Advicesheet

Ethics in dentistry

B1

Advicesheet

Ethics in dentistry

B1

contents
The duty of care and professional obligations Professional regulation and registration The patients best interests Equal treatment and human rights Professional competence and experience Lifelong learning Clinical audit, peer review and clinical governance Professional indemnity/insurance Revalidation Checklist Consent Key definitions The need for valid consent Obtaining consent Material risks Consent under duress Treatment at the patients request Making claims Battery The age of consent Children in care Incompetent patients Where consent is not obtainable Clinical trials, research and lectures Consent forms Checklist Confidentiality What is personal health information Data Protection Act 1998 Age of consent to disclosure What information can be disclosed Training and disciplinary procedures Checklist Model confidentiality policy Data protection code of practice
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6 6 6 6 7 7 8 8 8 9 9 9 10 10 12 13 13 14 14 14 15 15 15 17 18 18 19 19 20 20 21 24 25 25 27

This advice sheet provides detailed, practical advice and information on the major aspects of ethics in dentistry. The sections are:

contents
Dental records Good record keeping practice Storage, retention and disposal Fair processing Subject access Third party access Sale/transfer of records Checklist Patient care Patient communication Agreeing to provide care and treatment Patient choice Treatment planning Health checks Alternative therapies Non-surgical cosmetic procedures Tooth whitening Medical emergencies Misleading patients Maintaining appropriate boundaries Referral fees Missed appointments Debt collection Handling complaints Checklist Professional relationships Professional agreements Duties of a dentist manager Second opinions Raising concerns Specialist practice Veterinary dentistry The death of a dental practitioner Checklist Commercial interests Financial interests Advertising and canvassing Shared arrangements with other health professionals Buying, selling or closing a practice Bodies corporate and limited liability partnerships Practices owned by dental care professionals Promotion of products and services Private dental plans Bankruptcy Checklist

page
29 30 31 32 32 33 34 35 35 35 36 37 37 37 37 38 38 38 38 39 39 39 39 40 41 41 41 41 42 42 43 43 43 44 44 44 45 45 45 46 47 47 47 48 48

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Child protection Types of abuse Practical steps Recording and reporting Child protection policy Criminal record checks Further information Checklist The dental team Vicarious responsibility Dental hygienists and dental therapists Dental technicians and clinical dental technicians Dental nurses Dental receptionists Training Terms and conditions of service Staff management and appraisal Checklist General anaesthesia and sedation General anaesthesia Conscious sedation Conscious sedation in Scotland Alternative techniques Consent Checklist of ethical principles Dentists Health Support Programme BDA Benevolent Fund

48 48 49 50 51 52 53 53 53 53 53 54 54 54 54 55 55 55 55 55 56 58 58 58 59 61 62

The guidance gives members essential advice on ethical issues that will enable them to practise safety and in accordance with high standards of professional conduct and behaviour. The BDA is able to provide ethical advice and support to members, contact practicesupport@bda.org or telephone 020 7563 4574. Dentists are facing greater demands from patients, regulators and NHS commissioners. Cases going before the General Dental Council are rising and dental negligence claims are also becoming more common. In order to manage these risks successfully, dentists need to ensure that they understand and keep up-to-date with changing professional regulations and are fully conversant with what is expected of them. Use these advice booklets as reference documents and in conjunction with guidance issued by the General Dental Council (www.gdc-uk.org).

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This section gives an overview of the main obligations of a dentist and covers: Professional regulation and registration The patients best interests Equal treatment and human rights Professional competence and experience Lifelong learning Clinical audit, peer review and clinical governance Professional indemnity/insurance Revalidation Checklist Until recently, dentists had a professional monopoly, being the only individuals who could carry on the business of dentistry, that is, profit directly from dental practice. This changed in 2006 with amendments to the Dentists Act and the opening of the Dental Care Professionals Register. Since then, all GDC registrants can own dental practices. It is now also possible for non-dentists do be involved in an incorporated dental practice as long as the majority of directors of the company are GDC registrants. Dentistry is a self-regulated profession, which means that the General Dental Council determines the standards against which dentists are judged. As is the case with all health care professionals, dentists must retain public trust and confidence, both as individuals and in the profession as a whole. Complying with certain fundamental principles, which are the basis of sound ethical practice, will ensure that dentists continue to maintain their status as respected professionals: Acting in the patient's best interests and respecting their dignity and choices Communicating with patients and listening to their concerns Obtaining consent to treatment and keeping personal health information confidential Complying with the rules and regulations that apply to dentists Providing patients with the best possible clinical outcomes Being trustworthy Keeping their skills and knowledge up-to-date Co-operating with other members of the dental team and other health professionals in the interests of patients. In some circumstances these principles can place great demands on dentists and this section identifies some of the issues involved. The GDC has a set of standards guidance booklets with which all registrants must familiarise themselves. These are available on their website at www.gdc-uk.org. A dentist must act in the patients best interests and provide a high standard of care and service. Acting in a patients best interests can be interpreted widely but includes: Providing appropriate, necessary care and treatment to a high standard Not misleading patients Putting the patients needs first Treating the patient regardless of race, sex, religion, sexual orientation, social class, medical or dental condition or disability Providing information that is necessary for the patient to make an informed choice about care Providing care in an emergency and out of hours.

The dentists duty of care and professional obligations

Professional regulation and registration

The patients best interests

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Complying with these rules can be difficult, particularly where financial constraints mean that dentists are not always able to spend enough time with their patients. Communication failures can mean that dentists can inadvertently mislead patients about the type or quality of care they can expect, and this is a particular danger in dental advertising. Sometimes, the patients and dentists perceptions of what is an acceptable standard of care can differ, for example in what constitutes a dental emergency. Equal treatment and human rights The Human Rights Act came into force in October 2000. The Act makes it unlawful for the human rights of individuals (as defined by the European Convention) to be infringed by public authorities, which includes NHS organisations. The effect of the Act is to allow individuals to pursue public authorities in the UK courts rather than having to go to the European Court. The Act covers issues such as consent to treatment and physical restraint of patients. Dentists must not undertake procedures for which they are not competent or do not have appropriate experience. Asking for help from colleagues or ceasing treatment and referring a patient to another practitioner can be difficult, but is always a wise course of action. Inexperienced dentists particularly can encounter difficulties undertaking complex procedures and, although many problems are solved during vocational training, sometimes they continue in practice, resulting in great stress and loss of confidence for the dentist and potentially harm to patients. Help is available from postgraduate dental deans, dental schools, General Dental Practice Advisers to PCTs/Health Boards and professional organisations. Contact the BDA Practice Support on 020 7563 4574 or email: practicesupport@bda.org for further information. Unsatisfactory treatment or failure to provide treatment without adequate skill and care can lead to civil cases of negligence, disciplinary proceedings by PCTs/Health Boards, referral to an NHS Tribunal or allegations before the GDC of unfitness to practise. Where dentists encounter colleagues in this situation they have a professional duty to raise their concerns with an appropriate individual. Dentists responsibilities in this regard are discussed on page 42. Lifelong learning Dentists are expected to undertake continuing postgraduate development (CPD) by attending relevant courses, reading professional journals and making use of other educational resources such as videos and CD-ROMs. This activity will generally ensure that a dentist is kept up to date with changes in clinical techniques and is able to adapt their practice accordingly, maintaining professional standards. Individual dentists also benefit in achieving greater satisfaction from their work, contact with professional colleagues, building a good professional reputation amongst patients and peers and being able to prevent and defend complaints. GDC registration includes participation in its CPD scheme, whereby registrants are required to undertake a minimum number of hours (250 for dentists, 150 for DCPs) to show that they are keeping up to date. The GDC also requires all registrants to undertake CPD in a number of set core subjects: medical emergencies (ten hours per cycle), disinfection/decontamination (five hours per cycle), and radiological protection (five hours per cycle). Registrants should also keep up to date with ethical and legal issues. Short postgraduate courses are organised by postgraduate dental deans, specialist dental societies, the BDA, the Faculty of General Dental Practice (UK) and commercial organisations. Information on courses is available from the BDA on request. Dental schools, the Royal Colleges and other bodies also award postgraduate qualifications. Information on postgraduate courses is available from the BDA's Education Team.
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Professional competence and experience

Clinical governance is the name for quality assurance within the NHS. An overall clinical governance system is in place throughout the NHS, but a specific framework has also been developed for dental practice. PCTs are using this framework to assess dental practices locally and to ensure that procedures are in place to comply with the wealth of legal requirements governing health. The practice framework is subdivided into twelve distinct areas, ranging from infection control, radiation, patient safety through child protection, consent, confidentiality, staff development and patient involvement to clinical audit and peer review. The BDA has a clinical governance kit which provides all relevant policies and models to comply with the requirements. Clinical audit and peer review are an integral part of clinical governance. Reviewing treatment outcomes either through individual assessment or on a group basis is fundamental to modern ethical practice. PCTs take varying approaches to these activities; some require the practices to carry out audit projects on set subjects, whereas others expect practices to choose their own. The BDA has an Advice Sheet E10 CPD, clinical governance, audit and peer review and a number of sample audits on its website. Dentists must have appropriate professional indemnity/insurance cover to undertake any form of practice. The cover may be in the form of membership of one of the dental defence organisations or insurance with a company that offers an appropriate level of cover to protect patients and the dentist. Currently there are three defence organisations in the UK; some, such as Dental Protection and the Medical and Dental Defence Union of Scotland, offer indemnity cover, while the Dental Defence Union offers cover underpinned by an insurance policy. Indemnity cover is discretionary so that they do not guarantee to cover claims. Indemnity covers occurrences within the period that a dentist is a member, even if they are no longer a member when the claim is made. This is occurrence-based cover. Medico-legal insurance guarantees to cover the insured up to the limit of the policy provided that the claim falls within the scope and conditions of the policy and is within the policy period. The company will cover on a claims-made basis, that is the dentist will be protected against claims made during the policy period and matters arising out of the dentists clinical relationship with patients occurring whilst the dentist is insured. If a dentist discontinues a policy and wishes to be covered for the period of insurance, run-off cover must be purchased. When choosing appropriate cover, dentists should consider whether the proposed cover meets their current and future practising needs, will provide help with proceedings by the General Dental Council as to matters of professional conduct and health and provides suitable professional support that is appropriate to their practice. It should be noted that sometimes defence organisations will terminate the membership of dentists following a GDC case or will require the member to pay a higher membership fee. For more information see BDA Advice Note Professional indemnity cover. The GDC is committed to introducing a system of revalidation, in which registrants will have to demonstrate that they are fit to stay on the register. There is no definite timescale for this, but plans for pilots are well advanced. Revalidation will include continuing professional development, but will also look at other professional achievements and activities of registrants, such as compliance with clinical governance and further postgraduate qualifications. These positives will be counterbalanced with any negatives, for example high numbers of complaints or an appearance before the GDC. It is also expected that appraisal will play a part. The vast majority of all registrants will be able to show their fitness to remain registered, but, where there is a case where
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Clinical audit, peer review and clinical governance

Professional indemnity/insurance

Revalidation

questions remain, the GDC will be able to take further steps, for example an inpractice assessment or a full assessment through the National Clinical Assessment Service (NCAS). Checklist Always act in a patients best interests be familiar with the GDCs Standards for dental professionals guidance and supplementary booklets (Principles of dental team working, Principles of patient consent, Principles of patient confidentiality, Principles of raising concerns, Principles of complaints handling, Principles of management responsibilities, Conducting clinical trials, Responsible prescribing, and Child protection) Only undertake procedures for which you have the necessary training, competence and experience Undertake continuous postgraduate education and comply with clinical governance arrangements Obtain and keep up appropriate professional indemnity/insurance cover.

Consent

The law on consent is subject to change and further specific advice should be obtained from BDA Practice Support on 020 7563 4574 or practicesupport@bda.org. This section gives general guidance on the dentists responsibility to patients to obtain consent to examination and treatment. It is not intended to be comprehensive, but it contains sufficient information for dentists to gain a general understanding of a complex subject. The case law on medical consent is constantly developing and advice should be sought from the BDA/defence organisation when particular problems arise.

Key definitions

Express consent A patient gives express consent when he or she indicates orally or in writing consent to undergo examination or treatment or for personal information to be processed. Implied consent In very limited circumstances consent may be implied. An example is where the patient indicates agreement to an examination by lying in the dental chair and opening their mouth. Consent to other types of dental procedures cannot normally be implied from compliant actions; an open mouth does not necessarily mean that the patient has understood what the dentist has proposed to do or the reasons why. Informed consent Informed consent requires a full explanation of the nature, purpose and material risks of the proposed procedures, and the consequences of not having the treatment, in language that the patient can understand (using an interpreter and visual aids where necessary). The patient should have the opportunity to consider the information and ask questions in order to arrive at a balanced judgement of whether to proceed with the proposed treatment. Specific consent Specific consent means that the patient consents expressly to each of the procedure(s) to be undertaken. An agreement to undertake a course of treatment without knowing what is to be done is not specific consent. For example, obtaining a patients informed consent to sedation does not mean that the patient has given specific consent to the treatment that will be carried out.

