Professional Documents
Culture Documents
Ethics in dentistry
B1
Advicesheet
Ethics in dentistry
contents
B1
page
This advice sheet provides detailed, practical advice and information on the
major aspects of ethics in dentistry. The sections are:
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Consent
Key definitions
The need for valid consent
Obtaining consent
Material risks
Consent under duress
Treatment at the patients request
Making claims
Battery
The age of consent
Children in care
Incompetent patients
Where consent is not obtainable
Clinical trials, research and lectures
Consent forms
Checklist
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Confidentiality
What is personal health information
Data Protection Act 1998
Age of consent to disclosure
What information can be disclosed
Training and disciplinary procedures
Checklist
Model confidentiality policy
Data protection code of practice
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contents
page
Dental records
Good record keeping practice
Storage, retention and disposal
Fair processing
Subject access
Third party access
Sale/transfer of records
Checklist
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Patient care
Patient communication
Agreeing to provide care and treatment
Patient choice
Treatment planning
Health checks
Alternative therapies
Non-surgical cosmetic procedures
Tooth whitening
Medical emergencies
Misleading patients
Maintaining appropriate boundaries
Referral fees
Missed appointments
Debt collection
Handling complaints
Checklist
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Professional relationships
Professional agreements
Duties of a dentist manager
Second opinions
Raising concerns
Specialist practice
Veterinary dentistry
The death of a dental practitioner
Checklist
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Commercial interests
Financial interests
Advertising and canvassing
Shared arrangements with other health professionals
Buying, selling or closing a practice
Bodies corporate and limited liability partnerships
Practices owned by dental care professionals
Promotion of products and services
Private dental plans
Bankruptcy
Checklist
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Child protection
Types of abuse
Practical steps
Recording and reporting
Child protection policy
Criminal record checks
Further information
Checklist
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The guidance gives members essential advice on ethical issues that will enable
them to practise safety and in accordance with high standards of professional
conduct and behaviour. The BDA is able to provide ethical advice and support
to members, contact practicesupport@bda.org or telephone 020 7563 4574.
Dentists are facing greater demands from patients, regulators and NHS
commissioners. Cases going before the General Dental Council are rising and
dental negligence claims are also becoming more common. In order to manage
these risks successfully, dentists need to ensure that they understand and keep
up-to-date with changing professional regulations and are fully conversant with
what is expected of them. Use these advice booklets as reference documents
and in conjunction with guidance issued by the General Dental Council
(www.gdc-uk.org).
This section gives an overview of the main obligations of a dentist and covers:
Until recently, dentists had a professional monopoly, being the only individuals
who could carry on the business of dentistry, that is, profit directly from dental
practice. This changed in 2006 with amendments to the Dentists Act and the
opening of the Dental Care Professionals Register. Since then, all GDC
registrants can own dental practices. It is now also possible for non-dentists do
be involved in an incorporated dental practice as long as the majority of
directors of the company are GDC registrants.
The dentists
duty of care and
professional
obligations
Professional regulation
and registration
The Human Rights Act came into force in October 2000. The Act makes it
unlawful for the human rights of individuals (as defined by the European
Convention) to be infringed by public authorities, which includes NHS
organisations. The effect of the Act is to allow individuals to pursue public
authorities in the UK courts rather than having to go to the European Court.
The Act covers issues such as consent to treatment and physical restraint of
patients.
Professional competence
and experience
Dentists must not undertake procedures for which they are not competent or do
not have appropriate experience. Asking for help from colleagues or ceasing
treatment and referring a patient to another practitioner can be difficult, but is
always a wise course of action. Inexperienced dentists particularly can
encounter difficulties undertaking complex procedures and, although many
problems are solved during vocational training, sometimes they continue in
practice, resulting in great stress and loss of confidence for the dentist and
potentially harm to patients. Help is available from postgraduate dental deans,
dental schools, General Dental Practice Advisers to PCTs/Health Boards and
professional organisations. Contact the BDA Practice Support on 020 7563
4574 or email: practicesupport@bda.org for further information.
Unsatisfactory treatment or failure to provide treatment without adequate skill
and care can lead to civil cases of negligence, disciplinary proceedings by
PCTs/Health Boards, referral to an NHS Tribunal or allegations before the GDC
of unfitness to practise. Where dentists encounter colleagues in this situation
they have a professional duty to raise their concerns with an appropriate
individual. Dentists responsibilities in this regard are discussed on page 42.
Lifelong learning
Clinical governance is the name for quality assurance within the NHS. An
overall clinical governance system is in place throughout the NHS, but a
specific framework has also been developed for dental practice. PCTs are using
this framework to assess dental practices locally and to ensure that procedures
are in place to comply with the wealth of legal requirements governing health.
The practice framework is subdivided into twelve distinct areas, ranging from
infection control, radiation, patient safety through child protection, consent,
confidentiality, staff development and patient involvement to clinical audit and
peer review. The BDA has a clinical governance kit which provides all relevant
policies and models to comply with the requirements.
Clinical audit and peer review are an integral part of clinical governance.
Reviewing treatment outcomes either through individual assessment or on a
group basis is fundamental to modern ethical practice. PCTs take varying
approaches to these activities; some require the practices to carry out audit
projects on set subjects, whereas others expect practices to choose their own.
The BDA has an Advice Sheet E10 CPD, clinical governance, audit and peer
review and a number of sample audits on its website.
Dentists must have appropriate professional indemnity/insurance cover to
undertake any form of practice. The cover may be in the form of membership of
one of the dental defence organisations or insurance with a company that offers
an appropriate level of cover to protect patients and the dentist.
Professional
indemnity/insurance
Currently there are three defence organisations in the UK; some, such as
Dental Protection and the Medical and Dental Defence Union of Scotland, offer
indemnity cover, while the Dental Defence Union offers cover underpinned by
an insurance policy. Indemnity cover is discretionary so that they do not
guarantee to cover claims. Indemnity covers occurrences within the period that
a dentist is a member, even if they are no longer a member when the claim is
made. This is occurrence-based cover.
Medico-legal insurance guarantees to cover the insured up to the limit of the
policy provided that the claim falls within the scope and conditions of the policy
and is within the policy period. The company will cover on a claims-made basis,
that is the dentist will be protected against claims made during the policy period
and matters arising out of the dentists clinical relationship with patients
occurring whilst the dentist is insured. If a dentist discontinues a policy and
wishes to be covered for the period of insurance, run-off cover must be
purchased.
When choosing appropriate cover, dentists should consider whether the
proposed cover meets their current and future practising needs, will provide
help with proceedings by the General Dental Council as to matters of
professional conduct and health and provides suitable professional support that
is appropriate to their practice. It should be noted that sometimes defence
organisations will terminate the membership of dentists following a GDC case
or will require the member to pay a higher membership fee. For more
information see BDA Advice Note Professional indemnity cover.
The GDC is committed to introducing a system of revalidation, in which
registrants will have to demonstrate that they are fit to stay on the register.
There is no definite timescale for this, but plans for pilots are well advanced.
Revalidation will include continuing professional development, but will also look
at other professional achievements and activities of registrants, such as
compliance with clinical governance and further postgraduate qualifications.
These positives will be counterbalanced with any negatives, for example high
numbers of complaints or an appearance before the GDC. It is also expected
that appraisal will play a part. The vast majority of all registrants will be able to
show their fitness to remain registered, but, where there is a case where
BDA March 2009
Revalidation
questions remain, the GDC will be able to take further steps, for example an inpractice assessment or a full assessment through the National Clinical
Assessment Service (NCAS).
Checklist
Consent
The law on consent is subject to change and further specific advice should be
obtained from BDA Practice Support on 020 7563 4574 or practicesupport@bda.org.
This section gives general guidance on the dentists responsibility to patients to
obtain consent to examination and treatment. It is not intended to be
comprehensive, but it contains sufficient information for dentists to gain a
general understanding of a complex subject. The case law on medical consent
is constantly developing and advice should be sought from the BDA/defence
organisation when particular problems arise.
Key definitions
Express consent
A patient gives express consent when he or she indicates orally or in writing
consent to undergo examination or treatment or for personal information to be
processed.
Implied consent
In very limited circumstances consent may be implied. An example is where the
patient indicates agreement to an examination by lying in the dental chair and
opening their mouth. Consent to other types of dental procedures cannot
normally be implied from compliant actions; an open mouth does not
necessarily mean that the patient has understood what the dentist has
proposed to do or the reasons why.
Informed consent
Informed consent requires a full explanation of the nature, purpose and material
risks of the proposed procedures, and the consequences of not having the
treatment, in language that the patient can understand (using an interpreter and
visual aids where necessary). The patient should have the opportunity to
consider the information and ask questions in order to arrive at a balanced
judgement of whether to proceed with the proposed treatment.
Specific consent
Specific consent means that the patient consents expressly to each of the
procedure(s) to be undertaken. An agreement to undertake a course of
treatment without knowing what is to be done is not specific consent. For
example, obtaining a patients informed consent to sedation does not mean that
the patient has given specific consent to the treatment that will be carried out.
Valid consent
For consent to be valid it must be specific, informed and normally be given by
the patient or a parent or guardian (if the patient is under 16 and is unable to
give informed consent).
