As the coronavirus pandemic continues to impact on every aspect of our family and working lives, dental professionals are faced with a whole range of difficult decisions to make and ethical dilemmas to wrestle with, many of which would have been inconceivable at the start of 2020. Consequently, here at the DDU we continue to receive many phone calls and emails from members seeking our advice and support to help them to stay the right side of the regulatory line.
These queries are often prefaced by, "Am I indemnified if…?", so it's worthwhile reiterating the DDU's position. We are not an insurance company with small print or policy exclusions, and it is not our role to set clinical standards, to give purely clinical advice, or to intervene in the clinical decisions of our members caring for patients.
As members appreciate, standards are set by the dental profession as a whole, through such bodies as the universities, the Royal Colleges, the specialist societies, and the UK Departments of Health.
Accordingly, while we would advise members to be aware of and follow current guidance from a responsible body of opinion, members practising in good faith can seek our assistance, including access to indemnity, in the usual way, whatever their clinical decision may be when caring for patients during the pandemic. We do not make access to indemnity conditional upon adopting a particular treatment modality or safety precaution.
Show your working
In considering how to approach decision-making, it's often useful to 'start with the end in mind' - in other words, to ask yourself, "If I follow this particular course of action and I receive a complaint, what would I say in response?"
If, in addressing that question, you can confidently point to a decision-making process that put patients' best interests first and was in accordance with a responsible body of opinion (such as a current standard operating procedure), then the risk of justifiable criticism is greatly reduced. You may recall your maths teacher imploring you and your fellow pupils to 'show your working'; the reason being that even if the answer or conclusion is slightly different to what was expected, there would still be marks given for logical thinking and process.
In dentistry there is often no single right or wrong answer and a whole plethora of factors will impact on decision-making. It is important to note in this context that a responsible body of opinion need not necessarily be the majority view. The important issues in being able to justify a decision are many and varied, but by documenting one's thought process in the records it makes life much easier in the (often years ahead) future.
In dentistry there is often no single right or wrong answer and a whole plethora of factors will impact on decision-making.
One of the 'current hot topics' raised by members is whether to offer recall appointments in the current national lockdown situation; a query that serves as an example of how one might apply the approach set out above.
Essentially, CQC has said the decision to offer care is one for the provider to take, and it will only take regulatory action where there is evidence that that care is not being provided in accordance with its regulations (safely etc.).
The GDC does not itself set clinical standards but expects registrants to act in accordance with a responsible body of opinion. From the earliest stages of the pandemic it has acknowledged the difficult circumstances registrants are working under, and that clinicians will need to exercise judgement in making often difficult treatment decisions. Latterly, it has issued welcome guidance to decision makers (around FTP matters) to take into account the context of the care being provided.
The most recent guidance from the office of the CDO (England), included again in the most recent Primary Care Bulletin (dated January 19 2021), makes clear that government guidance on the current national lockdown says that patients can leave home to access public services, including medical services and thereby including dentistry. The CDO further states that, "Dentistry is an essential medical service. It is a priority for the NHS. Patients are entitled to travel for medical appointments, including dental."
The statement also says, "In line with the standard operating procedure, within the available capacity, when recommencing deferred courses of treatment, recall and re-assessments practices will need to prioritise groups with the greatest need, such as children."
In light of the above, practices should not be justifiably criticised for offering patients a recall appointment, as there are clearly valuable oral health and disease screening benefits to be had. As ever, patients are entitled to make their own decisions as to whether they choose to accept such an invitation and attend - and particularly in the current circumstances, will have their own views on the subject. Indeed, some may complain if they are offered a recall and others if they are not.
As care in practice has been made as safe as current knowledge allows, it may be appropriate to focus on those aspects, and for patients to make their own decisions on matters such as travel which are outside the control of the practice.
If asked directly for guidance as to whether a patient should attend, dental professionals should offer this on the basis of a risk benefit analysis of that individual patient's needs. For some patients with high clinical needs, the risk of deferring might outweigh the risk of attending, while for others it may be possible to confidently extend the recall period without greatly adding to the risk.
This is, in my view, preferable to a blanket ban on recalls, as it gives patients a choice and reduces the risk of future allegations that a practice's policy has given rise to issues such as a late diagnosis or deterioration in condition or prognosis.
Irrespective of payment circumstances, in accordance with GDC Principle 1.7, advice and decisions should be made on the basis of clinical need and patients' best interests, rather than purely to meet any financial target. For those with NHS targets, it is my understanding that local primary care commissioning organisations are to have some leeway in dealing with year-end shortfalls.
For this reason, it would seem prudent to 'start with the end in mind', noting and evidencing the rationale for the offer of care and prioritising on the basis of need in accordance with the CDO's advice. This may well vary from area to area and practice to practice, according to the patient base and demographic need.
In summary, dental professionals making considered decisions in patients' best interests should not be justifiably criticised - but as ever, the importance of good record keeping cannot be underestimated. Please, never hesitate to contact our team at the DDU if we can help in any way.