WELSH HEALTH CIRCULAR

Transcription

1 WELSH HEALTH CIRCULAR WHC (2005) 086 Parc Cathays Caerdydd CF10 3NQ Cathays Park Cardiff CF10 3NQ Issue Date: December 14th 2005 Status: Action Title: Guidance for local Health Boards on Local Procedures for General Dental Practitioners and Dental Care Professionals whose performance gives rise to concern For Action by: see attached list Chief Executives, Local Health Boards Action required See paragraph(s) : 3, Page 3 For Information to: see attached list Local Health Boards-Medical Directors, Business Service Centres Sender: Mr John Sweeney Director of Community, Primary Care & Health Services Policy Directorate, Health & Social care Dept. National Assembly contact(s) : Dr Hugh Bennett, Deputy Chief Dental Officer Enclosure(s): None Tel: GTN: 1208 Llinell union/direct line: Minicom:

2 DISTRIBUTION LIST For Information to: Local Health Boards Medical Directors, Business Services Centres Chief Executives NHS Trusts Contractor Services Director Chief Officer Secretary Regional Head of Health Welsh Secretary Secretary Secretary to the Welsh Board Secretary to the Welsh Board Chief Officer Secretary for Wales Senior Dietician Deputy Secretary Secretary Senior Industrial Relations Officer Regional Officer Regional Organiser Regional Officer Industrial Relations Officer Officer for Wales Research Assistant Secretary Chief Executive Secretary Information Officer Dean of Faculty Chief Executive Chief Pharmaceutical Advisor Welsh Central Pharmaceutical Committee Welsh Executive Chief Officers Mr P Gray Chief Executive Undergraduate Dental Dean Director Chairman, Secretary Director NHS Confederation in Wales Association of Welsh Community Health Councils Welsh Local Government Association UNISON British Medical Association Wales TUC Royal College of Midwives Royal College of Nursing Amalgamated Electrical and Engineering Union British Dental Association British Dietetic Association Association of Optometrists British College of Optometrists British Orthoptic Society Chartered Society of Physiotherapists Electrical & Engineering Staff Association General Municipal Boilermakers Manufacturing, Science, Finance Society of Chiropodists & Podiatrists Society of Radiographers Transport & General Workers Union Union of Construction Allied Trades & Technicians NHS Staff College, Wales The Institute of Health Services Management (Welsh Division) Wales Council for Voluntary Action University of Wales Bangor Commission for Racial Equality Clinical Effectiveness Support Unit, Llandough Guild of Health Care Pharmacists PSNC Royal Pharmaceutical Society Community Health Councils NAO Dental Practice Board UWCM Department Postgraduate Dental EDUCATION Welsh GDPC Wales BDA NCAS Wales 2

3 Summary 1. Professional standards and performance sit at the heart of the NHS. It is essential that where valid concerns arise there are in place the effective means to investigate and act upon, where appropriate, the findings from such investigations. It is important that there is a consistency in the processes and procedures applied by all Local Health Boards. 2. The attached guidance for LHBs provides a framework for taking forward investigations of concerns in a professional manner that is both sensitive to the need to protect patients and fair and supportive to the individual general dental practitioner or dental care professional. Action 3. To note and ensure investigations of concerns about general dental practitioners and dental care professionals are carried out in accordance with the principles and procedures set out. Yours sincerely John Sweeney Director of Community, Primary Care & Health Services Policy Directorate Health & Social Care Department 3

