Motion to Consider
My Lords, the Dentists Act 1984 established the General Dental Council and sets out its functions and processes. The GDC is responsible for regulating the dental workforce in all parts of the UK. It has powers and duties which include setting the standards of conduct, performance and behaviour that dentists and dental care professionals are expected to adhere to. In addition, it is responsible for investigating any complaints or concerns which suggest that a dental professional may have failed to meet those standards.
The Government are keen to ensure that the GDC has the appropriate framework in place so that it can carry out its statutory responsibilities effectively. At present, the legislation governing the early stages of an investigation into a dental professional’s fitness to practise does not provide sufficient flexibility to enable the GDC to carry out this function in the most effective and efficient way. Legislative change is needed to address this.
This order, made under Section 60 of the Health Act 1999, amends the Dentists Act 1984 to reform the investigation stages of the GDC’s fitness-to-practise procedures. The Department of Health has publicly consulted on the proposals contained in the order and the vast majority of respondents agreed that the measures should be introduced and would have a positive effect on the GDC’s fitness-to-practise procedures. Through this Section 60 order I propose to provide the GDC with the powers to make five key amendments to its processes.
First, the GDC will be provided with a rule-making power that will allow it to delegate the decision-making functions currently exercised by its investigating committee to case examiners. The GDC’s current framework requires that following the triage of a fitness-to-practise complaint about a dental professional, if that complaint falls within the GDC’s remit it must be considered by an investigating committee. This means a panel must be convened for every case that reaches this stage. By introducing case examiners, it is anticipated that there will be a swifter resolution of fitness-to-practise cases, as a full investigating committee will not need to be convened for every case and instead allegations will be considered by two case examiners. The faster resolution of cases will enhance public protection. It will also remove some of the stress from the procedure for all parties involved. In addition, greater consistency in decision-making should be achieved, because case examiners will deal with a higher volume of allegations than the investigating committee, as the committee is convened from a large pool of individuals.
I realise that the fact that case examiners will be employees of the GDC may be a cause of anxiety for some. It is important to remember that they will not be making findings of fact in respect of whether a registrant’s fitness to practise is impaired. They will make the decision as to whether a case needs to proceed to the adjudication stage and be considered by a practice committee.
Additionally, the GDC, in its rules and guidance, will provide that the case examiners must make decisions based on documentary evidence which will be supplied to them in the same manner as is currently the case for the investigating committee. The case examiners will not be involved in evidence-gathering. There will also be one lay and one registrant case examiner, from the same part of the register as the individual whose case is being considered, considering an allegation, which will provide another safeguard in the process ensuring fairness.
I am also aware that interested parties will be keen that case examiners are recruited, trained and supported in the right way. I have been assured by the GDC that case examiners will receive comprehensive and robust training. The GDC is developing a robust system of review and appraisal that will monitor and support performance and ensure appropriate decision-making. The quality of the case examiners’ decisions will be underpinned by ongoing training and detailed guidance. The GDC will also introduce mechanisms for auditing decisions on a routine basis and will apply the lessons learnt from the audits to the guidance material.
Secondly, provision will be made to allow both the case examiners and the investigating committee, in certain cases, to address concerns about a registrant’s practice by agreeing appropriate undertakings with that registrant. This will be instead of referring them to a practice committee.
Undertakings will be applied, where appropriate, at the end of the investigation stage of the fitness-to-practise process. The introduction of this change will mean that some cases that are currently referred to a practice committee may not need to be. This would be in instances where it is determined that the agreement of undertakings would lead to the resolution of a case in a way that is sufficient to protect patients and the public. For example, if a case involved an allegation that a registrant’s health was affecting their fitness to practise, it may be possible to agree undertakings that would address any risks posed to the public and to the registrant themselves as a result of this health condition. This would also avoid the anxiety, time and cost incurred by referring the case for a full hearing. Rules will provide that a registrant must not be invited to comply with undertakings if there is a realistic prospect that if the allegation were referred to a practice committee, the registrant’s name would be erased from the register.
Thirdly, the GDC will be provided with the power to make rules to provide, first, for a review of a decision that an allegation should not be referred to the case examiners or to the investigating committee, and, secondly, for a review of a decision that an allegation should not be referred to a practice committee. However, this will not be an unfettered power. Through rules, the GDC will provide that a review can be undertaken by the registrar if it is considered that the original decision was materially flawed or if new information has come to light which may have altered that decision and a review is in the public interest. Such a review can occur only within two years of the original decision to close the case. Allowing the review in these circumstances adds a further safeguard to the system. Providing the GDC with the power to take suitable action will improve public protection and maintain public confidence in dental regulation.
