FINAL PENDLEBURY LECTURE JUNE 2014
Thank you very much for inviting me to give this lecture.
I – obviously – didn’t know Malcolm Pendlebury. Since I had no connection to
dentistry before taking on the chairmanship of the GDC, and have had no
professional reason to spend much time in the East Midlands, our paths never
However, I have read the obituary of him that the British Dental Journal printed
in April 2005. It paints a picture of a man immersed in dentistry – not just
treating patients, although clearly he did a lot of that in general practice and as a
specialist at Queen’s in Nottingham, but also a leader in developing education
and vocational training, in setting standards and quality assurance systems and
generally spreading the message that constant improvement is a key element of
professionalism. The obituary concluded: “….he sought to raise the status of
general dental practitioners, provide them with standards they could aspire to
and thereby to raise the quality of patient care.”
The challenges that Malcolm Pendlebury identified and tried to tackle have
become more pressing in the ten years since his death. How to define service
quality and clinical outcome, how to regulate the providers of services and who
should do so, how to meet the legitimate expectation of patients that they will
be treated with respect and not be damaged by the care they receive – all these
questions and more are now at the forefront of the debate about healthcare.
As a relative newcomer to both the dental sector and professional regulation,
four things seem clear to me:
1. The exposure of failure and bad performance will not reduce, it will
increase. And the volume and intensity of patients’ complaints about
quality and safety is also unlikely to reduce very much, if at all, although
it may fluctuate;
2. The GDC, like all professional regulators, will continue to be under
strong and growing pressure to tackle more fitness to practise cases, faster
and to come down harder on unsafe or poor quality care, or unacceptable
3. A concerted effort is required by the sector itself and by its various
regulators and commissioners to prevent fitness to practise cases arising
and to give patients better information about the performance of
individual practitioners and better and faster redress mechanisms. A
fitness to practise case shouldn’t be the only remedy on offer, or even the
most common one.
4. Service users will become increasingly consumerist in their outlook –
many already are - and so the pressure will not lessen for services to be
designed around the needs of patients and for care to be delivered in ways
that patients are happy with. If anything, it will increase.
WHY WILL THE EXPOSURE OF FAILURE GROW?
Why do I say that the exposure of failure will continue to grow? The main
reason is a change in attitude on the part of politicians and the public.
Since the creation of the NHS successive governments have tried to find ways
to improve efficiency and productivity across the NHS. Beveridge’s assumption
that the NHS would be increasingly affordable as a healthier population
required less care quickly proved to be completely false. The demand for all
forms of healthcare has grown well beyond anything that might have been
expected and shows no sign of slackening. Different forms of central planning
and direction have made no real impact.
Most recently the Blair and Cameron reforms to the organisation and
functioning of the NHS in England have been designed to bring market
pressures to bear by:
giving patients increasingly wide choice of where and how they are
setting performance targets for services
developing funding mechanisms that (supposedly) reward increased
activity – attracting more patients – and penalise failure to attract patients
tougher regulation and inspection
greater transparency about service quality and clinical outcome.
The main focus has been on hospitals, especially acute hospitals. Dentistry has
not been centre stage. Indeed dentistry already operates in a market. Patients
are free to choose their dentist. Roughly half of the dental sector’s income
comes from private payments, not general taxation. To a reasonably large extent
the success or failure of a dental practice depends on it serving its patients well.
I know that not everyone likes or accepts the proposition that dental service
providers compete in a market place, but that is the reality and increasingly it is
the viewpoint of patients.
However, dentistry has not been unaffected by the development of a quasi-
market in the wider healthcare system and will not be in the future. Why?
Markets produce failures as well as successes. Indeed, for a market to function
properly customers have to be aware of whether a provider is good or bad. So, it
was, and remains, a central objective of policy that the customers for different
healthcare services should be able to make rational choices, based on reliable
information about the quality of performance of different providers. In other
words, for the policy to work Ministers have had to acknowledge - indeed,
publicise - failings in clinical and service quality – some of which were
highlighted by the targets set by government.
Simon Stevens, in his recent speech to the NHS Confederation’s annual
conference highlighted the importance of publishing reliable and easily-
accessible data on clinical performance. Not for the first time most effort is
focussed on acute hospital care. But, in time this will become routine in every
part of the English healthcare system, I believe. Already there are several social
media sites where patients offer their own, often highly-subjective, assessment
of the quality of care they have received. So, it would be foolish to think that the
information revolution will pass by dentistry.
