These cases are based on actual calls made to MDDUS advisers and are published here to highlight common challenges in dental practice. Details have been changed to maintain confidentiality.
Staff pay equality
Q. I’m a practice manager and have been discussing with the partners their decision to offer staff a four per cent pay increase this year. It is recognised that currently we have marked inequality in pay across practice staff in similar or comparable roles. We would like to use this pay rise to help remedy this. Can we give a higher uplift to lower paid staff?
Most standard contracts of employment state that salaries will be reviewed annually but this does not automatically translate into a pay rise. Should the practice decide to offer a pay increase it would normally be at the partners’ discretion how much that rise would be and whether provided to all employees equally or based, for example, on other variables such as individual or team performance throughout the year. A greater percentage could be offered to staff on lower salaries to reduce pay inequality. However, it is important to ensure that you are able to justify your decisions if challenged and exercise caution that you do not disadvantage certain staff (e.g. part time workers).
Implant training and indemnity
Q. I am a dental associate and would like to broaden my clinical expertise by providing implants. Can MDDUS recommend a suitable training course?
MDDUS does not recommend particular courses or suites of learning materials. However, it would be reasonable to expect that such a course should run for an extended period of time (usually one year) and integrate both theoretical and practical learning in relation to providing implants, including patient assessment, planning, placement, superstructure placement, review and maintenance. All courses must comply with GDC learning outcomes. The benefit of an extended learning programme is that it allows delegates to engage with one another and fully embrace the concept of continuing professional development to keep up to date in skills/competence in relation to all aspects of implant placement. Various types of implant courses are advertised in dental journals and MDDUS would encourage careful reflection on the content before choosing the one most relevant to your learning needs. We would encourage you to speak to other colleagues who may have undertaken such courses. You will require indemnity for the practical component of the course, which can be provided with an indemnity upgrade for the duration of the course. This would be for the practice element of the course only and not for any implant work done at your dental surgery, which would require a further review of your indemnity requirements. You can phone MDDUS for more details.
Patient disengaged with treatment
Q. We are an orthodontic practice and a patient recently started Invisalign treatment. She underwent the first stage of treatment and had her radiograph and scan but at her last appointment refused to have the aligners fitted. The patient paid in full for the treatment but we have been unable to make contact either by email or phone. What should we do?
Ensure you have a clear recorded chronology of attempts made to engage with the patient. This should include a letter sent by recorded delivery setting out options going forward, which would include either proceeding with treatment or providing a refund for uncompleted treatment. This will enable tracking of the document by the postal service and proof of delivery – or allow you to update your database if the patient is no longer at the listed address. In regard to the funds for uncompleted treatment, these should be held in reserve securely within the practice account.
Changes to the dental records of a transgender patient
Q. We are a small practice in the south of England and have a transgender patient. Can you provide advice on managing their NHS records?
A patient changing gender should be provided with a new NHS number from Primary Care Support England (PCSE) and will need to be re-registered as a new patient. PCSE will return the patient’s old notes to be incorporated into their new number. See guidance on the PCSE website (note that guidance will vary in Scotland, Wales and NI). For patients who have a Gender Recognition Certificate, it is unlawful (under the Gender Recognition Act 2004) to disclose their previous gender without their consent and it is important that steps are taken to ensure personal data is protected. Information related to their previous identity (name, pronouns, etc) should be redacted from the notes, and any clinical information which is gender-specific should only be retained (e.g. for safety and/or continuity of care) with the patient’s consent and after discussion explaining the importance of maintaining full clinical records and the risks of not doing so. See further information from MDDUS.
Q. I recently experienced racist abuse from a patient dissatisfied with treatment. This was witnessed by a dental nurse. The patient has now made another appointment with me by name for further dental care but I no longer wish to offer her treatment. The practice manager has said I do not have the right to decline. Is this correct?
Dental professionals are obligated to treat patients in a dignified and respectful manner without discrimination, and it is therefore expected that patients should treat dental professionals with equal dignity and respect. Your practice should have a policy stating that physical and verbal aggression from patients toward staff members will not be tolerated. The GDC’s Standards for the dental team (paragraph 1.7.8) recognise that, in rare circumstances, it may be necessary to end a professional relationship where there has been a breakdown in trust between dental professional and patient. If you feel that the earlier incident with this patient has led to such a breakdown of trust, you would be within your rights to decline continuing treatment. You should be satisfied that any such decision is fair and make a clear record of the decision-making process and justification. The practice should take steps to ensure that “arrangements are made promptly for the continuing care of the patient”, as per GDC Standards (paragraph 1.7.8). This might be with another dentist within the practice or at a different dental surgery. The practice owner can seek advice from their own indemnifier and should write to the patient and inform her of the decision and the reasons for it.
Retention of study models
Q. How long are we legally required to retain orthodontic study models and does the retention period start from when you de-bond the appliance?
There is both a procedural and legal dimension to the retention of dental records, including models. The NHS Terms of Service sets out governance requirements in relation to the retention of NHS treatment records. These require that treatment records, radiographs, photographs and study models are retained for a period of two years after completion of any course of treatment, or care under a continuing care capitation arrangement, treatment on referral or occasional treatment. However, there are broader dento-legal considerations that apply to retention of records more generally, both NHS and private. This is of great importance when dealing with potential complaints/claims, GDC investigations and in regard to provisions of the Consumer Protection Act 1987 (as suppliers and users of products). Original pre-treatment and post-treatment orthodontic models should be retained for a minimum period of 10 years, or for a child patient up to the age of 25 years, or whichever is the longer. The retention period starts when the patient last attends for orthodontic care and not when the appliance is de-bonded. Retention of multiple study models may be inconvenient and some practices have begun using electronic scanning, which courts have accepted if the original document or model is not available.
GDC disclosure request
Q. I am a practice owner and have received a letter from the GDC requesting a copy of a patient’s records. This is in regard to an investigation of a former associate at the practice. Do I need the patient’s consent before complying with this request?
You should contact the patient advising them that you have received a letter from the GDC requesting disclosure of their records and that you wish to obtain their consent. Should the patient decline to provide consent then the GDC can pursue a disclosure request with powers invested in them under Section 33b of the Dentist’s Act. Should the patient consent to disclosure, you should ensure the relevant (only) information is sent by secure means (i.e. recorded/special delivery) to the GDC caseworker, with the case reference clearly visible. Electronic records can be sent via the secure GDC file-sharing facility, and a table listing the documents, images, etc supplied should also be provided. Members can contact MDDUS for advice in regard to any correspondence with the GDC over conduct matters.
Journalist asking for comment
Q. A journalist has contacted the practice asking for comment on criticism made by a patient on social media regarding how our NHS list is managed. We intend to reply that GDPR concerns would preclude discussing complaints from a particular patient but that we can explain our policy and procedures for NHS treatment. Would this be a reasonable response?
Our usual advice to members is to be very cautious when responding to press requests for comment because of the professional duty of patient confidentiality. Any response beyond a brief generic reply could imply that the patient is registered at the practice, which may be seen as a confidentiality breach and could damage patient trust. Therefore it would be preferable to say that you cannot comment due to your duty of confidentiality. The GDC has specific guidance on using social media and reminds dentists that: “you must maintain and protect patients’ information by not publishing any information which could identify them on social media without their explicit consent”. It is also important to consider that disputes with patients conducted in public may prolong or intensify conflict and may lead to reputational damage. Consider contacting the patient directly and apologising for any distress that has been caused and invite them to raise their concerns via your complaints procedure.