This order will also introduce a power to enable the investigating committee and the case examiners to review their determination to issue a warning. A registrant will be able to request such a review within two years of the original decision to issue the warning. At present, there is no mechanism through which a registrant who is issued with a warning can appeal this decision with the GDC. Instead, the only route of appeal open to them is to apply for judicial review. This can be costly for both the registrant and the GDC and stressful for the registrant. Warnings can remain on an individual’s record for a number of years, for as long as the warning has been issued, and accessed by patients and employers. Providing individuals with a route of appeal that does not require application for a judicial review is a fairer and more proportionate approach.
Finally, provision will be made to ensure registrants can be referred to an interim orders committee at any time during the fitness-to-practise process. Currently, the legislation is ambiguous around when a case can be referred to an interim orders committee at certain points in the process. This amendment will remove any ambiguity and maintain public protection and confidence throughout the entire fitness-to-practise process. It will provide a higher level of patient protection, ensuring that those who are potentially unsafe to practise can have their registration suitably restricted while inquiries and investigations are made. In addition to enhancing patient safety and improving the fitness-to-practise processes for a registrant and all parties concerned, it has been identified that making these amendments will create approximately £2.5 million of efficiency savings per annum over the next 10 years.
In summary, these proposals to reform and modernise the GDC’s fitness-to-practise processes will make the system more efficient and effective, benefiting patients, practitioners and the health service. They will result in improved public protection and an increase in public confidence in the GDC. I commend the order to the Committee.
My Lords, I thank my noble friend for his explanation of the order, and I look forward to reading in Hansard what exactly it is. It is complicated. I declare my interest as listed on the register.
I am sure all noble Lords will agree with me that the measures included in the order are a welcome and very long overdue step in the right direction toward speeding up the overall process of complaints handled by the GDC. The current legal framework hinders improvements to the effectiveness and efficiency of this process—improvements which, with a major case backlog and cases costing an average of £78,000 to process, the GDC badly needs. However, I will make some brief comments about some conditions that must be met for the implementation of these changes to make a meaningful difference.
First, the case examiners this order introduces must be properly independent from the GDC, as well as appropriately trained and supported in carrying out their new duties. The success of the new system will lie with the calibre and qualifications of the individuals carrying it out. Case examiners might be exposed to significant internal and external pressure when carrying out their functions, and their credibility will ultimately rest on their independence from the GDC. It is also crucial that the clinical case examiner should always be a professional from the same profession as the individual whose case is being examined. That is very important.
However, it is equally important that, for the new system to bring the expected time and cost savings, we need to see a proper culture change in the regulator’s management of fitness-to-practise cases. The BDA has raised with me the hard-line approach of the GDC in its fitness-to-practise investigations. Dentists say that the GDC tends to treat even the most vexatious or minor complaints as potential cases, which leads to heightened and often undeserved stress for the dentists concerned. I share their fear that if this culture prevails, the new case examiners might simply become an additional layer in the fitness-to-practise process, without any meaningful reduction of case loads and costs.
I hope that the GDC will take these points into consideration when implementing the order, so that these changes achieve a decrease in the cost and increase in the speed of decision-making in fitness-to-practise cases—which we all want to see.
My Lords, I, too, thank the Minister for his careful explanation of the order. I welcome the opportunity to debate it as well as the performance of the General Dental Council.
This is one of a number of Section 60 orders that the Minister has brought before your Lordships’ House in the absence of a Bill following up the Law Commission’s work. Will the Minister be able to update the Committee on exactly where we stand with the Government’s intention with regard to whether they see that any part of the Law Commission’s work will lead to legislation in the future? On the order itself, its terms seem unexceptional, although I would like to raise a few points with the noble Lord. The real question before us is whether the General Dental Council is a fit and proper organisation, capable of implementing the changes.
I shall start, however, with the order and will come on to the issues with the GDC and the various reports that have been published about its poor performance over the past four years. On the order, first, I refer to paragraph 8.4 of the Explanatory Memorandum, which refers to a number of organisations which have commented. The British Dental Association is not listed there. I have received a briefing from the British Dental Association, and I wondered whether it had submitted a response to the department. If it has, I am surprised that it is not listed in paragraph 8.4.
