Health, justice and the BDA
Sophie Bracken talks to Judith Husband about GDC regulation, her long relationship with the BDA, dentistry at Her Majesty’s pleasure and the upcoming EU referendum.
Judith Husband and the British Dental Association go way back. In fact, it’s a relationship that pre-dates the BDA Principal Executive Committee member’s career as a qualified dentist. Judith began her involvement with the association as a student at the University of Liverpool, but, she says, it was ‘purely by accident’.
As a student in the early 1990s, Judith successfully applied for the role of British Dental Students’ Association junior rep for the University of Liverpool, spurred on by fellow students’ assertions that ‘they won’t let girls do it’.
From this early involvement, Judith has been an instrumental force within the organisation on behalf of its members. In particular, as chair of the Education, Ethics and the Dental Team Working Group – a sub-committee of the PEC – Judith is responsible for the BDA’s educational remit.
But her work with students and young dentists goes back to her very first involvements with the BDA, when she aided in negotiations to set up bank loans for dental students. ‘For me it was never just clinical dentistry’ she says. ‘There was always this additional area of help and support, which was fundamentally very interesting, and intellectually stimulating as well’.
Education and ethics
These days, Judith’s role within the BDA is varied, and chairing the Education, Ethics and the Dental Team Working Group keeps her busy. ‘We cover everything to do with postgraduate education – so that’s all foundation training and specialist training – regulation, which of course has really hit the headlines the last couple of years, and ethics. We used to have a separate ethics committee, and pretty early on we started to work very closely with them so joining both those strands has worked very well.
‘We’ve also joined with the dental team committee, which also used to be separate, but joining it all together is helpful, although it gives a very broad remit. In my working group we have representatives of all across the profession, so it’s a very diverse group of individuals.
‘We’ve got dental students, young dentists, hospital reps, General Dental Practice Committee members, members of the community and a lay member…I always like to think of it as a safe place. It’s a place where you can bat around ideas and we can bring our combined intelligence and pieces of information and look at what the broad picture is. There does come a point where we have to distil our themes and the main issues of the day, be it foundation training or currently the GDC, and the wider regulatory environment as well.
‘I report directly to the PEC. They can choose to take our advice or not! We’re a very collegiate organisation. There’s a huge respect for the individuals in my working group and it’s a real privilege to chair it. But it’s never a case of chairing as such, it’s more listening than chairing, it’s a lovely environment.’
Regulating the profession
According to the BDA, the Education, Ethics and the Dental Team Working Group’s recent work has included advising the PEC on General Dental Council underperformance issues. I ask Judith to elaborate on this.
‘The main theme over the last couple of years has been regulation in the sense that we’ve had problems with the GDC’s governance structure. We focus very much on the governance rather than fitness to practise, and I think that’s one of the issues in the profession, that we’re getting a little bit side-tracked in some respects, as they’re two very separate challenges.
‘Our profession has shone a stark light on accountability [of regulators]. We’ve held on to an independent regulator for many years, and yet by that very independence, it means that they’re not answerable. How do we bridge that accountability deficit?
‘The general thrust of the Professional Standards Authority’s report last summer, Rethinking Regulation, was that regulation should be an enabler, and protect patients, but when it goes too far we end up with a situation where we are currently, where regulation is hampering care, stifling innovation and frightening people. That’s no way to work, and it’s no way to provide care for a population.’
But it’s not just the unaccountability of the GDC that is eroding the profession’s trust in regulation. The sheer volume of bodies that dental care professionals are answerable to – the GDC, the Care Quality Commission, NHS England and equivalent organisations in the devolved nations – can be intimidating and confusing. Despite the regulators’ recognition of this, and attempts to address the issue through the Regulation of the Dental Services Programme Board (of which the GDC, CQC, NHS England and the NHS Business Services Authority are members), Judith agrees that the current model of regulation is a negative force within the profession.
‘It’s this multiple jeopardy that’s an issue. The problem is that as the organisations and the legislation have built up and intertwined and multi-layered. It’s unsustainable in the long term. But it’s really really difficult to turn that tide. The legislation is hefty and there are chunks within the Dentists Act that need to be changed, but even getting time for a Section 60 Order in parliament takes years.’