Even today the exposure of failure has had an impact on dentistry as well as on
teaching hospitals and DGHs. Today media stories about healthcare, including
dentistry, are as likely to be about failings as successes. Politicians and the
media are prepared to criticise the healthcare system in a way that would have
been unthinkable a decade ago.
This pressure to expose failure in all its forms will not reduce in the future.
Indeed, the financial pressures that lie ahead for the healthcare sector may well
increase the risk of bad practice and poor treatment.
The case for protecting the funding of the NHS is increasingly questioned. As
the economy grows, so too will the funding of the healthcare
system……probably. However, we won’t see repeated the scale of increase in
funding of the early part of this century.
If additional funding is forthcoming, acute hospitals are likely to continue to
absorb a growing proportion of the available money. There will also be new
priorities to accommodate. For example, ministers are increasingly emphasising
the need to support the funding of social care from the NHS budget, and to give
mental health a degree of protection.
Somewhere in the system funding will be squeezed. It seems unlikely that
dentistry will escape. But a squeeze on funding can create unforeseen incentives
to take risks – to cut corners in diagnosis or treatment, to use cheaper materials,
to spend less time per patient, to avoid investing in new equipment or in
maintaining premises, and so on. These are precisely the kinds of behaviour that
generate complaints to the GDC and other regulators about fitness to practise.
DEMAND FOR DENTISTRY IS GROWING…AND SO ARE
Public attitudes have also changed. The users of dental services are now much
more consumerist in their attitude. Dentists and dental care professionals now
have customers, not clients ………or, indeed, patients. Part of a consumerist
attitude is an expectation that services will be organised around my needs and
preferences, that quality will be good and the price fair. And if the service is
poor or the quality unacceptable, consumers are willing to complain and to seek
whatever form of redress seems appropriate to the circumstances of the case.
These consumer pressures are compounded by the increase in demand for dental
treatment, and in the volume of complaints. 1.4 million more people have been
seen by an NHS dentist since 2010. Not all of this is traditional oral healthcare
work. Demand for cosmetic treatments continues to rise - there has been a 50%
rise in cosmetic dentistry in the past 5 years
So, this increase in demand for services coupled with changing attitudes have
together generated an unforeseen level of complaints. There has been a 110%
increase in complaints to the GDC between 2010 and 2014. Well over half of
our budget is spent on fitness to practise.
And it’s not just the GDC that is getting more complaints about dentists and
dental care professionals.
It is extremely difficult to get a completely accurate picture of dental complaints
across the UK as it isn’t centrally recorded. But in 2012-13:-
NHS England received 7637 complaints about primary and secondary
The Dental Complaints Service dealt with 1876 cases
The CQC received 1043 complaints
The Ombudsman investigated 3770 NHS health complaints, some of
which would have included dentistry (but there’s no breakdown of the
figure to help us)
Add to these figures the 2972 complaints made direct to the GDC.
In 2013 there were just over 38500 dentists and 62500 dental care professionals
on the GDC’s register. So very crudely – and I stress that caveat - these very
rough figures could mean that 17 per cent of the profession were the subject of
some form of complaint. Even allowing for some overlap between the referrals
to different agencies, this is staggeringly high.
It also undermines somewhat the proposition that there is a high level of patient
satisfaction with dentistry.
Bear in mind that the GDC doesn’t aggressively market its disciplinary
role………we don’t behave like a claims management company! However, the
Francis report said regulators should raise their profile with patients and engage
in more pro-active regulation. The GDC can’t ignore that.
All of us – we and you and the other professional bodies - need to understand
better what is causing this apparently high and growing level of complaint, and
what can be done. Perhaps we should meet to pool intelligence and to identify
areas for research or further analysis.
THE GOVERNMENT WANTS BETTER AND FASTER
REGULATION…….THE GDC IS UNDER PRESSURE
My second theme tonight is the need to recognise that the regulators themselves
are not immune from scrutiny. We are under pressure.
A big part of the focus of the Francis inquiry into Mid-Staffs was on actual and
potential failings in the overall regulatory system – both professional and
system regulators. The Healthcare Commission (now CQC), Monitor, the
GMC, the NMC were all criticised to different extents.