The other point I want to make about the order concerns the question raised by the noble Lord, Lord Colwyn, which is about the performance of the GDC. The BDA briefing that I have received states that while the GDC is,
“Britain’s most expensive healthcare regulator”,
“is also the least efficient, most troubled and enjoys little confidence among”,
either dentists or the Professional Standards Authority. It states that the GDC failed to meet eight out of 24 of the PSA standards of good regulation in its 2014-15 performance review and, crucially, fully met only one of the 10 standards relating to fitness-to-practise processes, representing what the PSA describes as,
“a significant decline in its performance compared to the assessment of the year before”.
The BDA points out that, in comparison, last year, the GMC met every one of the 24 standards while charging its members less than half of the annual retention fee that the GDC charges.
I also pick up the point raised by the noble Lord, Lord Colwyn, about the importance of the independence of case examiners. This is a point that we have raised before on some of these Section 60 orders. It is crucial because of the problems that have arisen from the way the GDC has conducted cases in the past, as identified by the various inquiries. I very much support the noble Lord in emphasising that case examiners must be, and be seen to be, independent.
We then come to the real issue for me, which is GDC governance. The Minister will be aware that in February 2013, the Professional Standards Authority published a report following the resignation of the GDC’s chair, Alison Lockyer, in May 2011. The Department of Health had asked the PSA to investigate several concerns which the then chairman had raised in a letter she had written to the Secretary of State on her resignation.
The PSA’s findings were complex. It did not find that the GDC was failing, but it identified some general learning which could be gained from the experiences of the GDC. Following the PSA’s report into the allegations made by Lockyer, it wrote that new evidence had come to light about poor practice in the support and operation of the GDC’s investigation committee. In July 2013, a member of the investigation committee raised concerns under the GDC’s whistleblower policy that certain processes were compromising the independence of the investigating committee’s decision-making. The GDC also commissioned an independent review into the concerns of the whistleblower, which was published in 2014, but in April 2014 the PSA started its own investigation. This was published on 21 December 2015.
The PSA came to a number of conclusions and found several areas of improvement for the GDC. I will come to the main recommendation but I read this report with considerable disquiet. I do not think I have ever seen a report relating to a statutory regulator quite like it. It was published only a few weeks ago, before Christmas. Paragraph 2.1 of the summary states:
“The approach taken by the GDC to recruiting, training and supervising the Investigating Committee Secretaries is likely to have contributed to the development/continuance of objectionable practices”.
These are objectionable practices by the statutory professional body concerned with dentistry. It is a very long report of more than 300 pages but, to get the flavour of it, here are some of the objectionable practices listed that the PSA looked into. First, there are:
“Discussions about cases between Investigating Committee Secretaries and Investigating Committee Chairs prior to Investigating Committee meetings”.
Then, quite remarkably, there is,
“advance drafting of Investigating Committee decision documents/reasons by Investigating Committee Secretaries”.
There are irregularities around the,
“provision of legal advice by Investigating Committee Secretaries to the Investigating Committee during Investigating Committee meetings … Inappropriate interventions/undue influence by Investigating Committee Secretaries during Investigating Committee meetings”,
“amendment of Investigating Committee decision documents after Investigating Committee meetings by Investigating Committee Secretaries without appropriate authorisation”.
There are other identified irregularities but I do not need to go into them; I have made the point. The PSA report goes through this in great detail and its overall recommendation is:
“The GDC’s Council, executive management team and the relevant committees should consider this report in full, both individually and collectively, in order to identify all the lessons that should be learnt in particular in relation to governance, accountability and management oversight, as well as the actions the GDC should take to address our recommendations”.
The point I want to make about this is that these matters now go back some years. It was 2011 when the then chairman first raised those issues. This report was started in 2014 and finished only a few weeks ago. It clearly found continuing improper practices—or at least those that would not accord with good practice. Reading between the lines, I see here a culture of utter complacency within the GDC. It looks as though the GDC has simply not accepted the core conclusions of the various reports written about its conduct and carried on with that complacent culture. It is also clear from reading between the lines of the report and the careful way it has been put together that the PSA lacks confidence in the performance of the GDC. Frankly, I would have expected the entire board of the GDC to resign in the light of that report just before Christmas. I understand that the chief executive has resigned but no one else on the board seems prepared to take responsibility for a culture that has clearly lasted over a good many years. That is not acceptable. Can there be any confidence that this organisation is fit for purpose?