A dentist has a legal requirement to obtain the valid consent of the patient to
the treatment proposed. Before carrying out an examination or treatment, valid
consent must be obtained. For consent to be valid, the patient giving the
consent must be:
1. Competent to give it
2. Adequately informed of the nature of the procedure that is being agreed to
and
3. In a position to give consent freely.
The need to obtain a patient's informed consent arises from the moral
obligation and ethical principle to respect a person's autonomy and right to selfdetermination. Any treatment or intentional physical contact with the patient
undertaken without valid consent may amount to assault and a breach of the
patients human rights. A court may award damages for assault and the General
Dental Council considers that assault or treatment without consent can amount
to serious professional misconduct. Consent should be regarded as an ongoing
process rather than a specific event and is another instance where effective
communication between dentist and patient is vital. Refer to the GDCs
guidance in Principles of patient consent (www.gdc-uk.org)
Obtaining consent
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During the discussion about proposed treatment, the dentist should not make
assumptions about patients views but ask whether they have any concerns
about the proposed treatment or its risks. Engaging in open and helpful
dialogue takes up clinical time but, as well as satisfying a dentists ethical and
legal obligations, it increases the quality of care that is provided.
Material risks
In deciding which risks are material and should be explained, a practitioner will
rely on professional judgement, but must warn patients of any substantial or
unusual risks involved and of consequences which may be slight but which
commonly occur. Examples include the possibility of nerve damage in oral
surgery procedures, perforation or instrument breakage in endodontics, and
crown and bridge failures. To what extent risks must be described to patients is
influenced by public and professional expectations and dependent on case law.
Some of the relevant cases in the fields of medical negligence and consent are
described below.
Bolam and Sidaway
In Bolam v Friern Hospital Management Committee (1957) it was held that a
doctor should not be found guilty of professional negligence if a reasonably
competent doctor in a similar position would have acted in the same way and
the actions would have been supported by a responsible body of medical
opinion. This is known as the Bolam test. Applying the Bolam test to dental
consent means that a dentist would not be found guilty of failing to warn a
patient of a material risk if a reasonably competent dentist in similar
circumstances would not have warned of the risk and that decision would have
been supported by a responsible body of dentists.
The Bolam test was affirmed and extended in the Sidaway v Board of
Governors of Bethlem Royal and the Maudsley Hospital case (1985) where the
House of Lords held that a decision on the degree of disclosure of risks that is
best calculated to assist a particular patient to make a rational choice must
primarily be a matter of clinical judgement and that the attention of a patient
should be drawn to any danger which may be special in kind or magnitude, or
special to that patient, with sufficient information being provided to enable the
patient to reach a balanced judgement. In deciding on whether to warn of a
particular risk, the Sidaway judgment held that the health professional must
take account of all of the relevant factors such as the severity of the risk to the
patient and the likelihood of the risk, as well as the patients specific need for
the procedure. Where risks could result in grave and adverse consequences to
the patient (referred to in the judgement as substantial risks), the dentist has a
duty to inform the patient of them even if a substantial body of dental opinion
would not have done so.
Increasingly, the legal profession, the public and health care professionals
expect that patients are informed of all of the risks that apply to proposed
treatment, not just those that a responsible body of medical opinion would have
warned them of. While the
Bolam test is still of importance in the UK courts, recent judgments in Ireland
and the UK have challenged it.
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Consent is not valid if it is obtained under duress. The consent must be given
voluntarily and freely. Claims of lack of voluntariness do not, for the most part,
involve brute force or duress. The courts wish to ensure that patients are not
unduly influenced if it is deemed that patients have not given consent
voluntarily, the consent will not be valid. It has been argued in Court that
consent could never be given voluntarily where
the patient is a prisoner and the doctor was also a prison officer. This argument
was rejected by the Court of Appeal.
Care should be taken in obtaining consent in the presence of third parties,
including family members, that confidential information is not disclosed without
the patients prior authorisation and that third parties are not unduly influencing
the patient to consent.
Treatment at the
patients request
Cases arise where patients ask a dentist to undertake treatment that is not in
their best interests and is against the dentists clinical judgement, for example,
removal of healthy teeth, crown and bridgework instead of extraction and
dentures or dental implants (where these are not clinically advisable). In these
situations, dentists still have responsibility for the clinical treatment provided
and always to act in the patients best interests. Treatment should not be
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Making claims
Battery
A person who has reached the age of 18 and who has the capacity to reach
decisions on their own behalf is a competent adult and can give or withhold
consent. Capacity will necessitate being able to understand, believe and retain
the information provided about treatment and having the ability to weigh up the
information in order to choose whether or not to proceed. No-one else is able to
consent for a competent adult.
The Family Law Reform Act 1969 provides that any person age 16 years or
over and of sound mind may legally give consent to any surgical, medical or
dental treatment. A parent theoretically could lawfully consent to treatment of a
child who is refusing consent, but a parent cannot overrule such a childs
consent to treatment. Best practice would be to make an application to court
where parents are prepared to consent but a child is capable of understanding
what is involved and is refusing to consent to some major form of treatment.
Children under 16 who are of sufficient maturity and intelligence to understand
fully the nature of the treatment proposed and its ramifications are also entitled
to give consent to treatment. This is known as Gillick competence after the
1985 case of Gillick v West Norfolk and Wisbech Area Health Authority where
the Law Lords ruled that a child under 16 was able to consent if he or she
understood the nature of the treatment, its purpose and hazards. It will
ordinarily be for the practitioner to decide whether the child satisfies these
criteria of competence. The ability of a child to understand will depend on the
childs age, maturity and the proposed treatment. For example, a twelve yearold child might be able to give consent to a dressing, but may not be able to
consent to an extraction. A parent can lawfully consent to treatment of a Gillick
competent child who is refusing consent, but a parent cannot overrule a Gillick
competent childs consent to treatment.
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The Children Act 1989 reinforces the right of a child with sufficient
understanding to make an informed choice to refuse to submit to examinations
or treatment. But if a child aged 16 or 17 refuses treatment, this will not
override parental authorisation. Alternatively, where parents refuse treatment
that is in the childs best interests, a court can be asked to make an order for
the treatment to be carried out lawfully.
More than one person may have parental responsibility for the same child at
the same time. Where more than one person has parental responsibility, each
may act alone and without the other. In the absence of agreement by all those
with parental responsibility, the specific approval of the court must be obtained
if the treatment involves an important decision.
The following have parental responsibility: the childs father and mother, where
they were married to each other at the time of birth; the childs mother but not
the father where they were not so married, unless the father acquires parental
responsibility either by order of the court or pursuant to a parental
responsibility agreement with the mother; a person appointed as the childs
guardian and a person in whose favour the court makes a residence order with
respect to the child.
Where a child who is unable to consent is accompanied by an adult relative
without parental responsibility and consent from the parent has not been
obtained, the adult cannot give consent to the treatment. If the parent cannot be
contacted then treatment should only proceed in exceptional circumstances, for
example where the child is in pain and the treatment is undertaken to alleviate it.
In Scotland, the Age of Legal Capacity (Scotland) Act 1991 is specific and
provides that a person under 16 who, in the practitioner's opinion, is capable of
understanding the nature and possible consequences of the procedure or
treatment shall have legal capacity to consent on his or her own behalf to any
surgical, medical or dental procedure or treatment. In Northern Ireland the age
of consent for medical and dental treatment is 16.
Children in care
Where a child is taken into local authority care, the local authority may acquire
parental responsibility in addition to the child's natural parents. If the child is in
care, usually the dentist can obtain consent from an authorised representative
of the local authority. Where a major surgical procedure is involved, however,
the consent of the parents would usually be sought as well. In the case of
children under 18 who are wards of court, the consent of the court must be
obtained before any major intervention can take place.
Incompetent patients
Incompetent patients are those who, for reasons of mental incapacity or illness,
cannot give informed consent to treatment on the basis of full understanding of
the need for, nature of and consequences of treatment proposed. Not all
mentally ill or incapacitated patients are incompetent. But in the case of minors,
the informed consent of the parent or guardian should be obtained. Full details
of the law regarding consent and mental incapacity is available in a BDA Advice
Note Assessing mental capacity.
15
Notes must be made in the patients clinical record to explain why consent was
not obtained, to record the second opinion that was given, and include any
other views that were sought.
In the case of both minors and people with mental incapacity, a patient may be
competent to consent to some treatments but not to others. Some patients with
mental illness may be competent to consent at some times and not at others.
The dentist's responsibility with regard to confidentiality should also be borne in
mind in these cases.
Where patients are detained under the Mental Health Act 1983 without their
consent, treatments can be performed without consent if the treatment is for the
mental disorder and as such the normal rules for obtaining consent should be
followed for dental treatments. The courts have extended this to allow
treatments to be performed without consent that are unrelated to the mental
disorder but which could cause the patients mental health to deteriorate.
Decisions made by the Court of Protection
The Court of Protection is the final arbiter in relation to the legality of decisions
concerning patients who do not have capacity to consent. In addition to
adjudicating in relation to specific, one-off decisions, the Court will have the
power to appoint deputies to assist with continued decision making. Although
health care decisions can be lawfully made without a deputy, they can be useful
where there are disputes over care and treatment
Lasting Power of Attorney
Individuals over the age of 18 who are competent can nominate another person
to make health care decisions on their behalf when they lose the capacity to
make such decisions. The person nominated is known as having a lasting
power of attorney (known as a welfare power of attorney in Scotland).
