or she uncovers are shared with the team and corrections discussed and implemented. Also, a dentest is neither a one-off exercise or a standalone one. With new compliance requirements coming on stream all the time, new systems being introduced and new staff joining the team, vulnerabilities may surface again – so regular dentesting is required.

Also, you may wish to enlist a ‘secret shopper’ to check for vulnerabilities. Obviously it needs to be a person your can trust and who will respect confidentiality. Perhaps someone from your plan provider or the dental lab you use or, better still, your favourite dental business management consultant…

 

 

Image credit -Andy Maguire under CC licence -  modified.

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© Nicki Rowland, GDPUK Ltd 2016

6308 Hits
MAR
19
1

Fight or Flight

Fight or Flight

We all know what fight or flight means. We all know the situations where you feel the rush of tension before you panic and go one way or the other.

The third response, freeze, is often overlooked. But freeze is exactly what I did, day in, day out, for years.

I froze. Standing, at the counter in my local big name coffee shop, for what felt like an hour. In reality it was only a second. What had caused this rush of fright?

The barista repeated. “Do you have a busy day?”.

That was it.

This wasn’t in my mentally rehearsed plan. I was ordering a cappuccino, the same as I did every Thursday in the morning, part of my weekly coping strategy. Going out of the house, doing SOMETHING, was better than sitting at home, waiting for the afternoon shift to start. I had become accustomed to going to the coffee shop, ordering the same thing every week, and gradually became more and more comfortable with my surroundings. And then this happened. I couldn’t go back. Well, at least not for a long time. I was comfortable, and she had ruined it by asking a straightforward question that any reasonable person would have answered without hesitation.

Social anxiety is a problem I’ve had since I was 8. I don’t remember exactly how it happened, but I was never really comfortable around people. Having someone who was obviously uncomfortable around other children drew the bullies out like flies to a turd. So I was a very obvious target of bullying. I froze, all the time. I couldn’t do anything. It got worse and worse, every time I was asked anything by an authority figure, I ground to a mental halt, unable to answer and unable to move. Rabbit in the headlights.

I was pushed into social events by my parents, who were clearly at their wits end and thought that forcing me to go to interact with other people would help. It didn’t. It made things worse.

As a teenager I got great solace in music. The louder the better. By putting earphones in, I could block out the cacophony of the outside world, and if anybody tried to talk to me, the brief time it took to take the earphones out gave me a fraction of a second to steady my nerves.

And then I discovered alcohol. I went to university, unable to feel comfortable when surrounded by anybody, and I found that at first beer took the edge off, then it became whisky. At the same time, I started smoking cannabis. Cannabis was wonderful. My anxiety was gone, I could be much more “myself” and it even allowed me to sit in a room and have no nerves at all.

But illicit drugs and alcohol soon took their toll and were starting to take over my life, as I descended down the path of alcoholism, and being so anxious of normal life that I couldn’t function without the instant and total relief brought on by cannabis.

I decided to stop everything. I stopped drinking, I stopped smoking cannabis. I was left (briefly) with the one drug that provided any form of relief, nicotine, although I stopped that fairly soon after.

Meeting new people was always very tough after that. It went back to how it was when I had been at school. I completely froze. When you freeze and struggle with conversation, people make all kinds of assumptions, with the stories sometimes making their way back to me through friends. If only they had known the truth, I don’t think people would have been so judgemental. The worst experiences were when people talked ABOUT me, to a third party, when I was right in front of them, on one occasion telling the third party that I was “the weirdest person I’ve ever met”, and the other, that I had “zero personality”. That was a trigger for a complete meltdown, and when it happened I struggled to leave my flat for a couple of weeks afterwards on each occasion.

And so on to the world of work. Eye contact became increasingly difficult. I somehow managed to develop a different persona for dealing with patients, and could blag my way through. I was able to talk to patients with comparative ease, but I always kept it very informal. Staff, however, were almost impossible to deal with. The more people tried to assert themselves as an “authority figure”, the worse it became. I once again got labelled as “weird”, got left out of social events, and then told that I made no effort to socialise. I do wonder if they knew how much effort it was to smile and say “Hi” to somebody in the morning, whether the same judgement would be made.

I recently decided to get treatment for this as I was incapable of living a normal life. It’s a lonely existence, plodding through life without any real social interaction. Social media has equally helped and hindered me at the same time, in that while providing an outlet for at least some socialising, it has also acted as a crutch, and got in the way of normal social interaction.

I had 8 sessions with a psychotherapist to try to overcome the social anxiety, and while progress is slow, the realisation that nobody looks or cares about me or what I say, was actually a huge relief. My GMP prescribed some antidepressants that unfortunately made my anxiety worse. However, after nearly a year of pushing myself into more and more uncomfortable situations, I’m much better. I can finally look somebody in the eye, and I don’t freeze when the conversation goes “off script”. I don’t take any medicines and I am no longer receiving any psychotherapy.

 

My only regret is that I hadn’t been able to access the treatment earlier. 

 

Image credit -PracticalCures under CC licence - not modified.

 

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Anthony Kilcoyne

Anxiety syndrome?

A very insightful and informative blog. We are too quick to judge others sometimes, yet too slow to consider and appreciate how o... Read More
Wednesday, 23 March 2016 23:08
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Tooth decay in children – why don’t parents care?

Tooth decay in children – why don’t parents care?

Walk down any high street and you’ll likely witness a cornucopia of contrasts and contradictions. Overweight people, painfully thin people. Healthy looking pensioners, teenagers who couldn’t run for a bus. Naturally wrinkly old people, unnaturally smooth-skinned middle-aged people. Adults with bright shining teeth, children with a mouth full of decay.

It’s deeply ironic that in an age when many of us could live to a 100 and all but the most serious diseases can be treated, some people are clearly missing out. As a mother of two and former practice manager it particularly disturbs me to see children with bad teeth. The numbers are staggering. According to the Health & Social Care Information Centre recent report NHS Outcomes Framework for England, tooth extractions due to decay in children admitted as inpatients to hospital, aged 10 years and under were at the rate of 462.2 per 100,000 population in 2014/15. That’s about one in every 216 children.

That’s an average for England, in Yorkshire and The Humber the figure was about one in every 112. The report also showed that: ‘Nationally, there is a strong correlation between area deprivation and the rate of tooth extraction. As deprivation increases so does the rate of tooth extraction. The rate of tooth extraction in the most deprived decile is almost 5 times that in the least deprived decile (808.7 compared to 167.5 per 100,000 population).’

 

What does Google say?

To attempt to answer the question posed in the title of this blog I decided to post it into Google. The result was many references to information on children’s oral health and an article in the Daily Mail with the headline: ‘The lazy middle-class parents who don’t teach children to brush their teeth: By a teacher who’s seen the horrific consequences’.

The article claimed that parents were too busy to show the children how to brush their teeth and when the teacher opened a pack of tiny toothbrushes and tubes of toothpaste in her class of four-year-olds ‘the children were saucer-eyed with curiosity.’

An article on parents.com claims: ‘Many parents are surprised to learn that kids need help brushing their teeth until at least age 6. Young children simply don't have the manual dexterity to do the job well.’

In October 2014, in guidance aimed at local authorities, NICE said: “Schools and nurseries should run tooth brushing schemes to help standardise the oral health of younger children.”

In an article about this guidance in The Telegraph, Joyce Robins from Patient Concern was quoted as saying: “Nice has often been accused of pushing nanny state measures but this is more like a ‘supernanny state’.

“What will they suggest next, that parents can drop their children off at school naked and unwashed, and leave the state to step in and do the rest?”

Oh dear.

 

There is an answer

So if parents are too lazy, too ignorant, too impoverished, living in area of deprivation or are combination of some of these factors, what is to be done? The answer comes from the USA. Tegwyn H Brickhouse D.D.S., Ph.D. Department chair, research director and associate professor in Pediatric Dentistry at the Virginia Commonwealth University was the lead author of a paper presented to the IADR/AADR/CADR conference in March 2013. In it she wrote about a study into a scheme to decrease the number of low-income children in the Roanoke Valley with long term dental disease. The Child Health Investment Partnership of Roanoke Valley (CHIP) provides in-home preventive oral health services designated as the Begin with a Grin Program. The paper states: ‘In the context of a home visit, Community Health Nurses (CHNs) and Pediatric Nurse Practitioner (PNP) apply fluoride dental varnish (FV) to the teeth of CHIP-enrolled children from tooth eruption to 36 months. They educate the caregiver in preventing tooth decay and the importance of a dental home.’

The study found that: ‘Two applications of FV to the child’s teeth significantly reduced the likelihood of having any decay.’ The conclusions were: ‘Home visiting programs such as CHIP’s Begin with a Grin serves as a model to improve the oral health of high-risk children. The CHIP program provides an innovative solution for providing oral health care to the nation’s medically underserved populations.’

NHS Choices states: ‘From the age of three, children should be offered fluoride varnish application at least twice a year. Younger children may also be offered this treatment if your dentist thinks they need it.’

That presupposes a parent takes their child to a dentist. The CHIP Begin with a Grin programme avoids that requirement. However, dental practices would need to be informed when children are born in their area.

Is this something the GDC and NMC (Nursing & Midwifery Council) should be liaising about? Another question seeking an answer…

 

 

Image credit -Tiffany Terry under CC licence - not modified.

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Can a bit of stress be healthy?

Can a bit of stress be healthy?

My previous post about stress was posted here on 28 January. This time, I’m attacking (more accurately, sneaking up on) stress from a different angle. And I’m starting by going back in time. Way, way back to pre-CQC. It seems prehistoric man suffered stress, would you believe? And guess what – we know it from their teeth! In 2010, George Armelagos, an anthropologist from Emory University in the USA, discovered enamel defects in teeth dating back one million years indicating that, ‘During prehistory, the stresses of infectious disease, poor nutrition and psychological trauma were likely extreme.’ This stress reduced life expectancy – remains from Dickson Mounds, Illinois, showed that individuals with teeth marked by early life stress lived 15.4 years less than those without the defects.

So is stress bad then?

Not necessarily; read on. According to the Mental Health Foundation: ‘Some stress can be positive. Research shows that a moderate level of stress makes us perform better. It also makes us more alert and can help us perform better in situations such as job interviews or public speaking. Stressful situations can also be exhilarating and some people actually thrive on the excitement that comes with dangerous sports or other high-risk activities.’ The Foundation does point out that stress is only healthy if it is short-lived.

