General Dental Council (Professions Complementary to Dentistry) Regulations Order of Council 2006 (SI 2006/1440)
I welcome everybody to today's unusual meeting of the Health Committee, which is being held at a time when we do not normally have a meeting. I welcome committee members and members of the public in the public gallery.
Yes, I am substituting for Euan Robson.
I am advised that other members of Parliament will attend today's meeting, but they do not seem to be here at the moment—apart from Ken Macintosh, who is in the clerk's seat behind me.
The primary aim of the instrument is to enhance public safety by ensuring that anyone who undertakes clinical work with patients is fully trained and qualified to do so. As well as protecting the public, the instrument will open up the practice of dentistry and create new opportunities for a range of dental staff. I believe that the approach in the instrument has wide and warm support from the vast majority in Scotland's 4,000-strong dental care workforce and professions complementary to dentistry as well as, of course, from the many other such practitioners elsewhere in the United Kingdom. The instrument will apply to professions complementary to dentistry, including dental nurses, dental technicians, orthodontic therapists and clinical dental technicians. I understand that a number of their professional bodies and associations will present their views to the committee today.
Thank you. I invite Nanette Milne to ask the first question, after which I will seek expressions of interest from committee members and others present.
I thank the minister for his statement, which has clarified some of the relevant issues. I feel that, in principle, any proposal to register all those involved in dentistry would be a sound move.
In response to the first question, the intention is to design courses that will be available in Scotland. We are still at an early stage of the design process, but we expect the training to take about two years. Courses could be undertaken on a part-time basis, which would allow people to earn a living. However, we want to encourage people who intend to make dentures to practise legally as dental technicians instead of taking on clinical responsibilities for which they have not yet been trained. Once they have completed the course, they will be qualified to take on such responsibilities.
Do you know what proportion of practising denturists are not trained at all?
I find it difficult to respond to that question. Because the practice of clinical denturism by dental technicians is currently outwith the law, outwith the reach of the NHS and outwith any form of registration, it is hard to get a clear idea of the number involved. Our impression is that most denturists are qualified dental technicians; however, only a relatively small number have the Canadian clinical qualification.
Will people who have not been trained be eligible for those courses, or will they have to be assessed?
If someone has had no training at all, they will have to undertake some form of dental technician or clinical dental technician training. If they do not have the basic qualification in dental technology, it will take them more than the two years that I have suggested to complete both that course and a clinical course. However, as I have indicated, we believe that the majority of denturists have already qualified as dental technicians and the clinical course, if taken part time, could take two years to complete.
The minister said that the courses might be available early next year. Can the chief dental officer tell us just how soon the training courses can be made available?
Most courses in Scotland usually start around August or September. We are trying to ensure that some of the preliminaries, including assessment and other aspects of evaluating people's experience, take place before then. We will try to bring the courses forward as soon as possible. It is useful to remember that the majority of courses that are run in Scotland and throughout the United Kingdom normally start at the beginning of the academic year in August or September. I repeat, however, that we will do everything possible to bring the courses forward.
Some of the people we are talking about have been practising, albeit outwith the law and regulation, for some time. It is important for education providers to make some assessment of the validity of those people's experience for the purposes of training. When the chief dental officer talks about an assessment period prior to the formal beginning of training, that will be informed by those who are already in practice, so that some assessment can be made by the providers of whether people's experience and skills are such that they will not require the full two years to complete the course. We cannot judge the extent to which that will apply to people until those conversations have taken place.
It might be too soon to get a definitive answer to this but how, practically, would such assessments be made? Would they involve someone viewing the work of the people concerned in their practices? At present, those practices are illegal, and they would still be illegal after 31 July.
We would need to discuss those issues with those who are in practice and with representatives of the profession. The absolute first requirement must be to protect patient safety and to ensure that nothing is done by either the NHS or education providers that could be held to compromise that.
A meaningful discussion could be held—
A meaningful discussion could be held around how experience may be taken into account.
I very much welcome the opportunity to ensure registration and regulation in the dental professions, but we must ensure that the practical effect of any legislation that we pass is thought through very carefully. We are examining the instrument today to ensure that we are on the right track for bringing in those who are currently outside the profession and who are not operating legally. There is potential to bring in a pool of people who have a great deal of experience.
The process is not an exact science, for the reasons that I have explained. However, our estimate is that the majority are in the middle category: they have a dental technician qualification but do not have the Canadian qualification as clinical dental technicians. For that majority, the process will be as I described, which is that NHS Education for Scotland's representatives will have discussions with the GDC and education providers in colleges to seek to facilitate putting in place the courses next year to allow dental technicians to qualify as clinical dental technicians.