Independent mental capacity advocates
For incompetent adult patients who lack any form of external support in relation
to serious treatment and there is no-one close to the adult to provide advice or
guidance, including an attorney or deputy, then the services of the Independent
Mental Capacity Advocate can be engaged.
This service will only be available in the case of a single treatment being
proposed where there is a fine balance between its benefits to the patient and
the burdens and risks it is likely to entail, or what is proposed would be likely to
involve serious consequences for the patient.
Advance statements or directives to refuse treatment
People over the age of 18, who are competent, are able to make advance
statements that they refuse a particular type of medical treatment (which will
include dental treatment) if they lose capacity.
If a patient is incapable of consenting, the dentist must ensure that the advance
decision exists and is valid. The advance statement must refer to the particular
treatment in question and should explain the circumstances to which the refusal
applies.
It is only possible to make an advance refusal of medical treatment. A person
cannot make an advance request for treatment.
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Research should not be carried out on patients without specific consent given
on the basis of a full understanding and explanation of the research and its
possible effects. Participation of a patient in research must be voluntary and
recorded. The same rules regarding age of consent and capacity to consent
apply in the case of research.
Research protocols should always be submitted to the appropriate Local
Research Ethics Committee and a consent form devised which is specific to the
procedure. Guidance is available from the National Research Ethics Service at
www.nres.npsa.nhs.uk
Where a dentist wishes to use photographs or other images of patients in
clinical lectures, papers, videos or presentations, consent should also be
obtained.
Consent for records-based research
Wherever possible, where research is being undertaken using data taken from
patients records, explicit consent must be obtained from the patient. If this is
not possible, because of the cost and time involved, the data must be encoded
or anonymised as early as possible within the data processing. If it is
anticipated that this type of research will be undertaken, then this should form
part of the stated purposes for which data might be disclosed and information
should be included in the practices data protection policy (see the BDA
Practice Compendium for a model).
Any research that is carried out must be approved in advance by the Local
Research Ethics Committee/Multi-Centre Research Ethics Committee. The
Medical Research Council has issued guidance on the use of personal
information in research
Consent forms
Model consent forms are available for use in general dental practice and the
hospital and community dental services. Signing a form, however detailed and
specific, is no substitute for the communication between dentist and patient that
is the essential component in obtaining valid consent. Forms have a place in
recording consent and in some cases (for example general
anaesthesia/conscious sedation, extensive or expensive treatment) are a
professional requirement.
Salaried services: The Department of Health in England has published a
consent form (available in a number of languages) to be used for medical or
dental investigation, treatment or operation and one to be used for mentally
incapacitated patients). The form emphasises the patients right to a full
explanation of the proposed treatment, the right to ask questions and the right
to be accompanied by a relative, friend or nurse. It also states that the patient
may refuse or withdraw consent.
General practice: Copies of treatment plans and estimates may be used to
record consent, provided that they accurately reflect not only that the patient
has agreed to the proposed treatment, but that the necessary explanations
have been given and incorporate a signature. A suggested model form for use
in extensive intervention is given below and is available in the BDA Practice
Compendium.
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Signature_______________________________ Date__________________
(Patient/parent/guardian)*
I confirm that I have obtained a full medical history and explained to the person
who signed the above form of consent, in terms which in my judgement are
suited to his/her understanding, the nature, purpose, risks and alternatives of
this treatment and that the anaesthetic techniques and usual pain control
procedures have also been explained to him/her.
Signature_________________________________Date__________________
Name____________________________________
(Dental practitioner)
*Delete whichever is inapplicable
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Checklist
4. Maintaining
confidentiality
Dentists have a professional and common law duty to keep confidential all
personal information gained about patients in the course of their professional
relationship. The patient-dentist relationship is built on the premise that a
patient who gives information to a dentist or member of the dental team is
normally entitled to assume that the information will not be disclosed without
the patients consent to anyone for any purposes other than the provision of
health care. This principle is included in the GDCs Standards for dental
professionals. The Council has also issued specific guidance on confidentiality
in Principles of patient confidentiality (www.gdc-uk.org).
Clinical dental records and other items of personal information are held by
individual dentists and dental practices as well as by health service bodies such
as trusts, private hospitals, dental hospitals and government payment agencies
such as the Business Services Authority Dental Services Division. In general
dental practice, responsibility for disclosing information without patient consent
rests with the patients dentist (unless, for NHS contract purposes, the dentist is
a deputy, assistant or an employed performer). In the salaried primary care
dental services, responsibility rests with the particular employing trust, although
the dentist who is treating the patient should be consulted if a request for
disclosure is made.
This section considers:
19
The 1998 Data Protection Act protects the confidentiality of sensitive personal
data (which includes information on the data subjects physical or mental health
or condition) by placing obligations on the data controller (that is the person or
legal entity responsible for the data) only to disclose information to a third party
in prescribed circumstances included in the Act and to keep the data secure.
The Act applies to manual data and data that are processed automatically.
An important requirement of the Act is that data must be processed fairly and
lawfully. Data processing includes the obtaining, holding, use and disclosure of
personal data. Applying the terms used in the Act to dentistry, the patient is the
data subject and the dentist responsible for care is normally the data controller.
Processing includes taking records, submitting claims to the NHS, sending out
recalls, sending work to laboratories and referrals.
Among the information that should be given to the patient is that data will be
shared on a need-to-know basis with certain organisations (such as the BSA
DSD/ SDPD/ CSA) in order to provide the patient with appropriate care and
treatment and for the provision of general health services.
Under the Act, information should only be held for the period for which it is
required and for the purposes that have been stated to the data subject. For
example, in dentistry, dentists should not send information to patients about
non-dental business ventures unless they have the patients consent to do so.
This also applies to information about financial products such as personal
loans.
The relevant principles of the Data Protection Act must be followed: that is data
must be kept for no longer than is necessary and must be obtained for
specified and lawful purposes. An illustration of this might be when a dental
chart of a missing person is given to the police for the purpose of identifying a
body. If the body is not found to be the patient, the charting should be returned
to the dentist and not kept on file by the police.
If the practice operates an appropriate confidentiality policy (see page 25) and
provides a data protection policy, then it is likely that the requirements of the Act
will be met. BDA Advice Sheet B2 Data protection contains further information
and a model data protection policy, which also appears in the BDA Practice
Compendium.
Patients aged 16 and over can consent to the disclosure of their health records
and can withhold their consent. Mature minors of any age, who understand the
implications of their decisions, can give or withhold consent to disclose
information. Legal rights to confidentiality depend not just on age but also on
understanding. Thus, a parent does not automatically have the right of access
to a childs records, even if the child is under 16, and the dentist cannot discuss
the childs treatment with the parents without the childs consent. It is for the
dentist to judge whether a child is competent in the circumstances, taking into
account the childs age, maturity and the consequences of disclosure or failing
to disclose. For detailed advice on consent for minors see page 14.
Questions of consent to disclosure also arise where the patient might be judged
to have a mental impairment that may make them incapable of consenting to
disclosure. In these circumstances the dentist must follow the guidelines for
consent included on page15 , which comply with the Mental Incapacity Act and
associated Code of Practice. BDA Advice Note Assessing mental capacity
available, on the BDA website www.bda.org/advicenotes, provides more
information.
20
Age of consent to
disclosure
21
Patients should be made aware that information will be sent to a third party
(that is, a payment authority) for the purposes of paying the dentist and
monitoring the quality of care provided by, for example, the dental reference
service. Their consent to such disclosure can be implied if they do not object.
Additional details about the treatment, such as patient records and radiographs,
can also be disclosed to a payment authority. NHS payment authorities (the
Business Services Authority, Scottish Dental Practice Division and the Central
Services Agency) have their own procedures for ensuring that patient
information is kept confidential, as do the private dental schemes.
The need to ensure that the NHS is administered efficiently can sometimes
conflict with the need for patient confidentiality. NHS bodies must have clear
procedures for safeguarding patient confidentiality.
The NHS confidentiality code of practice sets out procedures with which health
service bodies (NHS Trusts, Primary Care Trusts/Health Boards/Local Health
Boards) must comply to ensure patient confidentiality. A copy is available on the
DH England website www.dh.gov.uk.
The guidance includes information on:
Safeguarding NHS information
Complying with the law
Giving information to patients on the purposes for which their data will be
used
Security measures
Subject access
Where and how information about patients may be passed on.
Justified disclosure:
Although information belongs to the patient, there may be circumstances in
which the disclosure of patient information without consent may be justified.
Dentists may be asked or required to disclose personal data about patients
without consent, for reasons such as:
Health research
Health research involving access to patient records in England must be
approved by Local Research Ethics Committees, Details of your local REC is
available from the National Research Ethics Committees website
www.nres.npsa.nhs.uk/contacts/find-your-local-rec
In the area of confidentiality, the LREC will wish to be satisfied that:
Arrangements to safeguard confidentiality are satisfactory
The use of identifiable patient information is fully justified
Published research findings will not identify individual patients without their
specific agreement.
Where patients will be involved personally in teaching and research activities,
their specific consent must be obtained. The Medical Research Council
publishes guidelines on confidentiality of personal information - Personal
Information in Medical Research - that emphasises the researchers
responsibilities, the obligations on hospitals and practices to ensure that
patients are made aware that their information may be used in research, and to
explain the safeguards that are in place for protecting confidentiality. A copy of
the guidance is available from the MRC website on www.mrc.ac.uk.
