The GDC Specialist Lists were introduced in the UK in 1998 as a result of developments in European Legislation. As of October 2015 of the 40,953 registered dentists there were 4342 registered specialists; an increase of 31 on the previous year. A significant number of patients require specialist dental treatment each year; in 2012/13 approximately 3.5% of all NHS outpatient appointments were in a dental speciality clinic. There is no precise data as to the number of private treatments being carried out by specialists each year, but it is likely to be in the millions.
Whilst the state of the nation’s teeth used to be a cause for international mirth, over the last decade our love affair with cosmetic dentistry has blossomed. Implants are so popular that there are now calls for implant dentistry to be added to the already voluminous list of dental specialities; the UK has more recognised specialities than any other European country. On the face of it specialist dentistry is big business, but for who? Is it the practitioners themselves, or those who provide and regulate the training?
Becoming a Specialist:
One thing is clear, it is hard work. To be entitled to enter onto one of the specialist lists the dentist has to complete a recognised training programme, ranging from three to five years, have a National Training Number (NTN) and to hold the agreed qualification awarded by one of the Royal Colleges. In total there are in the region of 500 specialist trainees each academic year; many of whom do sadly not complete or meet the programme requirements.
It is the GDC who set the standards required for specialist training, approving the curricula and quality assurance. The Joint Committee for Postgraduate Training in Dentistry (JCPTD), through the Royal Colleges and the Specialist Advisory Committees (SACs), is responsible for the development of curricula, devising assessments and examinations and making recommendations to the GDC on specialty training. The GDC embarked upon a review of the regulation of specialists in 2015; our dental bulletin considering this review can be found here. The second stage of the review began in 2016, and the first results are expected in the autumn. They propose creating a generic template that will serve the basis for all the speciality curricula, bringing a uniformity of language and structure.
The alternative “assessed route” is also under consideration by the GDC. This is where an applicant is required to illustrate to the GDC Specialist List Assessment Team that they have the knowledge and experience derived through academic or research work which they might reasonably be expected to acquire had they completed the specialist training. However, there is limited guidance from the GDC as to what this actually means, the approach to assessments lacks continuity, and applications are routinely returned having been deemed incomplete. Many applicants feel that the only way to ensure success is to seek legal assistance. What is clear is that clinical experience is not evidence of equivalence.
The decision of the GDC not to include clinical experience as admissible evidence is a frustrating one for many, particularly bearing in mind that many dentists were effectively passported onto the lists under the “grandfathering” scheme. This allowed experienced practitioners entrance to their chosen list where they could illustrate that they have the requisite knowledge and experience, wherever acquired. The scheme remained open for two years after the formation of each list. As such it is possible for dentists with no postgraduate qualifications and having passed no exit examination, such as the MRD or equivalent mono specialist exam, to hold the title of specialist.
Is this fair?
Patient safety must be paramount in this argument. The assessment of specialist trainees is so rigorous that members of the public can generally be satisfied that they are receiving treatment from an appropriately qualified dentist. For those “assessed” or “grandfathered”, there is less clarity as the assessment criteria appears to be reasonably subjective, and dependent upon the assessors view of a paper application rather than any face to face assessment over time.
There are also a limited number of training posts available; and recent attempts by universities outside of the “Big Three”, KCL, The Eastman and Queen Mary’s, to increase supply has been met with some resistance. The lack of available NTN’s has also frustrated many applicants hoping to enter onto a training post. The Dentists Gold Guide (June 2016) states that the purpose of NTNs is for “Education planning and management” enabling Postgraduate Deans to keep track of trainees and “Workforce information”, to document within each country and speciality how many trainees are in each programme and to provide information as to when training is likely to be completed. There is anecdotal evidence that some dentists working in hospitals and universities can wait years for a training number to become available. Whilst there is a clear advantage to requiring a minimum number of placements to ensure there are sufficient specialists available, it is hard to justify a cap on the maximum. A large number of specialists do not practice in the NHS, and commercial interests will inevitably dominate private practice. An increase in the number of specialists would allow greater freedom of choice and drive down costs for patients. Why not simply maintain competitive entry onto programmes and keep a register of all specialist trainees, doing away with the NTN system in its entirety. Thus removing the lottery of when a number may come up.
The inequality of the playing field for those entering training is another problem. A three to five year, expensive training programme and a limited number of NTNs inevitably means that established practitioners, particularly practice owners, can rarely afford to take the time or money out of running their businesses to undertake the programme. Many of these individuals have been honing particular specialist skills in practice for a decade and simply don’t require extensive clinical training; indeed it is not unheard of for dentists who have limited their practice to a particular area teaching on Masters programmes in their chosen field. They missed the grandfathering window, and can’t afford to have a three year career break, but they can’t rely on their considerable clinical experience to show that they are already practicing at the level of a specialist.
A further disparity arises in relation to European dentists registered in the UK. At present a broader test is applied to European Citizens than is applied to UK dentists, who are assessed on the basis of all their experience, including clinical. So whilst an extremely experienced Spanish endodontist may rely on the number of treatments she has completed in practice, her English equivalent cannot. Although the rules were designed to give individuals coming from European countries, that follow different training pathways and recognise different specialities, an equal playing field, they have arguably ended up allowing European applicants an easier ride. Of course, post Brexit, this may all change.
Looking to the future, what could the GDC do to improve the current position?
1. They could scrap the assessed route in its entirety. This would ensure uniformity across the specialisms and create a clear quality control of all specialists.
2. Alternatively they could include clinical experience as a factor in the current assessment process, applying the same equivalence rules to all practitioners, regardless of their origin. This would open up the lists to a vast number of practitioners and has the potential to drive up competition in the fields. However this process would be open to criticism as the assessment process is hugely subjective, and there is no hands-on assessment required.
3. I would propose a third option. The GDC could create a more structured assessed process; mapping an individual’s experience, both academic, research and clinical, against the specialist training programme, require a minimum number of years PQE and the successful completion of the relevant exit exam for each speciality. There would remain an element of subjectivity of course, but considerably reduced, and a candidate’s ability would be appropriately tested through the examination.
The GDCs 2015 review talked about “tightening up” the assessed access, but gave no guidance as to how this would be done. They also considered doing away with it in its entirety. That in my view would be a mistake. The assessed route allows diversity and experience that would be lost should all specialists follow the prescribed training programme. It would also unfairly discriminate against older applicants who would not have the years of practice ahead of them to recuperate the considerable costs involved. We wait in anticipation of the results of the next stage of the review, and can only hope that good sense prevails and a fit for purpose assessment route is unveiled.