This dilemma is fictional, but based on the types of calls we receive on our advice line.

The scene

The DDU received a call from an associate dentist member in Scotland. They told the adviser they were struggling with a demanding patient, who was insisting on treatment the member believed was inappropriate.

The patient had chipped a lower incisor and believed they were entitled to a crown on the NHS. Our member advised the patient that the tooth was vital and would best be treated conservatively, with a resin filling.

The patient was unhappy with this advice and demanded to see a senior dentist at the practice. The only other dentist was unwilling to see the patient, so the practice manager instructed our member to write to the patient to deregister them.

Unsure if this was the right course of action, our member called to get our advice on writing to the patient.

DDU advice

Refusing treatment

A dental professional shouldn't be pressurised into providing treatment they don't consider to be in a patient's best interests. Even if the treatment is technically available on the NHS, this doesn't mean it's appropriate to offer it in all circumstances.

A robust consent process should be followed and documented. This should include informing the patient of the risks, benefits and alternatives, taking into account their individual circumstances. Having had this discussion, if the patient still demands a treatment you consider to be inappropriate, you should refuse to provide it.

It can be helpful to think about how you might justify providing treatment if you needed to explain your actions during a third-party investigation. It would be much easier to explain a refusal made on 'best interests' grounds than trying to explain why you knowingly provided inappropriate treatment.

If a patient is unwilling to accept your advice, it can be helpful to arrange a second opinion - but if this isn't possible, you can suggest the patient seeks one elsewhere themselves. Of course, there can be legitimate differences of opinion between clinicians, and a differing opinion does not create an obligation for you to provide the treatment.

A patient asking for a second opinion doesn't necessarily mean the patient-provider relationship has broken down. If the patient is new to you, it could simply be that their confidence and trust is not quite there yet. And if they are a regular patient, they might just be anxious and need reassurance.

However, if the patient has no trust or confidence in your abilities, it may be in their best interests to have their treatment with another provider.

Ending a patient-provider relationship

GDC Standard 1.7.8

In rare circumstances, the trust between you and a patient may break down, and you may find it necessary to end the professional relationship. You should not stop providing a service to a patient solely because of a complaint the patient has made about you or your team.

Before you end a professional relationship with a patient, you must be satisfied that your decision is fair and you must be able to justify your decision. You should write to the patient to tell them your decision and your reasons for it. You should take steps to ensure that arrangements are made promptly for the continuing care of the patient.

Any dental professional can decide to end their own practising relationship with a patient, but you must have a clear justification for doing so. A patient complaint is not always sufficient grounds for refusing further treatment.

If you believe there has been an irretrievable breakdown in the relationship, then it would clearly be in no-one's best interests for it to continue. The GDC would expect you to explain this to the patient and make reasonable efforts to arrange alternative care.

If there is no one else willing or able to take over patient's care at the same practice, or if a 'zero-tolerance' decision has been reached, this should be communicated to the patient by someone with overarching responsibility, and not an individual clinician. This is because any potential complaint about access to care would likely be directed to the practice, so it's important that someone with responsibility for the practice makes the ultimate decision.

The outcome

As no-one else at the practice was willing to see the patient to give a second opinion, the DDU adviser suggested the dentist contact a dental adviser at the NHS to explain the scenario. Our member was able to speak to a senior NHS adviser and was reassured that they had given appropriate advice to the patient about treating the tooth conservatively with a resin filling.

The member was also advised to discuss the rationale for deregistration with the practice manager. After this discussion, our member and the practice manager concluded that this patient's request for a second opinion didn't justify deregistering them at this time.

Our member relayed the advice from the NHS dental adviser to the patient, who was disappointed but nonetheless accepted the decision. They were also offered another appointment, but declined because they had since found a private dentist who was willing to crown the tooth, and they no longer wished to be registered at the practice. Our member therefore sent the relevant deregistration paperwork to the Health Board.