22
Public interest
In limited circumstances, disclosures may also be made in the public interest:
23
24
Model practice
confidentiality policy
25
All members of the dental team have an ethical and legal duty to keep patient
information confidential. The duty of confidentiality applies to all information
about the patient which is learnt in the professional role. This information must
be kept confidential even after a patient dies.
If confidentiality is breached by any member of staff, it is the patients dentist
who is responsible to the Council. A registered dental care professional whose
act or omission has breached confidentiality may also be called before the
Council.
What is personal information?
In a dental context personal information held by a dentist about a patient
includes:
The patients name, current and previous addresses, bank account/credit
card details, telephone number/e-mail address and other means of personal
identification such as his or her physical description
Information that the individual is or has been a patient of the practice or
attended, cancelled or failed to attend an appointment on a certain day
Information concerning the patients physical, mental or oral health or
condition
Information about the treatment that is planned, is being or has been
provided
Information about family members and personal circumstances supplied by
the patient or others
The amount that was paid for treatment, the amount owing or the fact that
the patient is a debtor to the practice.
Principles of confidentiality
This practice has adopted the following three principles of confidentiality:
Personal information about a patient:
is confidential in respect of that patient and to those providing the patient
with health care
should only be disclosed to those who would be unable to provide effective
care and treatment without that information (the need-to-know concept) and
such information should not be disclosed to third parties without the consent
of the patient except in certain specific circumstances described in this
policy.
Disclosures to third parties
There are certain restricted circumstances in which a dentist may decide to
disclose information to a third party or may be required to disclose by law.
Responsibility for disclosure rests with the patients dentist and under no
circumstances can any other member of staff make a decision to disclose. A
brief summary of the circumstances is given below.
When disclosure is in the public interest
There are certain circumstances where the wider public interest outweighs the
rights of the patient to confidentiality. This might include cases where disclosure
would prevent a serious future risk to the public or assist in the prevention,
detection or prosecution of serious crime. It may also be necessary in instances
where the patient puts their health and safety at serious risk.
26
27
Access to records
Patients have the right of access to their health records held on paper or on
computer. A request from a patient to see records or for a copy must be
referred to the patients dentist. The patient should be given the opportunity of
coming into the practice to discuss the records and will then be given a
photocopy. Care should be taken to ensure that the individual seeking access is
the patient in question and where necessary the practice will seek information
from the patient to confirm identity. The copy of the record must be supplied
within forty days of payment of the fee and receipt of identifying information if
this is requested.
Access may be obtained by making a request in writing and the payment of a
fee for access of up to 10 (for records held on computer) or 50 (for those
held manually or for computer-held records with non-computer radiographs).
We will provide a copy of the record within 40 days of the request and fee
(where payable) and an explanation of your record should you require it.
Note :
The fact that patients have the right of access to their records makes it
essential that information is properly recorded. Records must be
Practical rules
The principles of confidentiality give rise to a number of practice rules that
everyone in the practice must observe:
Records must be kept secure and in a location where it is not possible for
other patients or individuals to read them
Identifiable information about patients should not be discussed with anyone
outside of the practice, including relatives or friends
A school should not be given information about whether a child attended for
an appointment on a particular day. It should be suggested that the child is
asked to obtain the dentists signature on his or her appointment card to
signify attendance
Demonstrations of the practices administrative/computer systems should
not involve actual patient information
When talking to a patient on the telephone or in person in a public area,
care should be taken that sensitive information is not overheard by other
patients
Do not provide information about a patients appointment record to a
patients employer without their consent
Messages about a patients care should not be left with third parties or on
answering machines. A message to call the practice is all that can be left
Recall cards and other personal information must be sent in an envelope
28
Dental records
Good record keeping is central to good dental practice: accurate records are
essential to ensuring that patients receive appropriate and safe treatment.
Clinical records should be viewed as a communication tool, helping anyone
with access to them to understand what was done, when and how.
Dentists are often first judged on the quality of their record keeping and poor
records can sometimes render complaints and claims for damages indefensible.
Unfortunately, inadequate record-keeping systems are very common in dental
practice, often due to time constraints. But dentists must be aware that they are
responsible for the acts and omissions of their staff, including information
documented in the dental record, and it is therefore essential that the following
standards be adhered to:
29
30
Patient safety
Monitoring
Basis for accounts
Probity enquiries
Evaluation of treatment.
Records can be held on paper and on computer. Where written records are
kept, legible handwriting is essential and pencil must not be used. Removing
agents such as Tippex should not be used; alterations, where necessary,
should be made by striking a single line through them. Records should always
be signed and dated with the recorders name printed underneath or a central
record of signatures kept at the practice. Accurate dating of entries can greatly
assist with the defence of later claims, ensuring that a claim cannot be made
that the record has been subsequently altered. Abbreviations used should be
uniform throughout the practice so that they can be universally understood.
Computerised record systems must record exactly the same information as
paper records. They must also contain robust audit trails so that subsequent
alterations will be recorded. NHS dental payment agencies issue advice on
requirements for dental systems and, before purchasing a system, dentists
must ensure that the manufacturer complies with the guidance. Further
information on the requirements for dental systems can be obtained by
contacting the Business Services Authority Dental Services Division (for
England and Wales), the Scottish Dental Practice Division (Scotland) and the
Central Services Agency (Northern Ireland).
In view of the fact that patients have the right of access to their records,
derogatory comments about the patient or relatives should be avoided.
Sensitive information (such as a patients HIV status or termination of
pregnancy) should only be recorded if it is necessary to ensure that the patient
is treated properly and safely and the patient has consented.
The 1998 Data Protection Act requires that patients are given information about
the processing of their personal data (see page 20).
Storage, retention and
disposal
Dental records should be stored securely so that they are safe from
unauthorised access, theft, fire, flood and other disasters. This is a requirement
of the 1998 Data Protection Act. Records should not be accessible to patients
31
Fair processing
32
Subject access
access but a parent or guardian does so on their behalf, the data controller
should be satisfied that the child has consented to the request for access.
A solicitor or other person may have access on behalf of the data subject if the
data subject has consented in writing to the disclosure.
Any person having a claim arising from a patients death may apply and the
data controller may judge what is relevant to a claim. Where the patient has
asked that a note be made on the records that they are not disclosed after
death, disclosure cannot take place without a court order.
How can access be requested?
To obtain access, the data subject must:
Make a request in writing (which may be delivered electronically, that is by
fax or email)
State the name of the applicant and an address for correspondence
Describe the information requested
Pay the prescribed fee
Provide any information that the data controller may reasonably require in
order to satisfy himself as to the identity of the individual and the location of
the information.
Where a request for access to a manual health record is made, the fee for
access and providing a permanent copy of the record is a maximum of 50.
Where access to the health record has already been provided within forty days
of the request for access (and a permanent copy is not supplied) no fee is
payable. This charge includes administration and photocopying costs including
the cost of copying radiographs.
For computer-held records the maximum fee is 10 including photocopying and
administration.
What must be provided?
Within 40 days of the original request, or 40 days from the fee and/or
identification information being provided, the data controller must supply the
data subject with a permanent copy of the requested information unless:
the supply of a copy is not possible
copying would involve disproportionate effort
the data subject consents otherwise.
If a similar request has been made by the same individual within a reasonable
timescale, the data controller is not obliged to accede to the request. The
definition of a reasonable timescale will depend on the nature of the data, its
purpose in processing and the nature of the alteration. The information must be
supplied in an intelligible form and, where it is not intelligible, an explanation
should be given. In dentistry it would be usual for the dentist to offer to provide
an explanation of part or all of the record. The information supplied must be by
reference to the information held on the day the application was received,
subject to any routine processing.
Information about third
parties
Where personal data about third parties is part of the record (including being
identified as a source) it should be disclosed where:
1. The third party has consented
2. It is reasonable in all the circumstances to supply the information without
consent
33
Sale of a practice
Where a dental practice is sold, patient records are normally transferred to the
new owners as part of the goodwill of the practice. Sale agreements should
contain a provision that the purchaser retains the vendors records (and those
of any dentists who practised there) for a given period and allows access if
necessary. Subsequent disposal should only be undertaken confidentially.
Ownership of records taken by dentists who are no longer associated with the
practice is generally determined by any agreement between the dentists
concerned or, if there is no agreement, by a court. Difficulties can arise if an
associate moves to a nearby practice and patients wish to follow. Our advice
here is that a patient has the right to choose the practitioner and, in the
interests of patient care, the records, including radiographs, should follow the
patient. Copies should preferably be retained at the practice.
The goodwill relating to the patients of a practice which is closing down may be
sold to another practitioner. In other cases, the retiring dentist should retain the
patient records in case of future complaints or legal action. In cases of death,
the dentists personal representative would have custody of the records.
Transfer of records
Generally speaking there is no problem sending patient records to their new
practice at the request of the patient. The practice should retain a copy or
obtain agreement from the new practice that the records will be returned on
request.
Faxing dental records to another practice is permissible provided that the
receiving practice ensures that the fax is secure and out of sight. The practice
should be alerted and their fax number confirmed prior to sending the fax
through.
BDA March 2009
34
If the patient records are being emailed, the patient must consent to their
medical records being transferred in this way. It would also be wise to check
that the email address is that of the intended recipient.
