Questioning the GDC

InterviewAfter she announced her decision to step down as chief executive and registrar of the GDC, Seb Evans questions Evlynne Gilvarry about her time at the regulator and some of the decisions she’s made.

How do you think your time at the GDC has gone?

Evlynne Gilvarry (EG): It’s been enourmously interesting, during a period of immense change, it’s been extremely challenging.

I’m particularly interested in the way regulation can make a difference for patients and the public, but can also make a difference for the profession too.

The last five years have been particularly frustrating for regulators, we’ve been repeatedly promised lots of legislative change, that would have enabled us to make a difference.

Are you referring to a question of the Section 60 Order?

EG: No, the Section 60 Order is secondary legislation. Over the last five years, we worked very hard with the Department of Health on a bill that would have helped us to introduce better systems of handling complaints.

The GDC experienced an increase in complaints of 122% between 2010 and 2014. When you experience that kind of growth in your workload, you have an organisation that comes under stress.

So when it happened between 2010 and 2014, we were dealing with an increased workload and trying to meet all our other statutory responsibilities at the same time, and that’s when our existing legislation started to prove to be particularly outdated.

GDCOver the last five years, we faced those challenges and we had to make some really tough decisions. We had to go to the profession to ask for extra money during a very challenging time. It’s obviously difficult to ask for more money to handle all these additional complaints. While it might have been tough, we had to do it.

Thankfully the caseload is now stabilising, so we’re in a much more favourable state. The lesson we have learned is the patterns from the past are no indicators of what might be on the horizon. We’re a wiser organisation, we know more about the profession and its concerns, I hope we’re more empathetic to those concerns.

Next year, there’s a programme of work to improve our relationships with the profession, stakeholders and the public. Clearly we’re a body that’s here for patients and the public, that’s our primary role, but we won’t be able to discharge that role at all well if we don’t have the confidence of the profession.

The other thing we achieved in 2015 was to agree a new plan which sets out the blueprint for the next three years. So when I leave the organisation at the end of January, I will be handing over a new three-year plan that has been agreed by the council and consulted on internally with staff. We took it out to external stakeholders and amended accordingly.

Why have you chosen to step down now?

EG: Five years in a job like this is quite a commitment and it’s been very challenging.

I’ve got masses of energy, which I want to use for a different challenge coming up the path. I work with fantastic colleagues here making the most challenging day’s at the GDC enjoyable. So it’s not lightly that I’ve chosen to step down.

But I’ve agreed with the chairman that it’s a good time for me to move on and to leave the organisation. The organisation has changed utterly since I’ve arrived. I don’t say that boastfully, I say that because I had the support of a fantastic team and we had to make some tough changes.

I have lots of energy, which I’d like to use for a new challenge.

Is it all change? Is Mr Moyes planning on stepping down too? (asked before PSA report was released)

EG: I don’t think Bill Moyes has the slightest intention of stepping down. He’s a great leader of an organisation. He brings clarity and depth to the leadership of regulators and he’s a very experienced person.

There are two years left of his term so even for that reason alone he’s got no intention of stepping down.

It was extremely important to have a chairman of Bill’s strength alongside me to lead, to take those tough decisions to go out to the profession and to raise the income levels necessary. We did it together and it was a good partnership.

There is a PSA report due to be released into whistleblowing at the GDC, does the impending release of this have any influence on your decision to step down?

EG: No, it wasn’t an influence. I acted on it by taking a number of steps at the time. A clear action plan was drawn up in response to the incident, and we commissioned an independent review within days of the concerns being raised.

We implemented all the recommendations from that review – a process that was overseen by the Audit Committee and the council. We also commissioned a further review six months later to make sure the recommendations from the original report were implemented.

Our actions were acknowledged by the PSA in its report.

The GDC held a consultation on the annual retention fee (ARF) in 2014 and last year. Despite the responses to the ARF consultation you went ahead and increased the fee last year and kept it at the same level this year. Why did you hold the consultation if you weren’t going to listen to the profession?

EG: We went out to consultation in 2014 with a budget that clearly indicated we needed to raise a great deal of extra money. If you’re asking for money from the profession, it’s more than just a courtesy to ask its views. We don’t have a statutory obligation to consult, but I felt a strong ethical obligation to, particularly given the extra funds we were seeking. So it wasn’t a token exercise.

We set up our budget, we set out to explain clearly why we needed the extra money, we went through a lengthy consultation process.

When eventually it came to the council, there were several options of different levels of fees for the council. And the council took a decision on a level of fee that was different to the one we originally consulted on. So I think that in every respect we did listen to the profession.

We weren’t able to concede to the general wish that we wouldn’t change the fee at all, it simply wasn’t realistic.

