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Where would we be without the CQC?

Praise_the_CQC

Where would we be without the CQC?

In Praise Of

The Care Quality Commission

By DentistGoneBadd

Believe it or not, it’s just over ten years since the CQC came into being.

I know! It doesn’t seem five minutes since the CQC burst into existence. Sometimes it seems like it’s been hanging over dentistry forever - like the extended impact winter that wiped the dinosaurs out after that postulated asteroid crash-landed without warning – which was a bit like the CQC itself really.  

Where would we be without the CQC?

In England, the CQC is the independent regulator for the quality and safety of care, although to many practitioners, it’s more regarded as a major irritant – another regulatory body to which you have to kowtow, pay an exorbitant fee and produce a forest’s worth of paperwork.

I vaguely remember that the CQC landed on dentistry’s doorstep in about 2011. I was a practice owner in those days and I remember only too clearly, spending most of my spare time writing policies to fulfil forthcoming CQC requirements and being too busy to notice I could have just downloaded them from the internet.

I didn’t have any direct contact with the CQC until I had to go down to one of the organisation’s regional headquarters in the Midlands, for the registered manager’s interview, sometime in 2012. I seem to remember then having to go again a few months later, when the bizarre individual who was about to buy my practice had to have his registered manager’s interview and we had to tell the CQC how we were going to effect the ownership changeover. Naively, I had thought he would simply give me the dosh, and I would skip over the horizon, happily whistling the ABBA hit, Money Money Money. But no, the CQC wanted to make it more complicated and we had to outline our contingency plans for provision of treatment if the practice was consumed by a flood or a volcano. I thought I’d made that clear at my first interview – canoes and a Dyson.

I finalised my practice sale in 2013 so I’ve had no real exposure to CQC fees since, but I seem to remember a registration fee of £1500 or thereabouts.   I had a quick Google this morning and there nowadays seems to be a complicated formula for working out how much dental practices have to pay in fees, based on the number of chairs the practice has, and if you are insane enough to work at more than one site.

I remember that there was a lot of resentment among dental practice owners around

2011-2012 at the introduction of the CQC to the dental field. Many questioned the need for yet another authority to oversee the profession. We’d already got the Health and Safety Executive, the Primary Health Care Trusts (as they were then) and the General Dental Council. Did we REALLY need another?

Yes. We certainly did.

Over the 19 years I had my practice, I had only a couple of informal routine visits from an NHS dental practice advisor. Near the introduction of CQC registration, I had a visit from the area infection control coordinator (until that point I didn’t know such a person existed) to ensure we were complying with HTM-01-05. As it happened, we weren’t - a sink in the decontamination room was in the wrong place and we had to move it to comply with the rules. Apart from that, there was no real oversight of the practice. In most of my ownership days, we still had the random checks from the RDO where the Dental Practice Board would choose a few patients for inspection at the local correction facility (as I liked to call the community dental clinic), but that was it. What went on in your practice was very much your own affair. Nobody randomly checked to see if you were boiling the instruments properly in new saucepans, or diligently spraying the reusable patient bibs with Febreze.

Where would we be without the CQC?

As it happened (and it was probably more luck than judgement), apart from a few bits of paperwork we needed to spruce up, we were pretty near compliant before the CQC came-a-calling. But having worked in a number of practices as an associate before I bought my own place, I can attest that there were a lot of places that would have really struggled to come up to basic CQC expectations, let alone those required by the CQC.

I will describe ONE such practice that I worked at.

It was 1990 and I’d been qualified a couple of years. I joined an old established practice on the Cotswolds border as an associate. The practice had five surgeries and was manned by a husband and wife who were the owners, a long-term associate, a hygienist and moi. The bosses had taken over from two very old school and respected dentists, one of whom appeared to have been grandfathered on to the dental register from his primary job as a barber and blood-letter.

Where would we be without the CQC?