Stress causes a surge of hormones to better help you deal with ‘fight or flight’ situations. According to NHS Choices: ‘Once the pressure or threat has passed, your stress hormone levels will usually return to normal. However, if you're constantly under stress, these hormones will remain in your body, leading to the symptoms of stress.’

How much stress is normal?

Now we come to the science – specifically the Depression, Anxiety and Stress Scale (DASS). This is a self-report questionnaire whereby you answer questions, add up the score and convert these to severity ratings for depression, anxiety and stress. There are two versions – DASS and DASS 21. The former has 42 questions, the latter 21 (so you multiply the scores by two). Ignoring depression and anxiety for the purposes of this article, the severity scores for stress are:

·        Normal 0-14

·        Mild 15-18

·        Moderate 19-25

·        Severe 26-33

·        Extremely severe 34+

DASS is not a diagnostic tool. If you are feeling anxious, depressed or stressed, you should see your GP – even if you get low DASS scores. However, if you wish to get some idea of how stressed you are and so gauge whether it could be considered healthy, go to https://www.cesphn.org.au/images/mental_health/Frequently_Used/Outcome_Tools/Dass21.pdf for DASS 21 (remember to double your scores for the full DASS severity ratings.

No added stress

In my previous post, I urged you to stop putting stress on others – particularly colleagues and staff in your practice. Now we see that some stress is normal and may well be beneficial. So does that contradict what I wrote before? Not at all. Yes, some stress is normal and healthy but so very few of us lead completely stress-free lives that we need added stress at work. Relationships, health, family obligations, household maintenance, cars, money worries all cause stress. Many of us are also good at getting stressed about things that haven’t even happened yet! So who are you to add to the stress of your colleagues or staff and maybe move them from normal to mild, moderate or severe on DASS?

Stress as a management tool?

Excuse me? Think twice (or more) before you decided to ‘push’ members of your team to make a greater effort. It is far more effective to motivate people to work more effectively or efficiently. People work best through their lunch hour when they don’t hold a grudge at you demanding it but because they genuinely want to get the patient records up to date.

As a manager you should be familiar with the theory of psychological type as introduced by Jung and the Myers-Briggs Type Indicator – so you know how to get the best out of each member of your staff.

This is a topic covered on my courses – come and find out.

 

Image credit -Bottled_Void under CC licence - not modified.

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Me, STRESSED? Nah!

Me, STRESSED? Nah!

What a day! Traffic jams, a flat battery in my mobile, a parents’ meeting tonight and I’ve still got to write this blog about being stressed.

Ah, that’s better. It’s another day and instead of writing the blog when I was tired and grumpy, I wisely left it until now. If only all stress would dissipate so easily.

This is not an examination of stress in dental practice. For that, I recommend an excellent study on the Yorks and Humber Deanery website.

And this is not about managing stress because I agree with dentist and communication coach, Brid Hendron, who says we need to be eliminating stress.

This is also not a guide to stress relief. There are plenty of those available and the Stress Management How to Reduce, Prevent, and Cope with Stress article here is better than many.

So what is this blog about?

Oh dear, I can sense you’re become a bit stressed reading this, so I need to get to the point. Which is to ask: are you the source of stress in your practice?

Can you honestly say you don’t ever put stress on your subordinates/superiors/equals? Think carefully, do you bang on endlessly about problems that cannot be solved within the practice (government policy, for example)? Do you set your staff unnecessarily tight deadlines to complete work? Are you careless about returning equipment so that colleagues can’t find it? Do you leave an empty loo roll in the toilet and a dirty mug in the sink?

#LoveYourImperfections (not)

Such behavior may, according to the online dating service TV advertisement, result in you finding true love but that won’t be in your practice. Instead, it will result in stress, which will have consequences. According to the HSE, 9.9 million working days were lost to work-related stress, depression or anxiety in Great Britain in 2014/15.

Just stop

Like ceasing smoking or the consumption of alcohol in too large quantities or (as in my case) pigging out on cream buns, stopping causing stress is easier written than acted upon. Here’s what you should do. Suffers of stress are advised to keep a stress journal. Do likewise but instead of recording stressors on a daily basis, you should identify ‘stressees’ (the colleagues to whom you’ve caused stress). This won’t be easy. Not everybody reacts to stress by pigging out on cream buns or bursting into tears. Quite probably, you won’t witness the effects of your stressful action within the practice. So here comes the clever bit.

Stress balls

At a team meeting, explain you’ve read an article about stress in the workplace and want to learn how many people in the practice feel it. Now place a bowl of marbles, walnuts or (if you are in an upmarket practice) Ferro Rocher chocolates in the tea room (staff lounge) with a mug (porcelain cup) beside them. Ask your staff to place one of the items in the mug (cup) at the end of each week if they’ve felt stressed.

Self-regulating stress reduction

Once this has been done for a few weeks (so that staff have become comfortable with it), explain that you’re keeping a stress journal and would like others to do likewise (anonymously, of course). While there is no direct correlation between what people note in their stress journals and the weekly marbles/walnuts/chocolates ‘score’, it is in everybody’s interest to reduce the stress they place on colleagues in order to decrease how many ‘stress balls’ are in the mug (cup) at the end of the week.

Let me know how you get on with this exercise (and perhaps you can come up with a name for it).

 

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GDC hearings: The imbalance of probabilities

GDC hearings: The imbalance of probabilities

GDC hearings: The imbalance of probabilities

Can we make the Regulators serve the Public and the Profession in foro conscientiae (the court of the conscience), rather than just a notion of what the regulations might say?

I have attended and been asked to make some input into a variety of cases recently involving several different Regulators.

It has become clear that there is a real danger that rules and regulations which may have been drafted for the protection of the Public and the guidance of the Profession are sometimes widely misinterpreted at best and occasionally deliberately corrupted and applied at worst.

How does this occur?

Whilst it might be considered that most regulation has been drafted to improve standards and reduce the risk of poor practice continuing; it is quite obvious that it can be applied in a manner to exert control or ‘manage’ the Profession. Sometimes this may occur deliberately and because it broadly serves the purpose of a government administration, it is allowed to continue at least as long as it serves a purpose. Sometimes it occurs at a much lower level and whilst not serving any particular purpose, it is allowed to continue because there is nobody at that level who is prepared to question it.

I’ve got nothing against shop assistants, however I wouldn’t be wanting them to draft the GDC Charge Sheet which might end a Professional career. There is a high turnover of staff at the GDC which I suggest leads to a poor understanding and there appears to be a low level of dental knowledge.

What this might mean if you are in the dock

One of the cases to which I refer involved a young colleague, and for whom funds were raised at very short notice thanks to the excellent GDPUK membership.

If you read the Charge Sheet, you would be forgiven in believing this dentist was a real danger to the Public. However I’m sure that you will all remember me reminding you to read between the lines whenever you are dealing with a Regulator. That is certainly necessary in this case.

Example appearing on a Charge Sheet

(i)            The use of a double cantilever (the bridge was fixed-fixed)

(ii)           Not adequately assess that a RCT was required (the tooth was root treated and had been a symptom free bridge abutment for 20 years)

(iii)          Fitted an inadequate post which was a) short of the apex, b) not extending to the apical third and c) was inadequate in width. (The post was temporary and deemed too wide).

If the Charge sheet is a nonsense, the solution is simple. The Panel changes it, strikes it out or substitutes different wording. In other words, it moves the goalposts. The Panel, which is independent by hearing both parties then asks its own questions of the witnesses. It is advised by experts and can choose which expert it ‘prefers’. The expert appearing on behalf of a registrant might then be warned by the Prosecution barrister that the GDC may take action against them. The prosecuting barrister is instructed by the GDC and regularly prompted by their expert witness.

In one of the cases to which I refer, four patient witnesses who had made a complaint were called. One of the witnesses was travelling to London and it was found that she intended to speak in favour of the Defendant and it was agreed therefore that this patient would not be heard.  

The Panel seemed to have some ability to read between the lines, but in the end ‘prefers’ the testimony of two patients. One of these patients produces a hand annotated diary of the treatment dates containing some dates that the defendant was actually not in the practice (a screen shot of practice diary was produced as evidence). The patient was receiving treatment from more than one dentist at two different practices simultaneously, but on the ‘balance of probability’ is to be believed. This patient was heard to say that she was seeking ‘redress’ on at least four occasions.

Our young colleague describes how he always uses rubber dam for RCT and yet on his last day in the practice he finds there is no rubber dam available. He admits that on this single solitary occasion, rubber dam was not used. The patient has pleaded that a temporary post crown be placed (the same inadequate temporary post that was short of the apex) and he accedes to the request of RCT and temporary post, since the broken tooth was within the patients smile. He uses rotary RCT instrumentation, floss on hand instruments and high volume aspiration. The patient is the same one who was not given the opportunity to give further evidence in support or denial of the registrant. Our young colleague is guilty therefore of serious clinical failures and therefore misconduct.       

Another patient gives evidence about never having received treatment he has paid for, but the Panel agrees that this evidence is just not credible, which it isn’t.

A fourth patient was having a long and complex treatment plan part of which had been incomplete and following a tooth fracture needed to be modified. The patient didn’t clearly understand the new treatment plan and for that our colleague was criticised.

It’s worth mentioning that there were NO PATIENT RECORDS available because there had been a burglary declared immediately following the practice change of ownership. This was highlighted to the Panel. 

Communication was a big word in this Hearing. Other significant words are ‘insight’ and whether or not the Panel consider that this is ‘embedded’ sufficiently. Our young colleague was supported by Sir Peter Bottomley in person who made a statement and also by the testimonials of 47 patients.

The GDC however do not need to give weight to the above in making their determination, although I noted that the prosecution barrister frequently returned to the GDC to ask for further instructions. I think it worthy of note that the Panel describe our young colleague within the Determination as follows ‘It is clear from all of this evidence that you are viewed as a competent and caring dentist, who will go out of his way to assist his patients.’

Do the GDC therefore need to apply Conditions, because that’s what they did? 

Please read the GDC Determination when it is published.

So what?

If you recognise any of the issues above, you are guilty of misconduct and your standards will be deemed serious failings. Approximately 1 in 7 dentists in the UK currently face some form of investigation which could result in imposition of sanctions either through the GDC, CQC or NHS and this number is growing constantly. This might mean that we have the worst performing Dental Profession in the World bar none or that we have the most disproportionate Regulators.

You may consider yourself lucky and are happy to cross the bridge with your indemnity organisation when your time comes; or you may be sufficiently confident to wade across the raging torrent alone when your indemnity organisation makes an unexpected discretionary decision against you.  

What type of indemnity organisation are you currently paying for?

How can it be legal?