4 INTRODUCTION Professional standards and performance sit at the heart of the NHS. It is essential that where valid concerns arise there exist the effective means to investigate and, where appropriate, act upon the findings of such investigations. The Welsh Assembly Government is seeking equity across Wales in the processes LHBs use to address the problem of general dental practitioners (GDPs) and dental care professionals (DCPs) whose performance gives rise to concern. Local Health Boards are encouraged wherever possible to seek local resolution of poor performance issues. Local procedures have to be sensitive to the over-riding need to protect patients and yet be fair and supportive to individual dentists and DCPs. We would also encourage LHBs, especially those with a very small GDP population, to consider their capacity and the opportunity for reciprocal arrangements with each other. Numerous ways exist in which concerns about a practitioner's performance can be identified. It is important that all stakeholders note that in many cases appropriate remedial and supportive action if taken quickly, can resolve these issues before problems become serious or patients are put at risk. Expressions of concern about a conduct or capability concern can come to light in a wide variety of ways, for example: Expressions of concern expressed by other NHS professionals, health care managers, vocational trainees and non-clinical staff Serious incidents or patterns of problems identified from incidents Serious complaints or patterns of problems identified from complaints Review of performance against personal development plans, annual appraisal, revalidation Monitoring of data on performance and quality of care Clinical governance, clinical audit and other quality improvement activities Information from regulatory bodies Information from the Dental Practice Board Counter Fraud Services Information from the police or coroner Court judgements Unfounded and malicious allegations can cause lasting damage to a practitioners reputation, career prospects and have an adverse effect on patient care. Therefore all allegations, including those made by relatives of patients, or concerns raised by colleagues, must be properly investigated to verify the facts so that the allegations can be shown to be true or false. Possible causes of performance giving rise to concern by GDPs and DCPs: Professional isolation Lack of continuing professional education Physical health problems Mental health problems Drug & alcohol problems Stress-related problems Low morale Complaints Poor practice infrastructure Workload problems Interpersonal relationship problems Tragic and upsetting professional experiences Unexplained idiosyncratic behaviour 4

5 Defining under-performance Three major themes arise when attempting a definition of under-performance:- Performance that places patients 'at risk' i.e. safety of clinical practice. Performance that fails to meet required standards Performance that departs from what is considered normal practice It is important to note that: Under-performance relates not only to clinical care but also to organisational and managerial skills in the delivery of health care. Under-performance covers knowledge, skills and attitudes. Under-performance is often a pattern of performance, in a range of areas, over a period of time. Dentists or DCPs may under-perform but the team or whole practice may also be dysfunctional. Under-performance can be viewed under the four elements of the commissioning accountability framework, namely: Clinical and professional Patients and the wider public Management Finance Consensus opinion would suggest that the most important criterion to apply is that of 'when patients are placed at serious risk of harm by any aspect of a dental service'. THE PURPOSE OF LOCAL PROCEDURES Local procedures are designed to: Protect the safety and well being of patients Respond to expressions of concern about practitioner performance (at an early stage whenever possible) Provide a structured framework for investigation of concerns Ensure any investigation is open, transparent and fair to all parties Provide an accurate assessment and report upon which to base decisions and appropriate action Offer a low-key approach to an expression of concern which is not high risk Allow an early investigation of minor problems to ensure that the practitioner can return to work as quickly as possible if the expression of concern is not substantiated Focus on good practice LHBs are responsible for investigating concerns expressed to them about any practitioner either listed with them or working within their area. At all stages of the process LHBs retain responsibility for the investigation. LHBs also carry the responsibility to determine, within the contractual and professional regulatory framework, what action to take in light of the findings of an investigation. The National Patient Safety Agency - National Clinical Assessment Service (NPSA-NCAS) in Wales is available at all stages of the process to provide advice to the LHB on any aspect of applying local procedures and the investigative process. Referral for advice and support is available to LHBs and practitioners irrespective of whether an NPSA-NCAS assessment is the potential outcome to the individual case. The NPSA-NCAS service, within Wales, will provide a source of consistent, independent and expert advice. Each case will present a unique set of concerns and require a tailored approach. The Dental Reference Service have a team of dental officers who can advise LHBs and the National Public Health Service for Wales Dental Team has a group of primary care dental practice advisers who with their local 5