And even before the Francis report was published and the Government started
to think about its response, it was becoming increasingly clear that, despite a
sophisticated system of commissioning and regulation, Mid-Staffs was not
unique in mistreating patients and delivering care of an unacceptably poor
standard. The Government realised with some shock that poor professional
performance was being unearthed in many parts of the healthcare system. This
was – and is - a bigger problem than just Mid-Staffs.
As a result the political and media focus was, and remains, as much on the
performance of the regulators as on the performance of clinicians.
So, the Government wants better – tougher and faster - regulation. The
following quote from the Government’s response to the Francis report in March
2013 illustrates this.
“……where standards are not met, the health and care system must be
quick to detect problems, take robust action and hold those who are
responsible, to account“
A regulator must be seen to act. Any delay or hesitation leads politicians to
question whether the public can have confidence in the regulator…… which, of
course tends to undermine public confidence!
But, there is, I think, confusion in the minds of politicians and the public – and
certainly the media - about whether good professional regulation is intended to
punish registrants for past failures, or to establish that registrants have changed
their behaviour or improved their skills – or are willing and able to do so under
supervision – so that they are fit to practice again either now or in the near
future. That’s an issue that needs further exploration.
So, this is the era of conspicuous regulation, when rapid and tough intervention
by a regulator, with maximum transparency and publicity, is the expected
response to any failure in the healthcare system. And, of course, there are many
occasions when that is a reasonable expectation.
THE IMPLICATIONS FOR THE REGULATION OF DENTAL
What does this mean for dental regulation?
The GDC has to respond. Our system of regulation has to be, and be seen to be:
focussed on protecting patients;
able to respond quickly, and fairly, to all kinds of allegation of bad
practice or bad behaviour on the part of professionals; and
capable of reaching sensible conclusions about increasingly complex
However, we operate in a complex regulatory environment, with different
organisations policing different, but sometimes overlapping, parts of the
healthcare system. For example, both CQC and the GDC regulate dentistry, and
the MHRA regulates medical devices and the HSE can have a role in policing
safety issues such as radiography. No doubt there are other bodies which might
have roles in specific types of case – fraud, for example.
So, the GDC needs to be clear about its role and responsibilities, although these
are nowhere defined very clearly so far as I can establish.
My current view is that the GDC’s responsibilities might be defined as:-
to protect patients from harm;
to enable patients to get effective redress when harm occurs;
to enable patients to secure high-quality care and effective treatment at
a fair cost;
to help the profession to be more responsive to patients and to offer
effective services efficiently; and
to meet current requirements for professional regulation (as defined by
the Government, the devolved administrations and the Professional
Standards Authority) and to help these bodies to develop regulatory
standards and regimes.
This isn’t very different to the obituarist’s summary of Malcolm Pendlebury’s
professional ambitions, although perhaps more prosaically expressed.
If this is indeed a correct formulation of the mission of the GDC, everything we
do should be determined by it, and we should do everything we reasonably can
to achieve these purposes. I want to spend a few minutes summarising our
current activities and future plans to discharge this remit.
However, we mustn’t lose sight of the fact that the GDC is only one of several
actors on this stage. Dental care, like most sectors of healthcare, is part of a
system in which different elements – policy makers, commissioners, regulators
and service providers – have distinct but complementary parts to play in the
organisation, delivery and oversight of good and improving care. The dental
professions, and, indeed, patients, have big roles to play and I want to say more
about this before I conclude.
Fitness to practise reforms
Returning for the moment to the GDC, undoubtedly the Council’s first priority
for 2014 is to strengthen our fitness to practise regime. And we have already
made a good start. While the decisions taken by the panels are judged by the
Professional Standards Authority to be generally sound, we know from the
audits undertaken by the Authority that our basic administration has been
sloppy – poor communication, inadequate record keeping, deadlines missed etc.
Part of the reason has been poor training and supervision of the staff. That is
Part of the reason has been excessive caseloads. By investing in new teams to
clear the growing backlog of cases, we have also managed to reduce caseloads
to an efficient level. Already the benefits are clear. We are also using our
technology better to manage processes – to ensure deadlines are met and
Each of these is a small thing in itself, but in total they will create - are creating
- better, more efficient processes that will enable us to offer a better service to
patients and to registrants. The recruitment of an expanded pool of IC panel
members and the creation of a much stronger support function for the panels
will also play a big part in improving our performance in this area.
One consequence of this scale of investment is that fees will rise, probably
substantially. And they need to keep pace with the increasing volume and cost
of fitness to practise cases, although the GDC is no more immune to pressures
on its costs than any other public body.