I now understand the concerns that the profession has about the GDC. I had not realised until I went through this information just why there was so much angst within the profession. It is absolutely justified. I would be doubtful of putting any order through in relation to the GDC unless we were absolutely certain that it is able to carry out its job properly.
My Lords, a number of points have been raised. I will start with those raised by my noble friend Lord Colwyn. He said that independence is critical for the case examiners; I will address that issue first. It is important to remember that case examiners will not be making findings of fact in respect of whether a registrant’s fitness to practise is impaired. They will make the decision about whether a case needs to proceed to the adjudication stage and be considered by a practice committee.
Additionally, in its rules and guidance, the GDC will provide that the case examiners must make decisions based on documentary evidence, which will be supplied to them in the same manner as is currently the case for the investigating committee. The case examiners will not be involved in evidence-gathering. There will be one lay and one registrant case examiner considering an allegation. I accept, however, that they will be employees of the GDC. Nevertheless, our feeling is that sufficient safeguards are built into the way that case examiners will work.
The issue raised by my noble friend and expanded on by the noble Lord, Lord Hunt, is fundamental. If the GDC is not a fit organisation—if its governance and performance are not right—that is a much more profound worry than the details of the order before us today. Before I address this, I will deal with one other point that the noble Lord raised. He asked whether the BDA had submitted anything. It has; it was omitted in error and is now being attached.
Clearly, we are concerned about the performance of the GDC. The report from the PSA is indeed extremely worrying. As the noble Lord said, this has not happened just recently; it goes back many years. It is very important that the council takes responsibility for the proper running of its organisation. My colleague Ben Gummer is the Minister with direct responsibility for the GDC and he has a meeting coming up in the very near future to discuss the GDC’s performance in the light of the PSA report. It is not all bad news in that report. There are some signs that the GDC is working hard to improve. Nevertheless, as my noble friend and the noble Lord have both said, there is a lack of confidence in the GDC among the profession and that confidence must be rebuilt.
Perhaps I might bring to Ben Gummer’s attention the comments that have been made by my noble friend and the noble Lord and ask him to draw them to the attention of the GDC when he meets it in the near future. Clearly, he will wish to keep a very close eye on the performance of the GDC as we go forward. I do not think I can say much more today about that. I do not have the information with which to comprehensively address the issues that the noble Lord has raised. Is he content on that basis? If he would like to meet my honourable friend Ben Gummer, I can arrange for him to do that.
My Lords, I am very grateful. One of the problems is that this was scheduled very late and therefore I was able to look at the information only over the weekend. I suspect that I would have put a Motion down for a debate in the Chamber if I had had time to do that.
Secondly, I realise that this is quite a difficult situation. Clearly, the independence of the regulators of the health profession is very important and I have always been keen to protect it. The PSA has a crucial role and I think it does a great job. I pay tribute to the chairmanship of my noble friend Lady Pitkeathley, and Mr Harry Cayton, the chief executive. I think they have done a fantastic job, but it seems to me that there is a gap.
It is patently obvious when you look at it from the outside that the board should have read those reports, accepted its ultimate responsibility and stood down. I accept the invitation; I would be very glad to meet Mr Gummer. Of course, this will be debated tomorrow in the other place, and other Members may come back on that. This message clearly needs to go to the GDC council: that it is not good enough and the members should consider their position. I wonder whether it is right that the board carries on willy-nilly simply because the chief executive has stood down.
I am not someone who rushes to say that this, that or the other board should resign because something has gone wrong, but this has been a continuing problem. I accept that improvements have been made, but only a few weeks ago the PSA had to publish a report that continues to draw attention to what is, essentially, the culture of the organisation. Therefore, I very much hope that Ministers will take the appropriate action; that is all that they can do. Ultimately, I am surprised that the board of the GDC feels that it is able to carry on and I think there needs to be a change.
I am grateful to the Minister for the way that he has responded; clearly, he understands the issues that are being faced.
My Lords, perhaps we can leave it on the basis that I will organise for the noble Lord to meet Ben Gummer and perhaps ask Harry Cayton to come along, too, as he fundamentally authored the report, so that the noble Lord can express his concerns directly to them. On that basis, I beg to move.