I preface my comments with the fact that we do not know who the people out there are or what experience they have, so we must be very careful. Some people have worked as dental technicians for many years. There are transitional arrangements under which they can become registered dental technicians with the GDC. If they registered, they could present that as part of the basis for their going on to the next course in clinical dental technology.
It is a two-year transitional arrangement under the instrument.
I am aware of that. I suppose I am just looking for a reassurance that for denturists who may have operated for a number of years but who do not necessarily have the qualification there will be options and possibilities on the table for them to discuss. I know that there is a difficult balance around the competence test and whether someone's competence can be assessed when they are regarded as having operated illegally. Nevertheless, there must be some kind of competence test to gauge where a course could start for people in that position. I am looking for a bit of reassurance that there will be something on the table for them.
It is a difficult balance, but those who are practising without qualifications must be taken into account. Clearly, we would seek to encourage that all concerned practise within the law—members would not expect a minister to say otherwise. What we would look to do for those people who are currently not qualified to make dentures is contained in the instrument, which will provide a two-year transition arrangement for those people to obtain a qualification to do basic dental technology. I ask Ray Watkins to confirm whether that is an accurate description.
Yes, it is. They can also get the equivalent through experience. Again, a partnership arrangement is required. The Executive alone cannot say yes or no to this type of arrangement. We need to work with education providers, NHS Education for Scotland and the GDC and pull all the groups together to work with the denturists and to try to get people round the table so that we can be as helpful as possible in progressing matters. That is why I am not loth to be inexact about the process, because we need all those people to get around the table and discuss the issues. The minister alone cannot just say that something will happen; all the people to whom I referred must be round the table in order for matters to be progressed.
I thank the deputy minister and his officials for their attendance for this part of the meeting. The minister will return shortly for the next stage of the process.
I am grateful for the opportunity to make a statement. I am a national health service general dental practitioner in Edinburgh. I am also one of the elected Scottish members of the General Dental Council and its president.
Thank you. I invite members' questions, which may be to any member of the panel. When questions are asked, I do not want every member of the panel to try to answer them—we would be here all day. If there is a specific point that you want to comment on that has not been addressed to you, you should raise your hand to let me know. I will do my best to work out who is who.
I address my questions to Tony Ward, from the Association for the Promotion of Denturism. We heard from the minister that it is difficult to assess how many practising denturists are qualified dental technicians. Does your association have any figures on that and on how many have no qualifications?
We have no exact figures. We tend to believe that the majority of denturists are trained as dental technicians. Many of them are trained in hospitals or in private practice. I would think that the majority are qualified dental technicians.
The figure that I have seen is that only six people have applied so far for the George Brown College course, which is based in Canada. The minister said clearly that the training was to be made available in Scotland. Have you any knowledge of the likely demand for that training and will you encourage your members to register an interest in doing it?
We will certainly encourage our members to register interest. We can guesstimate the figures from simple facts. As part of the Scottish Executive's "Modernising NHS Dental Services in Scotland" consultation in 2003, it emerged that one fifth of all Scots rely on dentures of some sort and that 18 per cent have no natural teeth at all. Of the over-65s, only 50 per cent are totally dentureless. The figures lead us to believe that there are approximately 500 denturists working in Scotland. Members must realise that, in more isolated areas, those people are not an alternative service to the dentist; rather, they are the service. We are concerned that, if the order is allowed to go through, it will in effect eliminate that service for up to three years, while people acquire a registrable qualification.
You have said that most of your members are trained technicians. For the small group who, it is alleged, do not have training, do you take comfort from the fact that people will, as was said earlier, be allowed two years to achieve a basic qualification in dental technology?
We certainly take comfort from that and from the point that many people will be able to register based simply on the fact that they have years of experience.
One basic point is that many members of your profession have been practising outwith the law for many years. Do you accept that, if the order goes through and the requirement for registration is introduced on 31 July, the situation will remain as it was because those who have been practising illegally will still do so, until such time as qualifications are demanded?
I could not possibly encourage my members to continue to practise illegally. If they did so, that would be a tragedy, because they would not be encouraged to take up further education, they would not be allowed to acquire indemnity insurance and they would not receive the many other advantages of being recognised and practising legally.
But nothing will change from the status quo.
No—nothing will really change.