You are required to have professional indemnity and it is considered a serious failure if you have ANY gaps in your cover period. Indemnity providers however do not guarantee to provide legal representation to you and if they exercise their discretion in favour of their balance sheet (or dressed up as other members interests) you will find yourself alone or facing a huge legal bill.

A recent Hearing which I attended over 7 days starts at £32,000 and it’s uphill from there.

Does anything need to be done about this?

You read the PSA report published 21st Dec, I hope.  https://www.professionalstandards.org.uk/docs/default-source/psa-library/investigation-report---general-dental-council.pdf?sfvrsn=6

What exactly have we learned about whistleblowing from the Sir Robert Francis Report (Mid Staffs)?

And you can see how the whistleblower was treated, you can see what the PSA thinks about it and you have seen how the GDC are going to be dealing with your ‘serious failings.’

You tell me, do you need to do something about this?

So where are we now?

From a variety of recent cases we can conclude:

·         The GDC consider failure to use a rubber dam in endodontics to fall seriously below the required standards and therefore to represent IMPAIRMENT and worthy of sanctions.

·         In my view neither the CQC nor the GDC have a currently correct understanding of CONSENT which conforms with the recent Supreme Court judgement of Montgomery – v Lanarkshire Health Board. This needs to be challenged in the High Court.

·         The GDC will always use the ‘balance of probability’ in forming an opinion on which evidence it prefers. 

So where are we going in 2016?

The Profession must for once in its life join together. The issues regarding Consent and use of rubber dam will need to be challenged and this requires more than a well-intentioned individual or some crowd funding. It requires a strongly actioned move being taken by the BDA and the indemnity providers.

 

 

Image credit -Michael Coghlan under CC licence - not modified.   

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Hope got me through . . Terry Waite CBE

Hope got me through  . .  Terry Waite CBE

‘Hope got me through…..’ Terry Waite CBE

A warming Xmas story to boost practice manager’s morale

 

I have been to many a Christmas carol concert over the years but this festive season I attended one that I will never forget! The concert was held in aid of Emmaus, a UK charity that helps homeless people off the streets and of which Terry Waite CBE is president. For those young readers who may not know, Terry was an envoy for the Church of England in the late 1980’s. He travelled to Lebanon to try to secure the release of four hostages but was kidnapped himself and held captive from 1987 to 1991. Terry spent almost five years, including four Christmases, in solitary confinement without any news of his family, his friends or the outside world. Torture and mock executions were a regular occurrence.

Terry was invited to be a guest reader at the concert and he relayed a story to us of his fourth Christmas in solitary confinement……the room was dark, damp and cold. There was no source of heating and only a single blanket to keep him warm. Terry was forced to sit on the floor in the tailor’s position whilst shackled to a radiator which for a very tall man must have been torture in itself. His only source of light was a single candle; his only company, a bible. One day, after many attempts, Terry managed to encourage his guard to tell him the time and date. He was surprised to find that it was late afternoon on Christmas Eve. Terry decided to celebrate Christmas by holding his own, personal Holy Communion so saved a small piece of bread and drop of water from his meagre rations. His candle was burning low but he wanted to wait as long as possible to be sure that his celebration was as near to Christmas Day as possible. In the dying light of his candle, Terry took the morsel of bread and water, blessed it and savoured it whilst reading a passage from his bible. The moment passed as the light finally died.

When asked how he survived these lonely, unbearable years, Terry’s answer was ‘hope’!

I think in the world of the practice manager there is much hope that can be taken from this message and many synergies too. I work with many practice managers who feel lonely and isolated incarcerated in their cold offices in the rafters of their practices. Communication with busy staff can be scarce increasing the sense of segregation. On the rare occasion that a staff meeting is held, everyone wants a ‘piece of flesh’ or demands answers about something. The practice principal is generally focused on the clinical workload leaving the burden of renewed CQC inspections, financial management and human resource issues to the overloaded practice manager. The pressure to perform is sometimes torturous. On top of the internal workload scrutiny is increasing from the outside world. A week rarely goes by without dentistry featuring in media headlines and public observation of the dental profession being heavily influenced by this bad press. The weight of complaints handling and demands from patients also falls on a practice manager’s shoulders and sometimes ‘giving blood’ is still not enough in some cases!

So, where can a practice manager find ‘hope’ in such difficult circumstances? How can they release the burden, shake off the shackles and find freedom and enlightenment as Terry did? One definition of hope is ‘a feeling of expectation and desire for a particular thing to happen’. This is all well and good, but in business, hope sometimes needs to be accompanied by a ‘mental shift’ to allow change and escapism to happen.

Here are my ten top tips for seeing your hopes come to fruition:-

1.      Define your purpose – be clear as to what kind of manager you wish to be. Take responsibility for shaping the future.

2.      Embrace change – be proud of what you have achieved to date but embrace change and make improvements.

3.      Keep moving forward – view failures and disappointments as an opportunity to improve, evolve and succeed.

4.      Communicate – plan, organise and review communications with your team and patients to be effective.

5.      Lead authentically - be sensitive, open, firm and fair. Learn to listen. Be you!

6.      Believe in yourself – be prepared, have faith in yourself and be true to your inner beliefs.

7.      Make everyday count – give 100% to everything you do.

8.      Act now – deal with situations as they arise. Don’t leave things to fester.

9.      Keep a positive attitude – do not tolerate negativity or poor attitudes. Stay focused on steering a buoyant ship!

10.  Stay healthy – sleep, eat and exercise well. It has a direct impact on your mental wellbeing as well as your body.

 

Happy Christmas everyone and here’s to a New Year full of hope!

 

Image credit Mararie under CC licence - not modified.

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Are you giving your patients what they want this Mouth Cancer Action Month?

Are you giving your patients what they want this Mouth Cancer Action Month?

Are you giving your patients what they want this Mouth Cancer Action Month?

 

A recent survey highlighted by the British Dental Health Foundation (www.dentalhealth.org) found that 9 out of 10 dental patients want to be screened for oral cancer but only 14% of those surveyed were aware that they had been whilst visiting the dentist. An estimated 90% of dentists are screening for oral cancer during a dental examination but do not talk to the patient about what they are doing!

Why is the dental profession so reluctant to talk about the ‘C’ word when patients want to hear it? Is this due to our fear of litigious activity if patients know too much or is it because dentists lack knowledge, confidence and experience in dealing with oral cancer management? It seems irrational when we hear about skin, cervical, breast and testicular cancer all the time. The public is exposed to messages about these types of cancer on the television, through other media and even in GP’s waiting rooms. At certain ages we are invited to be screened for a variety of cancers and given advice about screening ourselves regularly too. People are generally well informed about prevalent cancers and aware of Government initiatives to tackle the problems.

Why is oral cancer any different? Why is our profession so fearful of talking to our public about this developing epidemic? Why is there no Government initiative to combat this hidden killer? Why are girls not informed that the HPV vaccine will safeguard them against oral cancer as well as cervical cancer? Oral cancer is not just a hidden killer but also a silent one as nobody seems to be talking about it!

So, this Mouth Cancer Action Month (https://www.dentalhealth.org/our-work/mouth-cancer-action-month) give your patients what they want! Train your team to talk to patients in a confident, knowledgeable and appropriate way particularly during screening. Teach patients to self-screen on a monthly basis and arm them with the information that they need to look out for the early signs of the disease. Self-screening is particularly important as NHS recall intervals continue to be unreasonably stretched. The way I see it, if patients are given joint responsibility to screen themselves for oral cancer, this may help to counteract the barrage of litigation we are experiencing. As a profession, if we screen for, talk to and educate our patients about oral cancer, we will be meeting our professional obligation to do so as well as keeping the CQC happy when they come knocking at our door.

Talking to patients about oral cancer not only raises their awareness but it also helps to spread the word about the disease. Give people what they want and they will also tell their friends and family about the fantastic job that you are doing. ‘Word of mouth’ is the most effective marketing tool at your fingertips, so go ahead and use it!

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HPV Vaccinations - Make Some Noise for the Boys!

 

 

Squamous papilloma -- very low mag.jpg
"Squamous papilloma -- very low mag" by Nephron - Own work. Licensed under CC BY-SA 3.0 via Commons.

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The FCA is more than just the OFT with a new name . . .

The FCA is more than just the OFT with a new name . . .

The FCA is more than just the OFT with a new name . . .

 

by Martin Gilbert 

Offering credit to your patients used to be so simple. All you needed was a Consumer Credit Licence and that was it. When a patient wanted to spread the cost of the treatment, you forwarded an application to the lender, they sorted out the paperwork, you did the work and you got paid.

Then the credit crunch came along, and in the aftermath it was decreed that the Office of Fair Trading wasn’t the best organisation to supervise consumer credit (think about the unfettered antics of payday lenders and home reversion scheme providers) and responsibility was transferred to the Financial Conduct Authority.

And they are a different animal altogether. They started gently enough, by writing to all CCL holders and telling them that if they wanted to continue to be credit brokers, they just needed to register for Interim Permission.

Then all IP holders were notified of the Allocation Period in which they have to apply for Authorisation. The last ones finish in February 2016. Applying for authorisation (which for most dentists, who just need to act as Secondary Credit Brokers, will be for Limited Permission) is not too difficult, as long as you have the time and understand the terminology (who knew that ‘agreeing to carry on a regulated activity’ was itself a regulated activity, and one which you have to have).

So you complete the online application and pay the fee. The letter arrives (within their 6 month’s SLA) with your Authorisation, your Firm Reference Number and information about your ongoing obligations. You skim through it, and then file it.

But this is only the start of your relationship with the FCA.

Next you get an email telling you that a Return is due. So you phone the FCA Helpline, who tell you that you should have registered for GABRIEL. Which you didn’t bother with, because you hadn’t really read the letter, and the OFT never used to ask you for any returns, so it hadn’t occurred to you that the FCA would. (CCR008 is required quarterly, CCR007 is annual, and there are fines if you miss the deadlines).

Then you get an email telling you that your Periodic Fee is due. So you phone the FCA Helpline, who tell you that you should have registered for online invoicing. And when you do so, and find the invoice, you’ll see that you also have to pay a Money Service Advice Fee and a Financial Service Ombudsman Levy.

So then you think, I can’t be bothered with this, I’m going to cancel my authorisation. So you phone the FCA Helpline, who tell you that you should have registered for CONNECT (not the one you used for your original application, but the one that was mentioned in that letter) to enable you to make any changes to your standing data. And when you do eventually manage to login, you have to find your way through ‘Start a new application’ to get to the cancellation option.