Checklist
Patient care
This section is about the type of care dentists provide for patients, as well as
the way that care is delivered. Dentists are able to provide care and treatment
that they are competent to provide. They are also able to provide care that is
not dental care but, if they do so, they must ensure that the care is lawful, they
are properly trained to provide it and they have suitable indemnity.
The section covers
Patient communication
Patient communication
Agreeing to provide care and treatment
Patient choice
Treatment planning
Health checks
Alternative therapies
Non-surgical cosmetic procedures
Tooth whitening
Medical emergencies
Misleading patients
Maintaining appropriate boundaries
Referral fees
Missed appointments
Debt collection
Handling complaints
Checklist
35
Relations between dental teams and patients should always be friendly and
patients must always be treated politely. Patients should be put at ease and
made to feel that they are active partners in their care. At all times, patients
dignity must be maintained. Dental staff must be accessible and prepared to
answer patients questions clearly, accurately and promptly. Dentists are
responsible for the acts and omissions of members of the dental team that they
lead or supervise and must ensure that they are well trained. Registered dental
care professionals are also responsible for their own acts and omissions.
There are points in the dentist/patient relationship where good communication
by dentist and practice team becomes particularly important in avoiding
complaints and allegations of misconduct. This section considers some of these
areas and includes some useful aids.
Many difficulties and complaints are caused by patients being unclear about the
basis on which they have been accepted for treatment. It is the dentists
responsibility to ensure that this basis is understood at the time of the initial
appointment. In England and Wales it is not possible to examine a patient to
make a decision on whether or not NHS care should be offered. It is possible to
do this in Scotland and Northern Ireland and is not unethical, provided that the
patient is clear at the time of booking that it is a screening appointment and the
cost (if any) of the individual consultation is given.
Patients must be given full information about treatment to be carried out and
the nature of the contract with the dentist, whether NHS or private. It is
important that cost indications are given at the outset and that any necessary
changes to treatment plans or estimates are fully explained and agreed to by
the patient. One way of ensuring that the basis of the contract is unequivocal is
to give new patients a suitably worded welcome letter or include the information
in a practice leaflet. Where new patients are being accepted under NHS
regulations, dentists are required to provide an acceptance form
(FP17DC/GP17DC/HSA45). This form is useful in that it includes a written
treatment plan and cost estimate, as well as the option of recording any
treatment that has been agreed privately. The BDA has a range of advice
sheets on NHS rules and regulations that are listed at the end of this section.
Cases sometimes arise where patients realise that care has not been carried
out under the NHS only when they wish to make a complaint or query the
amount that they have been charged. Intentionally misleading patients might
constitute fraud or give rise to a fitness to practise investigation by the GDC.
Patients have the right of free choice of dental practitioner and to change their
dentist if they wish. The dentist also has the right not to accept patients for
treatment provided that there is no unlawful discrimination. In Standards for
dental professionals, the GDC states that patients must not be refused
treatment or otherwise discriminated against on the following grounds:
Sex, age, race, ethnic origin, nationality, special needs or disability
Sexuality, health, lifestyle, beliefs or any other irrelevant consideration.
GDS regulations in England and Wales also provide that patients cannot be
discriminated against on the grounds of their dental or medical condition.
There is no obligation to provide reasons for a decision not to accept or to
cease to provide NHS care (provided that NHS regulations regarding notice are
complied with), but it is good practice to do so. Generally, dentists should seek
to maintain a continuing professional relationship with their patients.
36
Patients must be treated as individuals who have the right to make choices
about their care. This includes who will provide that care. Dentists are
sometimes consulted by patients who were treated by them at a former practice
where they were engaged as employed dentists or associates. If the dentist is
prevented from treating the patient by a contractual obligation to the former
practice owner, this should be explained to the patient.
Considerable problems can face departing assistants or associates when
questioned by patients about their future plans. The departing general dental
practitioner has a professional commitment to complete or arrange for
completion of any treatment commenced. Except in exceptional circumstances,
it would be unacceptable for a dentist to connive in any arrangement whereby a
patient makes an appointment believing it to be with the former dentist only to
find on arrival that it is with another, perhaps unknown, practitioner. The precise
details of the arrangements for leaving should be left for agreement between
the parties involved according to their contractual arrangements but it must be
remembered that the dentist who performs the treatment has the responsibility
for the best interests and dental care of his or her patients.
Treatment planning
Health checks
Many patients attend their dentist more regularly than they do their doctor.
Dentists may offer patients the opportunity, if they wish, to have other simple
physiological measurements such as measuring blood pressure or cholestoral
levels. Such services can enhance the service available to patients and
demonstrate a caring, preventive approach. Provided that the dentist is properly
trained to undertake the tests and patients are given appropriate information on
the results, such tests can be undertaken and a reasonable charge made.
Dentists are responsible for the accuracy of the results and the advice and
information provided.
Alternative therapies
37
In these cases, dentists are responsible for the treatment that is undertaken
and must not make any misleading claims about the treatment or its outcomes.
Care that is provided must be based on available up-to-date evidence and
reliable guidance. This makes the use of unproven or controversial techniques
unwise outside of clinical trials or research that have ethics committee approval.
The General Dental Council has issued guidance on alternative therapies.
Some alternative therapies can have a legitimate use in dental treatment, such
as hypnosis used to help an anxious patient. However, the Council is
concerned that registrants should not use their standing as a dental
professional to offer alternative therapies such as acupuncture or pain relief
which are not provided to a patient as part of their dental treatment, for example
hypnosis for smoking cessation or acupuncture for the relief of non-dental pain.
This is the case even if a registrant is trained and registered as an alternative
therapist.
The Council is of the view that alternative/complementary therapies that are not
provided in conjunction with, or linked to, a patients dental treatment must be
provided separately to a registrants practice of dentistry. The practice of
alternative therapies must be advertised or otherwise publicised separately to a
registrants practice of dentistry.
Care should be taken when providing for cosmetic reasons treatment to
patients that does not constitute the practice of dentistry, for example dermal
fillers or Botox. Dentists are responsible for the treatment that they provide and
must ensure that they have appropriate indemnity/insurance cover. It is
essential that they have the appropriate skills and training to undertake the
procedure. The word Botox is copyright and cannot be used in advertisements.
Non-surgical cosmetic
procedures
The GDC requires only dentists, dental hygienists and dental therapists (if
trained and competent) to undertake tooth whitening.
Tooth whitening is covered by the Cosmetics Products (Safety) Regulations
which control the amount of hydrogen peroxide they are able to contain. This is
subject to change, so for the latest information, see the BDA website.
Tooth whitening
Medical emergencies
Dental teams should be trained to ensure each member knows exactly what to
do in the event of patient collapse or other emergency and practise regularly in
a simulated emergency situation.
Dentists must not mislead their patients. It is all too easy inadvertently to
mislead by failing to communicate properly or by statements in practice
literature or other advertising material which the patient misunderstands.
Information provided must be accurate and truthful and must not make claims
that cannot be substantiated, for example relating to the quality, longevity or
cost of treatment.
BDA March 2009
38
Misleading patients
The BDA is happy to check draft advertisements, leaflets and other literature to
ensure that they dont mislead. Having an outsider look at a draft often enables
inadvertent errors to be avoided.
Further guidance in relation to the provision of NHS and private care is
contained in BDA Advice Sheets A4 Private practice made simple and E13 A
guide to GDS regulations in Northern Ireland, E14 Guide to GDS regulations in
Scotland and E11 Guide to GDS/PDS regulations in England and Wales.
Maintaining appropriate
boundaries
Referral fees
Dentists should not enter into arrangements whereby, unknown to the patient,
fees for treatment are split between two dentists to encourage referral of certain
patients for particular forms of treatment, for example. A dentist should not ask
for, or receive, money gifts or hospitality in return for referring patients.
Missed appointments
Debt collection
As a last resort, dentists may pursue patients for debts in the civil courts, or
employ debt collectors. Prior to taking such action, however, the practice should
make every effort to recover debts by sending suitably worded written
reminders.
A dentist is not obliged to embark on or continue with a course of treatment if
an NHS patient is in debt to the practice. Where such a patient attends in pain
or with another dental emergency, however, the dentist must provide
emergency care and then may, if appropriate, deregister the patient in Scotland
and Northern Ireland or refuse to provide another course of treatment in
England and Wales. Information about de-registration is contained in BDA
Advice Sheets E11 Guide to GDS/PDS in England and Wales, E13 A Guide to
GDS regulations in Northern Ireland and E14 Guide to the GDS in Scotland.
It is a breach of the dentist's duty of confidentiality to disclose lists of debtors to
third parties, other than to recover the debt. Lists of patients with debts to local
practices should not be compiled or circulated.
39
Dentists are required under GDS/PDS regulations and by the GDC to have in
place a procedure to handle complaints from patients swiftly and satisfactorily.
Both NHS and private patients may complain to the practice about the
treatment or service that they have received and have their complaint
considered by their dentist and, if necessary, action taken. Most complaints
arise from a breakdown in communication and many patients are happy with an
apology and/or a refund. Sometimes the patient wants a sincere commitment
by the practice that the matter will be put right in order to avoid the situation
occurring to another patient. Where damage is alleged to have been caused,
the patient may refer the matter to court rather than using the complaints
procedure or take legal action after the complaint has been made to the
practice.