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Valid consent For consent to be valid it must be specific, informed and normally be given by the patient or a parent or guardian (if the patient is under 16 and is unable to give informed consent). A dentist has a legal requirement to obtain the valid consent of the patient to the treatment proposed. Before carrying out an examination or treatment, valid consent must be obtained. For consent to be valid, the patient giving the consent must be: 1. Competent to give it 2. Adequately informed of the nature of the procedure that is being agreed to and 3. In a position to give consent freely. The need to obtain a patient's informed consent arises from the moral obligation and ethical principle to respect a person's autonomy and right to selfdetermination. Any treatment or intentional physical contact with the patient undertaken without valid consent may amount to assault and a breach of the patients human rights. A court may award damages for assault and the General Dental Council considers that assault or treatment without consent can amount to serious professional misconduct. Consent should be regarded as an ongoing process rather than a specific event and is another instance where effective communication between dentist and patient is vital. Refer to the GDCs guidance in Principles of patient consent (www.gdc-uk.org) Who can obtain consent? Consent for examination and treatment must be obtained by a dentist (normally the dentist who is undertaking the treatment). In no circumstances should the obtaining of consent to treatment be delegated to staff, although they may be extremely helpful in reinforcing the information that has been given. For treatment undertaken by a dental hygienist or dental therapist, the prescribing dentist should obtain consent and the treating professional should check before it is done that the patient is still content for the treatment to be carried out. Who is competent? This is a question of fact in every case and requires that the patient is able to understand what is involved in the procedure. The patient must be able to (i) comprehend and retain the relevant information, (ii) believe it, (iii) weigh in the balance so as to arrive at a choice, and (iv) communicate their decision (whether by talking, using sign language or any other means). The patient does not have to make a mature or wise decision, nor do they have to achieve the unattainable, such as fully appreciating the consequences of the decision. The law will not impose unreachable expectations about a patients reasoning powers and experiences. A patient must be able to understand what is wrong, that it requires treatment and the consequences of undergoing or declining treatment. An assessment of whether a patient is able to consent should be carried out before any dental care or treatment. Obtaining consent The need for valid consent

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Express and implied consent

Consent may be express or implied. An example of implied consent for an examination is when a patient makes an appointment and presents for examination. Consent to other types of dental procedures cannot normally be implied from compliant actions - only in very limited circumstances consent may be implied. Express consent may be given orally or in writing. Oral consent would normally be adequate for routine treatments, such as restorations and prophylaxis, provided that full records are maintained. Written consent is necessary in cases of extensive intervention and essential where a general anaesthetic or conscious sedation is given (see pages 55 and 56). Specific consent The precise nature of the treatment to be undertaken must therefore be explained clearly and in terms that the patient can understand. Asking whether the patient has understood or whether more information is needed is useful, as is, where possible, providing supporting written information. Aids such as radiographs, photographs and models can be helpful in discussions as well as books such as the BDAs Pictures for patients portfolio. Going beyond the consent that has been given It must not be assumed that, because consent has been obtained for one procedure, it is implied for an alternative or subsequent treatment that may become necessary. Consent must therefore be appropriate and the changed circumstances must be explained to the patient and specific consent sought. The best interests of the patient are of course paramount and if, while under a general anaesthetic or sedation, it becomes clear that further treatment of complications is absolutely necessary, it would be reasonable to proceed, provided that the dentist is willing to be accountable for his/her actions in the patient's best interests. Where it is anticipated that this situation is likely to occur, the dentist should obtain prior consent to treat such problems that might arise. As soon as the patient is sufficiently recovered to understand, the treatment actually provided must be fully explained together with the reasons for undertaking it. Restricted consent Sometimes patients will consent to part of a treatment plan but withhold consent for treatment that may become necessary so that the procedure can be given further consideration. Such instructions must be fully documented and the patients wishes must be followed. Informed consent The dentist should endeavour to assess how much the patient wants and ought to know about the condition and its treatment. The patient's comprehension is an essential element in the validity of consent and the onus is on the dentist to be satisfied that the patient has understood the treatment to be carried out and the consequences of not having the treatment. Alternative treatments which may be available and their likely prognosis, any material risks involved in each option, methods of pain control to be used and any aftercare or precautions which may be necessary all form a vital part of the explanation leading to full comprehension and an informed choice by the patient. When all of these components are present a patient may have been judged to have given informed consent.

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During the discussion about proposed treatment, the dentist should not make assumptions about patients views but ask whether they have any concerns about the proposed treatment or its risks. Engaging in open and helpful dialogue takes up clinical time but, as well as satisfying a dentists ethical and legal obligations, it increases the quality of care that is provided.

Material risks In deciding which risks are material and should be explained, a practitioner will rely on professional judgement, but must warn patients of any substantial or unusual risks involved and of consequences which may be slight but which commonly occur. Examples include the possibility of nerve damage in oral surgery procedures, perforation or instrument breakage in endodontics, and crown and bridge failures. To what extent risks must be described to patients is influenced by public and professional expectations and dependent on case law. Some of the relevant cases in the fields of medical negligence and consent are described below. Bolam and Sidaway In Bolam v Friern Hospital Management Committee (1957) it was held that a doctor should not be found guilty of professional negligence if a reasonably competent doctor in a similar position would have acted in the same way and the actions would have been supported by a responsible body of medical opinion. This is known as the Bolam test. Applying the Bolam test to dental consent means that a dentist would not be found guilty of failing to warn a patient of a material risk if a reasonably competent dentist in similar circumstances would not have warned of the risk and that decision would have been supported by a responsible body of dentists. The Bolam test was affirmed and extended in the Sidaway v Board of Governors of Bethlem Royal and the Maudsley Hospital case (1985) where the House of Lords held that a decision on the degree of disclosure of risks that is best calculated to assist a particular patient to make a rational choice must primarily be a matter of clinical judgement and that the attention of a patient should be drawn to any danger which may be special in kind or magnitude, or special to that patient, with sufficient information being provided to enable the patient to reach a balanced judgement. In deciding on whether to warn of a particular risk, the Sidaway judgment held that the health professional must take account of all of the relevant factors such as the severity of the risk to the patient and the likelihood of the risk, as well as the patients specific need for the procedure. Where risks could result in grave and adverse consequences to the patient (referred to in the judgement as substantial risks), the dentist has a duty to inform the patient of them even if a substantial body of dental opinion would not have done so.

Increasingly, the legal profession, the public and health care professionals expect that patients are informed of all of the risks that apply to proposed treatment, not just those that a responsible body of medical opinion would have warned them of. While the Bolam test is still of importance in the UK courts, recent judgments in Ireland and the UK have challenged it.

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Bolitho v City and Hackney Health Authority (1997) The Bolitho judgment involved the issue of causation in medical negligence and refined the Bolam test of the practitioner being able to rely on what a responsible body of medical opinion would have held to be correct. Although the judgment specifically excluded the issue of disclosure of risks to patients when obtaining consent, subsequent consent cases have referred to it (see below). In the judgment, the Law Lords found that a practitioner who is alleged to have been negligent by omission could not rely on evidence that a body of medical opinion would have omitted to act in the same way. In the circumstances that the claimant and defendant call expert witnesses (as was the case in Bolitho), reliance could only be placed on opinion that was sensible in that it had a logical basis. Bolitho has been used in the case of Pearce v United Bristol Health Care NHS Trust (1999). Pearce v United Bristol Healthcare NHS Trust (1999) In this case a female patient was not warned of a one or two in a thousand risk of stillbirth in a delayed delivery. The body of medical opinion brought by the defendants concluded that the risk was not significant. The Court of Appeal held that a doctor must take account of all relevant circumstances when deciding how much information to give, including the patients ability to understand the information and emotional and physical state. The court held that it was for the court and not for doctors to decide on the appropriate standard of what should be disclosed to a particular patient about particular treatment. It would normally be the legal duty of a doctor to advise the patient of any significant risks that may affect the judgement of a reasonable patient in making a decision about treatment. In summary, the court decided that if there is a significant risk which would affect the judgement of a reasonable patient, then in the normal course it is the responsibility of a doctor to inform the patient of that risk if the information is needed so that the patient can determine for him or herself as to what course he or she should adopt. On the facts in this case the court held that the risk of stillbirth was not significant and it was not proper for the court to interfere with the clinical judgment of the doctor. Consent under duress Consent is not valid if it is obtained under duress. The consent must be given voluntarily and freely. Claims of lack of voluntariness do not, for the most part, involve brute force or duress. The courts wish to ensure that patients are not unduly influenced if it is deemed that patients have not given consent voluntarily, the consent will not be valid. It has been argued in Court that consent could never be given voluntarily where the patient is a prisoner and the doctor was also a prison officer. This argument was rejected by the Court of Appeal. Care should be taken in obtaining consent in the presence of third parties, including family members, that confidential information is not disclosed without the patients prior authorisation and that third parties are not unduly influencing the patient to consent. Treatment at the patients request Cases arise where patients ask a dentist to undertake treatment that is not in their best interests and is against the dentists clinical judgement, for example, removal of healthy teeth, crown and bridgework instead of extraction and dentures or dental implants (where these are not clinically advisable). In these situations, dentists still have responsibility for the clinical treatment provided and always to act in the patients best interests. Treatment should not be
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undertaken if it will cause permanent damage to the dentition or will be of no clinical or cosmetic benefit. If the treatment fails, the patient may seek damages for negligence or a refund of treatment costs. In these events it can be difficult to establish that treatment was undertaken with the required skill and care. Obtaining a signed statement from the patient instructing the dentist to carry out the treatment and absolving the dentist from any stated adverse consequences may not be a valid defence in court or before the General Dental Council. Finally, dentists should be careful that the claims they make for a particular form of treatment can be substantiated and that they do not unrealistically raise their patients' expectations of the benefits or results of particular treatments. In dentistry, it is also essential that the patient understands and agrees to the costs involved and is clear whether treatment is being provided under the National Health Service or privately (see page 36). To undertake treatment without the consent of the patient constitutes an assault on that individual and could render the dentist liable to an action in battery even if the treatment were not performed negligently. The practitioner would be liable in battery for failing to obtain consent at all, or failing to ensure that the patient understood even in broad terms the nature of what was proposed. The fact that the patient, if asked, would probably have consented to the procedure is no defence. Even where consent has been sought, the practitioner could still be liable in negligence for failing to give adequate information as to the risks involved in the procedure or the possible alternatives. There is also a possibility of action under the Human Rights Act 1998 where the dentist is providing NHS care. Further information on the implications of the Act is available from BDA Practice Support on 020 7563 4574. . A person who has reached the age of 18 and who has the capacity to reach decisions on their own behalf is a competent adult and can give or withhold consent. Capacity will necessitate being able to understand, believe and retain the information provided about treatment and having the ability to weigh up the information in order to choose whether or not to proceed. No-one else is able to consent for a competent adult. The Family Law Reform Act 1969 provides that any person age 16 years or over and of sound mind may legally give consent to any surgical, medical or dental treatment. A parent theoretically could lawfully consent to treatment of a child who is refusing consent, but a parent cannot overrule such a childs consent to treatment. Best practice would be to make an application to court where parents are prepared to consent but a child is capable of understanding what is involved and is refusing to consent to some major form of treatment. Children under 16 who are of sufficient maturity and intelligence to understand fully the nature of the treatment proposed and its ramifications are also entitled to give consent to treatment. This is known as Gillick competence after the 1985 case of Gillick v West Norfolk and Wisbech Area Health Authority where the Law Lords ruled that a child under 16 was able to consent if he or she understood the nature of the treatment, its purpose and hazards. It will ordinarily be for the practitioner to decide whether the child satisfies these criteria of competence. The ability of a child to understand will depend on the childs age, maturity and the proposed treatment. For example, a twelve yearold child might be able to give consent to a dressing, but may not be able to consent to an extraction. A parent can lawfully consent to treatment of a Gillick competent child who is refusing consent, but a parent cannot overrule a Gillick competent childs consent to treatment. Making claims

Battery

The age of consent

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The Children Act 1989 reinforces the right of a child with sufficient understanding to make an informed choice to refuse to submit to examinations or treatment. But if a child aged 16 or 17 refuses treatment, this will not override parental authorisation. Alternatively, where parents refuse treatment that is in the childs best interests, a court can be asked to make an order for the treatment to be carried out lawfully. More than one person may have parental responsibility for the same child at the same time. Where more than one person has parental responsibility, each may act alone and without the other. In the absence of agreement by all those with parental responsibility, the specific approval of the court must be obtained if the treatment involves an important decision. The following have parental responsibility: the childs father and mother, where they were married to each other at the time of birth; the childs mother but not the father where they were not so married, unless the father acquires parental responsibility either by order of the court or pursuant to a parental responsibility agreement with the mother; a person appointed as the childs guardian and a person in whose favour the court makes a residence order with respect to the child. Where a child who is unable to consent is accompanied by an adult relative without parental responsibility and consent from the parent has not been obtained, the adult cannot give consent to the treatment. If the parent cannot be contacted then treatment should only proceed in exceptional circumstances, for example where the child is in pain and the treatment is undertaken to alleviate it. In Scotland, the Age of Legal Capacity (Scotland) Act 1991 is specific and provides that a person under 16 who, in the practitioner's opinion, is capable of understanding the nature and possible consequences of the procedure or treatment shall have legal capacity to consent on his or her own behalf to any surgical, medical or dental procedure or treatment. In Northern Ireland the age of consent for medical and dental treatment is 16. Children in care Where a child is taken into local authority care, the local authority may acquire parental responsibility in addition to the child's natural parents. If the child is in care, usually the dentist can obtain consent from an authorised representative of the local authority. Where a major surgical procedure is involved, however, the consent of the parents would usually be sought as well. In the case of children under 18 who are wards of court, the consent of the court must be obtained before any major intervention can take place. Incompetent patients are those who, for reasons of mental incapacity or illness, cannot give informed consent to treatment on the basis of full understanding of the need for, nature of and consequences of treatment proposed. Not all mentally ill or incapacitated patients are incompetent. But in the case of minors, the informed consent of the parent or guardian should be obtained. Full details of the law regarding consent and mental incapacity is available in a BDA Advice Note Assessing mental capacity. Where consent may not be obtainable, for example in cases of incompetent adults, unconscious patients or an emergency, the same basic principle applies: the professional has a duty to make up their own mind and to act in the best interests of the patient, taking a second opinion where necessary. In cases of unconscious patients, a practitioner should carry out only that treatment which is necessary and should await such time as the patient is able to consent before undertaking further procedures. Consultation with the next of kin is advisable.

