At the recent roundtable discussion with the GDC and other dental organisations, we raised key issues such as the importance of engaging with the regulator at a Northern Ireland level, and the potential for a more supportive approach to regulation.
During the roundtable, we took the opportunity to highlight several urgent concerns affecting dentistry in Northern Ireland. These included the worsening crisis within General Dental Services, the growing impact of dental tourism, and serious workforce shortages across both the Community Dental Service (CDS) and Hospital Dental Service (HDS).
Raising our voice on systemic issues
Dentists and other professionals are trained to work in a system which, in Northern Ireland, no longer functions as intended. General practice has become unviable; it requires either refinancing or reform. If additional funding is not forthcoming, then reform becomes all the more urgent.
Within CDS and HDS, longstanding workforce issues have been allowed to persist; workforce planning has been largely absent, services struggle to meet rising demand while workforce levels have been largely stagnant. This is in direct contrast with the growth seen across the wider health and social care workforce, a workforce which has increased by 22% since 2016. And perhaps most damning, this is despite multiple reports recommending CDS workforce growth.
We wanted the GDC to recognise the particular pressures inadequate staffing is having on dentists working in salaried services in Northern Ireland. It is not only affecting staff wellbeing but also having a direct impact on patient care.
Our aim was to outline these issues to the GDC in its capacity as our regulator. The GDC has a powerful voice and, much like the Review Body on Doctors' and Dentists' Remuneration, should be encouraged to speak out on systemic issues. One thing we highlighted was the fact that there are no consultant dental radiologists in Northern Ireland, which poses a serious risk to patient safety and the entire system.
Encouragingly, the GDC appeared open to discussion. While they were keen to make the point that they are not part of our trade union, they looked at it in terms of practitioner wellbeing affecting patient outcomes. If the system is collapsing around clinicians, then the quality of care will inevitably suffer. Recruitment and retention problems are growing and, if left unaddressed, will become even more serious.
The relationship with our regulator
The new Chief Executive remarked that, in his experience, he had never encountered a profession so fearful of its regulator. When I qualified many years ago, the belief was that you would only come before the GDC if you had done something seriously wrong. Regrettably, the perception all too often is that you will be lucky to get through your career without a brush with the GDC. The statistics still point to the former but still the fear is real and is affecting the care provided, producing a defensive approach.
We also raised concerns about the GDC’s low-level concerns process. Although it has been in place for several years, no dentist in Northern Ireland has gone through it. A few cases have arisen in other nations, but the GDC indicated that all the cases from NI met the higher threshold. There is a sense that the regulator has been erring on the side of caution and referring cases that do not warrant escalation.
We welcome the GDC’s stated ambition laid out in its new corporate strategy to acknowledge many of these concerns and become a more supportive regulator, because if this is followed through it could make a real difference. The GDC’s role is to protect the public, but when dentists are investigated, the impact on their wellbeing can be profound. This is exacerbated by the long delays for substantive cases to be heard by the fitness to practise panels. Some may be innocent; others may be facing personal challenges, or simply need help. The GDC needs a broader understanding of the pressures dentists face and must regulate with that context in mind. That is why BDA NI representatives considered it so important to accept the Chief Dental Officer’s invitation to attend a roundtable event with the GDC held during the Summer.
Workforce pressures and system failure
In addition, we linked workforce issues to the wider failure of Health Service (HS) dentistry, in that patients who cannot access general practice are increasingly ending up in hospital or community settings. In an ageing population, we are seeing more patients with dementia and complex medical needs, which is making the situation worse. Fixing general practice would not resolve all the problems in CDS and HDS, but it would help significantly by reducing the number of patients being diverted into those services.
We also highlighted to the GDC that we have witnessed a 20% reduction of patients registered with an HS dentist in the past year alone. Many of these individuals are among the most vulnerable and now cannot access care, and the emergency scheme introduced by the Department does not address the lack of regular treatment. The argument that there is no money is often repeated, but we are not asking for large sums in terms of the overall health budget. Yet the impact of proper oral care would be enormous for the whole population. In fact, the lack of funding should be a driver for reform, not a reason to avoid meeting the challenge.
The current contract was deemed unfit for purpose in 2008; it is even worse now, and dentists’ loyalty to their patients is being abused by the system. The GDC are regulating dentists who work within a system that is unviable and unfit for purpose. It is essential they recognise this, and hopefully ongoing engagement with the profession locally will ensure that is the case, as well as lend their support to the reform agenda.
Regulatory clarity on dental tourism
As I wrote in June, dental tourism in Northern Ireland is causing significant harm. Patients are travelling abroad for treatment against the advice of their dentists, undergoing extensive procedures, and returning with complications. We need clear guidance from the GDC on our obligations to these patients. This was made clear to the GDC in our discussions. We also asked them to consider a public information campaign, perhaps in conjunction with the Department of Health to alert the public to the risks and long-term consequences associated with dental tourism.
We also raised concerns about dental consultations being carried out in the UK, especially in Northern Ireland by individuals who are not GDC-registered, and in premises which are unregistered for the practice of dentistry such as hotels. This is illegal. The GDC must act against those individuals and the businesses facilitating this activity.
Read my letter to Chief Dental Officer Caroline Lappin on dental tourism.
Training and career progression for other members of the dental team
We discussed the lack of training for dental hygienists and therapists in Northern Ireland. The closing of the Belfast School of Dental Hygiene has been much regretted and has removed a vital part of career progression for dental nurses. Career progression or the lack thereof was raised not just by ourselves but by the hygiene and therapy representative. In an environment where nurse retention and recruitment is extremely challenging we need every possible help we can get. We have increasingly had to rely on overseas staff, but changes to immigration rules will make this very difficult.
In fact, I know of practices that have had to close because they could not find dental nurses. In the private sector, they may be able to offer higher pay, but HS practices are restricted, and this puts even greater pressure on heavily HS-committed practices. We wanted the GDC to understand this reality for these practices.
A Northern Ireland-specific focus
One of the interesting things the GDC brought up was that 53% of new registrants in UK are not UK-trained. There is no shortage of people wanting to become dentists; the problem is the lack of places in dental schools. Our contract is entirely different to that of other UK nations, our financial situation is worse, and our waiting lists are longer, with no hygienists or therapists coming through the system. We also share a border with another country operating under a different system, and we are losing professionals from every area in dentistry across that border. Better pay and less onerous regulation are often the drivers for this.
All of this means that engaging with the GDC on issues specifically concerning Northern Ireland, as well as on the common UK-wide issues is essential. This is the approach we took in contributing to the recent BDA consultation response on the draft GDC three-year corporate strategy.
It is only by being fully aware of the particular context in which dentists in Northern Ireland are working, and by more proactively highlighting system challenges that the GDC can take on a more supportive stance towards registrants.
Developing our local engagement with the GDC will be an important priority for Northern Ireland Council in the triennium ahead.
Read our letter of thanks to the GDC following the roundtable event.