If you’ve got more money than time, there are plenty of firms out there who’ve made a business out of managing the authorisation for you – typically charging £600 to submit your application and £25 a month for ongoing compliance.

Or you could become an Appointed Representative of a specialist such as Chrysalis Finance, who look after the compliance and the reporting, and provide you with a state of the art online portal to process applications simply and easily. So you can not only get on with giving your patients the best treatments, but you also make them affordable for them. 

 

Martin Gilbert, a chartered accountant,  is a Director of Chrysalis Finance.

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Buy an AED - a patient arrested in my dental surgery

Buy an AED - a patient arrested in my dental surgery

 

Thursday 16th April 2015 is the day I will never forget.  I was in surgery with Amy.  Bea was at reception.  It was a life changing moment for me and I am sure, for all of us, by Dr Chris Tavares BDS

 

 

 

 

 

 

 

THE CARDIAC ARREST

We were ready to get the patient in.  At around 3:45 pm,  Amy went out to get him in.  As the surgery door opened I could hear him having a laugh with Bea.  He came in, we exchanged the usual superficial pleasantries, had a laugh.  Asked him how he was. He said “Fine, very well thank you”.   Soon, was this to change.

He told me he had fractured a tooth in the upper right area this morning. There was no pain but it was sharp.  I turned round to type this into the clinical notes.  I could see that his ASA rating was 1.  Nothing medically to worry about.  As I was typing, I heard heavy breathing behind me.  I turned round and saw his eyes had closed, his right leg was hanging off the side of the dental chair and as I faced him, calling his name and shaking him and lightly slapping his face, the breathing became more laboured.   I lowered the chair back right down and called him again.  Suddenly he came round and said: “Yes, yes I’m ok”…and then….he was ‘gone’ again. The breathing became more laboured to an alarming level. 

I asked for the emergency kit and Amy came back with it.  He was still breathing heavily.  As I attached the pulse oximeter to his finger, his head suddenly came forward, tongue protruded and his breathing become a desperate stridor.   His face then went completely purple / ashen. 

Immediately I instructed Amy to let reception know “Medical Emergency.  Cardiac Arrest. Call an Ambulance.”  She went straight outside.  I noted the time and started CPR immediately.  30 compressions to 2 breaths.   At one stage, I vaguely remember thinking part consciously, that If I don’t do this, he will die. It was a battle between death and I and death was not going to take him, not on my watch.  I pumped like mad.

I heard Bea, shout, if he was breathing. I shouted back: “No. Cardiac arrest. Not breathing.”  

Amy came back in and brought the AED in. We connected it up and followed the instructions.  Bea stayed on the phone in, in case 999 needed to speak to her.

 

 

The AED spoke in an incredibly loud ‘voice’:

“Stand back. Do not touch the patient.  Assessing rhythm…..Shock advised…….Press the red button and shock.”  I did this and the whole chest arched and lifted off the chair with part of his body.  The AED assessed the rhythm again and instructed us to continue to carry out CPR. 

Meanwhile as Bea had more training in Med Emergency, she came in and Amy went outside to wait for the ambulance.  As I carried out compressions, the pulse oximeter showed a pulse of 110  and oxygen content of 70%.   This little bit of information was reassuring as our AED did not have a screen with the ECG tracing. 

The AED instructed again:  “Stand back. Do not touch the patient.  Assessing rhythm…..Shock advised…….Press the red button and shock.”  I followed the instructions.

The first paramedic arrived. This was about 11 minutes from the time the patient went into cardiac arrest.   I continued CPR.  He took over immediately to check the back of the chair was firm enough and immediately said ‘yes’, good.  I then took over again as he got his gear out.

The AED instructed again:

“Stand back. Do not touch the patient.  Assessing rhythm…..Shock advised…….Press the red button and shock.”  I did this and the chest arched and lifted off the chair.  The AED assessed the rhythm again and instructed us to continue to carry out CPR. 

Suddenly the patient responded and pushed my hands off his chest!  Then went still again.

The paramedic was in no hurry to attach his AED.  He asked if our AED showed what was happening on a screen.  I said no.  He seemed happy to continue with our AED at the moment.

The AED instructed again:  “Stand back. Do not touch the patient.  Assessing rhythm…..Shock advised…….Press the red button and shock.”  I did this and the chest arched and lifted off the chair.  The AED assessed the rhythm again and instructed us to continue to carry out CPR. 

By now two more paramedic vehicles and the ambulance had arrived.  Literally minutes if not seconds, 4 more paramedics came into the surgery.   The lead paramedic, the first one who arrived, switched over to his AED which had an ECG tracing.   The second lead asked about the medical history of the patient and I informed him it wall all clear. 

The third paramedic took over external cardiac massage as the second put an IV line in.  Sugar level was tested. Negative.

It is difficult to recall exactly what happened when and what was done when and in what order.  An airway was put in.   A drip was set up.  At some time I think they also injected something.  They did other things I am not sure what.  They also attached a contraption that carried out external cardiac massage.

As they looked at the ECG I heard the second paramedic say to the lead, “That’s VT” (I think that’s what he said. There was definitely a ‘V’ in his sentence) and this was confirmed by the first.  Everyone was instructed to stand away from the patient, they pressed a button, you could hear a ‘whine’ as the defibrillator charged and they shocked the heart again. 

The ECG tracing went flat and suddenly started up again and I could see what appeared as a more ‘normal’ tracing.  Then it took on another pattern again. 

They were in the surgery for about 1 hr to 1 hr 30 mins.  The tracing on the ECG was erratic and inconsistent in that time.  Every time they shocked him, the line went flat and then started again.

I had to help to deliver the oxygen for a few minutes.   In total the patient’s heart was shocked 6 - 7 times.

I am sure he had ‘come’ round a few times in that 90 minutes.

After the last shock, I cannot say exactly when but I suddenly realised they had stopped the compressions and delivery of oxygen.   They were moving around more relaxed. The lead paramedic asked one of the ambulance drivers to bring something in.  Then he asked her to bring the stretcher in.  I thought: “What, is he…dead?”. 

I had forgotten about the ECG.  I suddenly remembered it and looked over at it…..even though the patient was unconscious and no obvious signs of life, to me, ……… there was a ‘normal’ heart tracing on the ECG.   Very regular and steady.  I looked at his chest…he was breathing on his own!  I thought: “My God, there’s a normal rhythm!”  

They lifted him onto the stretcher with the airway and ‘automatic cardiac massage’ contraption still in place, I think. The airway was definitely in.   I suppose in case he needed it again.

3 of the paramedics went with the patient to the hospital, having taken the patient’s personal details.  2 stayed behind to pack up and clear up.  I asked the second paramedic if the patient was OK.  He looked at me, looked at our AED the oxygen cylinder and said pensively:

“He’s OK. Will have to see if he pulls through.  Hopefully there is no brain damage.  You got the oxygen,…. (he looked at the AED again, which was lying on the surgery floor) …….you had the defib…….you saved his life.” He said nodding.   It had not dawned on me at the time the significance of what he was saying.

The two remaining paramedics left, saying that they’ll be back to pick up the last remaining paramedic vehicle when they’ve finished at the hospital.

 

THE IMMEDIATE AFTERMATH

The three of us sat down, numb and started talking about the incident.  Bea made cups of tea and we sat in the staff room.  We agreed we could not have done anymore.  When he had been put into the ambulance, Amy said she heard one paramedics say to another that the patient had pulled the airway out.  This was put back in then the doors were closed. So it was good, it was reassuring to know that he was alive when he left the surgery to be taken to the hospital. 

There were no elation and shouts of joy. Just numbness.  The shock and disbelief that we had just be part of and witnesses to a full blown cardiac arrest in our dental chair.

As Amy and Bea were talking, I remember I had asked one of the paramedics if there was something we should do or someone we should report to. He said there was nothing.  If the patient dies, the police will be round to make their enquires and investigate.  If he pulls through, we probably won’t hear from anyone.

When I look back now, I cannot help but feel what a sad and unacceptable and ridiculous situation the profession has been put into by those who have the authority to ‘rule’ over us but really have been given or taken more authority that they deserve.  I have been told by a paramedic that we did the right things and possibly saved someone’s life, at the moment, but instead of elation at a professional stance of doing the right thing, unfortunately I started worrying about whether I had all the right ‘paperwork’, dotted all the ‘i’s and crossed all the ’t’s if there was an investigation!

When we finished our tea and I could see we were alright, we went down stairs to tidy up.  Bea put a note to order a new set of adult pads for the defibrillator.  I checked the oxygen content whilst Amy put the Medical Emergency things away.

It would have been about an hour to 90 mins when the door bell rang. Paramedics 1 and 2 were there.  We looked at them holding our breaths.  I asked how the patient was.  The lead said, looking at the ground:

“We have some news for you.  Looked up and smiled. We have him up and talking.  He’s actually up and talking.  He must have had a massive blood clot in the artery. They are thinking of discharging him in a few days. Well done” as he looked at each of us.

The relief from the three of us was palpable in the air.  He’s OK!

The 2nd paramedic looked at the three of us, then at me in the eyes and said something about CPR, getting the oxygen in then…..

“You had the defib…….YOU SAVED HIS LIFE””, nodding and repeated as he looked round at the three of us: “you saved his life, well done” and smiled.

I thanked them for delivering the good news, thanked them for getting here so quickly and for all they had done.

The two then left.

 

We shut the door and elation!  The total release of suppressed, involuntary tension.  Earlier on once the paramedics had arrived, Bea had cancelled the rest of the patients for the day and evening. I felt they deserved to have the rest of the day off!  Fortunately we weren’t seeing patients the next day.  They went home.

I stayed behind for a bit.

 

PERSONAL REFELECTION

Bea and Amy were just great.  I could not have asked for better support.  This was the first, and last I hope (!), medical emergency we had to deal with and, for all that, in at the deep end.    Amy just carried out unquestioning what she was asked to do.  Bea, calmly called the ambulance and handled the reception area.  In fact, as Bea was cancelling one of the patients’ appointment, he commended her on how calm she was when talking to him, given what she was in the midst of.

We were lucky there were no other patients in then.  No one ‘collapsed’ , broke down in tears or freaked out.  They both held it together.  Just amazing.

I will forever be grateful for the regulation that insisted we had Continual Professional Development (CPD) on “Medical Emergency” every year.  Every year we had a hands on 3 hours training session and I would also attend an additional lecture session.  I was never sure how much of this I actually retained in my head.

I made sure we held a medical emergency drill once a month. Only I knew when I would call one. I would always choose a time so we had a different number of staff around. We may miss a month at most but we held the drill regularly.