Incompetent patients

Where consent is not obtainable

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Notes must be made in the patients clinical record to explain why consent was not obtained, to record the second opinion that was given, and include any other views that were sought. In the case of both minors and people with mental incapacity, a patient may be competent to consent to some treatments but not to others. Some patients with mental illness may be competent to consent at some times and not at others. The dentist's responsibility with regard to confidentiality should also be borne in mind in these cases. Where patients are detained under the Mental Health Act 1983 without their consent, treatments can be performed without consent if the treatment is for the mental disorder and as such the normal rules for obtaining consent should be followed for dental treatments. The courts have extended this to allow treatments to be performed without consent that are unrelated to the mental disorder but which could cause the patients mental health to deteriorate. Decisions made by the Court of Protection The Court of Protection is the final arbiter in relation to the legality of decisions concerning patients who do not have capacity to consent. In addition to adjudicating in relation to specific, one-off decisions, the Court will have the power to appoint deputies to assist with continued decision making. Although health care decisions can be lawfully made without a deputy, they can be useful where there are disputes over care and treatment Lasting Power of Attorney Individuals over the age of 18 who are competent can nominate another person to make health care decisions on their behalf when they lose the capacity to make such decisions. The person nominated is known as having a lasting power of attorney (known as a welfare power of attorney in Scotland). Independent mental capacity advocates For incompetent adult patients who lack any form of external support in relation to serious treatment and there is no-one close to the adult to provide advice or guidance, including an attorney or deputy, then the services of the Independent Mental Capacity Advocate can be engaged. This service will only be available in the case of a single treatment being proposed where there is a fine balance between its benefits to the patient and the burdens and risks it is likely to entail, or what is proposed would be likely to involve serious consequences for the patient. Advance statements or directives to refuse treatment People over the age of 18, who are competent, are able to make advance statements that they refuse a particular type of medical treatment (which will include dental treatment) if they lose capacity. If a patient is incapable of consenting, the dentist must ensure that the advance decision exists and is valid. The advance statement must refer to the particular treatment in question and should explain the circumstances to which the refusal applies. It is only possible to make an advance refusal of medical treatment. A person cannot make an advance request for treatment.

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Clinical trials, research and lectures

Research should not be carried out on patients without specific consent given on the basis of a full understanding and explanation of the research and its possible effects. Participation of a patient in research must be voluntary and recorded. The same rules regarding age of consent and capacity to consent apply in the case of research. Research protocols should always be submitted to the appropriate Local Research Ethics Committee and a consent form devised which is specific to the procedure. Guidance is available from the National Research Ethics Service at www.nres.npsa.nhs.uk Where a dentist wishes to use photographs or other images of patients in clinical lectures, papers, videos or presentations, consent should also be obtained. Consent for records-based research Wherever possible, where research is being undertaken using data taken from patients records, explicit consent must be obtained from the patient. If this is not possible, because of the cost and time involved, the data must be encoded or anonymised as early as possible within the data processing. If it is anticipated that this type of research will be undertaken, then this should form part of the stated purposes for which data might be disclosed and information should be included in the practices data protection policy (see the BDA Practice Compendium for a model). Any research that is carried out must be approved in advance by the Local Research Ethics Committee/Multi-Centre Research Ethics Committee. The Medical Research Council has issued guidance on the use of personal information in research

Consent forms

Model consent forms are available for use in general dental practice and the hospital and community dental services. Signing a form, however detailed and specific, is no substitute for the communication between dentist and patient that is the essential component in obtaining valid consent. Forms have a place in recording consent and in some cases (for example general anaesthesia/conscious sedation, extensive or expensive treatment) are a professional requirement. Salaried services: The Department of Health in England has published a consent form (available in a number of languages) to be used for medical or dental investigation, treatment or operation and one to be used for mentally incapacitated patients). The form emphasises the patients right to a full explanation of the proposed treatment, the right to ask questions and the right to be accompanied by a relative, friend or nurse. It also states that the patient may refuse or withdraw consent. General practice: Copies of treatment plans and estimates may be used to record consent, provided that they accurately reflect not only that the patient has agreed to the proposed treatment, but that the necessary explanations have been given and incorporate a signature. A suggested model form for use in extensive intervention is given below and is available in the BDA Practice Compendium.

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Valid consent is informed and specific Informed consent means that the patient understands the proposed treatment, its purpose, alternatives, material risks associated with it and the effect of not having it done Consent to treatment must be obtained by the dentist treating the patient Consent may be express (that is given orally or in writing) or implied (by compliant actions) Children aged 16 or over may consent to treatment although younger children who are Gillick competent may also do so The most important aspect of consent is communication between dentist and patient. Signing a consent form is of secondary importance although it is compulsory when general anaesthesia or conscious sedation are undertaken.

Checklist

Model consent form for treatment (without sedation) Name of patient. Name of parent or guardian (if applicable).. Address.

1. I hereby consent to undergo (or to .. undergoing)* the following dental treatment.. as explained to me by Dr/Mr/Mrs/Ms/Miss* (name of treating dentist) who has explained the nature of the treatment, its purpose, risks and alternatives to me. I have been given the opportunity to ask questions. I understand that should any change in this treatment be required, it will be explained to me and my specific consent obtained. Treatment :

2. I understand that the cost of the treatment will be

Signature_______________________________ Date__________________ (Patient/parent/guardian)*

I confirm that I have obtained a full medical history and explained to the person who signed the above form of consent, in terms which in my judgement are suited to his/her understanding, the nature, purpose, risks and alternatives of this treatment and that the anaesthetic techniques and usual pain control procedures have also been explained to him/her.

Signature_________________________________Date__________________ Name____________________________________ (Dental practitioner) *Delete whichever is inapplicable

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4. Maintaining confidentiality

Dentists have a professional and common law duty to keep confidential all personal information gained about patients in the course of their professional relationship. The patient-dentist relationship is built on the premise that a patient who gives information to a dentist or member of the dental team is normally entitled to assume that the information will not be disclosed without the patients consent to anyone for any purposes other than the provision of health care. This principle is included in the GDCs Standards for dental professionals. The Council has also issued specific guidance on confidentiality in Principles of patient confidentiality (www.gdc-uk.org). Clinical dental records and other items of personal information are held by individual dentists and dental practices as well as by health service bodies such as trusts, private hospitals, dental hospitals and government payment agencies such as the Business Services Authority Dental Services Division. In general dental practice, responsibility for disclosing information without patient consent rests with the patients dentist (unless, for NHS contract purposes, the dentist is a deputy, assistant or an employed performer). In the salaried primary care dental services, responsibility rests with the particular employing trust, although the dentist who is treating the patient should be consulted if a request for disclosure is made. This section considers: What is personal health information? Data Protection Act 1998 Age of consent to disclosure What information can be disclosed? Training and disciplinary procedures Checklist Model confidentiality policy Data protection code of practice Checklist

What is personal health information?

Personal health information is any information relating to the physical or mental health of an individual who can be identified from that information or from other information which is in the possession, control or held by or on behalf of a health service body or qualified health professional in connection with the provision of health care. In dental practice, personal health information includes: Clinical notes and medical histories (manual and computerised) Radiographs and study models Personal information about the patient or identifiable third parties Information held in appointment books/systems Financial payment records/NHS forms relating to the patient daybooks Receipt books with patients names Exemption status Video, audio tapes, photographs and other medical illustrations Information that is held in the dentists (or other team members) minds. Essentially, the fact that an individual is a patient at the practice is confidential and cannot, under normal circumstances, be disclosed without the patients consent. Removal of obvious identifying features from the information may not necessarily remove the need to maintain confidentiality. The patients condition or circumstances may be very unusual or unique so that disclosure of the information might make it possible to deduce or speculate on the patients identity.

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The 1998 Data Protection Act protects the confidentiality of sensitive personal data (which includes information on the data subjects physical or mental health or condition) by placing obligations on the data controller (that is the person or legal entity responsible for the data) only to disclose information to a third party in prescribed circumstances included in the Act and to keep the data secure. The Act applies to manual data and data that are processed automatically. An important requirement of the Act is that data must be processed fairly and lawfully. Data processing includes the obtaining, holding, use and disclosure of personal data. Applying the terms used in the Act to dentistry, the patient is the data subject and the dentist responsible for care is normally the data controller. Processing includes taking records, submitting claims to the NHS, sending out recalls, sending work to laboratories and referrals. Among the information that should be given to the patient is that data will be shared on a need-to-know basis with certain organisations (such as the BSA DSD/ SDPD/ CSA) in order to provide the patient with appropriate care and treatment and for the provision of general health services. Under the Act, information should only be held for the period for which it is required and for the purposes that have been stated to the data subject. For example, in dentistry, dentists should not send information to patients about non-dental business ventures unless they have the patients consent to do so. This also applies to information about financial products such as personal loans. The relevant principles of the Data Protection Act must be followed: that is data must be kept for no longer than is necessary and must be obtained for specified and lawful purposes. An illustration of this might be when a dental chart of a missing person is given to the police for the purpose of identifying a body. If the body is not found to be the patient, the charting should be returned to the dentist and not kept on file by the police. If the practice operates an appropriate confidentiality policy (see page 25) and provides a data protection policy, then it is likely that the requirements of the Act will be met. BDA Advice Sheet B2 Data protection contains further information and a model data protection policy, which also appears in the BDA Practice Compendium. Patients aged 16 and over can consent to the disclosure of their health records and can withhold their consent. Mature minors of any age, who understand the implications of their decisions, can give or withhold consent to disclose information. Legal rights to confidentiality depend not just on age but also on understanding. Thus, a parent does not automatically have the right of access to a childs records, even if the child is under 16, and the dentist cannot discuss the childs treatment with the parents without the childs consent. It is for the dentist to judge whether a child is competent in the circumstances, taking into account the childs age, maturity and the consequences of disclosure or failing to disclose. For detailed advice on consent for minors see page 14. Questions of consent to disclosure also arise where the patient might be judged to have a mental impairment that may make them incapable of consenting to disclosure. In these circumstances the dentist must follow the guidelines for consent included on page15 , which comply with the Mental Incapacity Act and associated Code of Practice. BDA Advice Note Assessing mental capacity available, on the BDA website www.bda.org/advicenotes, provides more information.

Data Protection Act 1998

Age of consent to disclosure

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What information can be disclosed?

The legal disclosure of personal health information to third parties can be divided roughly into two particular types of disclosure: those exempt from the disclosure restrictions of the Data Protection Act (broadly, disclosures that are in the public interest) and those to which the data subject has consented. Disclosure with consent Where a patient gives specific consent to disclose particular information (and the patient is able to give informed consent - see page 10), the information may be disclosed in accordance with the consent that has been given. An example might be the use of an identifiable photograph of the patient in a research paper or practice advertisement. The Data Protection Act requires patients to give explicit consent to the disclosure of information held about them where: the disclosure is not covered by one of the Acts exemptions; the patient has not been informed that such disclosure will occur and has not objected to it; or it cannot otherwise be held to be in the public interest. Sharing health information The most common instance of disclosure in dentistry is the sharing of personal health information in order to provide health care to the patient. Examples of the necessary sharing of information in dentistry include: Referral of a patient to another dentist or NHS Trust for specialist treatment. Referral letters should give full information about the treatment required and any information about the patient that the referral dentist needs to know There is a medical condition that may affect the patients ability to undergo a particular dental procedure safely and the dentist wishes to discuss the best approach with the patients GMP/hospital consultant The dentist is informed by the patient about changes to their medical condition after treatment has been carried out and needs to check the details with the patients consultant/GMP The issuing of a written prescription by the dentist to the DCP Prescribing work to a dental laboratory. The premise of these disclosures is that they can only be made to persons who need to know in order to provide care to the patient. The purposes for which the disclosure is made should also have been notified to the data subject and the information must only be used for the purposes for which it has been disclosed. For example, when responding to a GMPs request for information about the oral health status of a particular patient, information would not normally be given about the patients personal circumstances. The consent of the patient should be obtained. Similarly, if the GDP needs to know about a patients medical condition, which has a bearing on the dental treatment, consent should be obtained before approaching the doctor. Information given to a GMP would also normally be given directly to the doctor and not to the receptionist, even though the receptionist would be covered by confidentiality rules. It is for the dentist to decide what the third party to whom information is disclosed needs to know. Disclosure necessary to provide appropriate care and to ensure that the NHS is able to function In order to provide patients with appropriate health care and to ensure that the NHS can function, personal health data needs to be shared.