The practice was set in a grand Georgian terraced house, and once you went above the surgeries on the first floor, it appeared that the last vacuum cleaner ever to be used on the 2nd and 3rd floors, was the Batty-Fang Carpet Beater 1900. I never saw those floors during my interview, and neither did I see my surgery. When I turned up for the interview, my surgery was in use by the hygienist (apparently) and I couldn’t see into it, the door being solid wood. When I arrived for my first day of work, my surgery was decorated in the style of a 1940’s London Underground station lavatory. Every square inch of the walls, ceiling and floor were tiled in a faded turquoise and the pipes for the aspirator and services lay on top of the floor, presenting a tripping hazard to anyone entering the room. I found out later in the day that the practice was supposed to be haunted. The legend went that the house was originally owned by a well-to-do family and the man of the house had an affair with the housemaid, who I shall call ‘Flora.’ When it all went pear-shaped and Flora became pregnant and was shamed, she hung herself in my surgery (which was the kitchen originally – the fireplace was still in the one wall). Her feet would have dangled over the reclining headrest.  It’s another story, but my associate colleague heard Flora singing late one night on the top floor, and truly I saw an outline of her brushing her hair through a window, one dark winter’s afternoon.

Where would we be without the CQC?

After a week I could stand no more. I discovered that Tanya the hygienist only worked in the practice two days a week and although not spectacular, it at least had an acceptable, if dirty wall-covering. I asked if I could swap rooms and poor Tanya found herself in the lavatory. She never thanked me.  I asked the practice owners if I could decorate the room myself and at my expense. The bosses agreed. I did it in a nice bright pink and I put some decorative borders up. The husband came in first thing on the Monday after I had decorated, put his head around the door and said without a hint of humour: “It looks like a bleeding tart’s boudoir in here.”

Where would we be without the CQC?

Unfortunately, the equipment was as old as the building and the delivery unit was the size of a modest Buckingham Palace fridge and it was about as manoeuvrable as trying to get a Dalek up the stairs. It had polyoxybenzylmethylenglycolanhydride (Bakelite) control switches and buttons and piping that had been repaired by shortening so often, when you moved the drills in a patient’s mouth, the unit was dragged with it. In the two years I was there, I never saw an engineer come in to service the equipment (not that the spare parts were still made for the units). I’m sure it would never have come through a thorough PAT test with flying or even submerged colours. My unit had a dodgy connection with the handpieces and every now and then there would be an explosion of air and what remained of the air-tubing would fly off and snake wildly about the room like a twerking cobra. I point blank refused to have anything to do with fiddling about with the equipment and so my nurse would go and fetch the husband. I REALLY want to name him, but I can’t, so I’ll call him Boris. Anyway, Boris would invariably come with a pair of scissors in his hand and a cannister of sturdy floss, and tie the tubing back on to the handpiece coupling until the perished rubber broke again.

Where would we be without the CQC?

Fortunately, the CQC also ensure premises are safe and up to the mark these days. Boris’s place wasn’t. I doubt that the electrics of the practice had been checked since Thomas Edison was a lad. One day I was doing a full denture try in. I had just given a deaf lady a mirror so she could have a good look and the small, white, straight set up. There was suddenly a loud bang and a flash from behind her. A Bakelite electrical socket (without anything plugged in) had just exploded with no provocation. I jumped and my nurse shrieked, but the patient just sat there wondering if the shade was maybe a little bit dark. She even carried on looking intensely at the denture while Boris ran into the room behind her with a fire extinguisher and started spraying powder all over the place. I can’t remember off hand if the socket was ever dealt with afterwards. We were probably told never to use it again.

One of the worst incidents that happened at this place and inspired me to look for a job elsewhere was when I was treating a patient and Boris’s nurse flew in and said “Can you give Mr Aguecheek a hand…NOW!”

I went into the lavatory-surgery to find Boris was struggling to keep a child anaesthetised. “Just pop the E out for me” he shouted.   I went cold but did it. I hadn’t realised until that point that he was doing child general anaesthetics acting as operator and anaesthetist. I knew for a fact that his nurse wasn’t trained at all, being a newby. I rarely lost my temper, but told him as soon as the opportunity arose, that he was never to involve me in GA’s again.