6 focus can also provide valuable support to LHBs. The Local Dental Committee and the Department of Postgraduate Dental Education may also have roles to play. In Annex 1 we provide background information on the various bodies and organisations that may have roles to play in assisting LHB processes for assessing and dealing with poor performance issues. Also please note in Annex 2 the General Dental Council press release, GDC calls for views on fitness to practise guidance,dated 11 November 2005 GUIDING PRINCIPLES The procedure must be fair and workable. Any system developed should be in partnership between the local profession represented by the Local Dental Committee (LDC) and the LHB. The system must be accepted by the profession locally. There should be recommended time-bars for the procedure. The closing down procedure should include the responsibility to act on the recommendations made before any further action is taken. It should be seen as good practice that the investigation / procedure should be completed within 3 months. All reasonable steps should be taken to avoid double jeopardy which may occur if an LHB invokes the local procedure even when it has decided to refer the matter on to the NPSA-NCAS or General Dental Council (GDC). It must be open for self-referral, aim to be supportive and must guard against prejudice LOCAL PROCEDURES Where an expression of concern is received from any source the following procedure should be followed. Stage 1 An expression of concern from any source will need to be validated by the LHB. The first task of the Medical/Clinical Director is to identify the nature of the concern and to assess the seriousness of the issue on the information available. The NPSA-NCAS can provide a sounding board for the Medical/Clinical Director's first thoughts and provide advice on how to proceed. Where there are expressions of concern about a dentist or DCP in vocational training, the Director of Postgraduate Dental Education should be involved as soon as possible. The Medical/Clinical Director must decide whether the expression of concern warrants an informal approach or whether a formal investigation is needed because it is decided the concern is not of a serious nature and can be resolved simply through informal action. The decision and rationale over which approach to adopt may be discussed with the NPSA-NCAS before the case is closed. This can be helpful as occasionally concerns can re-emerge or practitioners may move location. It is important in this initial stage of validation that the expression of concern is dealt with sensitively and in confidence. The dentist or DCP should not be notified at this stage. Stage 2 Investigation to establish the facts. The Medical Director on behalf of the LHB will convene an investigating team to investigate the facts of the case and identify a team leader. The size and composition of the team will depend upon the circumstances and the 6

7 nature of the individual case. It is advisable that the team should contain at least one member with training and experience of using up to date tools for investigating clinical incidents such as the National Patient Safety Agencies' root cause analysis training and incident decision tree. The LHB may also wish to consider using an officer from the Dental Reference Service as part of the investigating team, particularly when independent dental advice is required. Advice is available to both the LHB and investigating team from the NPSA-NCAS in Wales at any time. The aim of the investigating team is to ascertain quickly what has happened and the reasons; to determine whether there is a continuing risk; to decide whether immediate action is needed to remove the source of the risk and to recommend action to tackle any underlying problem. The investigating team will compile a factual report and make recommendations for consideration by the LHB. The practitioner concerned must be informed in writing by the LHB as soon as it has been decided that an investigation is to be undertaken. They should be notified of the name of the investigating team lead and made aware of the specific concern or complaint that have been raised. The LHB must not notify the LDC without the consent of the practitioner, except in cases where public interest concerns override confidentiality. The Postgraduate Deanery may also need to be informed with regard to the appraisal process for the practitioner. At any stage of this process - or subsequent disciplinary action - the practitioner may be accompanied in any interview or hearing by a companion. Without prejudice to the procedure set out in Schedule 2 to the Employment Act 2002, the companion may be an official or lay representative of the British Dental Association or defence organisation; a representative of the LDC, or a friend, partner or spouse. The companion may be legally qualified but he or she will not be acting in a legal capacity. The investigating team lead has wide discretion on how the investigation is carried out but in all cases the purpose of the investigation is to ascertain the facts in an unbiased manner. Investigations are not intended to secure evidence against the practitioner. Information gathered in the course of an investigation may clearly exonerate the practitioner or provide a sound basis for effective resolution of the matter. If, during the course of the investigation, it transpires that the case involves more complex clinical issues than first anticipated, the investigating team lead should consider whether if not already involved an officer from the Dental Reference Service should be invited to join the investing team to provide independent dental advice. It is a matter for the LHB in discussion with the members to agree their role and responsibilities within the investigation process. Independent dental advice at the outset of any potentially difficult cases should help the LHB in handling the local procedure in a proper manner. LHBs must not use their dental board members for this purpose. Under certain circumstances it may be necessary for an LHB to act rapidly, and generally these cases are of a more complex nature, involving serious concerns over patient safety. The NPSA-NCAS in Wales and Dental Reference Service will provide a rapid response advice service under these circumstances (within 24 hours). The investigating team lead: must ensure that safeguards are in place throughout the investigation so that breaches of confidentiality are avoided as far as possible. It is the responsibility of the team lead to judge what information needs to be gathered and how - within the boundaries of the law that information should be gathered. must ensure that there are sufficient written statements collected to establish a case prior to a decision to convene a disciplinary panel, and on aspects of the case not covered by a written statement, ensure that oral evidence is given sufficient weight in the investigation report. must ensure that a written record is kept of the investigation, the conclusions reached and recommendations made. 7