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Patients should be made aware that information will be sent to a third party (that is, a payment authority) for the purposes of paying the dentist and monitoring the quality of care provided by, for example, the dental reference service. Their consent to such disclosure can be implied if they do not object. Additional details about the treatment, such as patient records and radiographs, can also be disclosed to a payment authority. NHS payment authorities (the Business Services Authority, Scottish Dental Practice Division and the Central Services Agency) have their own procedures for ensuring that patient information is kept confidential, as do the private dental schemes. The need to ensure that the NHS is administered efficiently can sometimes conflict with the need for patient confidentiality. NHS bodies must have clear procedures for safeguarding patient confidentiality. The NHS confidentiality code of practice sets out procedures with which health service bodies (NHS Trusts, Primary Care Trusts/Health Boards/Local Health Boards) must comply to ensure patient confidentiality. A copy is available on the DH England website www.dh.gov.uk. The guidance includes information on: Safeguarding NHS information Complying with the law Giving information to patients on the purposes for which their data will be used Security measures Subject access Where and how information about patients may be passed on. Justified disclosure: Although information belongs to the patient, there may be circumstances in which the disclosure of patient information without consent may be justified. Dentists may be asked or required to disclose personal data about patients without consent, for reasons such as: Health research Health research involving access to patient records in England must be approved by Local Research Ethics Committees, Details of your local REC is available from the National Research Ethics Committees website www.nres.npsa.nhs.uk/contacts/find-your-local-rec In the area of confidentiality, the LREC will wish to be satisfied that: Arrangements to safeguard confidentiality are satisfactory The use of identifiable patient information is fully justified Published research findings will not identify individual patients without their specific agreement. Where patients will be involved personally in teaching and research activities, their specific consent must be obtained. The Medical Research Council publishes guidelines on confidentiality of personal information - Personal Information in Medical Research - that emphasises the researchers responsibilities, the obligations on hospitals and practices to ensure that patients are made aware that their information may be used in research, and to explain the safeguards that are in place for protecting confidentiality. A copy of the guidance is available from the MRC website on www.mrc.ac.uk.

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Public interest In limited circumstances, disclosures may also be made in the public interest: Cases of suspected child abuse (see page 48) Protection against serious future risks to the health and safety of others A patient is putting their own health and safety at serious risk Where the law compels it, for example where a court order is obtained or Disclosure is necessary by statute. This includes: Certain Acts of Parliament Serious injury or dangerous occurrences Certain infectious diseases (not including HIV) Normally, dentists who receive a court order are required to disclose information or face being found guilty of contempt of court. In Gaskin v Liverpool City Council (1980), however, the Court of Appeal found that Liverpool City Council should not be required to produce confidential files and information that had been prepared in the course of caring for the child. This gives professionals bound by confidentiality rules scope to contest orders to appear in court and submit records. This sort of situation would not normally apply to dentists, however. In order for the data controller (the dentist) to pursue his or her bona-fide legal rights Cases involving serious crime or national security Disclosure without consent at the request of the police investigating a crime is one of the most difficult decisions that a dentist can be asked to make and each situation needs to be considered individually having regard to its nature, seriousness and the harm to the patient or others that might result from the crime. When in doubt, the dentist should ask the police to produce a court order for disclosure. It can also be in the Crown Prosecution Service's interests to obtain a court order to prevent the defendant being able to obtain a ruling that the evidence had not been correctly obtained and was therefore inadmissible. Where a court order is not made and the police demand that information about the patient is supplied, for example a record card or confirmation that the patient attended on a particular day, the dentist must weigh up the following factors: The seriousness of the crime The potential future danger to the public if a disclosure is not made The likelihood that the suspect will commit a serious injury to another person or persons. Where the crime of murder or rape is involved or the victims are children, most dentists will provide the necessary information. Normally robbery, assault or drugs offences would not be sufficient grounds for information to be supplied without patient consent or a court order. Where a request from the police is received, advice should be sought from the BDA or a defence organisation/ insurer. The duty of confidentiality does not preclude reporting to the police a crime to which the dentist has been a witness or which may have been committed against the practice, such as robbery or assault or threats to the personal safety of staff or patients. Where, for example, a full list of patients seen in a session is given to the police in order to investigate a theft from the practice, patients should be informed that the information is being disclosed.

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Road Traffic Act 1988 Where a dentist is asked by police for the name and address of the driver of a motor vehicle who may have been injured or committed an offence under the Act, the information must be provided. Clinical information should not normally be given. Prevention of terrorism Under the provisions of the Terrorism Act 2005 a dentist who has information on a planned or actual terrorist act must inform the police. HMRC inquiries In the course of routine inspections, tax inspectors frequently ask to see and take away appointment books, day books and patient records. The dentist should not supply this information unless the patients whose names or other identifiable details are shown have given specific consent to the disclosure or the patients names have been removed or obscured. If the inspector has reasonable grounds to suspect that an offence involving serious fraud has been or will be committed and that evidence will be found on the dentists premises, an order requiring the dentist to produce the information or a warrant for the inspectors to enter the premises, search and seize them can be obtained. Further information is available in BDA Advice Note HMRC access to records can be obtained from www.bda.org/advicenotes or BDA Practice Support on 020 7563 4574. Identification of missing and deceased persons It is not a crime to go missing. Patients can sometimes decide to leave their families for a period and would expect that their medical/dental records are not disclosed. Where the police find a body that they reasonably expect is a person who is a patient of a practice, relevant charts, models or other information can be handed over for identification purposes. The records should be returned to the dentist after they have been used and not kept on file for future reference. Dentists are also often asked for patient charting where the patient has died in an accident or fire and identification by relatives is not possible or desirable. Where the police have reasonable grounds to believe that the body is the patient, the charts may be provided. Patient fraud It is a criminal offence for a patient to secure for himself or another, the evasion, reduction or remission of an NHS charge. Patients may be convicted of a criminal charge, or may have to pay a penalty of up to five times the fee, or 100, whichever is the lesser. Dentists may be involved in giving evidence or providing information for prosecutions for the fraudulent claiming of NHS fees. This is not a breach of confidentiality. Every member of the practice must understand the need for confidentiality and that only the dentist responsible for the care of the patient can make a decision to disclose information to a third party. Training and disciplinary procedures

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Confidentiality training might be part of a general session on dental ethics or the main component of a staff meeting. The BDA's Consultancy Service can provide customised training for a practice or a group of practices. Maintaining confidentiality should also be part of a practice's conditions of employment and breach should be grounds for summary dismissal. Practices should also have a specific confidentiality policy as a condition of employment and a model is included (see below) and available in the BDA Practice Compendium. Checklist Personal health information gained in the course of providing care to patients is confidential and must only be disclosed with the consent of the patient and in particular circumstances The Data Protection Act 1998 must be followed regarding the non-disclosure of personal health information and patients should be given a copy of the practices data protection code of practice Patients should be asked to consent to the sharing of information with other health care professionals involved with their care. This disclosure should be done on a need-to-know basis Dentists must disclose personal health information about patients when required by a court order or under the terms of the Terrorism Act or the Road Traffic Act Dentists may disclose necessary information about their patients in order to defend their legal rights Information about patients may be disclosed to the police in order to identify a body where there is good reason to believe that the body is that of the patient Staff should be trained in patient confidentiality and practices should have a confidentiality policy Breaches of confidentiality should be included in staff disciplinary procedures as an offence which would result in summary dismissal. Compliance with this policy must be made a condition of employment for all staff. At this practice the need for the strict confidentiality of personal information about patients is taken very seriously. This document sets out our policy for maintaining confidentiality and all members of the practice team must comply with these safeguards as part of their contract of employment/contract for services with the practice. The importance of confidentiality The relationship between dentist and patient is based on the understanding that any information revealed by the patient to the dentist will not be divulged without the patients consent. Patients have the right to privacy and it is vital that they give the dentist full information on their state of health to ensure that treatment is carried out safely. The intensely personal nature of health information means that many patients would be reluctant to provide the dentist with information if they were not sure that it would not be passed on. If confidentiality is breached, the dentist/dental hygienist/dental therapist/dental nurse/clinical dental technician/orthodontic therapist/dental technician faces investigation by the General Dental Council and possible erasure,and may also face legal action by the patient for damages and, for dentists, prosecution for breach of the 1998 Data Protection Act. General Dental Council All staff must follow the General Dental Councils rules for maintaining patient confidentiality contained in Standards for dental professionals and Principles of patient confidentiality.

Model practice confidentiality policy

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All members of the dental team have an ethical and legal duty to keep patient information confidential. The duty of confidentiality applies to all information about the patient which is learnt in the professional role. This information must be kept confidential even after a patient dies. If confidentiality is breached by any member of staff, it is the patients dentist who is responsible to the Council. A registered dental care professional whose act or omission has breached confidentiality may also be called before the Council. What is personal information? In a dental context personal information held by a dentist about a patient includes: The patients name, current and previous addresses, bank account/credit card details, telephone number/e-mail address and other means of personal identification such as his or her physical description Information that the individual is or has been a patient of the practice or attended, cancelled or failed to attend an appointment on a certain day Information concerning the patients physical, mental or oral health or condition Information about the treatment that is planned, is being or has been provided Information about family members and personal circumstances supplied by the patient or others The amount that was paid for treatment, the amount owing or the fact that the patient is a debtor to the practice. Principles of confidentiality This practice has adopted the following three principles of confidentiality: Personal information about a patient: is confidential in respect of that patient and to those providing the patient with health care should only be disclosed to those who would be unable to provide effective care and treatment without that information (the need-to-know concept) and such information should not be disclosed to third parties without the consent of the patient except in certain specific circumstances described in this policy. Disclosures to third parties There are certain restricted circumstances in which a dentist may decide to disclose information to a third party or may be required to disclose by law. Responsibility for disclosure rests with the patients dentist and under no circumstances can any other member of staff make a decision to disclose. A brief summary of the circumstances is given below. When disclosure is in the public interest There are certain circumstances where the wider public interest outweighs the rights of the patient to confidentiality. This might include cases where disclosure would prevent a serious future risk to the public or assist in the prevention, detection or prosecution of serious crime. It may also be necessary in instances where the patient puts their health and safety at serious risk.

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If it is necessary to share confidential information, if practical, the patient must be persuaded to release this information themselves or give their permission for the information to be released. Failing this, it is advisable to contact the BDA or your defence organisation before acting. A court can order patient information to be released without consent. In such circumstances, only the minimum information should be released to follow the order. Before releasing any confidential information in the public interest, it must be necessary to be prepared to explain and justify the decision and any action taken. When disclosure can be made There are circumstances when personal information can be disclosed: Where expressly the patient has given consent to the disclosure Where disclosure is necessary for the purpose of enabling someone else to provide health care to the patient and the patient has consented to this sharing of information Where disclosure is required by statute or is ordered by a court of law Where disclosure is necessary for a dentist to pursue a bona-fide legal claim against a patient, when disclosure to a solicitor, court or debt collecting agency may be necessary. Disclosure of information necessary in order to provide care and for the functioning of the NHS Information may need to be disclosed to third party organisations to ensure the provision of care and the proper functioning of the NHS. In practical terms this type of disclosure means: transmission of claims/information to payment authorities such as the BSA DSD/SDPD/CSA in more limited circumstances, disclosure of information to the HA/HB referral of the patient to another dentist or health care provider such as a hospital. Disclosing patient information If the patient consents to their information being disclosed: An explanation must be provided about the circumstances in which the information about them might be shared The patient must be provided with the opportunity to withhold permission for disclosure of information The patient must understand what will be released, the reasons for releasing it and the likely consequences of releasing the information The person with whom the information is shared must understand that the information is confidential. Data protection code of practice The Practices Data Protection Code of Practice provides the required procedures to ensure that we comply with the 1998 Data Protection Act. It is a condition of engagement that everyone at the practice complies with the Code of Practice.

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Access to records Patients have the right of access to their health records held on paper or on computer. A request from a patient to see records or for a copy must be referred to the patients dentist. The patient should be given the opportunity of coming into the practice to discuss the records and will then be given a photocopy. Care should be taken to ensure that the individual seeking access is the patient in question and where necessary the practice will seek information from the patient to confirm identity. The copy of the record must be supplied within forty days of payment of the fee and receipt of identifying information if this is requested. Access may be obtained by making a request in writing and the payment of a fee for access of up to 10 (for records held on computer) or 50 (for those held manually or for computer-held records with non-computer radiographs). We will provide a copy of the record within 40 days of the request and fee (where payable) and an explanation of your record should you require it. Note : this paragraph should be edited to relate to the circumstances of the practice. Some practices prefer not to make a charge. If a charge is required, it is for copying and posting the information only. If a permanent copy of the record is not supplied to a patient, a fee is not applicable.

The fact that patients have the right of access to their records makes it essential that information is properly recorded. Records must be Contemporaneous and dated Accurate and comprehensive Signed by the dentist Neat, legible and written in ink Strictly necessary for the purpose Not derogatory Be such that disclosure to the patient would be unproblematic. Practical rules The principles of confidentiality give rise to a number of practice rules that everyone in the practice must observe: Records must be kept secure and in a location where it is not possible for other patients or individuals to read them Identifiable information about patients should not be discussed with anyone outside of the practice, including relatives or friends A school should not be given information about whether a child attended for an appointment on a particular day. It should be suggested that the child is asked to obtain the dentists signature on his or her appointment card to signify attendance Demonstrations of the practices administrative/computer systems should not involve actual patient information When talking to a patient on the telephone or in person in a public area, care should be taken that sensitive information is not overheard by other patients Do not provide information about a patients appointment record to a patients employer without their consent Messages about a patients care should not be left with third parties or on answering machines. A message to call the practice is all that can be left Recall cards and other personal information must be sent in an envelope

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Disclosure of appointment books, record cards or other information should not be made to police officers or HMRC officials unless upon the instructions of the dentist Patients should not be able to see information contained in appointment books, day sheets or computer screens Discussions about patients should not take place in the practices public areas. Disciplinary action If, after investigation, a member of staff is found to have breached patient confidentiality or this policy, he or she shall be liable to summary dismissal in accordance with the practices disciplinary policy. If the staff member is a registered dental care professional, the General Dental Council will be informed. Employees are reminded that all personal data processed at the practice must by law remain confidential after your employment has terminated. It is an offence under section 55(1) of the Data Protection Act 1998 knowingly or recklessly, without the consent of the data controller (name), to obtain or disclose personal data. If the practice suspects that you have committed such an offence, it will contact the Information Commissioner and you may be prosecuted by the Commissioner or by or with the consent of the Director of Public Prosecutions. Queries Queries about confidentiality should be addressed to [ ]. More information is contained in BDA Advice Sheet B1 Ethics in dentistry which is available for reference in [ ].