But that probably wasn’t the worst of it. Oh no. I discovered while I was working my notice, that Boris and his wife Priscilla didn’t dispose of sharps through a clinical waste company. He apparently used to box them up and dispose of them just as the local tip was shutting and it was getting dark. I found that out from one of the receptionists as I was having a chat between patients. I had only just muttered “That is absolutely disgusting” to turn round to find Priscilla was standing behind me. Well it WAS disgusting and again, I told them that I would have to report them to the local Family Practitioner’s Committee (as it was then) if I witnessed them doing it again.

Where would we be without the CQC?

Suffice to say, they also ignored employment laws. A trainee nurse who had gotten fed up with £2.40 per hour they paid, handed in her notice. At the end of the first week of her fortnight’s notice, they withheld her wages, only giving them to her after the rest of the nurses and I, threatened to strike. After I put my own notice in, I found two of my monthly payments were delayed and Boris used to sneak out of the practice so he didn’t have to see me. He worked on the first floor and I was told by his nurse that he daily tiptoed down the stairs quietly so I wasn’t aware he was leaving. One morning, I finished early and waited for him. I flew out and ran at him, catching him halfway up the stairs. I’m not a big bloke, but when I get angry, I can make myself big. When he came back from lunch, he gave me two cheques.

The thing that was interesting here, and it accounts for the fact that I am not impressed by people on committees is that both Boris and Priscilla were ‘upstanding’ members of the local dental community. Both were big in the British Dental Association locally, and both had been LDC members, yet they operated like that.

So do we need the CQC?

Yes we do. The pally pally relationship they must have had with the local dental practice advisor obviously didn’t address major problems with their practice. In these days where we are all faced with a torrent of potential litigation every day, at least complying with the high standards set by the CQC reduces risks marginally and prevents inadvertent swamping by an avalanche.

But it all turned out okay in the end for Boris and Priscilla.

They both dead now.

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Referral Letters

Writing Referrals by

Writing referral letters

The Definitive Guide To

Writing Referral Letters

By

@DentistGoneBadd

 

 

Basic Referral Writing

Let’s start with the essentials. Referral letters should contain the basics; name, sex (if any – I don’t like to ask really), date of birth and reason for returning….oh sorry, that’s sending a parcel back to Amazon. Long gone are the days of “Please see and treat,” so try and give the specialist you are referring to, a bit of a clue as to the reason for your referral. Throw in a couple of vague differential diagnoses if you can, just to demonstrate you aren’t completely gormless, with proper medical terms like ‘epidermolysis bullosa’ or ‘squishy lump.’ It’s probably best not to refer a patient just because you don’t like the look of them, tempting though it is.

Writing referral letters

Choice of Specialist

If you are worried about a lump, it’s best to send to a consultant lumpologist. But beware, some specialisms do cross over and consultants can get a bit elbowy and will fight over interesting lesions. I once witnessed a near fist-fight between an oral medic and an oral surgery registrar – both convinced they could write a paper about it. Every time, make sure you are referring to the most appropriate department. One department will treat a lesion with a spray and ineffective mouthwash, while another will cut it out and put an implant in its place.

 

Oral Surgery Referrals

Oral surgery referrals are probably the most common type made. It’s not quite clear why this should be. Fewer dentists get into trouble over oral surgery than perio neglect or root-treatments. I think that oral surgery is probably all a bit too gooey for a lot of dentals and the anticipation of complications is overthought. Because oral surgery departments are absolutely swamped, you have to make a convincing case. Warfarin patients are no longer a bar to treatment in practice, so throw in ‘difficult access’ and ‘a history of difficult extractions’ for good measure. ‘Proximity to the antrum’ doesn’t often wash. Since many oral surgery departments insist on you supplying a supporting radiograph, they can justifiably throw out the referral and tell you where to stick your jpeg when they realise it’s a lower molar you are talking about.