‘It was extremely important to have a chairman of Bill’s strength alongside me to lead, to take those tough decisions to go out to the profession and to raise the income levels necessary. We did it together and it was a good partnership’

I think that the way we responded in this year, I hope, picked up very carefully on some of the dissatisfaction that was expressed in the course of 2014’s consultation.

When it went back to the council for a decision we went back with two options and the council decided to hold the status quo. So these consultation exercises are not cosmetic, we do listen to people’s views on the fee.

This year we weren’t in a position to return any money to the profession, but we did hold it (the ARF) steady. And again we thought it was an important demonstration of transparency to go out to the profession and explain our decisions.

The response you received to raising the ARF last year and keeping it at the same level for this year was overwhelmingly negative. Is there any response that the profession could have given that would have had a greater influence on the GDC’s decision?

EG: The very fact that we came back to the council with an alternative option, which would have been feasible but only at the expense of not beginning to build up a reserve this year but waiting for a further year, proves it did have an influence. That was the option we put to the council, it decided that it was a risk that it wasn’t prepared to run.

At the end of the day it’s down to the council to make a decision, they’re the ones that have got to carry the risk. I firmly believe that a consultation is an important exercise in transparency and trust with the profession, because it’s their money we’re spending. So we need to set out our budget and explain it.

You mentioned the case examiners, if they were to come in, do you think the likelihood is they could push down the ARF for the profession?

EG: Absolutely. What I can say for absolute certainty is that case examiners will save us significant sums of money. We know that in a full year of operation case examiners will save us up to £2million.

This year we had thought we’d have case examiners, that didn’t happen. The legislation should come into effect in April 2016. By the time case examiners are recruited and trained, it will be autumn before they start working. So the likelihood of taking one quarter of savings next year is there and then a full year in 2017.

At the same time we build our reserves. One has to be cautious as there can be unforeseen events in regulation, but I know that the intention of this organisation is to become ever more efficient. This is an organisation that realises that the cost of regulation is significant and we have a responsibility to make sure that the cost of the ARF is no greater than it needs to be and that if there’s a possibility for it to come down, it’s our responsibility to bring it down.

You mentioned in a previous interview with Dentistry magazine, by creating your own in-house legal team, you had projected a saving of £838,000 by the end of 2014 and a further £1.2m per year after. Has this happened? And if so, why hasn’t it been reflected in the ARF?

EG: It has happened. In fact we hope to achieve a saving of £2m in 2015. And next year there’s a prospect of even greater savings.

But we have come to the decision that to leave the reserves at the current low level for another year was a risk too far.

But once we do build them up, the following year (2017) I think, with savings coming from case examiners on top of that, there’s a realistic opportunity, it would certainly be the organisation’s aim, to look to see how the cost of regulation could be reduced. We regard that as our responsibility.

Looking at the GDC’s accounts you have cash reserves of around £12,500,000. How much do you need?

EG: We have a policy of maintaining reserves between four and six months annual operating expenditure. That’s a policy that’s fairly prudent. We opt for maintaining between four and six months.

Last year we were down to reserves equivalent to two months of our expenditure. Reserves are our only recourse if unforeseen expenses arise. If we didn’t start to rebuild this year, we wouldn’t improve our position. We’re low at the moment and we believe we’re too low for comfort. So we need to start rebuilding those.

After the Health Select Committee meeting earlier this year, Bill Moyes and yourself were told that the GDC needed to improve its relationship with the dental profession. What have you done to achieve this?

EG: We have done a number of things. I hope that in 2015 we have progressively sent signals to the profession that we have learnt a great deal of lessons from 2014. We’ve also made it very clear that we know we need to improve our performance.

We’ve taken many opportunities to talk directly to the profession. I hope the tone and style of our communication is more empathetic, it’s meant to be.

During the development of the corporate strategy, we asked stakeholders for their views. I do hope in 2015 the profession recognises that while we acknowledge we haven’t always got things right, we are making every effort to improve our performance to become a more efficient organisation The figures show our performance is improving, but we know there is more to do.

The consultation on the ARF this year was a measure of our bid to be transparent about how we’re spending money.

The GMC has employed Professor Louis Appleby to help support those who are under investigation. Is the GDC looking to help those under fitness to practise investigations?

EG: Fitness to practise proceedings are undoubtedly stressful. The question is; where is the support best coming from?

I think there is a shared role of a number of bodies to ensure that an individual facing fitness to practise proceedings has adequate access to the kind of support that would be suitable for him or her.

Defence bodies of course have a big role to play here. Professional bodies have a big role to play too, regulators have some role to play.

It’s an issue, the scarcity of support for people facing fitness to practise is acknowledged by people within the system. The GDC is a member of a body that has been looking at the deficiencies of the complaints handling mechanism. The CQC is on it, NHS England, Health Watch England, we all acknowledge that there’s a lack of support on the ground.