Despite this, Judith has faith in the profession’s members to affect the changes needed to overcome these obstacles. ‘These issues are not insurmountable and I think the solution is to go back down to the basics and decide what we want, and rebuild. Unfortunately, at the moment there’s no confidence or faith in regulation as a whole.’
And so the profession’s eyes are currently on Ian Brack, the new permanent chief executive and registrar of the GDC, who is under close scrutiny as he attempts to win back the confidence of those the GDC regulates. ‘He has a huge amount of work to do’, comments Judith, but she’s hopeful that it can be achieved. ‘I’m a great believer in governance and boards and the responsibilities there. It’s getting that relationship and that balance between the senior management team and board that’s absolutely key. There’s a lot of lost ground to be made up.’
At Her Majesty’s pleasure
We next focus on Judith’s clinical career, a significant part of which has been spent providing dentistry to prison inmates. I’m keen to find out what a typical day in this niche area of dentistry entails.
‘A typical day varies hugely from prison to prison because you have to fit in with the regime’, Judith says. ‘Normally it takes a good 10-15 minutes to get through the prison to our surgery, and there are security checks along the way that restrict us as to what can be brought in. Every prison dental team has to set up a system – you need to know what you start with, and what you finish with is the same, and no bits have gone missing along the way.
‘Patients tend to arrive en masse – you’d get almost the entire session’s worth of patients all at once, which can present a slight stress if you know you have 10 people waiting for you, but it gives the added advantage of knowing who’s turned up. Because believe it or not, failure to attend rates are very high in prison.
‘Sometimes that’s a communication issue, sometimes it’s that wings are on lockdown. And sometimes prisoners just don’t want to turn up! That’s not the day that they fancy having any dentistry done, which is any individual’s right.
‘On the whole the clinical dentistry in prison – especially now compared to 15 years ago – is very much crisis management. It’s emergency care, so good diagnostic skills, good communication skills, and really cutting to the chase with the patients, are important. We always try to have that honesty and trust, which is absolutely key. The actual dentistry is exactly the same [as in general practice]. We work under a PDS agreement, so all the usual NHS rules apply.
‘Consent is always fascinating because there’s lots of non-UK individuals in prison, so we’d have to use interpreters. Also the levels of education and the backgrounds that these individuals are coming from means they’re often not very eloquent. We’d have to change the language that we used. Often we’d see quite, damaged individuals with severe mental health issues as well. So there would be competence issues at times. Although they are adults, it was not unheard for patients to ask, “Will my tooth regrow?”’
Due to the confrontational nature of some prison inmates, Judith believes being able to stand up for yourself will hold any prison dentist in good stead. ‘We all face patients with high expectations trying to force us down a path that perhaps we think clinically isn’t the best. It’s no different in prison. You’d get the threat of solicitors and things like that. So I would give them my name and address, and say “I look forward to the letter”.
‘Standing up to people is important. You very quickly get a reputation in prisons because they’re small, closed communities and word travels. I treat everybody evenly and fairly, which is what we should be doing anyway.’
Prevention in prison
As Judith previously noted, the majority of clinical work in prison is ‘crisis management’, but she ventures that ‘just sitting and filling teeth is not going to solve the wider problem’. Often Judith’s prison dental team would train prison officers to not only spot the most chronic cases, but to pass on oral healthcare messages to inmates.
‘The guys that we’d treat – it’s not just them we were treating. They have families, many of them were dads. It was a real opportunity to sew that preventive message far and wide. The more opportunities to deliver that message and the more messages got through the better. I think that’s something we should be taking out into the community more as well.
‘And of course prison dentistry doesn’t work in isolation, you’re still referring to the same pathways as GDPs, so if that work isn’t being done in the prisons it’s clogging up the wider NHS dentistry service and hospitals, and so what goes on in jail matters outside. It shouldn’t be isolated, because the whole of dentistry is an interlinked mesh, as we’re seeing with referrals for kids’ general anaesthetic in hospitals. Additional things can add pressure.’
With that in mind, I ask Judith if she thinks NHS England is doing enough to promote prevention in prisons, and in other institutions such as schools and care homes.