My questions are in a similar vein. Progress appears to be being made, but it is important to seize the opportunity. How do Tony Ward and Chris Allen envisage the discussions with NHS Education for Scotland developing? There are several organisations to which denturists belong, so it is important that we bring those organisations together with NHS Education for Scotland and come up with the best training opportunities for the range of people who are involved. Are you willing, happy and able to do that?
We are working with an education provider, which I hope will provide an outreach course in Scotland. Once again, time is the problem—the time between now and the course becoming available is likely to be about 12 months. We hope that, in the interim, we can have pre-registration, to assure the GDC that denturists present no danger to the public. We also hope that denturists can, after they undertake the course, acquire full, rather than provisional, registration.
I presume that that possibility will have to be discussed with the GDC. After people have registered and started the course, they might be able to carry out certain procedures at various stages of that course—I know that that happens with other courses.
A lot more could be done under supervision in training than could otherwise be done. For example, I hope that practitioners do not need to go to Canada for the clinical aspects of the George Brown College qualification, which could be covered in this country under supervision. The top-up course for the George Brown College scheme came to the council in the first week of May and was approved in the third week of May; it will start in August. That is how quickly we are prepared to take on board such matters. From our point of view, there is no need for significant delays.
The truth is that nobody seems to know.
The Nuffield inquiry made a careful estimate in 1993. All the individuals involved will say that they have been doing the job for a long time, so most of them will have been around in 1993. At that time, the estimate for the UK was that there were fewer than 300 denturists.
Whatever the number, what is important is how we put in place the training that will ensure that such people can operate legally and on a registered basis.
It was said that only six George Brown College graduates have registered with the Royal College of Surgeons of England. That is misinformation.
Is it?
Yes. Uptake was slow in the two weeks after the forms were sent out, but after that, I wrote to all the graduates and the figure is now more than 60 and is rising every day.
Is that the figure for Scotland?
That is the figure for Scotland and England.
What is the figure for Scotland?
I believe that only one or two graduates from George Brown College are in Scotland, anyway.
Our concern is what is happening in Scotland, so we need to know the figure for Scotland.
I reassure the committee that both those graduates in Scotland have registered with the royal college to upgrade.
Is your organisation happy and willing to participate in discussions with NHS Education for Scotland about denturists' training needs? Will your organisation be involved in that?
Undoubtedly. We will support anything that will achieve what the GDC has striven to do—particularly in Scotland, where the problem of denture provision is bigger than it is in England—provided that people are trained and competent to perform the procedures, in the interests of patient safety.
Hew Mathewson emphasised alleviating the pressure on dentists. Considering that, it is extremely important that people have well-fitting dentures, which is important to their digestion and their general health. A significant minority of people use dentures. It seems that everybody must be registered to trigger qualification and indemnity, with which everybody agrees.
Any education provider that wants to recognise prior learning is likely to assess patients of the individual who came forward for training, in order to help to assess their skills and knowledge. We would look favourably on that.
Would anybody have difficulty with involving patients? Would patients or customers be willing to be involved?
I am certain that many of our patients would be only too pleased to give evidence that they have had satisfactory service over a great many years.
It would be fair to say that we get a great many complaints from patients who have dentures. Their number 1 complaint is when they discover that denturists are not regulated or indemnified. People take that very seriously and feel that that is remiss of us. Of course, if someone breaks the law it is not our responsibility; we can only seek to prosecute.
I worked in general practice for 25 years and had 35 years in the national health service. It was stunning to realise that, but it has been going on for a long time, although many people have been remiss about noticing it. We have few dentists and there are people out there who require that service. As we have said, it is important to have well-fitting dentures and to have repeated fittings for those dentures. If somebody breaks a denture and goes to get their denture fixed, it is illegal for the person who fixes it to put it in the patient's mouth.
I do not believe so.
It is not an illegal act to repair a denture and give it back to a patient, but it is illegal to put your fingers in a patient's mouth. I want to go back to accreditation of prior learning, or APL. It is now accepted that individuals can use experience towards degree modules. We have just put a top-up course for dental technicians through the General Dental Council. As part of that course, students can work in clinics with dentists—not in clinical dental technology but in other aspects of dentistry. The ability to use APL exists.
On patient complaints and harm, there is a ridiculously low level of prosecution. There has been one prosecution in the past five years in Scotland, which was for an act of illegal dentistry, not for causing patient harm. The Department of Health has no evidence that a denturist has ever caused any harm. I have that in writing.
That is a good point to come in on. There are two concerns. I think I am right in saying that denturists agree that increasing regulation stems from people's wanting to drive up standards in the profession. However, because there is no course here in which they can get accreditation, there is a gap. The minister helpfully outlined a number of steps, which is an encouraging expression of good will from the Executive.