Handling complaints
There is a formal complaints service for private patients provided by the Dental
Complaints Service, funded by the GDC but independent of it. The Dental
Complaints Service assists private dental patients and dental professionals to
resolve complaints about private dental services. It would be very wise to cooperate with the service to help resolve the complaint quickly and without
escalation to the courts or the GDC. For more information visit
www.dentalcomplaints.org.uk.
Further information on dealing with complaints is contained in BDA Advice
Sheet B10 Handling complaints and B11 Private Practice Complaints.
Patients must be treated fairly and reasonably and not misled about the
treatment they will receive, the contractual basis on which it is provided or
its cost
Dentists are free to accept or not accept patients but non-acceptance must
not amount to discrimination
Patients should have freedom of choice of dentist
Where an associate leaves a practice, his or her patients should be informed
Ownership of dental records depends on the agreement between associate
and practice owner
Patients must see a dentist first to undertake a full mouth assessment and a
treatment plan, the only exception being edentulous patients who require full
dentures who may be seen by a clinical dental technician
Where planned treatment is taking place, there should be two people in the
room who are trained in medical emergencies
Dentists may pursue bad debts using debt collecting agencies or the courts
but must not circulate lists of debtors to other practices
Dentists should not refer patients to colleagues in return for a fee
Dental practices should have a complaints procedure. Where treatment is
offered that does not amount to dental treatment, the dentist must have
appropriate indemnity cover and be fully trained and competent to provide
the treatment
Where dentists offer patients treatment under private dental plans, the scope
of care to be provided by the plans should be clear and its terms should not
interfere with the contract and relationship between dentist and patient
Full and clear communication with patients is vital to successful practice
Patients should not be misled as to the arrangements under which they are
being treated or its cost
Dentists may offer patients alternative therapies as part of their treatment,
provided that any additional cost is made clear at the outset
Care must be evidence based and unproven techniques should only be
used as part of clinical trials or research.
40
Checklist
Professional
relationships
Professional agreements
Professional agreements
Duties of a dentist manager
Second opinions
Poor performance
Specialist practice
Veterinary dentistry
The death of a dental practitioner
Checklist
It is essential for both dentists and their patients that dentists practising together
enter into reasonable arrangements that are confirmed in a comprehensive
written agreement. This is particularly important for practitioners entering
general dental practice for the first time. Terms of such agreements should not
place any undue pressure on an associate or assistant to reach an
unreasonable target since this may compromise patient care. Agreements
should guarantee clinical freedom for dentists, provide for adequate chairside
support, suitable facilities and contain full financial arrangements. The BDA
provides advice sheets for members on performer agreements, assistantships,
associateships, locumships and partnerships, all of which contain model
agreements. BDA Practice Support can look at draft agreements and advise in
the case of disputes. A conciliation and mediation service is also offered where
both parties agree to its use, avoiding costly litigation. Contact
practicesupport@bda.org or telephone 020 7563 4574.
Most written agreements contain restrictive clauses preventing one party from
practising within the vicinity of the practice for a defined time period after the
end of the arrangement and from soliciting or treating former patients. The
terms of these clauses must be reasonable and reflect such factors as the
location of the practice, the number of local dentists, patient catchment area
and other relevant aspects. Restrictive clauses must not operate to the
detriment of patients on termination and should only aim to prevent unfair
competition, not competition itself.
Courts do not automatically uphold restrictive covenants and either party has
the option of asking a court to rule whether a particular clause is reasonable. If
it is judged unfair, it will be struck out without a more reasonable term being
substituted.
Duties of a dentist
manager
41
Second opinions
Clinical dental opinions vary widely and dentists often have very different
treatment philosophies. In some cases dentists may conclude that the
treatment provided has been of very poor quality or treatment proposed is
either unnecessary or insufficient. The dentist then has a responsibility to give
an accurate clinical opinion to the patient and might wish to discuss the
treatment of the previous dentist with a senior colleague.
Where a second opinion is given, the patient should be told of the consultation
charge before an appointment is made. In all cases, the dentist must put the
patient's best interests first, rather than professional loyalties.
Dentists are sometimes faced with a colleague who they believe is putting
patients at risk because of their health, behaviour or professional performance.
In these cases, the GDC guidance document Principles of raising concerns
must be followed. The guidance places a professional responsibility on dentists
and dental care professionals in this situation to raise concerns if patients may
be at risk. Further guidance is also available in BDA Advice Sheet B12
Handling underperformance.
There are two stages for raising concerns, locally and then centrally. If a dentist
becomes concerned by the behaviour, health or professional performance of a
colleague that does not pose an immediate risk to public safety, then they
should raise the matter with the appropriate local authority.
First, talk to the dentist/DCP directly to try to persuade them to seek
appropriate professional help
If the dentist is self-employed the designated person within the local primary
care organisation should be informed.
If the dentist concerned is in a salaried position, the employing authoritys
procedures for handling such cases should be followed.
If alcohol or drug dependence is suspected, contact the Dentists Health
Support Programme (which is a confidential service) for advice (see page 61).
If the case appears to be serious or a local referral has been made and no
action has been taken, speak to the General Dental Council. Action should be
taken if the dentist is in any doubt. The dentist should be kept informed of the
action taken to deal with concerned that have been raised. Dentists have a
responsibility to ensure that people they employ or manage are encouraged to
raise concerns and are protected if they do so.
BDA Practice Support will advise on appropriate local contacts.
42
Raising concerns
Specialist practice
Treatment on referral
Dentists have a professional duty to refer a patient to a colleague where
treatment is required that is beyond their clinical capabilities. Responsibility for
making an appropriate referral rests with the referring dentist and particular
care must be taken when referring for treatment under general anaesthesia or
sedation. It is not acceptable to refer a patient for financial reasons alone or the
need to meet targets.
Where the patient is treated by a second dentist on referral, responsibility for
the treatment provided and for providing for emergency care in connection with
that treatment lies with the second dentist. The referring dentist remains
responsible for the general care of the patient and related emergency cover.
The second (referral) dentist must endeavour to complete any treatment that
has been started, but, if this is not possible, the patient will normally return to
the first dentist who must make another suitable referral.
Specialist lists
Only dentists who have been admitted to one of the specialist lists held by the
General Dental Council may use the title specialist or claim or imply specialist
expertise. This applies to information for patients as well as other professional
colleagues. A practice wholly or mainly devoted to a particular type of dental
treatment can be advertised as such.
Patients must not be misled about the practice, or that the treatment is provided
by specialists, if the dentists practising on the premises are not on the
appropriate GDC specialist list.
Veterinary dentistry
Dentists may provide dental treatment to animals provided that it is for health
rather than cosmetic reasons and that it is done under the direct personal
supervision of a vet who is present throughout.
43
Dental practices must operate using sound business methods to ensure that
sufficient income is generated to facilitate a high standard of care and treatment
for patients. Commercial business methods can be at variance with caring
professional practice and in certain areas dentists must be careful about
breaching ethical rules.
Checklist
Commercial
interests
Financial interests
Advertising and canvassing
Shared arrangements with other health professionals
Buying, selling or closing a practice
Bodies corporate and limited liability partnerships
Practices owned by dental care professionals
Promotion of products and services
Private dental plans
Bankruptcy
Checklist
Dentists must not put their own financial interests above the interests of their
patients. This is a specific requirement of NHS contracts in England and Wales.
Financial interests can come into play, particularly where NHS care is provided,
and it is important that dentists treatment decisions are not influenced by
associated costs or NHS targets.
Financial interests may have an influence on treatment planning and making
NHS recommendations to patients. One question that professionals in general
practice in England and Wales need to ask themselves on occasions is Would
I recommend this course of treatment if the patient was paying privately? If the
answer is no, then their care may be being influenced by their own financial
situation. If a dentist finds that they are unable to provide a good standard of
care while working under a particular contractual situation, then alternatives
should be considered.
A patient must be given full information about the various appropriate treatment
options and be able to make an informed and free choice.
Dentists must have full clinical freedom to provide the most appropriate
treatment in the best interests of the patient and to a high standard. Dentists
should not practise in circumstances where recommended standards of health
and safety and infection control are not achieved.
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Financial interests
Advertising and
canvassing
The general professional rules set out in Standards for dental professionals
apply to the way that dentists are able to advertise and market their practices.
Best practice in dental advertising and marketing is discussed fully in BDA
Advice Sheet A6 Marketing your practice. Dental advertising must comply with
the Advertising Standards Authoritys Code of advertising practice
(www.cap.org.uk).
In summary, dentists should not:
Claim to specialise unless they are on a GDC specialist list
Say or imply anything that is untrue or misleading, particularly regarding the
services or treatment that are available from the practice
Make a claim that is not capable of substantiation
Use the courtesy title Dr in advertising or promotional material
Be associated with any publicity or advertising material that is likely to bring
the profession into disrepute.
Advertisements should contain the name of at least one dentist normally in
attendance at the practice.
Methods of practice promotion are varied and can include open days,
circulation of leaflets to surrounding houses and businesses, sponsoring local
sports teams, giving dental health education talks to interested groups.
Marketing to the public via unsolicited telephone calls or house to house
canvassing should not be undertaken.
Dentists sometimes instruct advertising agencies or marketing companies to
prepare advertising or publicity material for them which may not comply with
GDC standards. The BDA is happy to check draft advertisements or other
publicity material. Contact BDA Practice Support.