Dental records

Good record keeping is central to good dental practice: accurate records are essential to ensuring that patients receive appropriate and safe treatment. Clinical records should be viewed as a communication tool, helping anyone with access to them to understand what was done, when and how. Dentists are often first judged on the quality of their record keeping and poor records can sometimes render complaints and claims for damages indefensible. Unfortunately, inadequate record-keeping systems are very common in dental practice, often due to time constraints. But dentists must be aware that they are responsible for the acts and omissions of their staff, including information documented in the dental record, and it is therefore essential that the following standards be adhered to: Consistency of management of the records Confidentiality Quality assurance Access to information through appropriate recording, clear handwriting That records are made contemporaneously or as nearly contemporaneously as possible That care is taken that there is no risk of confusing two patients with the same or similar names. In such cases, the notes should carry a warning to check the address or date of birth of the patient at the time of the consultation to ensure that the correct notes have been selected That record entries are made only by those people who are authorised to do so. Generally this would be the dentist, the dental nurse, dental hygienist and dental therapist, orthodontic therapist, clinical dental technician.

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Records must be stored according to the provisions of several Acts of Parliament. This section summarises the law and good practice and covers: Good record keeping practice Storage, retention and disposal Fair processing Subject access Sale/transfer of records Checklist It is good practice that all records are: Factual, consistent and accurate Legible, written in black ink/ball pen or typed electronically Dated, with the time and signature Altered by scoring out with a single line with the date, time and signature added Not abbreviated unless the abbreviations are recorded separately and periodically updated Chronological and demonstrating all the events Identified on each page with the patients name, date of birth and unique number Secured within the record folder if the record is manual. A dental record should comprise: The patients personal details (including full name, address, date of birth, gender and contact telephone numbers/email address) A comprehensive, up-to-date medical history including alerts, precautions, current treatment and GP contact information Dental and periodontal charting A contemporaneous record of the treatment provided from which the operating dentist/dental hygienist/dental therapist/clinical dental technician can be identified The date, diagnosis and treatment notes each time the patient is seen, with full details of any particular incidents, episodes or discussions, including options and advice given Contemporaneous descriptions of complications or problems Records of appointments cancelled or not kept A record of the advice given and consent obtained for treatment including, where appropriate, consent forms A record of any unusual incidents, instances where the patient does not consent to treatment/record keeping Investigations (printouts from monitoring equipment etc) Notes of telephone conversations Computerised records Handwritten clinical notes (record cards/ envelopes) Information about the patient's personal circumstances that is relevant to the dental care Copies of test results, referral letters and other correspondence Batch numbers of materials used Radiographs (named, dated), study models, photographs A record of drugs prescribed/given (with dosages) together with any adverse reactions A reference to any complaints received and action taken (though complaints records should be stored separately) X-ray films and other imaging records Records of estimates and treatment plans and copies of those supplied in writing Good record keeping practice

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Laboratory orders/work sheets/papers required to comply with medical devices requirements Written prescriptions for dental hygienists and dental therapists. Models Photographs All payments made by the patient All correspondence to and from the patient, or any third party Other information, for example laboratory instructions, statements and receipts Videos Contemporaneous description of problems or complications Monitoring information, such as BPE scores, tracking oral pathology etc Findings/diagnosis on radiographs Drugs and dosages given Updated list of medications and known allergies NHS treatment plans NHS referral letters NHS orthodontic treatment plans Where NHS claims are submitted electronically, a signed patient PR form When compiling records, the purpose for which they are written should be considered. This includes Patient safety Monitoring Basis for accounts Probity enquiries Evaluation of treatment. Records can be held on paper and on computer. Where written records are kept, legible handwriting is essential and pencil must not be used. Removing agents such as Tippex should not be used; alterations, where necessary, should be made by striking a single line through them. Records should always be signed and dated with the recorders name printed underneath or a central record of signatures kept at the practice. Accurate dating of entries can greatly assist with the defence of later claims, ensuring that a claim cannot be made that the record has been subsequently altered. Abbreviations used should be uniform throughout the practice so that they can be universally understood. Computerised record systems must record exactly the same information as paper records. They must also contain robust audit trails so that subsequent alterations will be recorded. NHS dental payment agencies issue advice on requirements for dental systems and, before purchasing a system, dentists must ensure that the manufacturer complies with the guidance. Further information on the requirements for dental systems can be obtained by contacting the Business Services Authority Dental Services Division (for England and Wales), the Scottish Dental Practice Division (Scotland) and the Central Services Agency (Northern Ireland). In view of the fact that patients have the right of access to their records, derogatory comments about the patient or relatives should be avoided. Sensitive information (such as a patients HIV status or termination of pregnancy) should only be recorded if it is necessary to ensure that the patient is treated properly and safely and the patient has consented. The 1998 Data Protection Act requires that patients are given information about the processing of their personal data (see page 20). Storage, retention and disposal Dental records should be stored securely so that they are safe from unauthorised access, theft, fire, flood and other disasters. This is a requirement of the 1998 Data Protection Act. Records should not be accessible to patients
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or visitors and, when the practice is closed, there should be reasonable measures in place to ensure their security, for example storage in lockable cabinets, shelving with a lockable shutter, or be placed in a locked room. Where records need to be removed from the practice premises, they must not be left in unattended cars in case of theft. Ideally, for medico-legal purposes, dental records (including radiographs and study models) should be retained indefinitely. For the purposes of the Consumer Protection Act 1987 they should be kept for at least eleven years for adults, and, for children, for eleven years or up to age 25, whichever is the longer. Personal representatives can take legal action in respect of a deceased patient, although in dentistry this is very rare. Records for deceased patients should therefore be retained for the same period. NHS regulations require dental records to be retained for only two years (and now six years in Northern Ireland), but this does not negate the above requirements. There are commercial companies that offer secure confidential storage facilities for records and microfiching is also an option. Disposal of patient records should be by incineration or shredding with appropriate safeguards for confidentiality during the procedure. Local hospitals may offer a service either free or for a small charge, and again there are companies that provide a confidential disposal service. Domestic refuse services must not be used. Failing to dispose of records without regard to their confidential nature could lead to action for damages by patients, prosecution by the Information Commissioner and complaints to the General Dental Council as well as adverse local publicity. Special care must be taken with destruction of e-records, which can be reconstructed from deleted information. Erasing or reformatting computer disks or personal computers with hard drives which once contained confidential personal information is not sufficient. Dentists could be liable to action for damages by patients, be prosecuted by the Information Commissioner and be reported to the General Dental Council if they fail to dispose of records without regard to their confidential nature. The Data Protection Act describes several requirements for data to be processed fairly. These include the obligation to provide information stating: The identity of the data controller or their nominated representative The purposes for which the data are intended to be processed Any further information which is necessary, having regard to the specific circumstances in which the data are, or are to be, processed to enable processing in respect of the data to be fair. The Data Protection Act 1998 gives every living person the right to apply for access to their health records This section summarises the procedures for giving access to patients, but further specific help is available from BDA Practice Support and BDA Advice Sheet B2 Data Protection. Request for access Who can obtain access? A data subject has the right of access to personal data about him or her. Where the data subject is a child (that is, someone aged under 16) the data controller must make a judgement as to whether the child understands the nature of the request. If so, the data controller should reply to the child, but, if not, the parent or guardian is entitled to make a request on the child's behalf and to receive the reply. Parents or guardians should only make such requests in the childs interests, not their own. Where the child is capable of making a request for
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Fair processing

Subject access

access but a parent or guardian does so on their behalf, the data controller should be satisfied that the child has consented to the request for access. A solicitor or other person may have access on behalf of the data subject if the data subject has consented in writing to the disclosure. Any person having a claim arising from a patients death may apply and the data controller may judge what is relevant to a claim. Where the patient has asked that a note be made on the records that they are not disclosed after death, disclosure cannot take place without a court order. How can access be requested? To obtain access, the data subject must: Make a request in writing (which may be delivered electronically, that is by fax or email) State the name of the applicant and an address for correspondence Describe the information requested Pay the prescribed fee Provide any information that the data controller may reasonably require in order to satisfy himself as to the identity of the individual and the location of the information. Where a request for access to a manual health record is made, the fee for access and providing a permanent copy of the record is a maximum of 50. Where access to the health record has already been provided within forty days of the request for access (and a permanent copy is not supplied) no fee is payable. This charge includes administration and photocopying costs including the cost of copying radiographs. For computer-held records the maximum fee is 10 including photocopying and administration. What must be provided? Within 40 days of the original request, or 40 days from the fee and/or identification information being provided, the data controller must supply the data subject with a permanent copy of the requested information unless: the supply of a copy is not possible copying would involve disproportionate effort the data subject consents otherwise. If a similar request has been made by the same individual within a reasonable timescale, the data controller is not obliged to accede to the request. The definition of a reasonable timescale will depend on the nature of the data, its purpose in processing and the nature of the alteration. The information must be supplied in an intelligible form and, where it is not intelligible, an explanation should be given. In dentistry it would be usual for the dentist to offer to provide an explanation of part or all of the record. The information supplied must be by reference to the information held on the day the application was received, subject to any routine processing. Information about third parties Where personal data about third parties is part of the record (including being identified as a source) it should be disclosed where: 1. The third party has consented 2. It is reasonable in all the circumstances to supply the information without consent
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3. The information is contained in a health record and the other individual is a health professional who has compiled or contributed to the health record or has been involved in the care of the data subject in his capacity as a health professional (this provision was added in an Order) In deciding what is reasonable in the circumstances in (2), the data controller should consider the following circumstances: Any duty of confidentiality owed to the third party Whether the third party has refused consent Any steps taken by the data controller to obtain consent Whether the individual is capable of giving consent. The most common instance of information supplied by third parties in dentistry might be information contained in letters from hospital consultants about a patients medical or dental condition or personal circumstances. This information should be disclosed to the patient on request except where it is likely to cause serious harm to the health professionals physical or mental health. This exemption is unlikely to be applicable in dentistry, but BDA Practice Support is happy to advise on individual circumstances. Where appropriate, a health professional whose identity has been disclosed should be informed that this has occurred. There is an exemption to the subject access requirements for health information if disclosure is likely to cause severe pain or distress to the data subject or severely affect the mental or physical health of the health care professional. This provision is also unlikely to be applicable in dental circumstances, but BDA Practice Support is happy to advise on individual circumstances Sale of a practice Where a dental practice is sold, patient records are normally transferred to the new owners as part of the goodwill of the practice. Sale agreements should contain a provision that the purchaser retains the vendors records (and those of any dentists who practised there) for a given period and allows access if necessary. Subsequent disposal should only be undertaken confidentially. Ownership of records taken by dentists who are no longer associated with the practice is generally determined by any agreement between the dentists concerned or, if there is no agreement, by a court. Difficulties can arise if an associate moves to a nearby practice and patients wish to follow. Our advice here is that a patient has the right to choose the practitioner and, in the interests of patient care, the records, including radiographs, should follow the patient. Copies should preferably be retained at the practice. The goodwill relating to the patients of a practice which is closing down may be sold to another practitioner. In other cases, the retiring dentist should retain the patient records in case of future complaints or legal action. In cases of death, the dentists personal representative would have custody of the records. Transfer of records Generally speaking there is no problem sending patient records to their new practice at the request of the patient. The practice should retain a copy or obtain agreement from the new practice that the records will be returned on request. Faxing dental records to another practice is permissible provided that the receiving practice ensures that the fax is secure and out of sight. The practice should be alerted and their fax number confirmed prior to sending the fax through.
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Sale and transfer of records

If the patient records are being emailed, the patient must consent to their medical records being transferred in this way. It would also be wise to check that the email address is that of the intended recipient. Checklist Dental records must be full, contemporaneous, accurate and legible Records must be retained for at least eleven years and, for children, up to age 25 or eleven years, whichever is the longer Patients have the right of access to their manual and computerised records and to receive a copy Patients are entitled to a copy of their manual records including radiographs on payment of a fee of up to 50 Clinical records that are held on computer must have appropriate audit trails and safeguards to ensure that the record cannot be altered or otherwise tampered with Records should be kept securely and safeguarded against accidental destruction or theft Computer screens and manual files should not be available to third parties Practices should have a Data Protection Policy (see BDA Advice Sheet B2 Data Protection or the BDA Practice Compendium) which should be given to patients.

