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.  

Julia Furley is a barrister with a special interest in dentistry. She has assisted and represented a large number of dentists at both the application and appeal stages of their specialist list applications and has an extremely good record of success. If you are interested in applying for entry onto the GDC specialist list you can email Julia on This email address is being protected from spambots. You need JavaScript enabled to view it., or call us on 020 7388 1658.

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The GDC specialist lists were established in 1998; the most recent, Special Care Dentistry, being added in 2008. The UK has more recognised areas of specialism than any other European country.  There are currently 4261 registered specialists across the 13 disciplines. The GDC are not obliged to have specialist lists, but are empowered to do so by various pieces of European and domestic legislation and regulation. If they wanted to dispose of the lists it would not require legislative change, but would need a compelling policy reason and would require a significant amount of regulatory change.

There is no comprehensive data about the total number of patients treated by Specialists each year; although there were 2.7 million outpatient appointments within dental speciality clinics and a further 320,000 consultant episodes in 2012/13 according to NHS data. This of course does not account for private patients.

The GDC recently undertook a review of the way in which the specialist lists are regulated. The aim was to determine what the benefit of regulation was when it comes to patient protection and whether the lists did in fact help patients make a more informed choice about their dental treatment.

The first phase of the review began in January 2014; whereby information was obtained from both the public (with a representative sample of 500 adults) and the profession regarding their experiences (there were 68 responses from the profession, including 25 from individual specialists and 5 from GDPs).

Background

Registration

The most common way to obtain entry onto a specialist list is to undertake a recognised training programme. Approximately 500 students per year attempt this route. Alternatively, candidates can seek to illustrate equivalence in “knowledge and experience gained through academic or research work”; commonly known as mediated entry.

European registrants with qualifications in Oral Surgery or Orthodontics are automatically recognised.

In 2011 there were 175 additions to the list, in 2012 245 and in 2013 231.

Title

Only a registered specialist can use the title. This is also true for the use of the “ist”; endodontist, periodontist etc. It is not permissible to use the phrase “specialising in” if you are not registered on a specialist list. The only permissible terms are “special interest in”, “experienced in” and “practice limited to”. Using an incorrect term can lead to professional disciplinary proceedings and/or a conviction and fine.

Cost

The cost of registering on a specialist list are relatively low; just £345 for initial registration and £72 per year thereafter.  

The GDC have calculated that the cost of regulating the specialist lists in 2014 was £339,000, which income is forecast to exceed by 6%. There does not appear to be any comparison with earlier years, and as such it is not known whether this is a constant figure. However, this cost also includes the cost of the review so is likely to be much higher than previous years.

Conclusions of the Review

Does specialist regulation bring any benefits in terms of patient and public protection?

The reality is that public awareness of the specialisms is extremely low; shockingly more than half of those surveyed did not know ANY specialism existed. Only 1% was aware of periodontists and restorative specialist, only 2% of prosthodontics and only 3% of endodontists. The highest recognised term was “cosmetic dentist” at 22%, closely followed by orthodontist at 19%. Worryingly 10% believed implantologist to be a recognised speciality. However, most people felt that it was important that specialists were properly regulated. Unfortunately, only a third of those questioned had even heard of the GDC (and this was when prompted!).

It is useful for specialists and practice owners to bear in mind that when choosing a specialist most of those who did recognise specialisms relied on their dentist’s referral rather than their own research. What is abundantly clear is that dental specialists are not effectively marketing their existence, and by implication their value.  

Of those in the profession who responded, the general view was that regulation should not be decreased and that deregulation risked those not properly qualified attempting procedures outside their capability. However others pointed out the lack of evidence that regulation does in fact improve patient care. Concern was raised re the lack of regulation of specialists post-entry. At present CPD requirements are the same for both GDPs and Specialists.

Is regulation proportionate to the risks posed by dentists providing complex treatments?

Perhaps understandably specialists were more supportive of the lists than GDPs. Some respondents felt that the fees charged were disproportionate. However this is surprising bearing in mind the amount of administration required in certain cases. £345 may seem a lot for someone who has been awarded the CCST, but is a small reflection of the cost of mediated entrance. It is curious that a more diverse fee structure has not been recommended and that practitioners are not being asked to fund appeal hearings, particularly if unsuccessful.

Many respondents questioned the need for the number of specialist lists. However the review concluded that they were necessary due to the number of complex procedures undertaken.

Are the specialist lists the appropriate mechanism for helping patients make more informed choices about care seen as falling outside the remit of a GDP?

74% of patients who had visited a Specialist had been referred by their GPD. Only 4% of those questioned said that they would check the details of their Specialist with a regulator. Although the majority responded that it was important that the information was there if they did want to check.

GDPs and Specialists generally agreed that the lists do assist in making appropriate referrals.

In reality although specialist lists are available on the GDC website, the public a) doesn’t know about the GDC website and b) doesn’t understand the terminology used and significance of qualifications recorded. It would appear that it is the GDC who are failing in the provision of information to patients.

Should the GDC be the body to regulate the specialities?  

It was generally agreed that the GDC are the appropriate body to regulate, however it was pointed out the GDC was reliant on the Royal Colleges to provide guidance on the skills, knowledge and behaviour of specialists. Nor does it quality assure specialist training or have a separate revalidation process in place.

The review made for possible proposals for the future:

1.       Strengthen the GDC’s approach to regulation. The GDC are developing a “work programme” to achieve this and intends to give a clearer definition as to the meaning of specialist, ensuring the lists are correct, “tightening up” mediated access or removing this route entirely, quality assuring specialist training and providing information to patients.

It appears that the only rational for proposing the removal of mediated entry is to reduce costs. Surely a fairer and more sensible approach would be to charge applicants appropriately.

2.       Explore alternative models of regulation:

If the Council is of the view that the current regulation does not offer significant benefits to either the public or patients; is not proportionate; or that resources could be more properly focussed on key regulatory functions; then there would be no further policy changes and instead possible alternatives to statutory regulation would be explored. This could include investigating the possibility of removing all specialist lists save Oral Surgery and Orthodontics:

3.       Continue to regulate the Specialties, but not make any significant policy changes. Although it is still suggested that the mediated entry route would be reduced.

4.       Further analysis of the evidence of improved patient outcomes.

Overall the review has uncovered the alarming lack of understanding by the public regarding Dental Specialists and the Lists. However, on a more positive note, appears to suggest that those within the profession believe that the lists are both necessary and helpful. Of the proposals, only one thing is clear that dentists can expect an attack on the mediated entry route over the coming years; although there seems little justification for this save on costs grounds.

**Blog image from Creative Commons

***This blog has been written for Rumpole of the Surgery by Julia Furley of JFH Law