We need to make it clear that if people enter training, that training would have to have been approved by us; therefore any clinical work within the context of that training would be entirely acceptable. That there have been no prosecutions in Scotland is the result of a feature of Scots law—there have been, and continue to be, successful prosecutions in England and elsewhere in the United Kingdom. Scots law requires a corroborative witness: when denturists are taking impressions or working in a patient's mouth they will normally ask family members or others to leave the room, so there is a lack of corroboration, which the Scottish courts do not find acceptable. There are no, or very few, prosecutions in Scotland. That is not the case in the rest of the UK. I, of all people, would not criticise Scots law, but the suggestion that we have been turning a blind eye is made only in Scotland. I do not think that denturists in England feel at all comfortable with the current situation and they certainly do not feel that anyone is turning a blind eye.
I accept that. There are complaints against dentists, just as there are against denturists. The question is whether denturists operate to a poor standard or are just, as it appears to me, people who do a job to the best of their abilities and in good faith and who are willing to seek any accreditation that they can. I ask for the GDC to give me a sign that it will meet them halfway.
If there are complaints against dentists, there are well-established complaints mechanisms to deal with them, whether they are from NHS or private patients. Ultimately, if a complaint is sufficiently serious, it can come before the GDC. Moreover, we are about to launch a scheme for registrants who perform poorly. It will deal with individuals who do a number of things that are sub-optimal but not, in themselves, awful.
I take your point about corroboration in a Scottish court. However, Mr Ward pointed out that the only attempted prosecution in the past five years was not for malpractice, poor practice, substandard work or overcharging but for illegal dentistry. In other words, it was an attempt to stop denturists doing what they do. All I am looking for is an expression of good will from the GDC. There will clearly be a gap between the order being agreed to and denturists being able to gain their accreditation, so will you confirm that, in the interim, you will not try to close down denturists who are trying to come into the profession?
That is self-evident from the way in which we have interacted with the Clinical Dental Technicians Association, which is a longer-established organisation than Tony Ward's Association for the Promotion of Denturism, which is relatively new. The way in which we have interacted with all the different groups, the way in which we respond to the request and the fact that we have a team of staff who work proactively to help those groups to make successful bids for educational approval all speak for themselves. There is no question that we would do anything other than co-operate as effectively as we can.
Strictly speaking, denturists have been operating illegally until now, but my assumption—which I think most of us share—is that the order marks an end to the turning of a blind eye and that there will be a slightly stricter regime. Is it correct to assume that if the order is not annulled and, as a result, the way in which denturists operate is monitored far more actively than it was in the past, customers of denturists will soon not be able to get the service that they have been accessing until now?
That may be the case, although I remain to be convinced that the situation in Scotland will change materially. If something is happening that has been completely illegal for 80 years, I cannot think why it would stop on 1 August. It will be no more illegal than it has been; it will simply be illegal.
I take it that you do not think that we are all just wasting our time talking about the order because it will not change anything. We know that it will change things.
No. We want to encourage all denturists to register as dental technicians, which the majority will be able to do. By "majority", I do not mean 51 per cent, as we think that nearer 99 per cent will be eligible to register as technicians by one route or another because we have a variety of routes to ensure that people register. We will also encourage those who want to continue as denturists to find an appropriate course to achieve accreditation for their skills and to enable them to carry on.
However, those who are in that position will not be able to continue doing all the things that they have been doing if they want to stay onside while they go through that process. Is that the position?
In an ideal world, they would not.
So there will be people who currently go to denturists who, within the next couple of months, will realise that they will not get all the services that they normally got from their denturists.
That is absolutely true but, on the other hand, they will not be deluded into thinking that they have had their oral health and tissues checked by a professional or that the person is indemnified or registered in some way.
That is a fair point. I think that this is the right way to go, but I am slightly concerned that there are areas in Scotland in which individuals will not have any alternatives because accessing a dentist there on anything other than an expensive basis is almost impossible. That is a separate issue, which the committee has previously dealt with, but the truth is that some people will not receive any dental treatment for a time.
First, there is an illusion that denturists are somehow inexpensive, but the information that we have received from patients who have contacted us with complaints is that they are often far from inexpensive.
I am glad to hear it. Those of us who represent areas of Scotland in which that is not the case would be glad if you directed your failing candidates to those areas.