I am in no doubt this was one of five things that affected the outcome.

INSTINCT

When something like this happens, there is no time to think, no time to work your way through some mental venn diagrams or following the boxes of a mental flowchart.  It had to be instinct and what was already in your subconscious. 

Everyone just went into action. Everything just went so smoothly.  The call for the ambulance. Staying online with the 999 operator. Waiting outside for the ambulance.  Amy saw him and made a beeline for him.  CPR: 30 compressions to 2 breaths.

I have no doubts the regular drills helped us all.

 

STRIDOR & SUBSEQUENT LOSS OF COLOUR

I did not have to work out if he was breathing or his heart was beating. This just told me …negative.  I was lucky to have had these signs.

I just started immediate CPR and the ambulance was called. 

The rapid response I am sure contributed to the outcome.

CARDIAC COMPRESSIONS

One can never know if one is compressing chest deep enough.  You can’t measure the depth of compressions in such situations.In this case the colour of his face instructed me.  I could actually see the colour come back to his face.   This helped a lot when one is not consciously in a thinking mode and operating on instinct.

AUTOMATIC EXTERNAL DEFIBRILLATOR

The enemy to anything we do …….is ‘doubt’.  If you start asking yourself, doubting your actions, for anything, it is a recipe for disaster or failure.

He was, as I came to know, in VT/VF. I have no doubts the AED contributed to the positive outcome, directly and INDIRECTLY. 

Before the AED was connected, I was just pumping away but no idea if it was helping. 

The question always in the back of my mind is if I’m doing the right thing at the right time. 

When I connected the AED up, the minute I heard its “voice”, I was immediately aware of a sudden mental, physical and emotional relaxation. It was like having the consultant cardiologist in the surgery.

“Stand back…do not touch the patient…assessing rhythm….shock advised….press the red button and shock.”  I just thought: My God, his heart is being monitored now.  “Somebody” knew what was going on.  There is nothing more to do but follow the instructions.  It had an immediate calming effect on the whole process.

I had wondered if I should buy the AED.  I did. We’ve had it for 5 - 6 years now, every day checking the “green ready” light is on, never once thinking we will need it.  I have absolutely no regrets in buying it. 

I am well aware that there is still going on a major disagreement amongst professionals whether the AED is necessary in the dental surgery.  I will have no hesitation now to say YES.  I cannot be more appreciative of the AED.  It made the whole incident so much more easy to handle and I will forever be grateful we had one.  It actually helped to calm the room.   Was it ‘the thing’ that saved his life?  I don’t know.

I remember hearing at a lecture on Medical Emergencies.  I cannot remember who it was.  What he said was that we can never fully know exactly what is happening to the heart muscle and how it will respond to anything we do.  The patient, to all intents and purposes, is dying or nearly dead. If there is anything we can do that will remotely contribute to a positive outcome….DO IT.

Of course there is never absolute certainty in life.  The consequences of our actions can never be fully predictable.  If one will only act if one is always absolutely certain of the consequences of one’s actions, then one would just sit and do nothing.

The AED contributed in two major ways:

1    It really calmed the room whilst we waiting for the paramedics to arrive.

2    As I saw on the ECG screen later, it gave the heart a chance to re-establish a normal rhythm.

I HAVE ABSOLUTELY NO DOUBTS THE AED CONTRIBUTED TO THE POSITIVE OUTCOME in this case.

LUCK

Pure luck had a lot to do with it.  We were lucky the paramedics were able to arrive so quickly and there were so many.   They were just amazing.  They went about what they had to do in a calm, confident and controlled manner. 

We were lucky, before the paramedics arrived, none of us freaked out.  I have no doubts the regular drills we had played a large part.

One can never say for sure what exactly it is that brought about the positive outcome but I am sure luck played a part in it.

 

WHERE AM I NOW?

There is the disbelief that I was actually  deep in the middle of it all.  I actually looked at the face of someone who was clinically dead and he pulled through?   I came back from the Dentistry Show the day after ‘the event’ and went straight to the surgery, to call the hospital to see how he was. There was a slight eerie feeling going into that empty building, into the surgery. It was all clean, tidy and quiet. I could not help but wonder if 24 hours earlier, did all that really happen?

The suddenness of it all is what is so frightening. There were no medical history concerns.  One minute he was there, two minutes later he was gone. If he had been in his car, 5 minutes late for his appointment, he would have had it in the car and could have ploughed into a bus stop with men, women and children.

I value my life much more now.  An appreciation of what I have, life, wife and children,friends and who I am.  So much we take for granted. 

I was surprised how well we all were when we attended to patients two days later.  It will take some time for the slight apprehension to dissipate.  Is this person going to suddenly have a heart attack on me?

The recent developments, all the nonsense, in the dental profession had really got me down.   All the effort in having to keep a surgery running with all the nonsense regulatory compliance and then having more piled on, unnecessarily.  I had been tired of putting so much effort into working as a dentist and getting so little back in return as the pressure of legislature piled on.  I was tired of legislature getting in the way of patient care. 

This ‘event’ has helped me to see things in perspective. This has been a good boost in morale as at least, all this effort came to fruition.  I am very proud of my staff and I hope they are of themselves too.

There is a mixture of emotions or feelings in myself.  Of course there is an immense feeling of gratefulness that we had a positive outcome.  Then, there is the feeling that one has been in a ‘privileged’ place, if that’s the word to use.  To have been involved in the thick of things and have a positive outcome.  Then there is something else I am aware of.   I am not sure how to describe it but it is a good feeling……….there is a deep seated feeling of stillness.

Every so often, the words that still ring in my ears:  “You had the defib……you saved his life.”

That inner stillness…..is….good.

Chris.

 

Dr Chris Tavares,

Dental Practitioner, Derby

April 2015

 

This blog was first published in April 2015, a few days after the event. In May 2016, after seeing more data, Dr Chris Tavares added the following:

I wanted to correct a few inaccuracies so as to be fair to the East Midlands Ambulance Service who did such a fantastic job on the day and to give credit when and where credit is due.

In the heat of things, a second can seem like a minute. A minute can seem like three minutes. I was able to download the data from the AED which records an ECG tracing every second. The AED analyses the rhythm every 2 minutes and advises to shock or not.  I was able to work out the exact timeline from this.

The heart was in VF.  CPR was started within 10 seconds of cardiac arrest.  The first shock to the heart was within two minutes of cardiac arrest.  The first paramedic arrived 5 minutes from the time we dialled 999. The five paramedics were in the surgery for about half an hour when a normal heart rhythm and spontaneous respiration were re-established and the gentleman was taken to the hospital. 

I have no doubts the rapid sequence of responses added to the positive outcome.

 The whole situation can best be summed up:

 “We did what we had to do ... the paramedics did their magic ... and the hospital staff performed the miracle.”

The gentleman is alive and leading a full life, no brain damage, no external scars.

Buy an Automated External Defibrillator and save a life.

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© Dr Chris Tavares, BDS, GDPUK Ltd 2015

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Engaging- with-the-Friends-&-Family-Test

Engaging- with-the-Friends-&-Family-Test

Friends and Family Test [FFT]

 

This blog article is a personal opinion piece by Dr Ian Mills BDS (Glasg.), MFDS RCPS (Glasg.), MJDF RCS (Eng.), Dip Imp Dent RCS (Eng.), FFGDP (UK), FDS RCPS (Glasg.)

Ian is a partner at Torrington Dental Practice, in Devon.

 

The FFT will be introduced to dentistry in England on 1st April 2015, which some might consider an appropriate date to introduce such a tool. David Cameron is an enthusiastic supporter and believes this simple test will provide “a single measure that looks at the quality of care across the country."

Others, including the Picker Institute, the Kings Fund and the British Medical Association are somewhat less impressed with the value of implementing such a tool. Chris Graham of the Picker Institute has stated that “the ‘simple, headline metric’ used for the test does not provide a reliable basis for comparing services or identifying those performing best.” Dr Kailash Chand, deputy Chair of the BMA, is slightly more direct in his criticism. He has described the FFT as a “political gimmick” and asserts that the last thing we need is to collect “more meaningless or misleading data”, a comment which I’m sure will resonant with many dentists.

Sadly this point is obviously lost on the Prime Minister, who continues to believe that the FFT will allow everyone to “have a really clear idea of where to get the best care”. It is hard to believe that such a simplistic tool could actually improve the quality of patient care in dentistry. (I refer to the FFT, and not the Prime Minister!) 

The only value would appear to be in the free text question, which we have naively been given freedom to design ourselves.

The simplest approach would be to ask …. “Why?”

As in, “why did you answer the previous question in the way which you did?” Rather than “WHY?” in the context of a dentist screaming at the moon, as another pile of ill-conceived bureaucracy is dumped on them from a great height courtesy of some narcissistic NHS manager.

Other suggestions for free text questions have included:

“How much of a waste of time do you think this is?”

“What three words best describe the people who developed this questionnaire?”

In the spirit of Patient and Public Involvement, it might also be worth considering the following as a suitable second question…..

“What question do you think we should include as our second question?!!!!”

It is tempting to treat the FFT with the respect which it deserves. NHS England appears to be resigned to this approach, judging by the fact that there is currently no target set for the number of responses required! The introduction of FFT is a contractual obligation and I can’t imagine that this laissez-faire attitude will persist. Perhaps they will include it within a future iteration of the DQOF as another measure of how well we complete our paperwork. The term “biro dentistry” is about to take on a whole new meaning!

So what should you do?

In our practice, we are fortunate to have a highly motivated, efficient practice manager, who seems to revel in the imposition of NHS bureaucracy. She obviously looks at the FFT as yet another challenge to be overcome, and failure to do so would be seen as a sign of weakness. She has organised strategy meetings, staff training, team discussions and already delegated duties. None of which involve me filling in a pile of FFT forms…… as yet!

There is unanimous agreement within our practice that the FFT question is a complete waste of time. It is not a reliable indicator of quality and provides inadequate information compared to our existing patient questionnaires. We see this as an additional burden on our staff, our patients and our practice, but will reluctantly comply and attempt to use the free text question properly to gather some feedback.

So what should the profession do?

As a profession, we need the BDA to take a strong stance and challenge NHS England on the introduction of additional bureaucracy, which quite clearly has limited patient benefit. It is correct that the BDA support the introduction of measures of quality, but such tools need to be valid, appropriate and worth the paper they are written on. 