So I think, yes we have a role to play, but other bodies probably have an even bigger role to play, putting in the kind of support around practitioners who are hopefully only temporarily struggling in practice.

The latest issue of Dentistry Scotland magazine has a number of testimonials from dentists about their problems when dealing with the GDC, many focusing on fitness to practise proceedings. Why do you think dentists were and are upset with the GDC?

EG: Well I think what we found in 2014 and in our own discussions with the profession, was there’s a lot of real misunderstanding about the nature of our fitness to practise processes.

A strongly held view amongst those who spoke to us is that we accept complaints, which we should be sending back to be dealt with locally, and that we’re canvassing for complaints. It’s almost like a sense that we aren’t on the side of the profession because we are entertaining complaints about them that simply shouldn’t be entertained at all.

First of all you have to point out that that’s simply not the case. If you look at the fitness to practise workflow, there are several different stages. Of the 3,200 cases we got this year, about 35% of those were closed at the triage stage. If we were taking complaints willy-nilly we just simply wouldn’t be closing a third of our cases at the triage stage and that’s within the first month.

It’s not surprising to me that people who have faced fitness to practise proceedings are unhappy, simply because of the length of time it takes. Because we don’t yet have case examiners, it could be six months from the time coming in for a case to be heard. I can understand how stressful it is for people to be under investigation for that amount of time. It’s got dissatisfaction built into the heart of it.

‘We’ve learnt a great deal about the profession’s views on us. I hope the tone and style of our communication is more empathetic, it’s meant to be’

So even though it’s still the case, I think some of the dissatisfaction relates to the misunderstandings of the fitness to practise process. Even when you strip out the misunderstandings, you can still understand the profession facing fitness to practise proceedings would be stressed over that period of time. It’s not a system that’s proportionate, there is a better way.

Case examiners will help. The Section 60 Order will enable case examiners, who will be our employees, a mixture of dental professionals and lay people, to do the work of the investigating committee and we’ll have additional powers.

What does that do? It automatically knocks three months off the cases, because you don’t have to convene a committee, list etc. Equally it offers the prospect of using new powers to agree undertakings. So in certain cases, the possibility is that the case examiner will be able to make a formal undertaking with the professional concerned to do X or Y and then that’s agreed at that point. So the matter can be resolved earlier with an undertaking in a much shorter space of time, saving costs and saving stress.

Why do you think there has there been such a large jump in fitness to practise cases?

EG: It’s clearer to me now why. I think there are three main factors.

The first is certainly a better-informed consumer/patient. People have access to a web that’s full of health related information. There’s an enormous appetite for this type of information.

Also oral health care means different things for people in different socio-economic groups. Alongside this interest you have a corresponding expectation of what you’re going to get. When expectations aren’t matched, people raise questions. If the questions aren’t answered to their satisfaction, that question becomes a concern and a complaint.

Equally regulators, we’re no exception, have made the potential for making a complaint online easy to do. The forms we have are very easy to fill in. We regard this as our responsibility, it’s important that people find a way to raise a concern. So that’s one thing, a better-informed consumer.

GDCThe second, we saw a surge of complaints around the time of the transition from PCTs to the setting up of the new health system overseen by NHS England. The new regime saw deficiencies, and as a consequence, we believe the complaints that otherwise would have been dealt with locally started to come up to us. We don’t know this for absolute certain. We have enough information anecdotally about the fact that the previous regime for performance management was stripped away in many areas.

We’ve done a lot of work with NHS England, we’re doing parallel work with Scotland, to try and identify those cases that can better be handled on the ground under the NHS performance framework. And where we can be satisfied that they will be handled there we can send cases back to local area teams.

The third factor I think was there were changes to no win no fee arrangements. There’s evidence to suggest people with claims were being encouraged to make parallel complaints to the regulator in order to get a ruling that might enhance their chances of having a successful claim.

So all of those factors, and I suppose it is somewhat telling that after that period of time we’re still seeing our cases go up but it is flattening.

Many dentists, even those who haven’t been through the fitness to practise proceedings, are now finding themselves practising defence dentistry. Is the GDC having a negative impact on the profession?

EG: Honestly, I don’t really understand what defensive dentistry might be.

I think what I would say as a regulator is that we have standards that we revised in 2013. I think they very clearly set out the expectations that we have of people in practice. They’re very clearly written. It shouldn’t cause somebody to be overly cautious.

On a human level I can understand somebody who had been through the fitness to practise process, you’d be a changed individual after that, if you had made mistakes you wouldn’t want to repeat those. So if that’s what they mean by practising defensively then I can understand.

Our standards should really help practitioners; they’re certainly aimed at helping people to go about their practice in a way that would meet patients’ expectations. So there shouldn’t be any reason to be overly defensive. We’re very keen that people should not appear in front of us.

So I can understand people’s caution but perhaps I need to understand a little more about what practising defensively is.

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