I have worked in Lothian for 30 years and think that I have a good knowledge of the situation. Some 360-plus dentists work in general practice in Lothian and there are three known active and fairly busy denturists. Those figures give an idea of the proportion of denturists to dentists. Even if we accept that there may be more denturists in places that have a greater problem, if there are 2,000 dentists in Scotland, we can work out that there will be a small number of denturists. However, I suspect that it would be better if Chris Allen answered that question.
I can speak only about those who are members of the Clinical Dental Technicians Association in Scotland and those who are being trained on our courses in Scotland. At the moment, there are six.
The difficulty is that there is no compulsion to join the Clinical Dental Technicians Association or any other association and there is no monitoring.
Members will have read that the only available course at the moment is Canadian. That is true, but 90 per cent of the course is based in the United Kingdom. The restrictions on clinical training in the Dentists Act 1984 are the only reason why people must go to Canada. The course has been running for 10 years, and some ex-members of the CDTA started on it. Ten years ago, when he was chairman of the CDTA, Mr Ward signed the contract to bring in that education, and many members of his association would have started the course at that time. I must ask why they did not continue on it because, if they had done so, they would have been trained and qualified to take up the profession by now.
The course has been available for a great many years, but there was no agreement to validate it until early this year. There are problems with it. The Royal College of Dental Surgeons of Ontario has said of the radiography situation:
I am aware that significant ideological issues separate various associations, and I do not want to get into a Judean People's Front scenario.
I do not want to do so either, but I must correct what has been said. Clinical dental technicians in England and Scotland are not trained to prescribe dental radiographs—they are trained to take and read dental radiographs and refer appropriately, just as dental nurses and dental hygienists are trained to take and process radiographs. Are we seriously saying that, as well as denturists, dental nurses and dental hygienists are dangerous when it comes to taking dental radiographs?
The point has been made. I do not want us to go down that alley because we would find ourselves in a scenario that would not be helpful.
Meeting suspended.
On resuming—
I thank the minister for returning with his officials. The committee is now asked to consider a motion to annul the General Dental Council (Professions Complementary to Dentistry) Regulations Order of Council 2006 (SI 2006/1440), which is subject to the negative procedure. As the paper that was circulated to members points out, the Subordinate Legislation Committee considered the instrument and had no comment to make on it. Before the motion to annul is moved, I invite Nanette Milne to speak in support of it.
As I said at the outset, I am behind the proposal that all dental professionals be registered. I lodged the motion to annul so that we could discuss those denturists who do not have a recognised qualification that would allow them to register with the General Dental Council.
Will you confirm that you do not intend to move motion S2M-4568?
That is my intention.
As there is no other name in support of the motion, no further action can be taken on it. I thank the minister and his officials for their attendance; they are now free to leave, if they wish.
Contaminants in Food (Scotland) Regulations 2006 (SSI 2006/306)<br />National Health Service (Superannuation Scheme and Additional Voluntary Contributions) (Scotland) Amendment Regulations 2006 (SSI 2006/307)
Human Tissue (Specification of Posts) (Scotland) Order 2006 (SSI 2006/309)<br />Approval of Research on Organs No Longer Required for Procurator Fiscal Purposes (Specified Persons) (Scotland) Order 2006 (SSI 2006/310)
Plastic Materials and Articles in Contact with Food (Scotland) Regulations 2006 <br />(SSI 2006/314)<br />National Health Service (Pharmaceutical Services) (Scotland) Amendment (No 3) Regulations 2006 (SSI 2006/320)
National Health Service (General Dental Services) (Scotland) Amendment (No 2) Regulations 2006 (SSI 2006/321)<br />Human Tissue (Removal of Body Parts by an Authorised Person) (Scotland) Regulations 2006 (SSI 2006/327)
Anatomy (Specified Persons and Museums for Public Display) (Scotland) Order 2006 (SSI 2006/328)<br />National Health Service (General Ophthalmic Services) (Scotland) Amendment Regulations 2006 <br />(SSI 2006/329)
National Health Service (Discipline Committees) (Scotland) Regulations 2006 (SSI 2006/330)<br />Anatomy (Scotland) Regulations 2006 <br />(SSI 2006/334)
Human Tissue (Scotland) Act 2006 (Anatomy Act 1984 Transitional Provisions) Order 2006 (SSI 2006/340)<br />Human Tissue (Scotland) Act 2006 (Maintenance of Records and Supply of Information Regarding the Removal and Use of Body Parts) Regulations 2006 <br />(SSI 2006/344)
Item 3 on the agenda is the consideration of negative instruments. One of the instruments listed on the agenda—SSI 2006/343—was withdrawn by the Executive on 27 June and will be relaid at a later date, so we are not required to consider it today.