 

Patient experience data is of considerable value in terms of improving the quality of patient care and there is obviously an increasing amount of data that is going to be collected, analysed and interpreted. This takes time and resources, but can only be justified if the data collected is robust, reliable and can ultimately be translated into improvements in patient care. If the data is not robust and reliable, the exercise will be a waste of time and simply add to the level of unnecessary bureaucracy and administration, which we have to deal with. It is not acceptable to measure what is easy to measure, rather than what is actually meaningful. This is ineffectual, burdensome and demoralising for staff.  

Jocelyn Cornwell of the Kings Fund states that “patient experience measures will only work if clinicians as well as managers take them seriously, and in general they don’t. Clinicians will reject measures they see as inappropriate or unreliable, and will not act on the results.”

 

We have an opportunity to put quality at the heart of the dental contract reforms, and Patient Reported Experience Measures are going to play an important role in the evaluation of quality. The current approach of NHS England does not instill confidence and it is therefore vital that the BDA, the FGDP and others influence how quality is measured within general dental practice.

 

1.    Department of Health. NHS dental services in England - An independent review led by Professor Jimmy Steele. In: Health Do, editor. London: The Stationery Office; 2009.

2.    Professor the Lord Darzi of Denham K. High Quality Care For All. NHS Next Stage Review Final Report. London2008.

3.    Kings College London and The Kings Fund. What matters to patients'? Coventry2011.

4.    Department of Health. Dental contract reform: Prototypes, Overview document. In: Legislation and Policy Unit DaES, editor. London: HMSO; 2015.

 

 Image credit - Glyn Lowe  under CC licence

 

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Peter Varley

FFT

I completely concur with all the above. Perhaps it sholud also be pointed out by the BDA that this imposed changed is unfunded?... Read More
Monday, 06 April 2015 19:26
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Measuring Patient Experience in NHS Dentistry

Measuring Patient Experience in NHS Dentistry

Measuring patient experience in NHS Dentistry

 

 

This blog article is a personal opinion piece by Dr Ian Mills BDS (Glasg.), MFDS RCPS (Glasg.), MJDF RCS (Eng.), Dip Imp Dent RCS (Eng.), FFGDP (UK), FDS RCPS (Glasg.)

Ian is a partner at Torrington Dental Practice, in Devon.

 

A consistent criticism of NHS dentistry has been the continued focus on treatment and activity rather than prevention and oral health outcome; a pre-occupation with “quantity over quality.” Jimmy Steele acknowledged this in his 2009 report and highlighted the need to design a contract which provides “much clearer incentives for improving health, improving access and improving quality.”1

We would all agree that dental care professionals should provide care of a sufficiently high quality for our patients, and it would not be unreasonable to expect to work within a system that supports this. Sadly, it is generally accepted that the current NHS contract does little to incentivise or reward high quality care, and I guess we should be encouraged by the fact that the contract reforms appear to be addressing this by developing a Dental Quality Outcomes Framework (DQOF).

The DQOF was initially based on three dimensions of quality as recommended by Darzi2: Clinical Effectiveness, Safety and Patient Experience. This has subsequently been refined with the introduction of two additional domains (Best Practice and Data Quality) within the prototype contracts. The addition of a domain which rewards dentists for submitting NHS claims on time perhaps gives some insight into the level of confusion which exists around the concepts of quality management and performance management. Submission of claims on time is certainly important for the smooth running of the system, but it is difficult to comprehend how this is related to the quality of patient care.

The Dental Quality and Outcomes Framework (DQOF)

This lack of understanding about quality in dentistry is further highlighted by the current design of the “patient experience” domain within the DQOF. Patient experience is recognised as a key component of assessing quality within the NHS, and the current DQOF includes seven questions purportedly related to experience. At first glance these questions may appear relevant “How satisfied are you with the NHS dentistry received?” or “Would you recommend this practice to a friend?” or “How satisfied were you with the cleanliness of the practice?”

They all seem quite reasonable questions, but do they provide an accurate assessment of patient experience?

You would certainly hope so, as the current intention is to assign 10% of your GDS contract to DQOF, and a failure to hit your target will result in financial penalty. When the QOF for GPs was introduced in 2004, significant investment was made to incentivise improvements in quality with a 25 – 30% increase in practice funding. Unsurprisingly, the situation is very different in 2015 for dentists. There will be no additional funding and no financial incentives – only financial penalties if we don’t hit our targets. They get the carrot, we get the stick!

When we look more closely at the questions within the “patient experience” domain it becomes apparent that the focus is primarily on patient satisfaction. This would seem strange as the NHS Patient Experience Framework actually states that “measures of satisfaction have a commonsense and political appeal, but they are the measures that experts, including experts in quality improvement, consider the least useful”.3

 

This all might seem a bit academic, and in practical terms not that relevant. Surely if you provide a good patient experience you will end up with a high level of satisfaction? This is possibly true, but definitely not the whole story.

Patient satisfaction surveys are widely used within healthcare and are a very useful way to obtain feedback and improve services at a local level. Dental practices regularly use patient satisfaction surveys to understand what their own patients want and respond accordingly. It is a fundamental strategy in developing and maintaining a successful dental practice. However, there is a subtle difference in using patient satisfaction to improve services and attempting to use the same approach to measure quality across a wide range of providers.

Patient satisfaction has been developed from consumer marketing and is based on disconfirmation theory where the quality of the service is measured against the expectations of the individual. The level of satisfaction expressed can therefore be as much about the patient’s expectations as it can about the quality of the service provided.

This can perhaps be best illustrated by the example of two colleagues, let’s call them Eddie and Mick, who decide to go out for dinner at two separate eateries. Eddie decides to go to a Michelin star restaurant; Mick chooses McDonalds.

Eddie’s restaurant is very exclusive, with attentive staff and lovely surroundings. Unfortunately, Eddie has a bit of a weak stomach and he doesn’t particularly enjoy his grilled octopus. On completing his customer satisfaction form, Eddie considers himself to be “satisfied”, despite the disappointment of his main course.

Mick has fairly low expectations, but is pleasantly surprised with his ‘happy meal’ and the unlimited access to free ketchup. He is even more impressed when he receives a complimentary toy, which just happens to be ‘Olaf’, his favourite character from Frozen. On completing his customer satisfaction form, Mick considers himself to be “very satisfied”.

In analysing this data, one could conclude that both ‘customers’ were satisfied, although Mick was more satisfied than Eddie. We might therefore assume that the quality of the experience provided at McDonalds was superior to that of the restaurant. This may of course be entirely inaccurate, and could simply be an indication of the varying expectations of the two individuals.

I would not wish to repeat the same mistake as our beleaguered Chair of the GDC, by comparing dentistry to supermarkets, but hopefully this example might illustrate the dangers of using patient satisfaction as a measure of quality. In our world, the same situation applies where patients rate services based on their expectations and not on the quality of care provided. We all work in very different practices, in different communities with patients who have different backgrounds and very different expectations. It would therefore be inappropriate to use a measure of quality for dentistry based on patient satisfaction alone.   

There is extensive literature on measuring patient experience, which is closely aligned to the dimensions of “patient-centred care”. Various tools have been developed and validated, and it is disappointing, although perhaps not surprising, that NHS England have chosen to design their own non-evidenced approach. To be fair to NHS England, they have stated that they are developing new Patient Reported Experience Measures (PREMs) which they intend to validate before introducing them4. A refreshingly robust approach when compared to the imminent introduction of the Friends and Family Test.

 

 

Image credit -  Chance Projects  under CC licence - not modified.

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Tony Jacobs

Discuss this on GDPUK forum

Colleagues, Ian is keen to discuss this with GDPs, see thread on the forum, http://www.gdpuk.com/forum/gdpuk-forum/measuring-qual... Read More
Monday, 30 March 2015 12:25
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Prototype or re-hash?

Prototype or re-hash?

Will there ever come a time in the dental profession when solidarity will create meaningful change?

Recently some bus drivers in London realized that some drivers were getting paid more than others, so they called a 24 hour strike last week, with less than a days notice.  Around 2.3 billion bus journeys are made in the capital in a year and on that day millions of people were affected as they were forced to use alternative transport. Clearly the knock on effect means that the underground and road traffic becomes clogged up. Cab drivers drove the capital to a halt when they realized that a US competitor was taking their lunch.

What is always clear when the press covers these stories is that the system itself is identified as the fault, not the actual providers of the service. Striking workers comes as no surprise for most of us. whereas health professionals standing up for their rights seems to be rare. It is unlikely the bus drivers that were getting above average pay would be so keen to raise the alarm. Akin to those contract holders with UDA values well above national averages.

In truth, the announcement of “evolution not revolution” by Earl Howe with the imminent roll out of the prototype contract scheduled over the next 3 years will mean it’s a long wait for those unhappy NHS contract holders. Indeed has anything really changed in the last 9 years ? Limited exposure from an ever-hostile press rarely highlights the disparate and confusion of what is literally affecting the vast majority of hard working and ethical health professionals every working day.

The cynic in me would say this is classic posturing from the commissioner of the service. After all “If the profession hasn’t responded firmly in the past, it is unlikely to do so in the future”.

When the doctors went on strike in 2012 , the press did not make out it was money focused doctors at fault rather a change in their pension structure at the core of the story.

If history teaches us anything about the department of Health then we know that it's going to a lot longer than planned to see real tangible change in the dental contract, which is intended to remain in place for 20-30 years.

The pricing transparency issue unveiled by a Which consumer review makes it even easier to point the finger at the “ money focused” dentist. What is left for the profession? How can we take real action to illustrate what causes the problem and that hard working NHS dentists cannot continue like this for years to come? (?)

Consider the facts for a moment

-       No increase in NHS dentistry budget planned for the next 5 years

-       Marked decrease in patient access across every existing pilot site ( speak to any pilot site and ask them how long their patients are waiting for an appointment)

-       Hygienists and less so therapists will take an increasingly larger role in prevention and health assessments 5 years from now.

So the question of solidarity, can it actually happen in dentistry? I sadly suspect not. Perhaps because every NHS contract holder has too much to loose if they were held to account. Perhaps successive governments only take real notice about dentistry when the press shows the long lines outside a new NHS dental practice opening up. Perhaps its fear of persecution in the press, or genuine concern for our patients well being and we are not prepared to leave our patient in the lurch? So maybe its time for dentistry to take stock and unite to take its part in controlling its destiny?

If not, the finger of blame will continue to point at the dentists who appear to be the bad guys.

We launched http://www.toothpick.com in 2013 with a clear objective. Make dentistry more consumer friendly for patients and provide an efficient way of building a patient list.

Having travelled and experienced different dental remuneration models around the globe I became acutely aware how different patients perceive dentistry. I suspect the combination here of the press portrayal and the rising patient expectation under a limited system has created a terrible reputation for the profession.

