With Ian Brack almost finishing his first year as chief executive of the GDC, Seb Evans went to speak to him about how the last year has gone and the future for the dental regulator.
It’s been almost a year since the ‘uber-moustachioed man of dentistry’ (as Julian English describes him), Ian Brack, became the permanent chief executive of the General Dental Council (GDC). There are probably few positions in dentistry that can make so many headlines in such a short space of time.
The last time Dentistry interviewed somebody at the GDC, Evlynne Gilvarry was making the headlines, there was a genuine feeling of hostility from the profession towards its regulator and Bill Moyes (chair at the GDC) and Evlynne had recently appeared in front of the Health Select Committee, answering questions on the organisation’s performance.
A lot has changed since then. The GDC’s overall performance has improved according to the Professional Standards Authority (PSA), Evlynne has stepped down (or been dragged out) as chief executive, with Ian Brack stepping up to take her place and the GDC is starting to convince some within the profession that it really does care about those that it regulates. ‘The changes in the organisation had already started, they’d started long before I’d arrived,’ Ian mentioned when we went to speak to him recently. ‘There was enough that had been done to improve the performance of the GDC to suddenly liberate us and start to make a real leap forward. It’s a great start.’
Shifting the balance
Towards the end of January the GDC launched its future plans for regulating the profession. In the document titled Shifting the balance, the regulator hopes to ‘shift the focus from enforcement to prevention’. This basically means moving processes further upstream by:
- Improving CPD in the hope that fewer complaints arrive at the GDC’s door
- Ensuring patient complaints are appropriately raised and resolved within the practice, so that fewer complaints arrive at the GDC’s door
- And improve the GDC’s work with major partners like the NHS, all so that fewer complaints arrive at the GDC’s door.
‘It’s a lot of ideas, a lot of proposals, which are the result of a lot of hard work looking at the organisation and regulation,’ Ian explained.
‘We’ve identified areas where there are levers that go far outside the GDC, which can effect change going right the way from prevention, joint working, first tier resolution and our own processes. That’s what Shifting the balance sets out. It identifies areas where we think other people can do things that will change the regulation landscape as a whole.
‘The other thing that’s interesting about Shifting the balance is, we’re not letting our hopes lie with changes in legislation. We’re trying to work within the existing legislation, the existing frameworks but absolutely maximising what we can get out of them.’
Shifting the balance is currently in its consultation phase, which means now is a fantastic opportunity for registrants to have their say and provide constructive feedback on the future of dental regulation. As Ian puts it: ‘There are people who have a low opinion of the GDC. We’re really trying to listen, if they engage positively with us and try to change that, where’s the harm? There’s lots of benefit.’
Protecting the public
The GDC has been talking about change for as long as I can remember, but its primary purpose is to protect the public. So, are these changes it keeps talking about improving its protection of the public or is it just an excuse to justify charging such a large annual retention fee (ARF)?
The PSA oversees all health and social care regulators. It is the PSA’s standards that the GDC uses to work out whether it is improving. In 2015 the GDC received a damning report from the PSA. It failed to reach seven of the required 24 ‘Standards of Good Regulation’, causing many to point out that the GDC was the worst performing health and social care regulator.
Since 2015 things have improved, with the GDC meeting 21 of the 24 standards. ‘This year just gone, we have made a big improvement,’ Ian said. ‘We were not in the place we wanted to be previously, it was just not good enough. Things are a lot better now, we’ve still got three more standards to get, if we get these we’ve got the complete set.’
But Ian is quick to point out that the PSA’s standards aren’t the ‘be all and end all’ when it comes to improving the way it protects the public. ‘We’re also always looking at our own understanding of the world we regulate, partially in Shifting the balance, talking to our audience, to the patients, to the registrants, to help us understand when we’re delivering within that wider frame of the PSA’s standards.’
The GDC regularly holds panels to find out how people interact with their dentists and what they have done in their capacity as patients. Ian claims they find out a great deal about the GDC and the profession through this, but he adds: ‘We want to do more, you can always do more. We’ve never got enough intel.’
Is the GDC improving the way it protects the public? If the PSA’s standards are anything to go by, yes it certainly is. But the GDC is regulating a profession that in general doesn’t harm patients in the first place. So, it’s hard to tell whether all the changes have improved public protection, or whether they have just improved the way the GDC is run. Either way, the regulator will continue to make further changes stemming from Shifting the balance, and there will be a number of organisations keeping an eye on whether this improves public protection.
The GDC has spoken about case examiners for a long time too. Evlynne Gilvarry said it would save up to £2 million every year. The GDC needed to get parliamentary approval from all the devolved parliaments, which is why it’s taken so long.
Case examiners went live on 1 November 2016. They’re basically another step in the overall fitness to practise process. But they have been given new powers to agree ‘undertakings’ with practitioners to avoid the need for cases to go through to an investigation.
‘Case examiners have dealt with over 200 cases so far,’ Ian explained. ‘And they’ve closed or recommended for closure just over half of the cases they’ve dealt with. They are doing what we hoped and thought they would do. They’re providing a quicker, robust way of ensuring cases don’t just stay in the system and go to the panel. But it’s still very early. We’ve got about three months’ data, and part of that is Christmas and January. We’re going to be keeping a really close eye on that and watching it.’