Patient care

This section is about the type of care dentists provide for patients, as well as the way that care is delivered. Dentists are able to provide care and treatment that they are competent to provide. They are also able to provide care that is not dental care but, if they do so, they must ensure that the care is lawful, they are properly trained to provide it and they have suitable indemnity. The section covers Patient communication Agreeing to provide care and treatment Patient choice Treatment planning Health checks Alternative therapies Non-surgical cosmetic procedures Tooth whitening Medical emergencies Misleading patients Maintaining appropriate boundaries Referral fees Missed appointments Debt collection Handling complaints Checklist

Patient communication

Effective, clear communication with patients is essential in modern dental practice. Most patient complaints have at their foundation breakdowns in communication. The ability to talk and listen to patients is a major factor in building a successful practice. There are many aids to good communication available and the BDA Practice Compendium provides a range of advisory material, model forms, letters and leaflets. Courses are organised by the BDA, primary care organisations, postgraduate centres, private dental plans and other training providers which can be very helpful for dentists and the practice team.

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Relations between dental teams and patients should always be friendly and patients must always be treated politely. Patients should be put at ease and made to feel that they are active partners in their care. At all times, patients dignity must be maintained. Dental staff must be accessible and prepared to answer patients questions clearly, accurately and promptly. Dentists are responsible for the acts and omissions of members of the dental team that they lead or supervise and must ensure that they are well trained. Registered dental care professionals are also responsible for their own acts and omissions. There are points in the dentist/patient relationship where good communication by dentist and practice team becomes particularly important in avoiding complaints and allegations of misconduct. This section considers some of these areas and includes some useful aids. Many difficulties and complaints are caused by patients being unclear about the basis on which they have been accepted for treatment. It is the dentists responsibility to ensure that this basis is understood at the time of the initial appointment. In England and Wales it is not possible to examine a patient to make a decision on whether or not NHS care should be offered. It is possible to do this in Scotland and Northern Ireland and is not unethical, provided that the patient is clear at the time of booking that it is a screening appointment and the cost (if any) of the individual consultation is given. Patients must be given full information about treatment to be carried out and the nature of the contract with the dentist, whether NHS or private. It is important that cost indications are given at the outset and that any necessary changes to treatment plans or estimates are fully explained and agreed to by the patient. One way of ensuring that the basis of the contract is unequivocal is to give new patients a suitably worded welcome letter or include the information in a practice leaflet. Where new patients are being accepted under NHS regulations, dentists are required to provide an acceptance form (FP17DC/GP17DC/HSA45). This form is useful in that it includes a written treatment plan and cost estimate, as well as the option of recording any treatment that has been agreed privately. The BDA has a range of advice sheets on NHS rules and regulations that are listed at the end of this section. Cases sometimes arise where patients realise that care has not been carried out under the NHS only when they wish to make a complaint or query the amount that they have been charged. Intentionally misleading patients might constitute fraud or give rise to a fitness to practise investigation by the GDC. Patients have the right of free choice of dental practitioner and to change their dentist if they wish. The dentist also has the right not to accept patients for treatment provided that there is no unlawful discrimination. In Standards for dental professionals, the GDC states that patients must not be refused treatment or otherwise discriminated against on the following grounds: Sex, age, race, ethnic origin, nationality, special needs or disability Sexuality, health, lifestyle, beliefs or any other irrelevant consideration. GDS regulations in England and Wales also provide that patients cannot be discriminated against on the grounds of their dental or medical condition. There is no obligation to provide reasons for a decision not to accept or to cease to provide NHS care (provided that NHS regulations regarding notice are complied with), but it is good practice to do so. Generally, dentists should seek to maintain a continuing professional relationship with their patients. Agreeing to provide care and treatment

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Where a patient is referred to another practitioner for specific items of treatment, the terms on which the patient is being accepted for that treatment should be made clear whether NHS or private and the probable cost. Both the referring and the second dentist in these cases have an equal responsibility to ensure that the arrangements are acceptable to the patient. The patient should not find that what they thought was an NHS referral as part of the same course of treatment turns out to be a private arrangement at a cost they had not expected (see also page 36). Patient choice Patients must be treated as individuals who have the right to make choices about their care. This includes who will provide that care. Dentists are sometimes consulted by patients who were treated by them at a former practice where they were engaged as employed dentists or associates. If the dentist is prevented from treating the patient by a contractual obligation to the former practice owner, this should be explained to the patient. Considerable problems can face departing assistants or associates when questioned by patients about their future plans. The departing general dental practitioner has a professional commitment to complete or arrange for completion of any treatment commenced. Except in exceptional circumstances, it would be unacceptable for a dentist to connive in any arrangement whereby a patient makes an appointment believing it to be with the former dentist only to find on arrival that it is with another, perhaps unknown, practitioner. The precise details of the arrangements for leaving should be left for agreement between the parties involved according to their contractual arrangements but it must be remembered that the dentist who performs the treatment has the responsibility for the best interests and dental care of his or her patients. Treatment planning Patients must first be seen by a registered dentist who is responsible for providing a full mouth assessment of the patient. The only exception is edentulous patients who can be seen first by a registered clinical dental technician for the provision of full dentures. The dentist can either provide a full treatment plan or an outline treatment plan according to the needs of the patient. The treatment plan should include: Recall intervals for the patient to be seen by a member of the team The date of the next full mouth assessment A referral to another dentist or another dental care professional. A dentist can ask the other team member to set the recall intervals. Until the date of the next full mouth assessment, a patient can take the treatment plan to another registered dental care professional to provide the treatment. The second dental professional can then carry out the plan and are able to make recommendations to the patient within the scope of the plan, for example to suggest that a local anaesthetic is used. Health checks Many patients attend their dentist more regularly than they do their doctor. Dentists may offer patients the opportunity, if they wish, to have other simple physiological measurements such as measuring blood pressure or cholestoral levels. Such services can enhance the service available to patients and demonstrate a caring, preventive approach. Provided that the dentist is properly trained to undertake the tests and patients are given appropriate information on the results, such tests can be undertaken and a reasonable charge made. Dentists are responsible for the accuracy of the results and the advice and information provided. Dentists may offer their patients treatment using alternative methods of anxiety/pain control including hypnosis, reflexology and aromatherapy. Patients must be informed of the cost of the additional treatments in advance. Dentists should check that they have appropriate indemnity/insurance cover.
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Alternative therapies

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In these cases, dentists are responsible for the treatment that is undertaken and must not make any misleading claims about the treatment or its outcomes. Care that is provided must be based on available up-to-date evidence and reliable guidance. This makes the use of unproven or controversial techniques unwise outside of clinical trials or research that have ethics committee approval. The General Dental Council has issued guidance on alternative therapies. Some alternative therapies can have a legitimate use in dental treatment, such as hypnosis used to help an anxious patient. However, the Council is concerned that registrants should not use their standing as a dental professional to offer alternative therapies such as acupuncture or pain relief which are not provided to a patient as part of their dental treatment, for example hypnosis for smoking cessation or acupuncture for the relief of non-dental pain. This is the case even if a registrant is trained and registered as an alternative therapist. The Council is of the view that alternative/complementary therapies that are not provided in conjunction with, or linked to, a patients dental treatment must be provided separately to a registrants practice of dentistry. The practice of alternative therapies must be advertised or otherwise publicised separately to a registrants practice of dentistry. Care should be taken when providing for cosmetic reasons treatment to patients that does not constitute the practice of dentistry, for example dermal fillers or Botox. Dentists are responsible for the treatment that they provide and must ensure that they have appropriate indemnity/insurance cover. It is essential that they have the appropriate skills and training to undertake the procedure. The word Botox is copyright and cannot be used in advertisements. The GDC requires only dentists, dental hygienists and dental therapists (if trained and competent) to undertake tooth whitening. Tooth whitening is covered by the Cosmetics Products (Safety) Regulations which control the amount of hydrogen peroxide they are able to contain. This is subject to change, so for the latest information, see the BDA website. Prosecution of a dentist who exceeds the maximum allowable dose is the responsibility of local Trading Standards Departments rather than the General Dental Council. But if a dentist is prosecuted, the fact would be reported to the GDC who would consider it under their fitness to practise procedures. Also, if a dentist was using whitening products in a way that compromised professional standards, this would be investigated by the GDC. Whenever dental care is planned to take place, there should normally be at least two registered dental professionals trained to deal with medical emergencies available in the room. There may be circumstances where this is not possible, where out-of-hours emergency care is being provided or care on a domiciliary basis. In this case there must be an assessment of the risks of continuing treatment. Dental teams should be trained to ensure each member knows exactly what to do in the event of patient collapse or other emergency and practise regularly in a simulated emergency situation. Dentists must not mislead their patients. It is all too easy inadvertently to mislead by failing to communicate properly or by statements in practice literature or other advertising material which the patient misunderstands. Information provided must be accurate and truthful and must not make claims that cannot be substantiated, for example relating to the quality, longevity or cost of treatment.
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Non-surgical cosmetic procedures

Tooth whitening

Medical emergencies

Misleading patients

The BDA is happy to check draft advertisements, leaflets and other literature to ensure that they dont mislead. Having an outsider look at a draft often enables inadvertent errors to be avoided. Further guidance in relation to the provision of NHS and private care is contained in BDA Advice Sheets A4 Private practice made simple and E13 A guide to GDS regulations in Northern Ireland, E14 Guide to GDS regulations in Scotland and E11 Guide to GDS/PDS regulations in England and Wales. Maintaining appropriate boundaries It is important to maintain appropriate boundaries between dentists and patients. This is in terms of personal relationships and friendships with patients. It is not appropriate for a dentist to enter into a personal relationship with a patient. Further information is available in the publication Clear sexual boundaries between healthcare professionals and patients: responsibilities of healthcare professionals available on the website of the Council for Healthcare Regulatory Excellence www.chre.org.uk. Dentists should not enter into arrangements whereby, unknown to the patient, fees for treatment are split between two dentists to encourage referral of certain patients for particular forms of treatment, for example. A dentist should not ask for, or receive, money gifts or hospitality in return for referring patients. A reasonable charge may be made to private patients who fail to attend an appointment or cancel without reasonable notice. Patients should be aware in advance of any cancellation charges that may be levied, and commonly such information is contained in the practice's information leaflet or an appointment card. If patients are not aware that there is a cancellation charge in advance, it is unlikely that a dentist would be able to pursue a patient successfully in court for non-payment. In England and Wales, charges for missed NHS appointments may not be made. They are still permitted under NHS arrangements in Scotland and Northern Ireland. Exempt NHS patient cannot be asked to pay a refundable deposit in case an appointment is broken. Debt collection As a last resort, dentists may pursue patients for debts in the civil courts, or employ debt collectors. Prior to taking such action, however, the practice should make every effort to recover debts by sending suitably worded written reminders. A dentist is not obliged to embark on or continue with a course of treatment if an NHS patient is in debt to the practice. Where such a patient attends in pain or with another dental emergency, however, the dentist must provide emergency care and then may, if appropriate, deregister the patient in Scotland and Northern Ireland or refuse to provide another course of treatment in England and Wales. Information about de-registration is contained in BDA Advice Sheets E11 Guide to GDS/PDS in England and Wales, E13 A Guide to GDS regulations in Northern Ireland and E14 Guide to the GDS in Scotland. It is a breach of the dentist's duty of confidentiality to disclose lists of debtors to third parties, other than to recover the debt. Lists of patients with debts to local practices should not be compiled or circulated.

Referral fees

Missed appointments

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Dentists are required under GDS/PDS regulations and by the GDC to have in place a procedure to handle complaints from patients swiftly and satisfactorily. Both NHS and private patients may complain to the practice about the treatment or service that they have received and have their complaint considered by their dentist and, if necessary, action taken. Most complaints arise from a breakdown in communication and many patients are happy with an apology and/or a refund. Sometimes the patient wants a sincere commitment by the practice that the matter will be put right in order to avoid the situation occurring to another patient. Where damage is alleged to have been caused, the patient may refer the matter to court rather than using the complaints procedure or take legal action after the complaint has been made to the practice. There is a formal complaints service for private patients provided by the Dental Complaints Service, funded by the GDC but independent of it. The Dental Complaints Service assists private dental patients and dental professionals to resolve complaints about private dental services. It would be very wise to cooperate with the service to help resolve the complaint quickly and without escalation to the courts or the GDC. For more information visit www.dentalcomplaints.org.uk. Further information on dealing with complaints is contained in BDA Advice Sheet B10 Handling complaints and B11 Private Practice Complaints. Patients must be treated fairly and reasonably and not misled about the treatment they will receive, the contractual basis on which it is provided or its cost Dentists are free to accept or not accept patients but non-acceptance must not amount to discrimination Patients should have freedom of choice of dentist Where an associate leaves a practice, his or her patients should be informed Ownership of dental records depends on the agreement between associate and practice owner Patients must see a dentist first to undertake a full mouth assessment and a treatment plan, the only exception being edentulous patients who require full dentures who may be seen by a clinical dental technician Where planned treatment is taking place, there should be two people in the room who are trained in medical emergencies Dentists may pursue bad debts using debt collecting agencies or the courts but must not circulate lists of debtors to other practices Dentists should not refer patients to colleagues in return for a fee Dental practices should have a complaints procedure. Where treatment is offered that does not amount to dental treatment, the dentist must have appropriate indemnity cover and be fully trained and competent to provide the treatment Where dentists offer patients treatment under private dental plans, the scope of care to be provided by the plans should be clear and its terms should not interfere with the contract and relationship between dentist and patient Full and clear communication with patients is vital to successful practice Patients should not be misled as to the arrangements under which they are being treated or its cost Dentists may offer patients alternative therapies as part of their treatment, provided that any additional cost is made clear at the outset Care must be evidence based and unproven techniques should only be used as part of clinical trials or research.