Shared arrangements
with other health
professionals
Dentists may share practice premises with other health professionals. Common
arrangements involve rental agreements with chiropodists, physiotherapists or
being part of a health centre with general medical practitioners.
Where premises are shared, care should be taken that dental records are not
accessible to third parties and that drugs and other hazardous substances are
kept secure when the dental practice is not in use. Separate entrances and
telephone numbers are not necessary, but patients should not be made to feel
that they should be consulting other practitioners within the building.
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46
Promotion of products
and services
Many dental practices offer their patients the opportunity to pay for their private
dental care by joining a private plan. The plans may be either capitation
schemes or insurance schemes. Some dental corporates offer their own
insurance plans and a growing number of dental practices operate their own inhouse schemes. In-house capitation schemes should have appropriate
insurance cover to avoid contravening insurance law.
When giving information to patients about private dental plans, dentists should
not mislead about the cost of the schemes or the scope of the cover that is
offered. Patients should have the option of paying for their private care on an
item-of-service basis if they wish. Care should also be taken to ensure that
legal requirements regarding consumer credit licensing and the provision of
insurance are met. Further advice is available from BDA Practice Support.
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Private dental plans should have no effect on a dentists clinical freedom and
should not interfere with the relationship between dentist and patient. Many of
the larger plans require practices to adhere to particular standards and
membership can be beneficial to a practice in terms of raising the quality of
service given to patients.
Further information on private dental schemes is available in BDA Advice Note
Private dental plans.
Bankruptcy does not prevent a dentist continuing to practise and registration is
unaffected, provided that there is no attendant question of fitness to practise. A
dentist who is no longer able to run a business may take up an employed
position, either within the salaried services or as an assistant/employed
performer in general dental practice. Dentists in financial difficulties should
contact BDA Practice Support for advice.
Advertising material must not be misleading
Dentists cannot lend their names to specific products or services
Only companies with a majority of GDC registrant directors may carry on the
business of dentistry, that is own a dental practice
Dentists employed/engaged by companies must follow the same ethical and
legal rules as other general dental practitioners
Where dentists offer patients treatment under private dental plans, the
scope of care to be provided by the plans should be clear and its terms
should not interfere with the contract and relationship between dentist and
patient
Bankrupt dentists may continue in clinical practice
Lay people cannot enter into partnerships to own dental practices.
Members of the dental team are in a position where they may observe the
signs of child abuse or neglect or hear something that causes them concern
about a child. The dental team has an ethical responsibility to find out about
local procedures for child protection and to follow them if a child is or might be
at risk of abuse or neglect (Standards for dental professionals, GDC 2005).
There is also a responsibility to ensure that children are not at risk from
members of the profession. This section covers:
Bankruptcy
Checklist
Child
protection
Types of abuse
Practical steps
Recording and reporting
Child protection policy
Criminal record checks
Further information
Checklist
The dental team is not responsible for making a diagnosis of child abuse or
neglect, just for sharing concerns appropriately. Abuse and neglect are
described in four categories:
Physical abuse may involve hitting, shaking, throwing, poisoning, burning or
scalding, drowning, suffocating or otherwise causing physical harm to a child. It
may also be caused by a parent or carer fabricating the symptoms of, or
deliberately causing, illness in a child. Orofacial trauma occurs in at least 50
per cent of children diagnosed with physical abuse and a child with one injury
may have further injuries that are not visible.
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Types of abuse
49
Discuss your concerns with an appropriate colleague or someone you can trust.
If you remain concerned, informal advice could be sought first from your local
social services without disclosing the childs name. This will help you decide
whether you should make a formal referral by telephone so that you can
directly discuss your concerns.
Seek permission to refer
It is good practice to explain your concerns to the child and parents, informing
them of your intention to refer and seek their consent being open and honest
from the start, results in better outcomes for the children. Dont discuss your
concerns with the parents where
The discussion might put the child at greater risk
The discussion would impede a police investigation or social work enquiry
Sexual abuse by a family member, or organised or multiple abuse is
suspected
Fabricated or induced illness is suspected
Parents or carers are being violent or abusive and discussion would place
you or others at risk
It is not possible to contact parents or carers without causing undue delay in
making the referral.
Where there is serious physical injury arising from suspected abuse:
Refer the child to the nearest hospital Accident and Emergency Department
with the consent of the person having parental responsibility or care of the
child
Advise the A&E Department in advance (by telephone) that the patient is
coming
If consent is not obtained, the Duty Social Worker at the local Social
Services Department or the police should be told of the suspected abuse by
telephone so that the necessary action can be taken to safeguard the
welfare of the child
A telephone referral to Social Services must be confirmed in writing within
48 hours, repeating all relevant facts of the case and an explicit statement of
why you are concerned. The telephone discussion should be clearly
documented who said what, what decisions were made and the agreed
unambiguous action plan.
Where less serious injury is recorded or there is concern for the physical or
emotional well-being of the child, discuss the appropriate reporting procedures
and your concerns with a senior local colleague, such as a hospital consultant,
dental adviser or consultant in Dental Public Health or contact the health
professional for child protection at the local primary care organisation (PCO).
Recording and reporting
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A suitable child protection policy for a dental practice should affirm the
practices commitment to protecting children from harm and should explain how
this will be achieved. A policy by itself is not enough, however. Safeguarding
children also involves:
Listening to children
Providing information for children
Providing a safe and child-friendly environment
Having other relevant policies and procedures in place
Listening to children
Create an environment in which children know their concerns will be listened to
and taken seriously. You can communicate this to children by:
Asking for their views when discussing dental treatment options, seeking
their consent to dental treatment in addition to parental consent
Involving them when you ask patients for feedback about your practice
Listening carefully and taking them seriously if they make a disclosure of
abuse
Providing information to children
To support children and families, you can provide information about:
Local services providing advice or activities
Sources of help in times of crisis, for example, NSPCC Child Protection
Helpline, NPCC Kids Zone website, Childline, Samaritans
Providing a safe and child-friendly environment
Taking steps to ensure that areas where children are seen are welcoming
and secure with facilities for play
Considering whether young people would wish to be seen alone or
accompanied by their parents
Ensuring that staff never put themselves in vulnerable situations by seeing
young people without a chaperone
Ensuring that your practice has safe recruitment procedures in place
Other relevant policies and procedures
Clinical governance policies that you already have in place will contribute to
your practice being effective in safeguarding children. Relevant policies and
procedures include:
Safe staff recruitment procedures
Making potential job applicants aware of your child protection policy
Checking gaps in employment history
Requesting proof of identity
Taking up references
Complaints procedure so that children or parents attending your practice
can raise any concerns about the actions of your staff that may put children
at risk of harm
Public interest disclosure policy (underperformance policy) so that staff can
raise concerns if practice procedures or action of other staff members puts
children at risk of harm
Code of conduct for staff clarifying the conduct necessary for ethical
practice, particularly related to maintaining appropriate boundaries in
relationships with children and young people (including a statement that staff
members will be chaperoned when attending unaccompanied children, for
example).
BDA March 2009
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To increase patient safety, all new recruits into the NHS must undergo criminal
record checks.
The existence of a criminal conviction does not of itself prevent anyone from
working in the NHS and information should considered in the light of all relevant
circumstances including the nature of the offence and the relevance of the
offence to the work involved. Obtaining a disclosure for practice staff in private
practice is regarded as good practice.
England and Wales
Dentists working under a GDS contract or PDS agreement in England and
Wales must ensure that staff with direct patient contact undergoes criminal
records checks. This includes, for example, dental nurses and receptionists but
not cleaners that work out of hours. Dentists are checked automatically on entry
to a Primary Care Organisation performers list. The Criminal Records Bureau
(CRB) undertakes the criminal records checks.
There are two types of disclosure standard and enhanced. Standard
disclosures allow disclosure of criminal convictions (spent or unspent),
cautions, reprimands, warnings and bind-overs. Enhanced disclosures allow the
additional disclosure of information held by local police forces. The employing
dentist decides whether an enhanced disclosure is needed, although a
standard disclosure is usually sufficient for employees. The relevant paperwork
can usually be obtained from the local Primary Care Organisation. Many PCOs
do not charge for this service, but where one is made it should only reflect the
charge made by the CRB.
CRB checks can be undertaken by other organisations listed on the CRB
website. Being commercial, these organisations will charge a fee for providing
this service.
Scotland
Disclosure Scotland is a voluntary body established within the Scottish Criminal
Record Office (SCRO) to issue disclosure certificates. Its aim is to enhance
public safety and help employers and voluntary organisations in Scotland to
make safer recruitment decisions.
The bureau is responsible for issuing three levels of disclosure basic,
standard and enhanced. It draws on three sources of information the SCRO
database, the Police National Computer (PNC) and, where appropriate, local
police force records.
Basic disclosures show details of all unspent convictions and are available to
anyone. Standard disclosures are available for occupations whose duties
involve, for example, regular contact with children and young people under the
age of 18, vulnerable adults and professional groups in health. They contain
details of all convictions on record, whether spent or unspent under the
Rehabilitation of Offenders Act, so minor convictions, no matter when they
occurred, will be included. The highest level, enhanced disclosures, may also
contain non conviction information held locally by the police. The prospective
employer should decide which level of disclosure to apply for.