They’re not the only ones. Although the introduction of case examiners was welcomed when they were first introduced, John Makin from the DDU, amongst others, said that the performance of the examiners would be closely scrutinised going forward.
But now case examiners have been introduced, is the GDC on course to make a saving of £2 million every year? ‘It really depends on how the performance goes throughout the year. It should, but I can’t guarantee it by any means,’ Ian said. Suitably vague, with enough wriggle room a year down the line if needed. But as Ian pointed out, it is still early days and the GDC still hopes case examiners will be a more cost-effective approach.
Annual retention fee
In 2015 the ARF jumped 55% to £890 for dentists, due to ‘the high number of fitness to practise cases’. This led to the GDC being found to have acted unlawfully in the way it raised the ARF, but it still continued with the rise.
Despite a consultation on 2016’s fees and Evlynne Gilvarry pointing out that the GDC would do everything it could to reduce the ARF and that a reduction could be possible in the near future, the GDC continued with its high fees and froze the prices at £890 for a further year.
Whilst all this has been happening the GDC has been letting everybody know about the changes the regulator has been making to improve its performances and save money. So, the profession is left asking, when can dentists expect a drop in their ARF?
‘I can’t give a date,’ Ian Brack says. ‘Partially because the factors that determine what the ARF costs are lie outside the organisation. Case load shot up 120% in two years before the last ARF rise and since then it’s plateaued. We don’t know whether it’s going to scale down. There are other issues, we register all the dental professionals in the team. Registration costs may be varied by issues relating to freedom of movement, for example. If we find ourselves with a cost imposed on us we have to fund that. Those are just two examples and there are many variables.
‘What I would say is, we recognise the cost is high, we’re under no illusions about that. We have a plan, we’re looking at all of this. We’re very keen to be more efficient and more effective, and offer better value for money. However, any investment may be needed to deliver the long-term improvements proposed in Shifting the balance. In that sense, a reduction in the ARF may not be the first call on our resources. In any event, we also can’t be drawn on a date. I also have to replenish the reserves of the organisation.’
This is a point Ian’s predecessor highlighted, the GDC likes to keep four to six months of operational spend in reserves. When pushed on the point and Ian mentioned the GDC is currently operating at slightly under three months’ reserves at the moment. This is despite the number of fitness to practise cases actually dropping below the number in 2013, and the number of organisational changes the GDC is keen to highlight. So, why are the reserves not being replenished?
‘It’s the amount of resource that has been used to address problems that the big spike in caseloads caused,’ Ian said. ‘The average case life is about 18 months. It takes a long time for cases to get through the system. The other thing I would say is, any case work organisation that builds a backlog has a big problem, the backlog sticks. It takes a very long time and a great deal of effort to get rid of it. The amount of effort and extra resource that was needed to sort that out has eaten into the budget.
‘Also, one of the difficulties in the past was that the GDC was talking with imperfect knowledge about what was driving its costs. It’s got much better systems now, much better models. Now I feel that we’re able to make a more robust understanding of what’s really going on.’
Despite this, for some in the profession it will always feel like the GDC is asking for more but delivering less. The GDC is the most expensive health regulator and until recently was one of the worst performing too against the PSA’s standards. The perception amongst many is that the GDC is just being greedy.
‘I recognise that,’ Ian said. ‘That’s a point we’re very sighted on. I know what dental professionals and dentists earn, we never forget that they’re paying for this. We never forget that the principals paying for this have got businesses to run. It’s other people’s money that we spend. We have an obligation we use money as prudently and efficiently as we possibly can. I also want to be as light a burden as we can on the profession we regulate. But the point I have to make is that if the world changes and the drivers of cost are there, we have a legal obligation to charge for that. But it’s never far from my mind that I’m spending other people’s money.’
With all the changes the GDC is discussing and its future plans in Shifting the balance, it’s easy to forget that the future of all UK health regulators is currently being considered by Health Secretary, Jeremy Hunt. One of the proposals put forward is the merging of all nine health regulatory bodies into one ‘super-watchdog’ regulator.
‘The council is aware of this,’ Ian highlighted. ‘We haven’t seen details of the proposals. I would characterise their primary concern is patient protection and fairness for the regulated professions can’t be degraded by changes. But if patient protection and fairness can be maintained or improved, then how that is done would probably be a matter for government, and we can’t comment on that.
‘One of the difficulties is we regulate the whole dental team, unlike the GMC and the NMC. So it’s hard to imagine a way in which you can maintain the whole dental team being covered by one regulator unless you have this “hyper regulator”. It is important, we recognise that. But we cannot be in the position as a public body lobbying for our own survival, it’s not what we should be spending our money on.’
Dental regulation is always going to be a divisive topic amongst the profession. The GDC has certainly made huge strides forward recently. But it’s not quite the finished article yet and actions such as reappointing Bill Moyes as chair of the council and maintaining high fees will always have people questioning it.
Whether it be positive or negative, if you have some constructive feedback or suggestions to make, Ian is urging you to let the GDC know in its current discussion phase of Shifting the balance. It is a great opportunity for everybody involved in dentistry to have their say and make their voices heard, and it’s one of those occasions where the GDC is actually listening. Go to the GDC’s website, www.gdc-uk.org, to download your copy of Shifting the balance and let the regulator know what you think.