Handling complaints

Checklist

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Professional relationships

Dentists' relationships with other practitioners can be problematic and lead to stress and patient complaints. As with all aspects of dental practice, most problems can be avoided by good communication. This section looks at some of the most common situations in which difficulties arise: Professional agreements Duties of a dentist manager Second opinions Poor performance Specialist practice Veterinary dentistry The death of a dental practitioner Checklist

Professional agreements

It is essential for both dentists and their patients that dentists practising together enter into reasonable arrangements that are confirmed in a comprehensive written agreement. This is particularly important for practitioners entering general dental practice for the first time. Terms of such agreements should not place any undue pressure on an associate or assistant to reach an unreasonable target since this may compromise patient care. Agreements should guarantee clinical freedom for dentists, provide for adequate chairside support, suitable facilities and contain full financial arrangements. The BDA provides advice sheets for members on performer agreements, assistantships, associateships, locumships and partnerships, all of which contain model agreements. BDA Practice Support can look at draft agreements and advise in the case of disputes. A conciliation and mediation service is also offered where both parties agree to its use, avoiding costly litigation. Contact practicesupport@bda.org or telephone 020 7563 4574. Most written agreements contain restrictive clauses preventing one party from practising within the vicinity of the practice for a defined time period after the end of the arrangement and from soliciting or treating former patients. The terms of these clauses must be reasonable and reflect such factors as the location of the practice, the number of local dentists, patient catchment area and other relevant aspects. Restrictive clauses must not operate to the detriment of patients on termination and should only aim to prevent unfair competition, not competition itself. Courts do not automatically uphold restrictive covenants and either party has the option of asking a court to rule whether a particular clause is reasonable. If it is judged unfair, it will be struck out without a more reasonable term being substituted.

Duties of a dentist manager

An increasing amount of dental care is provided by large dental corporations and large practice chains. Dentists can be placed in management positions where they have little control over organisational management or decisionmaking. Dentists also manage dental services within the NHS, direct a dental company or own a dental practice, which gives them management duties and responsibilities. In their management activities, dentists must put their responsibilities to patients before responsibilities to themselves, colleagues, the organisation or business. In their business and commercial dealings they must be open and honest as well as generally acting honestly and fairly in their professional lives. For any dentist in a management or leadership position, any concerns about the organisations decisions or activities that may be putting patients at risk must be raised with colleagues. If no action is taken or the matter is ignored, contact the GDC.

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The GDC guidance document Guidance on principles of management responsibility contains further information on dentists management responsibilities (www.gdc-uk.org). Patients increasingly seek the reassurance of a second opinion about treatment that has been undertaken or proposed. This happens particularly where they are not satisfied with the treatment already undertaken or where the proposed treatment is expensive or extensive. A dentist who is asked by a patient for a referral for a second opinion is obliged to accede to the request as part of respecting patient choice and at patients best interests. Clinical dental opinions vary widely and dentists often have very different treatment philosophies. In some cases dentists may conclude that the treatment provided has been of very poor quality or treatment proposed is either unnecessary or insufficient. The dentist then has a responsibility to give an accurate clinical opinion to the patient and might wish to discuss the treatment of the previous dentist with a senior colleague. Where a second opinion is given, the patient should be told of the consultation charge before an appointment is made. In all cases, the dentist must put the patient's best interests first, rather than professional loyalties. Dentists are sometimes faced with a colleague who they believe is putting patients at risk because of their health, behaviour or professional performance. In these cases, the GDC guidance document Principles of raising concerns must be followed. The guidance places a professional responsibility on dentists and dental care professionals in this situation to raise concerns if patients may be at risk. Further guidance is also available in BDA Advice Sheet B12 Handling underperformance. There are two stages for raising concerns, locally and then centrally. If a dentist becomes concerned by the behaviour, health or professional performance of a colleague that does not pose an immediate risk to public safety, then they should raise the matter with the appropriate local authority. First, talk to the dentist/DCP directly to try to persuade them to seek appropriate professional help If the dentist is self-employed the designated person within the local primary care organisation should be informed. If the dentist concerned is in a salaried position, the employing authoritys procedures for handling such cases should be followed. If alcohol or drug dependence is suspected, contact the Dentists Health Support Programme (which is a confidential service) for advice (see page 61). If the case appears to be serious or a local referral has been made and no action has been taken, speak to the General Dental Council. Action should be taken if the dentist is in any doubt. The dentist should be kept informed of the action taken to deal with concerned that have been raised. Dentists have a responsibility to ensure that people they employ or manage are encouraged to raise concerns and are protected if they do so. BDA Practice Support will advise on appropriate local contacts. Raising concerns Second opinions

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Specialist practice

Treatment on referral Dentists have a professional duty to refer a patient to a colleague where treatment is required that is beyond their clinical capabilities. Responsibility for making an appropriate referral rests with the referring dentist and particular care must be taken when referring for treatment under general anaesthesia or sedation. It is not acceptable to refer a patient for financial reasons alone or the need to meet targets. Where the patient is treated by a second dentist on referral, responsibility for the treatment provided and for providing for emergency care in connection with that treatment lies with the second dentist. The referring dentist remains responsible for the general care of the patient and related emergency cover. The second (referral) dentist must endeavour to complete any treatment that has been started, but, if this is not possible, the patient will normally return to the first dentist who must make another suitable referral. Specialist lists Only dentists who have been admitted to one of the specialist lists held by the General Dental Council may use the title specialist or claim or imply specialist expertise. This applies to information for patients as well as other professional colleagues. A practice wholly or mainly devoted to a particular type of dental treatment can be advertised as such. Patients must not be misled about the practice, or that the treatment is provided by specialists, if the dentists practising on the premises are not on the appropriate GDC specialist list.

Veterinary dentistry

Dentists may provide dental treatment to animals provided that it is for health rather than cosmetic reasons and that it is done under the direct personal supervision of a vet who is present throughout. Arrangements must be made for the immediate continuing care of patients a general dental practitioner who dies, particularly those undergoing treatment. If the dentist was providing NHS care, the primary care organisation should be contacted for help and advice. Patients should be notified and told of the arrangements that have been made for booked appointments. The dentists widow/widower/personal representative may carry on the business of dentistry, that is own the practice (engaging dentists to provide care) for a period of up to three years after the dentists death. Where the dentist is in partnership, the partnership agreement should make arrangements for what happens to the business on the death of a partner. The practice owner must make arrangements for the care of the patients if the dentist is an associate/assistant/performer. If the dentist is a contract holder in England or Wales, the PCO should be contacted immediately to ensure that the contract continues. Dentists will often leave instructions with their will on what their next of kin should do in the event of their death. Sometimes single-handed practitioners will have previously agreed with a local dental colleague to help out in the initial stages to help the practice continue. Detailed help and advice is contained in BDA Advice Sheet B4 What to do when a dental practitioner dies.

The death of a dental practitioner

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A patient request for a referral for a second opinion must be acceded to Agreements between dentists must always be written down. The BDA is happy to comment on drafts Openness and honesty is necessary in business dealings and financial and other targets must not be set so that the quality of care is at risk Patients interests must be put before those of the dentist, his colleagues, organisation or business Where a patient is referred to another practitioner, a comprehensive referral letter should be sent Where a patient has been referred, the second dentist should undertake the treatment that is set out except where it is not in accordance with his or her clinical judgement. In this case the matter should be discussed with the referring dentist. Specialist expertise must not be claimed unless the dentist is on a GDC specialist list.

Checklist

Dental practices must operate using sound business methods to ensure that sufficient income is generated to facilitate a high standard of care and treatment for patients. Commercial business methods can be at variance with caring professional practice and in certain areas dentists must be careful about breaching ethical rules. This section covers Financial interests Advertising and canvassing Shared arrangements with other health professionals Buying, selling or closing a practice Bodies corporate and limited liability partnerships Practices owned by dental care professionals Promotion of products and services Private dental plans Bankruptcy Checklist Dentists must not put their own financial interests above the interests of their patients. This is a specific requirement of NHS contracts in England and Wales. Financial interests can come into play, particularly where NHS care is provided, and it is important that dentists treatment decisions are not influenced by associated costs or NHS targets. Financial interests may have an influence on treatment planning and making NHS recommendations to patients. One question that professionals in general practice in England and Wales need to ask themselves on occasions is Would I recommend this course of treatment if the patient was paying privately? If the answer is no, then their care may be being influenced by their own financial situation. If a dentist finds that they are unable to provide a good standard of care while working under a particular contractual situation, then alternatives should be considered. A patient must be given full information about the various appropriate treatment options and be able to make an informed and free choice. Dentists must have full clinical freedom to provide the most appropriate treatment in the best interests of the patient and to a high standard. Dentists should not practise in circumstances where recommended standards of health and safety and infection control are not achieved.

Commercial interests

Financial interests

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Advertising and canvassing

The general professional rules set out in Standards for dental professionals apply to the way that dentists are able to advertise and market their practices. Best practice in dental advertising and marketing is discussed fully in BDA Advice Sheet A6 Marketing your practice. Dental advertising must comply with the Advertising Standards Authoritys Code of advertising practice (www.cap.org.uk). In summary, dentists should not: Claim to specialise unless they are on a GDC specialist list Say or imply anything that is untrue or misleading, particularly regarding the services or treatment that are available from the practice Make a claim that is not capable of substantiation Use the courtesy title Dr in advertising or promotional material Be associated with any publicity or advertising material that is likely to bring the profession into disrepute. Advertisements should contain the name of at least one dentist normally in attendance at the practice. Methods of practice promotion are varied and can include open days, circulation of leaflets to surrounding houses and businesses, sponsoring local sports teams, giving dental health education talks to interested groups. Marketing to the public via unsolicited telephone calls or house to house canvassing should not be undertaken. Dentists sometimes instruct advertising agencies or marketing companies to prepare advertising or publicity material for them which may not comply with GDC standards. The BDA is happy to check draft advertisements or other publicity material. Contact BDA Practice Support.

Shared arrangements with other health professionals

Dentists may share practice premises with other health professionals. Common arrangements involve rental agreements with chiropodists, physiotherapists or being part of a health centre with general medical practitioners. Where premises are shared, care should be taken that dental records are not accessible to third parties and that drugs and other hazardous substances are kept secure when the dental practice is not in use. Separate entrances and telephone numbers are not necessary, but patients should not be made to feel that they should be consulting other practitioners within the building.

Buying, selling or closing a practice

There are ethical considerations to be taken into account when a practice changes ownership to ensure that patients, dentists and staff are not misled. Advice on all aspects of practice sale and purchase is contained in BDA Advice Sheet A2 Buying and selling a practice. Informing patients Patients (NHS and private) should be informed when a practice is sold, a dentist leaves or a practice closes down. NHS regulations in Scotland and Northern Ireland require patients to be given three months' written notice of a dentist ceasing to provide NHS dental care at the practice. There is no such requirement in England and Wales. It is not acceptable for patients to make an appointment only to find on arrival that the dentist they have been seeing for some time has left the practice (provided that the departure was known to the practice at the time). In answer to questions about the whereabouts of the dentist, it is important to avoid untruthful statements.

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On leaving a practice, every effort should be made to complete outstanding treatment or arrange for its completion. In rare cases, patients have discovered that a practice has suddenly closed and that they are left in pain or in the middle of treatment, with no means of contacting the dentist. This situation has led to the dentist facing a fitness to practise investigation by the GDC. The names of dentists no longer providing dental care at a practice should be removed from signs, professional plates and practice literature to avoid misleading patients, or suitable wording should be added to make it clear that the dentist is no longer at the practice. Such wording should only remain for a reasonable period. Informing dentists Dentists practising at the premises should be given adequate notice of a practice sale to ensure that, if they decide to cease to work at the practice, their patients can be informed and treatment may be completed. Informing staff Dental staff should be informed at an early stage if a practice is being sold. As well as being a matter of good management, it ensures that patients are given accurate responses to questions and staff anxiety about the future (which can lead to a lowering of standards) is minimised. Most employees have some employment protection when a business is sold and further detailed advice is available from BDA Practice Support. Provided they meet certain conditions, companies can carry on the business of dentistry. "Carrying on the business" is generally taken to mean directly receiving money from patients in respect of dental services. Companies must have a majority of directors who are GDC registrants and can be bought and sold. There must always be one more registered dental professional director than the total number of lay members: for example two registered dentists to one lay person or one registered dentist, one registered dental nurse and one lay person. A growing number of companies operate a large number of practices and large companies operating in other fields of healthcare have entered the dental market. Dentists who are directors of dental bodies corporate are liable for the actions of the company, which must conform to GDC rules. The individual dentists who are employed or engaged by them are also responsible to the GDC for providing proper standards of care and treatment, ensuring safe practice and all other aspects of professional conduct. Contracts of employment or engagement provided by companies should be considered carefully and advice taken from the BDA on their terms. Dentists working for a company are still responsible for matters of professional conduct and for ensuring that they observe the guidance in Standards for dental professionals. A companys commercial interests must not influence the dentists clinical relationship with patients and the company must not compromise clinical freedom. Dentists must ensure that they do not enter into employment or engagement with corporate bodies that do not comply with the legal requirements for dental corporates. To do so may lead to fitness to practise proceedings. Because of the restrictions on carrying on the business of dentistry by lay people, explained above, dentists cannot take persons who are not GDC registrants (such as wives, husbands or business people) into partnership
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Bodies corporate and limited liability partnerships