Its hard here as the NHS patient journey is far too short to form a positive opinion and a hostile press that is ready to dentist bash it becomes a downward spiral unless urgent action is taken from within to reverse this effect.

If it’s another rehash of the broken and failing system rather than a workable new contract formed then perhaps the new prototype signals the beginning of the end. Or could this be the trigger to start real action to identify the cause of the problem and have real inclusive dialogue for a solution that gives that gives a fair deal for the patients and the providers.

I feel only with this approach can we restore the professions reputation and trust with the public and the press, which takes years to build and seconds to destroy.

Sandeep Senghera

Image credit - Sludge Gulper   under CC licence - not modified.

 

Dr Sandeep Senghera BDS, CEO and Founder Toothpick
 

Sandeep combines his 12 years of experience and knowledge as a Dentist since 2002 with a passion for internet technology to create www.toothpick.com to help patients book a dentist online at over 3500 NHS and Private dentists in the UK.

Drawing from a family heritage in business and start ups, his entrepreneurial nature and desire to improve patient experiences in Dentistry drives his business.

 

 

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How is the CQC going to assess and inspect dental practices in 2015?

How is the CQC going to assess and inspect dental practices in 2015?

How is the CQC going to assess and inspect practices in 2015?

Here’s a check list that I have used BEFORE I plan a CQC visit:

·         Website for opening hours / NHS/private / services & treatment provided

·         Inspection history: Summary including date of last inspection, and including any breaches of regulation(s) or concerns identified at the visit. Date action plan completed.

·         Local Area Team (LAT) information return: Date sent and returned - any issues.

·         Provider information return: Notes re statement of purpose / compliments & complaints.

·         Feedback: A brief high level summary of any patient / other feedback from any other source.

·         Registration: Summary of changes to registration and registration issues, including details of the registered manager.

·         Notifications: Summary of notifications received at CQC, whether received when needed and within relevant timescales.

·         Concerns and enforcement: Summary of any concerns and/or enforcement not already covered above.

You have this information, so why not review it and decide what the CQC will make of it?

What does this mean in 2015?

CQC inspection in 2015 will be based on the following and in my opinion biased heavily towards Safe and Well-led. With this in mind, look down this check list and think about how exactly you could show me evidence that this is happening today in your practice.   I’ve put a few examples in each section.  

Safe

·         Lessons learnt and improvements made when things go wrong. Evidence? (risk assessments, RIDDOR, improvements made, changes planned etc.)

·         Care assessed to prevent unsafe care and treatment. Evidence? (Medical history checking system, treatment planning, record card audits, retrospective radiograph audit) 

·         There are systems, processes and practices in place to keep people safe and safeguard them from abuse.

·         There are systems, processes and practices in place to protect people from unsafe use of equipment, materials and medicines.

·         There are systems, processes and practices in place to prevent healthcare associated infections.

·         Potential risks to the service and individuals are anticipated and planned for in advance.

·         There are systems, processes and practices in place to ensure all treatment and care is carried out safely.

Effective

·         Patients are always involved in decisions about their treatment and the practice obtains valid consent and audits records of this. Evidence? (Record keeping audit, patient information in various formats, fees explained and written treatment plans, agreed practice wide system for recording treatment options understood by patient, pros and cons explained, time given for decisions, Mental Capacity Act understood)

·         Patients’ needs are assessed and care and treatment delivered in line with current legislation, standards and guidance. Evidence? (new patients survey considered, waiting time audit, opinion survey used, disability access audit performed, practice meeting minutes where GDC/CQC standards discussed, staff sign policy documents, system of governance operated)

·         There are effective arrangements in place for referring to other health professionals to ensure quality and continuity of care for the patient.

·         Patients’ oral health needs are assessed and care and treatment delivered, or referred, in line with current legislation, standards and guidance.

·         Staff have the right skills, knowledge and experience to enable the effective delivery of care and treatment.

·         Staff are recruited, inducted and appraised regularly and records are always available on the premises.

 

Caring

·       Patients are treated with kindness, dignity, respect and compassion while they receive care and treatment. Evidence? (Confidentiality always considered, patient survey acted upon, waiting times audited, comments book shows many patients are pleased with care, telephone answered promptly and politely with log kept, emergency spaces available every day, complaints tracker shows all complaints handled carefully, staff training logs, privacy and dignity respected).

·       Are people and those close to them involved as partners in their care.

·       Does the practice promote equality and diversity and recognise the needs of different groups.

Responsive

·         The practice staff routinely listen and learn from people’s concerns and complaints to improve the quality of care. Evidence? (Practice is growing, has plans for improvements, staff levels constant and staff encouraged to develop competencies, complaints handling regularly updated, everybody encouraged to participate, complaints tracker up to date and good comments in book, NHS Choices etc).

·         Patients receive an explanation of any need for referral with copy of letter and options/consequences.

 

Well-led

·         The governance arrangements ensure that responsibilities are clear, quality and performance are regularly considered and risks are identified, understood and managed. Evidence? (There is a written system of governance which is used in training and regularly updated, all staff are competent and have a personal development plan, there is a culture of openness and professionalism).

·         How does the practice engage, seek and act on feedback from people who use the service, public and staff.

·         How do the leadership and culture reflect vision and values, encourage openness and transparency and promote delivery of high quality care.

 

Let me ask you a few questions.

In your honest opinion, how do you think your next CQC report will look?

 

Bear in mind that It only takes one person to sink your ship.

Who actually runs your practice on a day to day basis?

Do you have a plan of where you want to be in a year, or five years?

How are you confident that all your staff know what the standards are?

How do you monitor standards of safety, effectiveness, care, profitability, popularity and are you moving ahead?

This is why you must have a system of Governance, I know this, you know this, the CQC insist on this. 

RightPath4 can provide a system of governance mapped to 2015 CQC requirements which is simple to implement and does not cost £thousands or run to thousands of pages. It is easy to bespoke it to your practice and use as an important part of your practice meetings and induction. We have a unique template tool which helps you give confidence to the CQC that your practice is safe, caring, effective, responsive and well-led.

£250, no ifs, buts or VAT

£540 and we’ll deliver it to you and spend a day showing you how to apply it to YOUR practice.  There are no ongoing payments, unless you want us to keep prompting you. (We do offer to update you and revisit your practice at a monthly cost of £70 payable by Standing Order, it’s optional though).

I hope we will be able to continue to help you.

Kind regards,

Keith Hayes BDS  Clinical Director RightPath4 Ltd.,

There when it counts.

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What's coming from CQC

What's coming from CQC

You’ve got CQC hindsight, but have you seen what’s coming?

The CQC have ‘Fresh Start’ plans for us in 2015        

It’s part of their strategy for 2013-2016, Raising standards, putting people first).

They are more focused than the previous ones and inspectors will be more

experienced in assessing dental practices.

The new standards are divided into eleven Fundamental parts. 

Fit and Proper Person (Directors) and Duty of Candour are 2 new standards.

The CQC have also beefed up their enforcement powers, meaning that they

may not give you a warning before they prosecute.

 

How do the old ‘Outcomes’ relate to the new Standards?

The simplest way to explain this is for you to complete my CQC survey: https://www.gdpuk.com/index.php?option=com_rsform&formId=57 and then I will send you an explanation of how to relate the old CQC to the new CQC and the new (ish) GDC principles. I will also send you an explanation of what the ‘Key Lines Of Enquiry’ (KLOE) is all about and how it will be applied in April 2015.

What effect have the CQC had so far?

Many of you kindly told me about your CQC thoughts in my survey, (see link above) which is still running.       By sending it back to me, you will now know what or who KLOE is. The CQC inspector will use these KLOE’s to guide the inspection process and make a judgement. The CQC still haven’t decided about publishing these.   

I have summarised what you have told me so far from my surveys and will be discussing them with the CQC. We may yet be able to have a sensible regulator looking at the right things in an intelligent way.

My prediction for 2015 is that FEES, Cosmetic dentistry and dermal fillers will also come under the spotlight.

Brief analysis (from 76 surveys)

I have used this as a pilot survey to determine whether there is a need to gather more information on how well the CQC registration and inspection process is received and what the beneficial effects may have been in driving improvement.

I think relatively few will have experienced re-registration and therefore a low %age answering YES to Q1 may be expected. However it is disappointing to see that 48% still felt that the process has not been made clearer. 

There continues to be much confusion over legal entities and I know (from personal experiences of clients that this is still a problem now, 76% of respondents agree.

 

81% felt that the inspection was not structured to reflect dental practices; even higher (87%) saying that the nuances were not understood and many said that a dental adviser is required.   

It seems that few felt that they understood what the CQC expectations are regarding safe, well-led and managed practices. I was particularly pleased that our own clients were in general more ‘upbeat’ about the potential benefits of CQC compliance and also felt more empowered and knowledgeable (judging from some open question comments).

The open questions were designed to test whether the process of declaring ‘compliant’ 48 times in the original application had sparked an interest in them to get things done before inspection, just in case. It seems that this was the case in as much as 72% said they had done some things, although I need to look more closely at this figure because some of what was said was fairly minor ‘window dressing’ was one comment.

The most significant results I feel were relating to the perceived benefit of CQC registration and inspection.

The positive improvements noted by patients and staff reached only 14% and the consequential improvements to the business reached 21%. Finally regarding your additional thoughts, there were many suggestions and yet only 6.5% of these were positive. I have concluded that an improved and much larger survey spread amongst a wider audience is required.

OK, so what?

From April 2015, CQC inspection reports will look quite different. Instead of considering just 4 or 5 Outcomes; the inspection will be constructed in a different way to test whether your practice clearly demonstrates that it is safe, caring, responsive, effective and well-led? A CQC inspector has described how the new process enables them to ‘get under the skin’ of the practice and see what is really happening.

Safety is now considered of paramount importance following on from the terrible instances of poor care graphically illustrated in the past few years. Although the CQC had considered that dentistry was relatively much lower risk; there was a severe jolt to this belief recently in Nottingham. The GDC are also convinced that there are also still much greater problems within the Profession. So it is my guess that safety will share top billing with being well-led.

It is hard to imagine that a well-led practice would be unsafe or that there would be many unresolved complaints or that there is a high staff turnover or patients don’t have fees explained properly.

RightPath4 can provide a system of governance mapped to 2015 CQC requirements which is simple to implement and does not cost £thousands or run to thousands of pages. It is easy to bespoke it to your practice and use as an important part of your practice meetings and induction. We have a unique template tool which helps you give confidence to the CQC that your practice is safe, caring, effective, responsive and well-led.