Requests for standard and enhanced disclosures must be countersigned by a
registered body, such as a Health Board.
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Further information
Checklist
The dental
team
Vicarious responsibility
Dental hygienists and dental therapists
Dental technicians and clinical dental technicians
Dental nurses
Dental receptionists
Training
Terms and conditions of service
Staff management and appraisal
Checklist
Vicarious responsibility
Dentists are vicariously responsible for the acts and omissions of their
unregistered staff. This includes dentists working as assistants, locums and
associates who, although they may not be the employer of the staff, are
responsible for the delegation of tasks to them and for the outcomes of their
actions on patients. Both dentists and registered DCPs may be held
responsible by the General Dental Council and NHS contractors will be
responsible for the acts and omissions of all dental professionals they engage.
The General Dental Council has published a Scope of practice for each group
of DCPs giving the tasks that they can undertake, providing they have
appropriate training. See the GDCs website at www.gdc-uk.org.
The dentist is responsible for checking the GDC registration of dental hygienists
and dental therapists and must ensure that they work within their competence.
Failure to do so may lead to a charge of covering the illegal practice of
dentistry, as well as fitness to practise proceedings against the DCP.
Dental hygienists may work without a dentist being on the premises. Hygienists
and therapists work within the treatment plan provided by the dentist stating the
treatment to be provided, the date of the next full mouth assessment and recall
intervals at which the patient should be seen. The dentist can ask the dental
hygienist or dental therapist to decide the recall intervals where appropriate.
Dental therapists can work in all spheres of dental practice.
53
Dental hygienists and dental therapists should have their own indemnity cover
to protect them in the case of proceedings by the GDC and action by a patient.
Dental defence organisations accept dental hygienists and dental therapists into
membership.
Dental technicians have to be registered with the GDC or be in formal training.
Dental technicians do not work with patients, that is take impressions, or fit or
adjust dentures.
Dental nurses
Dental receptionists do not work in the surgery. Since registration for dental
nurses became mandatory, receptionists cannot be asked to cover surgery
duties in the event of absence of a dental nurse unless he/she is registered. A
dentist asking the receptionist to do so would be subject to fitness-to-practise
procedures.
Dental receptionists
It is essential that all members of the dental team are adequately trained,
registered and competent to perform their required duties. Once trained, skills
and knowledge must be kept up-to-date.
Training
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A good staff appraisal scheme can help to deal with poor performance, reward
good performance and increase motivation. The BDA provides a
comprehensive guide to appraisal, available in the BDA Practice Compendium.
Dental undergraduates receive little or no staff management training, although
these issues are covered in the vocational training year. Communicating with
and motivating staff are skills that are learned in practice. Providing a high
standard of care and service to patients requires good management and
administration by dentists and courses are available. The BDA also has a large
amount of management information for use in dental practice. Contact the
BDA's Information Centre and Professional and Advisory Services and use the
BDA Practice Compendium. Also consider taking part in the BDA MasterClass
management training programme.
Checklist
General
anaesthesia and
conscious sedation
General anaesthesia
Dentists should ensure that their staff are properly trained and qualified to
undertake the tasks that have been delegated to them
Dentists are responsible for the acts and omissions of their staff
Dentists must comply with employment legislation
Training in the management of staff is important for dentists
All dental care professionals must be registered with the GDC or enrolled on
an approved training course
Dental practices should follow a comprehensive equal opportunities policy.
There are stringent requirements for the provision of general anaesthesia and
conscious sedation in dentistry. GDC requirements are contained in the annex
to Standards for dental professionals.
General anaesthesia, a procedure which is never without risk, should be
avoided wherever possible. It must only be provided within a hospital setting
which has critical care facilities. This means it cannot be provided within
primary care. General anaesthesia may only be given by someone who is:
on the specialist register of the General Medical Council as an anaesthetist
a trainee working under supervision as part of a Royal College of
Anaesthetists approved training programme, or
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56
Conscious sedation
Operating chairs and patient trolleys must be capable of being placed in the
headdown tilt position and equipment for resuscitation from respiratory and
cardiac arrest must be readily available.
Dedicated purpose-designed machines for inhalational sedation should be
used.
It is essential to ensure that hypoxic mixtures cannot be delivered.
There should be adequate active scavenging of waste gases.
All equipment for the administration of intravenous sedation including
appropriate antagonist drugs must be available in the treatment area and
appropriately maintained.
Supplemental oxygen delivered under intermittent positive pressure together
with back up must be immediately available.
It is important to ensure that each exposure to Conscious Sedation is
justified. Careful and thorough assessment of the patient ensures that
correct decisions are made regarding the planning of treatment.
A thorough medical, dental and social history should be taken and recorded
prior to each course of treatment for every patient.
There are few absolute contraindications for Conscious Sedation however
special care is required in the assessment and treatment of children and
elderly patients.
Patients must receive careful instructions and written valid consent must be
obtained.
Fasting for Conscious Sedation is not normally required however some
authorities recommend the same fasting requirements as for general
anaesthesia.
Recovery from sedation is a progressive step-down from completion of
treatment through to discharge. A member of the dental team must
supervise and monitor the patient throughout this period.
The decision to discharge a patient into the care of the escort following any
type of sedation must be the responsibility of the sedationist.
The patient and escort should be provided with details of potential
complications, aftercare and adequate information regarding emergency
contact.
The three standard techniques of inhalation, oral and intravenous sedation
employed in dentistry are effective and adequate for the vast majority of
patients.
The simplest technique to match the requirements should be used.
The only currently recommended technique for inhalation sedation is a
titrated dose of nitrous oxide with oxygen and it is absolutely essential to
ensure that a hypoxic mixture cannot be administered.
The standard technique for intravenous sedation is the use of a titrated
dose of a single drug; for example the current use of a benzodiazepine.
Oral premedication with an effective low dose of a sedative agent may be
prescribed.
No single technique will be successful for all patients.
All drugs and all syringes in use in the treatment area must be clearly
labelled and each drug should be given according to accepted
recommendations.
Stringent clinical monitoring during the procedure is of particular importance
and all members of the clinical team must be capable of undertaking this.
Conscious Sedation for children must only be undertaken by teams which
have adequate training and experience.
Nitrous oxide / oxygen should be the first choice for paediatric dental
patients.
Intravenous sedation for children is only appropriate in a minority of cases.
The management of any complication including loss of consciousness
requires the whole dental team to be aware of the risks, appropriately
trained and fully equipped. It is vitally important for the whole team to be
prepared and regularly rehearsed.
57
Attention must be given to risk awareness, risk control and risk containment.
Evidence of active participation in continuing professional development
(CPD) and personal clinical audit is an essential feature of clinical
governance.
The Scottish Dental Clinical Effectiveness Programme has produced specific
guidance on the provision of sedation in Scotland. Conscious sedation in
dentistry dental clinical guidance was published in May 2006 and evolved
from the report by the English Department of Health summarised above.
A full copy of the Scottish guidance is available at:
www.scottishdental.org/cep/guidance/dentalsedation.htm
In August 2007 the Royal College of Surgeons of England - Faculty of Dental
Surgery and the Royal College of Anaesthetists produced new additional
guidance encompassing the use of alternative conscious sedation techniques.
Standards for Conscious Sedation in Dentistry: Alternative Techniques - A
Report from the Standing Committee on Sedation for Dentistry can be
accessed at www.rcseng.ac.uk/fds/docs/SCSDAT%202007.pdf
Conscious sedation in
Scotland
Alternative techniques
58
Consent
Checklist of
ethical
principles
59
60
Dentists
Health Support
Programme
Established in April 1986 as the Sick Dentist Scheme, the Dentists Health
Support Programme is designed to help the dentist who is in need of but not
seeking - medical attention and whose condition is considered to compromise
well-being, the safety and welfare of patients and the reputation of the
profession. It is designed both to protect patients and to help dentists who may
be at risk of formal complaint to the GDC. Whilst the majority of cases are
alcohol/drug related, this is not always the case.
The Dentists Health Support Programme can be contacted by calling the
helpline number below. This line can be used by any dentist who has a problem
or by someone (a colleague, staff, family member or a friend) who knows a
dentist who might have a problem. The scheme is entirely confidential and
callers are assured that their identity will not be disclosed to the dentist at any
time. The caller will be put in contact with a Regional Referee in the appropriate
geographical area or with the Co-ordinator of the Programme.
Regional Referees are usually retired or semi-retired dentists who are trained
and willing to make time to help colleagues in trouble. The Regional Referee
will contact a Special Referee and help establish whether there is a problem.
Special Referees are recovered alcohol/drug addicts who have received
specialised training.
The Referees discuss and investigate the case in a careful and confidential
manner. If necessary, the sick dentist will be visited by both referees who will
discuss the problem, offer help and, with the dentists agreement, make suitable
arrangements for the provision of treatment and such other help as is
necessary. The key role of the Regional Referee is to provide practical help and
advice in dealing with practice problems and support for the family - both very
important. The management of the practice may have deteriorated and the
dentist may have to be absent from the practice and from home while receiving
treatment.
If you know of a dentist who might be helped by the Dentists Health Support
Programme, call the following confidential number, which is also widely
advertised in the dental press. Names and addresses of Regional Referees
may also be available from GDPC representatives and LDC Secretaries.
Tel: 01327 262 823
61
62
BDA
Benevolent
Fund