However, all that said, the legislative framework within which we currently
operate is badly in need of a complete overhaul. It’s disappointing that the
Government will not introduce in this session of Parliament the draft Bill
produced at its request by the Law Commission. A huge amount of time and
energy has gone into developing that draft legislation. I hope it hasn’t been
wasted. But I am clear that the bulk of the reforms it would have created will
not happen in my term of office in the GDC. We will lobby hard to rescue what
we can from it. Any help you can offer will be gratefully received!
However, fitness to practise should not be the main means of tackling under-
performance and patients’ dissatisfaction. In many cases a lengthy and complex
process dominated by lawyers, over which the patient can exert almost no
influence, is not what aggrieved patients want. They want an apology
(probably) and they want deficient dentistry put right, which in some cases
means funding to seek treatment from a different practitioner. This is what the
Dental Complaints Service offers, and it does so remarkably successfully. It’s
fast, it’s cheap and complaining patents and registrants are both very satisfied
with the results it achieves.
But, it’s available only to private patients.
My aspiration is to extend the work of the DCS to include patients funded by
the NHS. As well as giving a better service to patients who seek personal
redress and to registrjants whose professional work is generally acceptable in
quality but has failed in a specific incidence, making the simpler and faster and
cheaper processes operated by the DCS much more available ought to reduce
the current high level of expenditure on fitness to practise.
In addition to these internal process reforms the GDC is developing a strong
working relationship with the CQC. Information is being exchanged, areas of
risk are being identified and each regulator is gradually influencing the
approach of the other. I am confident that this process will continue, to the
benefit of both bodies. We aim to secure a similarly close relationship with
NHS England, particularly under Simon Steven’s inspiring leadership. Securing
close coordination of the specification and commissioning of services, system
regulation and professional regulation will be beneficial to both the dental
professions and also to the users of dental services. But, it’s work in progress.
Two other issues on our agenda deserve to be mentioned.
First, Continuing Professional Development. We attach importance to the
registrants we regulate keeping up with developments in their fields, adding to
their knowledge of their subject and related disciplines and learning new skills
and techniques. But, it feels to me intellectually unsatisfactory for the regulator
to focus on the volume of CPD undertaken by different dental professionals and
not to pay some attention to the quality of the CPD products on offer and the
effectiveness with which they are delivered. Can it really be left to individual
registrants to assess the quality and relevance of the wide range of CPD now on
offer? Shouldn’t the regulator, or the professional bodies, develop a better
means of identifying CPD products that will genuinely improve the quality of
dental care? I don’t pretend we have specific plans. But this feels to me an area
where not everything that should be done has been done.
Second, standards. As someone new to the field, I find the GDC’s standards
impressive – clear, pertinent, covering all the main issues, not over-prescriptive.
We know that a majority of registrants are aware of the standards, and that they
get referred to for guidance in dealing with specific issues that arise in practice.
However, our research suggests that knowledge and use of the standards is by
no means universal in the profession. That concerns me. It raises in my mind the
question whether the GDC should make a more explicit link between securing
registration – the right to practice dental care – and reliable evidence of
knowledge and use of the standards.
Our registration system puts a lot of effort into establishing the qualifications of
an applicant at the point of first registration, and rightly so. But, if we share
Malcolm Pendlebury’s stated aim of a high-status, high-standards profession,
shouldn’t we use the levers available to us to ensure that the standards we have
developed are properly understood by all registrants? It a thought I leave with
you tonight, but one I hope we might return to in the future.
A stronger focus on patients
A few moments ago when I was talking about the GDC’s responsibilities the
first thing I mentioned was protecting patients from harm. We need to develop a
better understanding of what those words mean in practice to patients. There is
little point in us pursuing programmes of action that patients think are irrelevant
to their needs and aspirations. So, in thinking about our future strategy, the
GDC’s starting point will be to develop a better understanding of the
perspective and priorities of patients.
The research we have done to date paints a confusing picture.
96% patients claim to be “satisfied” with their dental treatment. But they have
no clear idea of what might constitute quality of service or of treatment. And,
underneath the surface, there is evidence that the apparently high level of
patient satisfaction is wide but not deep.
So what drives patient satisfaction with their care and treatment?
Patients described a good dentist as being one who had excellent
communication skills, talked through the treatment that they are having, were
polite and treated them with respect. Trust that the patients’ interest is put first
is also key.