In the next blog article, I’m going to discuss how the CQC are going to assess and inspect in 2015.

Here’s wishing you a Happy, Healthy and Prosperous New Year,

Keith Hayes BDS

Clinical Director www.rightpath4.co.uk This email address is being protected from spambots. You need JavaScript enabled to view it.

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Does an FtP await me? - a 2014 dental poem

Does an FtP await me? - a 2014 dental poem

Oh cripes, oh crumbs! What have I gone and done?
I’ve only gone and broken GDC Principle Number One.
I tried so hard to put his interests well before mine,
But he works shifts and wanted me on Sunday at half-nine
Does an FtP await me?

Oh cripes oh crumbs! Now I’m in the poo!
I’ve only gone and broken GDC Principle Number Two.
I tried to communicate effectively, I really really did.
But he's a Glaswegian Kiwi and I couldn’t understand what he sid.
Does an FtP await me?

Oh cripes, oh crumbs! They’ll hang me from a tree!
I’ve only gone and broken GDC Principle Number Three.
I thought consent was valid, I really talked it through,
But his Uncle’s anti-fluoride and now they’re going to sue
Does an FtP await me?

Oh cripes, oh crumbs! They’ll strike me off for sure
I’ve only gone and broken GDC Principle Number Four.
His wife checked his appointment, the nurse said he wasn’t in
He was knocking off his secretary, committing carnal sin
Does an FtP await me?

Oh cripes, oh crumbs! They’ll boil me alive!
I’ve only gone and broken GDC Principle Number Five.
Anyone can complain to us, be it grumble, moan or wail
We thought me made it pretty clear, but we don’t have them in Braille!
Does an FtP await me?


Oh cripes, oh crumbs! They’ll torture me with sticks!
I’ve only gone and broken GDC Principle Number Six.
I referred her to a Specialist, one I’ve used a lot,
But she wanted to see another one, and now I’m in a spot
Does an FtP await me?

Oh cripes, oh crumbs! This is DLP’s heaven
I’ve only gone and broken GDC Principle Number Seven
I thought I could root fill a tooth, but I’m not able to you see
There are many many lawyers who know much much more than me!
Does an FtP await me?

Oh cripes, oh crumbs! Is another career too late?
I’ve only gone and broken GDC Principle Number Eight.
I thought her weight loss was down to a calorie controlled diet
I didn’t know she was under stress and I shouldn’t have kept quiet
Does an FtP await me?

Oh cripes, oh crumbs! Open the bottle of wine!
I’ve only gone and broken GDC Principle Number Nine.
I try to be upstanding, honest, good and true,
But I follow the GDC’s example – now that JUST WILL NOT DO!
Does an FtP await me?

Mike Ingram

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Upsetting the Applecart

Pantomime season with a Grimm warning   

     

I’ve had a busy couple of days and upset some applecarts; perhaps I should apologise if I have bruised any fruit?

On Friday the 21st, I spent an interesting day in Corpus Christi College, in Cambridge with my fellow NADA (National Association of Dental Advisers) colleagues as well as a selection of the great and the good and quite a few of our younger dental colleagues who had come along for the verifiable CPD and to find out what sort of profession they were entering into.

Sarah Rann (assistant medical director East Anglia Area Team NHS England) kicked off proceedings by asking us and then telling us what we should be doing as National Dental Advisers. The only aspect that she missed off her list was influencing the Regulators, (aka upsetting the established applecart by proffering an expert opinion).

We were then treated to a relatively complimentary double act between Barry Cockcroft and John Milne’s views on Contract Reform. There was a large amount of agreement even concluding with synchronised retirement from their respective roles early next year. Barry emphasised that ‘access’ was less of a political hot potato now than it had been and he saw this as one of his successes during his tenure. John talked about the impact of pilots and possible implications.

A little local difficulty about a dental practice not far from Nottingham was briefly mentioned.

A question regarding access to certain less privileged groups was aired and this is where I must apologise. I raised the question of ‘access to what quality of care?’ And I then asked ‘who was responsible for the World Class Commissioning of such ludicrously large and unmanageable contracts?’

Well there was a stunned silence and poor Barry looked like he had been stabbed in the chest. Fortunately John was on hand to ride to his rescue and acknowledge, although not answer the question and then draw stumps on this part of the meeting.  

We were treated to some joined up thinking from David Geddes (National head of primary care commissioning) who discussed intelligently and without too much smoke and mirrors what the future 5 year plan may mean to dentistry, please read this if you haven’t: http://www.england.nhs.uk/ourwork/futurenhs/

Amanda Crosse (consultant in Dental Public Health) went a little off piste with her unguarded comment regarding perhaps planning to have dental NHS commissioning overseen by CCG’s. An interesting idea which seemed to irritate the level headed David and which he was forced into backtracking a little.

David Behan was cut short, the previous part of the agenda having overrun by 50 minutes meant that David only had 10 minutes to get his message across about the new CQC. He did it very well I thought and was only sorry that it was necessary to tell the gathered throng of dental advisers that he was disappointed in their union attitude to pay and perhaps we would like to put something back into the profession. He was having no more of discussing an inflationary fee. Actually I agree and am happy to spend my time for free advising the CQC.

This is where all of you come in…...’Efficacy and the CQC inspection, on the right path now? ‘It’s your opportunity to get the message across and its coming to GDPUK soon.

 

 Poisoned apples for ‘afters’………..,

The afternoon was devoted to a Brother’s Grimm pantomime about a dodgy dentist with decontamination and NHS gaming tendencies, played brilliantly by Bryan Harvey (DDU), who was frighteningly good at getting into Character.  We were assured that this was not based on any recent situation and I pointed out that it couldn’t have been, since they failed to notify the Press or recall 22,000 terrified patients…., Oops!

The GDC on this NADA inspired day was represented by Mike Ridler (Head of Hearings) who displayed distressing figures on FtP hearings.  Mike expressed his inability to understand the reasons since in his experience there had not been an associated decline in professional standards. Somebody in the audience mentioned that it might have something to do with National advertising?!! Mike did not wish to be drawn further on this.

He obviously didn’t feel inclined to join in with the GDC pantomime either and suggested that if anyone wanted to talk about other ARF type issues they could do this individually later, although it wasn’t his ‘field.’ He then failed to answer the other questions, since they weren’t his field either.   

The meeting closed with another unplanned shedding of apples just as stumps were drawn and flat hats were on; Jason Stokes leapt up on stage and shouted that if the younger members of the audience felt slightly dismayed by opinions voiced by the demobbing great and the good; NOW is the time to make their voices heard. Oyez, oyez!

 

Keith Hayes

Right Path Ltd

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Faster horses

Faster horses

“If we’d asked people what they wanted, they would have said faster horses”, Henry Ford is famously quoted as saying.

And this week we have news reports about the car insurance industry being subjected to further “market reforms” in order to deliver cheaper end-consumer prices.

But this is a fundamental misunderstanding of the markets.

 

If you look at the résumé of our first appointed chair of the General Dental Council [GDC], Bill Moyes, you will see that he has led several market-driven initiatives in various roles, and it wouldn’t be a leap of the imagination to consider that he has been appointed into the GDC to fulfil a “market-driven” reform. Dentistry has long suffered an image problem; consumers feel that prices (and pay) are too high, that dentistry delivers poor value to the consumer and that there is a conspiracy of the profession against the public – it is only necessary to have the briefest of reads through the comments section on any newspaper that publishes a dental article to see that the accusations of “rip-off” rear their head at a very early stage.

But this premise is entirely wrong. The problem with a free market is that the results are entirely unpredictable. Economic journals are full of perfectly logical explanations as to why markets behaved in a certain way – crucially, behaved and not behave. That is, the analysis of the markets and the rationality of them is done post hoc.

One of the most fundamental problems I can see with the approach of trying to manipulate markets in order to deliver a specific outcome is that it rarely works, or often, even where it does work, often this is not what the consumer demands or buys, although they may insist at the outset that that is what they want.

In our particular dental industry, I would hazard a guess that many people (of a non-dental nature) believe that market reforms will deliver cheaper dentistry, through increasing the supply of the dental workforce. I would suggest that this is unlikely to work for a variety of reasons. Firstly, costs represent some 60-70% of the price that the patient pays. Given that the average pay for dentists has been declining in real terms for some time, if we were to cut pay for dentists by 10%, then this can translate into only a 3-4% price saving for patients. And I don’t believe that we can cut pay much further without running into another economic problem – that of a shortage. If you pay too little for something, you create a shortage. In this case, how many dentists do you think would leave the profession if average pay drops below a certain point? (I would suggest £50,000 for associates, on average, and £75,000 for principals)

So if cost savings are to be made for the end consumer prices, this will have to come from reduced costs. And here we already have an idea of what happens from another industry – the British car industry. Throughout the 60s and 70s, the British car industry suffered a slow and agonising death over many years, selling outdated cars, with poor workmanship and a reputation for declining quality, and in some cases, with cars selling at less than the cost of manufacture. Do these problems sound familiar?

Of course the British car industry eventually collapsed, superceded by German and Japanese competitors who were operating on free market conditions, and produced innovation and rapid improvements in delivering things people wanted rather than what they told government-led focus groups that they wanted. The eventual death of Rover marked a turning point and renaissance of the British car industry, and now we have world class manufacturing and design, but for this to happen we had to see the government leave the industry and several companies to go under.

I sincerely hope that dentistry has its “Rover moment” soon. I believe in the free markets, but a belief in the free markets also means accepting when they don’t deliver quite what you thought they would. And that doesn’t always mean that what will be delivered will be cheaper: sometimes, what is delivered is “better” rather than “cheaper”. I believe that health and dentistry falls into this camp.

After all, when was the last time you saw a car maker advertise how cheap they’d made the braking system?

Free markets tend to deliver better healthcare, by and large, which is often but not always cheaper. I would therefore issue a challenge – if this is truly the purpose of Mr Moyes’ appointment, I would suggest that he can best serve the public by completely withdrawing any government interference in the market, but only on the proviso that he and they MUST accept that prices will almost certainly rise, but also must accept that this may result in longer term reduction of cost. Otherwise we run the risk of delivering the cheapest horses in the world when the rest of the world has moved onto cars.  

 

 

Image credit - Coen Dijkman  under CC licence - not modified.

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Hershal Shah

stakeholders

Great first post. Just to add with this emphasis on markets, gorverning bodies and regulatory bodies must also be accountable to a... Read More
Sunday, 28 September 2014 21:46
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