8 Stage 3 The Medical Director on receipt of the investigating team s report must convene a reference panel to consider the outcome of the fact finding investigation and the report recommendations. Members of the investigating team should not form part of this panel but the team leader may be called to answer questions on the report. The LHB in considering the report and recommendations has a wide range of actions it may consider taking, depending on the circumstances of the case. However, in broad terms these will involve either, or in some cases both, taking steps in accordance with provisions in the practitioner s services contract or professional regulatory pathways. LHBs may under appropriate circumstances decide upon one or more of the following courses of action: no action is required where the investigation concludes that there is no evidence to support the concern or allegation; in cases where the investigation highlights educational and training issues, of such degree that they are insufficient to render referral to the NPSA-NCAS necessary, discussion with the Department of Postgraduate Dental Education on a remedial programme linked to subsequent appraisal; referral to the NPSA-NCAS, where there are concerns about the practitioner's performance of a degree that might require formal assessment; referral to the GDC where there are serious concerns that have or are likely to put patients at risk; referral to the police where there is evidence of possible criminal activity restrictions on practice or exclusion from work should be considered suspension from, conditional inclusion or removal from the LHB Performer List. This list is not exhaustive but any course of action that the LHB decides upon must be consistent with the terms of the practitioner s contract and professional regulation. The LHB must consult with the NPSA-NCAS in Wales if it is considering suspension, conditional inclusion or removal of the contractor from its Dental / Performer List. It is also recommended the LHB liaise with BSC Contractor Services who currently maintain General Dental Services Contractor Lists and who will probably, post April 2006, maintain the Performer List on behalf of LHBs

9 Annex 1 Local Dental Committees LDCs in Wales were set up in 1948 and became statutory bodies under the NHS Act LHBs should consult with LDCs on matters of local dental interest. LDCs will also make nominations to or may be consulted about membership of certain committees. LDCs represent dentists holding a NHS list number of the local health board. They can represent PDS dentists, assistants and deputies providing that the dentist concerned has notified the LHB that he wishes to be represented by the LDC (and has not notified them that s/he wishes to cease to be so represented). The National Clinical Assessment Service The National Clinical Assessment Service (NCAS), previously the National Clinical Assessment Authority, is a division of the National Patient Safety Agency. The Service was set up as one of the central elements of the NHS modernisation plan to ensure the high quality of healthcare and safer practitioners. NCAS provides its services in Wales under a Service Level Agreement with the Welsh Assembly Government. In Wales activities will be administrated in the NCAS Wales Office located in Sophia House, 28 Cathedral Road, Cardiff. As one of the central elements of the NHS's work on quality, NCAS aims to provide a support service to local health boards and trusts who are faced with concerns over the performance of an individual dentist. NCAS. The Dental Practice Board The DPB is accountable to the Secretary of State for Health and the National Assembly for Wales and is a centrally financed service. Principal functions covering England and Wales are: approval of payment applications; calculating and transferring payments; preventing and detecting fraud and abuse; providing dental health information. The Dental Practice Board (DPB) has a legal duty to ensure that any dental treatment is not only necessary but carried out to satisfactory standards. To achieve this, the DPB examine over 80,000 randomly selected patients annually. The Dental Reference Service (DRS), a team of experienced dentists, helps to monitor the quality of dental health provision. Working together, the work by dentists for NHS patients sampled, thus helping to maintaining high quality dentistry. It is anticipated that, from April 06, the DRS resource in Wales would have a named clinical manager to act as liaison and support to each local Region, supporting the Regional organisational structure of NHS Wales. Department of Dental Postgraduate Education Cardiff The Department is part of the University of Cardiff and provides a wide programme of educational and training initiatives and has an important roll to play in supporting LHBs and Trusts in addressing the problems of dentists and DCPs whose performance gives rise to concern. 9