Writing referral letters

Orthodontic Referrals

These are probably a little more clear-cut, if you completely ignore IOTN, which I did. I doubt very much if it’s done now, but the acronym ‘FLK’ (Funny Looking Kid) in the margins of the old paper files, acted as a reminder to refer to the orthodontist once the overcrowding started to hurt your aesthetic sensibilities. I find FLK’s generally DO get orthodontic treatment, so providing they are reasonably competent with toothbrushing, and generally look as if they’re using the hairy end, send that referral. Again, don’t just ask to ‘see and treat’. Throw in ‘well-motivated,’ ‘optimal oral hygiene’ and ‘very stroppy mother’ to emphasise the need for action. Chuck in a couple of measurements if you can, and try and crowbar in a stab at a ‘division’ to show to the orthodontist you’ve given it some careful consideration.

Writing referral letters

Periodontal Referrals

This type of referral is usually done in panic five minutes after you have just unexpectedly lost a BPE probe down a previously scoring ‘1,’ so do try and keep the panic out of your letter. Make it sound like you’ve been closely monitoring things for a considerable period of time and really emphasise that when you first saw the patient, most of the damage was already done. ‘Despite my oral hygiene instruction’ also shows that you have been caring, but don’t get too down about having to refer and being condemned by the periodontist. The specialist will probably only see the patient for twenty minutes max anyway, and will never see them again, immediately throwing the patient into the ‘Pit of Hygienists.’

Writing referral letters

Endodontic Referrals

Endodontic referrals are becoming incredibly popular and you are highly unlikely to get one rejected, since they are often made to private specialists. Don’t bother trying to refer to your local dental hospital. The sun will have died well before your patient gets to the top of the list. Besides, dental hospital endodontists are exceptionally picky about what they treat. My local dental hospital won’t treat any tooth beyond a first molar. They aren’t that clear why, though I suspect it’s because trying to get to a seven is a bit ‘too fiddly.’ Failure in endodontics is a growing area of litigation and if you are an NHS dentist in particular, don’t risk ANY root-treatment – refer. You can throw a lot of information into your referral letter – sclerosis, unusual anatomy or “There’s a prominent squiddly-do on my radiograph” – but it doesn’t matter. These are endodontists. They have to pay for swanky microscopes and German Sportwagen. They’ll accept anything.

magnification

 

Implant Referrals

See Endodontic Referrals. Patients think they are the same thing anyway.

 

Prosthetics Referrals

Tricky. Prosthetics specialists are a dying species. Their natural habitat in the 60’s and 70’s was gummy, but since forestation with teeth, the need for them has diminished. The few prosthetists left, tend to pack together at dental schools, desperately attempting to procure close relationships with implantologists, borne out of their innate instinct to survive. Having said all that, I have had more referrals rejected by prosthetics specialists than any other type. To be absolutely honest with you, whatever you say in your referral to a denture specialist, they’ll write back with “We would recommend extending the flanges and see no reason why this cannot be carried out in practice. Now leave me alone. I need to bury my nuts for the winter.” Good luck.

Writing referral letters

Community Clinic/Paediatric Referrals

This is where you send all of your ‘challenging’ patients, or those that take an hour to do an enamel-only incisal edge composite on. Terms you should include in your letter are ‘wriggly,’ ‘anxious,’ ‘fearful,’ ‘phobic’ and ‘gagger,’ though be careful you don’t end up making it sound like a Facebook advert for happy hour at the local S&M Club. Make it absolutely clear that this patient needs sedation. Forget about suggesting GA. The clinicians at these emporia don’t stop talking about the risk of death from the time the patient enters the place having found it after previously mistakenly walking into the adjacent STD Clinic. If your local clinics have their own referral forms and it gives you the option to have the patient back if they refuse sedation, tick ‘NO!!!’

Writing referral letters

Restorative Specialist Referrals

 

Quite a few restorative specialists lurk in dental schools, but despite this, they try not to have anything to do with teeth. There is only one important, indeed, CRITICAL sentence you need to include in your referral letter, and that is: “I am ALREADY monitoring the diet and wear.”

 

Oral Medicine Department Referrals

 

You will normally refer to the oral medicine specialists as a means of backing up your diagnosis, which is almost certainly, atypical facial pain/burning mouth syndrome. Often, you would save a lot of time by giving a nightguard or benzydamine hydrochloride rather than wasting your time on a referral letter.

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