‘Absolutely not’, she says. ‘Unless we invest financially in prevention and the preventive message, it’s not going to get through. The amount of prevention we used to do 10 years ago compared to this year has dropped significantly, mainly because clinical demand had overtaken our physical time. We had to devote every minute that we were there to seeing patients because the numbers had grown, their needs had grown, and yet there’d been no change to the number of hours or the service that we could provide.
‘There’s been some interesting talk about the potentials for the new GDS contract and looking after a population that perhaps would extend out to the wider community. That’s the ideal, but will it actually be funded? It takes a lot of time to do it well.’
But surely the government is recognising the importance of the health of the of UK’s prison population, as evidenced by its plans to roll out a smoking ban in prisons across England and Wales. Despite the smoking ban’s intentions, Judith is sceptical that it will be implemented at all.
‘Bearing in mind that illegal drugs are illegal, they are still freely available in prison’, she says. ‘There have been a number of minor prison riots that have stemmed from the smoking ban. I suspect that there will be a very slow, quiet slide to let it go. They don’t have the staff and they can’t put everybody in the segregation unit for lighting up a cigarette. And the vast majority do smoke. If it’s going to be brought in, then it needs to be supported with the staff on the wings.’
A sign of things to come?
Judith has recently ceased providing clinical care in prisons, although she still provides service reviews and consultancy advice. I’m curious to know why she is finished with prison dentistry – at least for the time being.
‘I was on a time limited PDS contract. New providers were awarded the contract and I decided on balance not to continue clinically at this time. It’s becoming a very challenging environment. It always has been challenging clinically, but politically, and with the underfunding, there have been profound changes in the actual contracting models used. Also, very large organisations are coming in, such as Care UK and Virgin.’
The tendering of care contracts is a provision that is gaining momentum in all aspects of healthcare, and could well reflect the future of the wider NHS.
Judith says: ‘One of the first areas for competitive tendering to be introduced in dentistry was in prison dental care back in 2005/6. Over the years the commissioning model has evolved to favour very large healthcare providers, limiting opportunity for individual dentists and practices to bid.
‘We now have many prison healthcare services (including dentistry) provided using the model. It’s a measure of commissioning care that – with the additional strain on NHS England – commissioners could find attractive. Just having one large overarching contract and the holder of that then being responsible for everything underneath takes a lot of the daily and year-end contract management away from the commissioners.
‘We’re looking at teams that have shrunk massively over the last few years and we’re likely to have further cuts in the future from NHS England’s side, and the same in Health Education England. If we look at social care where a similar approach was taken with care for the elderly as a classic example, we then end up with a situation where providers are too big to fail.
‘So this whole concept of a competitive market and driving up improvement, “stabilising costs” – that’s actually lost. As soon as you get major players in any market, they become dominant and they will ultimately dictate. So I’m not really sure how they’re going to manage that competing demand.’
As we move on, I’m keen to hear Judith’s views on the forthcoming EU referendum. What impact does Judith think a potential ‘Brexit’ would have on the provision of dentistry in the UK, if any?
‘I don’t think we know how exiting [the European Union] will affect the country, let alone dentistry’, she says. ‘But I will be voting to remain. If you ask me the reasons why they become quite complex and a bit wooly. But they fundamentally come down to the way I identify myself, which is as a European – more so than as British or English. I’m also very supportive of human rights legislation.
‘With respect to how it will affect dentistry, we don’t know. A lot of our regulation here is interpretation of EU legislation. If we look at the regulation of dentistry across Europe, it’s very different to here. That’s very much a local issue. Voting exit won’t get rid of the GDC!
As we draw our conversation to a close, I ask Judith what what her main professional focus is.
‘I’m always trying to get across to dentists that we are the BDA; it’s not a building, it’s not the PEC. And to get involved. I’m very worried that younger people are not getting involved. What will we be left with? It’s about taking control and being active and informed. I’ll keep on banging the drum.’
Judith Husband is a clinical dentist, formerly working in secure setting dental care. She sits on the BDA PEC and is chair of the association’s Education, Ethics and the Dental Team Working Group. She is also a member of the Wesleyan Advisory Board and chair of the Oxfordshire Local Dental Committee. Judith has a wide experience of healthcare reforms, liaising with significant stakeholders and keeping up to date with changes throughout healthcare, in particular NHS dentistry. Contact Judith via Twitter @Judith_Husband.