10 If problems are identified in relation to poor performance then the dentist might require additional supervision or training. The Director of Postgraduate Dental will be expected to take the lead in educational issues and in arranging and delivering the necessary training. National Public Health Service for Wales The All Wales Dental Public Health Team (AWDPHT) brings together, Consultants, Specialists in Dental Public Health and Primary Care Dental Practice Advisers. Primary Care Dental Practice Advisers Part of the role of Advisers is to provide advice and support to: Local Health Boards on General Dental Practice issues. The Business Service Centre on dental practice matters. The Office of the Chief Medical Officer and Regional Offices of the Welsh Assembly Government. General Dental Practitioners, including mentoring support. Advisors are also involved in networking with a range of individuals, NHS agencies and committees at local and national levels. General Dental Council The GDC is the organisation which regulates dental professionals in the United Kingdom. All dentists, dental hygienists and dental therapists must be registered with it to work in the UK. Currently over 37,000 dental professionals are registered to practise. The GDC is delivering a modernisation programme to extend their powers to cover all members of the dental team, and make them a more efficient and effective regulator. These reforms will strengthen their role in protecting patients and promoting good oral health and high standards of dentistry. Standards for Dental Professionals which was published on 1 June 2005 as the Council's ethical guidance for dentists, dental hygienists and dental therapists. It works to protect patients and promote confidence in dental professionals by: registering qualified professionals, setting high standards of dental practice and behaviour, quality-assuring dental education, making sure dental professionals keep up to date, and helping if you want to make a complaint about a dental professional. The Council - has 29 members - 10 members of the public and 19 dental professionals (15 dentists and 4 professionals complementary to dentistry) elected by dental professionals. Currently the Council is only able to consider complaints about dentists whose health or professional conduct has been called into question. However, a new area where the Council considers it important to have additional new powers to act in the public interest, is when a dentist's performance appears to fall below an agreed acceptable standard. It may be that such cases are triggered by a concern about several relatively minor incidents which individually would not amount to serious professional misconduct, but which might still be of concern when considered as a whole. These new arrangements aimed at preventing, recognising and dealing with poor performance in dentistry will enable the Council to ensure patient safety while offering registrants the remedial help they need. For more 10

11 information on the Council's proposed new poor performance procedures contact The GDC should be viewed as the final destination for cases of poor performance, conduct and health, which have not been resolved by any other route, or which may have a criminal aspect, The GDC is willing to give early advice to LHBs or NHS Trusts whenever formal referral to the GDC is being considered. Local Practitioner Advice and Support Schemes The GDC has issued a guide, available on the GDC website, on Local Practitioner Advice and Support Schemes. These are locally-owned, voluntary schemes, organised and run by clinicians, which are designed to detect and address problems of poor professional performance in dentists. They give dentists support and advice, and play an important role in patient protection by helping to resolve performance issues at an early stage - before they become serious. The GDC's guidance for local Practitioner Advice and Support Schemes aims to support existing schemes and offers advice to anyone who wants to set up a new scheme in their area. LHBs may wish to discuss Local Practitioner Advice and Support Schemes with the Local Dental Committee or other groupings of dentists. 11

12 Annex 2 General Dental Council press release 11 November 2005 GDC calls for views on fitness to practise guidance The General Dental Council (GDC) is developing new guidance to provide a framework for fitness to practise decision-making, and is calling for your views. Next year, the GDC will strengthen its arrangements for dealing with problems of behaviour, practice and poor health in dental professionals, and introduce much-needed new procedures to tackle problems of professional competence. The GDC expects to implement these changes in mid To support this new fitness to practise system, the GDC is publishing a series of guidance documents. The guidance aims to ensure consistency and clarity in decision-making, and should also help the public and professionals understand why and how decisions about dental professionals fitness to practise have been made. The GDC will be asking for your input on the draft guidance documents over the next six months. The first consultation is scheduled to take place during December and January and will cover: guidance to the new Investigating Committee (the criteria for deciding which cases should be referred for full hearing before a practice committee; when to close cases at the Investigating Committee stage, and when to issue advice and warnings instead of ordering a full hearing), and Interim Suspensions and Conditions guidance (the use of interim orders pending a full practice committee hearing). The second consultation is planned for March to April 2006 and will cover: case handling (the initial handling of complaints and information, including decisions about which matters should be closed without investigation; which should be considered by the Investigating Committee and which should be referred elsewhere), pre-hearing review (the use of procedural orders in the proposed new pre-hearing stage), and guidance to Practice Committees (guidance to the Health Committee and the Professional Performance Committee about the use of their powers). GDC President, Hew Mathewson, said: The guidance documents are a key element of the new fitness to practise system, guiding decisionmakers on the principles to apply when considering cases and giving the public and dental professionals insight into why and how decisions are made. We are keen to get others involved in the development of the guidance. Please keep an eye on our website for details of the consultations as they come up and share your views, and any concerns, with us. 12