Qualitative research the GDC carried out in 2013 suggested that for many
patients their satisfaction derives more from assumptions they have made rather
than firm evidence.
Patients assume that regulation is more extensive, unified and patient-centred
than those of us involved may believe to be the case in practice. Patients are
often poorly informed about the role of the GDC, but expect a proactive
approach to regulation. They assume that we and other regulators actively
search for consistent signs of poor care or malpractice, and expect evidence of
problems to be proactively followed up without the need for a dis-satisfied
patient to lodge a formal complaint. In our focus groups patients emphasised
the importance of regular, unannounced OFSTED or mystery shopping-style
inspections, which should focus on all aspects of quality dental care. And they
were keen on star ratings being applied to dental practices.
Patients had specific views about the type of information that would support
them in making choices and acting as informed consumers. They want to
understand issues such as how good their treatment is and how safe their dental
Of course, not all patients had identical expectations and attitudes. There was a
continuum. At one end were patients characterised as having a traditional
outlook – they assumed that all dental services were of a similar quality and so
they tended to base their choice of provider on convenience; they were unlikely
to complain, except where they received very poor care.
At the other end were patients with a strong consumerist outlook who were
likely to be more active and demanding. They would compare dental treatment
and shop around. They were much more likely to complain and to provide
feedback and they were consistently the most likely to be positive about
increasing patient choice.
Many patients were in the middle of this continuum and exhibited attitudes and
behaviour drawn from both types, but would be likely to be more demanding
when circumstances changed (moving to a new area and choosing a new
We will continue to research the attitudes of patients. In addition we are
launching an online patients’ panel. The three main objectives of this are;
1. To provide evidence about public views and perceptions of topical or
current issues in dental regulation
2. To provide public and patient views on their experience of the quality
of dental services
3. To obtain public and patient feedback about regulatory policy
initiatives or communications being developed or recently undertaken by
I hope that this will broaden and deepen our understanding of the perspectives
of different types of patient, and guide us in developing strategies driven by
what patients need and want.
I also hope that we, and NHS England and the devolved administrations, and
perhaps the profession itself can develop sources of information that patients
can use to make well-based choices. One sure way to reduce the growth in
fitness to practise cases is for patients to be able to choose where and how they
are treated based on reliable and easily-understood information about issues
such as quality of service, appropriateness and effectiveness of clinical
treatment, likely cost. Enabling potential service users to avoid weak
practitioners before damage is done is surely a lot better - and cheaper - rather
than prosecuting a fitness to practise case after the event.
THE CONTRIBUTION OF THE PROFESSION
I’ve talked in some detail about what the GDC is doing and what we aspire to
do and achieve. And I’ve also talked a little about the role that patients can play
in incentivising registrants to deliver high-quality care and treatment, given easy
access to good and relevant information. What can the profession, and bodies
like the Faculty do both to improve standards and prevent the continued growth
in fitness to practise?
I don’t have a to-do list for you. That wouldn’t be inappropriate. But, taking as
a starting point the aspirations of Malcolm Pendlebury, as his obituary
summarised them, I think I can be expected to pose some questions for your
First, does the public, especially users of dental care services, understand what
you do to protect them and to promote better and safer care? Is there more that
you can do – in concert perhaps with us and others – to educate potential users
of dental care services about what level of quality and safety they are entitled to
expect? About what “good” and “excellent” mean?
Second, how can you help us prevent the growth in fitness to practise? How can
you help to get our standards understood and used by all registrants? If that
were achieved, if our standards were internalised and put fully into practice,
many complaints would be dealt with in the practice and not in a GDC hearings
Third, can we work together to understand better what patients want from dental
care and why they feel it is necessary to complain? Can we, and other bodies,
join forces to develop a common understanding of the reasons for different
categories of complaint and to understand how the need for complaints might be
Finally, CPD. How can you help to ensure that what is on offer is of high-
quality and genuinely improves the knowledge or skills of registrants? This
seems to me a key issue for the profession to tackle, with every encouragement
from the GDC.
Mr Chairman, once again my thanks for inviting me to give this address. If
nothing else I have found it extremely helpful as a means of getting my own
thoughts in some kind of order, although I would be the first to acknowledge
that I have much to learn. I hope, however, it has been of some interest to you
and your colleagues tonight. And I hope it has helped to illustrate that the
agenda that Malcolm Pendlebury pursued throughout his professional life
remains as relevant today as it was ten years ago.