without operating a corporate body. The only involvement non-dental corporates can have in the operation of a practice is to provide services to the practice such as premises, staff, equipment and management. The contract with the company must not contain a charging structure linked to turnover or profits, in order to avoid the company being held to be receiving money from patients. Further information is contained in BDA advice Sheet B9 Running a practice as a company or limited liability partnership. Practices owned by dental care professionals Registered dental care professionals (dental hygienists, dental therapists, dental technicians, dental nurses, clinical dental technicians and orthodontic therapists) may carry on the business of dentistry. Where a practice is owned by a DCP, a dentist must be engaged to see patients and provide treatment plans. The only exception is if patients are edentulous and care is provided by a clinical dental technician or the practice only provides care to patients who have a written treatment plan from a dentist and the DCP is providing care in accordance with the plan. Advertising for appropriate products or services may be included in patient information leaflets and newsletters, provided that the products are not in conflict with health care. By accepting payment or sponsorship, the dentist should not have a conflict of interest which might jeopardise the professional relationship with patients. As well as advertising, dentists are sometimes approached to enter into commercial arrangements with third parties. Financial incentives may not be accepted from third parties in return for promoting to patients specific dental products, the uptake of insurance or enrolment in a particular scheme for the provision of dental care. Patient lists must not be sold or given to third parties without consent. BDA Advice sheet B2 Data protection gives further information on third party access to patient data. Dentists occasionally become involved in outside business ventures that involve selling products and services to the public. Great care should be taken when attempting to sell non-dental products to patients. Patients have trust and confidence in the dental profession and when attending a practice do not expect to be sold other products unrelated to dentistry. If purchases are made, dentists must ensure that they are aware of their liability under consumer protection legislation and of the possibility of a complaint if the patient feels that misleading statements have been made. Private dental plans Many dental practices offer their patients the opportunity to pay for their private dental care by joining a private plan. The plans may be either capitation schemes or insurance schemes. Some dental corporates offer their own insurance plans and a growing number of dental practices operate their own inhouse schemes. In-house capitation schemes should have appropriate insurance cover to avoid contravening insurance law. When giving information to patients about private dental plans, dentists should not mislead about the cost of the schemes or the scope of the cover that is offered. Patients should have the option of paying for their private care on an item-of-service basis if they wish. Care should also be taken to ensure that legal requirements regarding consumer credit licensing and the provision of insurance are met. Further advice is available from BDA Practice Support.

Promotion of products and services

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Private dental plans should have no effect on a dentists clinical freedom and should not interfere with the relationship between dentist and patient. Many of the larger plans require practices to adhere to particular standards and membership can be beneficial to a practice in terms of raising the quality of service given to patients. Further information on private dental schemes is available in BDA Advice Note Private dental plans. Bankruptcy does not prevent a dentist continuing to practise and registration is unaffected, provided that there is no attendant question of fitness to practise. A dentist who is no longer able to run a business may take up an employed position, either within the salaried services or as an assistant/employed performer in general dental practice. Dentists in financial difficulties should contact BDA Practice Support for advice. Advertising material must not be misleading Dentists cannot lend their names to specific products or services Only companies with a majority of GDC registrant directors may carry on the business of dentistry, that is own a dental practice Dentists employed/engaged by companies must follow the same ethical and legal rules as other general dental practitioners Where dentists offer patients treatment under private dental plans, the scope of care to be provided by the plans should be clear and its terms should not interfere with the contract and relationship between dentist and patient Bankrupt dentists may continue in clinical practice Lay people cannot enter into partnerships to own dental practices. Bankruptcy

Checklist

Members of the dental team are in a position where they may observe the signs of child abuse or neglect or hear something that causes them concern about a child. The dental team has an ethical responsibility to find out about local procedures for child protection and to follow them if a child is or might be at risk of abuse or neglect (Standards for dental professionals, GDC 2005). There is also a responsibility to ensure that children are not at risk from members of the profession. This section covers: Types of abuse Practical steps Recording and reporting Child protection policy Criminal record checks Further information Checklist The dental team is not responsible for making a diagnosis of child abuse or neglect, just for sharing concerns appropriately. Abuse and neglect are described in four categories: Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. It may also be caused by a parent or carer fabricating the symptoms of, or deliberately causing, illness in a child. Orofacial trauma occurs in at least 50 per cent of children diagnosed with physical abuse and a child with one injury may have further injuries that are not visible.

Child protection

Types of abuse

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Emotional abuse is the persistent emotional maltreatment causing severe and persistent adverse effects on the childs emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of the other person. It may feature: Age or developmentally inappropriate expectations being imposed on children Interactions that are beyond the childs developmental capability Overprotection and limitation of exploration and learning Preventing the child participating in normal social interaction Seeing or hearing the ill-treatment of another Causing children frequently to feel frightened or in danger Exploitation or corruption of children. Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (for example rape, buggery) or non-penetrative acts. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic material or watching sexual activities, or encouraging children to behave in sexually inappropriate ways. Neglect is the persistent failure to meet the childs basic physical and/or psychological needs, likely to result in the serious impairment of the childs health or development. It may occur in pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer: Failing to provide adequate food and clothing, shelter Failing to protect a child from physical and emotional harm or danger Failure to ensure adequate supervision Failure to ensure access to appropriate medical care or treatment Neglect of, or unresponsiveness to, a childs basic emotional needs. Practical steps If you are worried about a child practical steps It is uncommon for dentists to see patients with signs of child abuse and, generally, dentists are not in a position to assess all the factors involved. But where you have concerns about a child who may have been abused and there is no satisfactory explanation, prompt action is important. Ask yourself: Could the injury have been caused accidentally? If so, how? Does the explanation for the injury fit the age and clinical findings? If the explanation of the cause is consistent with the injury, is this itself within the normally acceptable limits of behaviour? If there has been any delay in seeking advice, are there good reasons for this? Does the story of the accident vary? Observe: The relationship between the parent/carer and child The childs reaction to other people The childs reaction to dental examinations Any comments made by the child or parent/carer that give concern about the childs upbringing or lifestyle.

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Discuss your concerns with an appropriate colleague or someone you can trust. If you remain concerned, informal advice could be sought first from your local social services without disclosing the childs name. This will help you decide whether you should make a formal referral by telephone so that you can directly discuss your concerns. Seek permission to refer It is good practice to explain your concerns to the child and parents, informing them of your intention to refer and seek their consent being open and honest from the start, results in better outcomes for the children. Dont discuss your concerns with the parents where The discussion might put the child at greater risk The discussion would impede a police investigation or social work enquiry Sexual abuse by a family member, or organised or multiple abuse is suspected Fabricated or induced illness is suspected Parents or carers are being violent or abusive and discussion would place you or others at risk It is not possible to contact parents or carers without causing undue delay in making the referral. Where there is serious physical injury arising from suspected abuse: Refer the child to the nearest hospital Accident and Emergency Department with the consent of the person having parental responsibility or care of the child Advise the A&E Department in advance (by telephone) that the patient is coming If consent is not obtained, the Duty Social Worker at the local Social Services Department or the police should be told of the suspected abuse by telephone so that the necessary action can be taken to safeguard the welfare of the child A telephone referral to Social Services must be confirmed in writing within 48 hours, repeating all relevant facts of the case and an explicit statement of why you are concerned. The telephone discussion should be clearly documented who said what, what decisions were made and the agreed unambiguous action plan. Where less serious injury is recorded or there is concern for the physical or emotional well-being of the child, discuss the appropriate reporting procedures and your concerns with a senior local colleague, such as a hospital consultant, dental adviser or consultant in Dental Public Health or contact the health professional for child protection at the local primary care organisation (PCO). Reports should be restricted to The nature of the injury Facts to support the possibility that the injuries are suspicious. Attendance of the referring dentist may be required by the Social Services Department at a case conference or if there is a court hearing, so comprehensive written records of the injury and its history (as reported) must be kept together with clinical photographs. Recording and reporting

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Child protection policy

A suitable child protection policy for a dental practice should affirm the practices commitment to protecting children from harm and should explain how this will be achieved. A policy by itself is not enough, however. Safeguarding children also involves: Listening to children Providing information for children Providing a safe and child-friendly environment Having other relevant policies and procedures in place Listening to children Create an environment in which children know their concerns will be listened to and taken seriously. You can communicate this to children by: Asking for their views when discussing dental treatment options, seeking their consent to dental treatment in addition to parental consent Involving them when you ask patients for feedback about your practice Listening carefully and taking them seriously if they make a disclosure of abuse Providing information to children To support children and families, you can provide information about: Local services providing advice or activities Sources of help in times of crisis, for example, NSPCC Child Protection Helpline, NPCC Kids Zone website, Childline, Samaritans Providing a safe and child-friendly environment Taking steps to ensure that areas where children are seen are welcoming and secure with facilities for play Considering whether young people would wish to be seen alone or accompanied by their parents Ensuring that staff never put themselves in vulnerable situations by seeing young people without a chaperone Ensuring that your practice has safe recruitment procedures in place Other relevant policies and procedures Clinical governance policies that you already have in place will contribute to your practice being effective in safeguarding children. Relevant policies and procedures include: Safe staff recruitment procedures Making potential job applicants aware of your child protection policy Checking gaps in employment history Requesting proof of identity Taking up references Complaints procedure so that children or parents attending your practice can raise any concerns about the actions of your staff that may put children at risk of harm Public interest disclosure policy (underperformance policy) so that staff can raise concerns if practice procedures or action of other staff members puts children at risk of harm Code of conduct for staff clarifying the conduct necessary for ethical practice, particularly related to maintaining appropriate boundaries in relationships with children and young people (including a statement that staff members will be chaperoned when attending unaccompanied children, for example).

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To increase patient safety, all new recruits into the NHS must undergo criminal record checks. The existence of a criminal conviction does not of itself prevent anyone from working in the NHS and information should considered in the light of all relevant circumstances including the nature of the offence and the relevance of the offence to the work involved. Obtaining a disclosure for practice staff in private practice is regarded as good practice. England and Wales Dentists working under a GDS contract or PDS agreement in England and Wales must ensure that staff with direct patient contact undergoes criminal records checks. This includes, for example, dental nurses and receptionists but not cleaners that work out of hours. Dentists are checked automatically on entry to a Primary Care Organisation performers list. The Criminal Records Bureau (CRB) undertakes the criminal records checks. There are two types of disclosure standard and enhanced. Standard disclosures allow disclosure of criminal convictions (spent or unspent), cautions, reprimands, warnings and bind-overs. Enhanced disclosures allow the additional disclosure of information held by local police forces. The employing dentist decides whether an enhanced disclosure is needed, although a standard disclosure is usually sufficient for employees. The relevant paperwork can usually be obtained from the local Primary Care Organisation. Many PCOs do not charge for this service, but where one is made it should only reflect the charge made by the CRB. CRB checks can be undertaken by other organisations listed on the CRB website. Being commercial, these organisations will charge a fee for providing this service. Scotland Disclosure Scotland is a voluntary body established within the Scottish Criminal Record Office (SCRO) to issue disclosure certificates. Its aim is to enhance public safety and help employers and voluntary organisations in Scotland to make safer recruitment decisions. The bureau is responsible for issuing three levels of disclosure basic, standard and enhanced. It draws on three sources of information the SCRO database, the Police National Computer (PNC) and, where appropriate, local police force records. Basic disclosures show details of all unspent convictions and are available to anyone. Standard disclosures are available for occupations whose duties involve, for example, regular contact with children and young people under the age of 18, vulnerable adults and professional groups in health. They contain details of all convictions on record, whether spent or unspent under the Rehabilitation of Offenders Act, so minor convictions, no matter when they occurred, will be included. The highest level, enhanced disclosures, may also contain non conviction information held locally by the police. The prospective employer should decide which level of disclosure to apply for. Requests for standard and enhanced disclosures must be countersigned by a registered body, such as a Health Board.

Criminal record checks

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Further information

Child protection and the dental team www.cpdt.org.uk Criminal Records Bureau (England and Wales) Tel: 0870 909 0844 www.crb.gov.uk Disclosure Scotland Tel: 0870 609 6006 or email info@disclosurescotland.co.uk www.disclosurescotland.co.uk

Checklist

Ensure the dental team in trained in child protection procedures Have a child protection policy Record and report cases Undertake criminal record checks

The dental team

Dentists have to place great reliance on members of their dental team to ensure that they comply with ethical and legal requirements. This section gives some practical ways in which dentists can ensure that their teams meet the required standards. Vicarious responsibility Dental hygienists and dental therapists Dental technicians and clinical dental technicians Dental nurses Dental receptionists Training Terms and conditions of service Staff management and appraisal Checklist

Vicarious responsibility

Dentists are vicariously responsible for the acts and omissions of their unregistered staff. This includes dentists working as assistants, locums and associates who, although they may not be the employer of the staff, are responsible for the delegation of tasks to them and for the outcomes of their actions on patients. Both dentists and registered DCPs may be held responsible by the General Dental Council and NHS contractors will be responsible for the acts and omissions of all dental professionals they engage. The General Dental Council has published a Scope of practice for each group of DCPs giving the tasks that they can undertake, providing they have appropriate training. See the GDCs website at www.gdc-uk.org. The dentist is responsible for checking the GDC registration of dental hygienists and dental therapists and must ensure that they work within their competence. Failure to do so may lead to a charge of covering the illegal practice of dentistry, as well as fitness to practise proceedings against the DCP. Dental hygienists may work without a dentist being on the premises. Hygienists and therapists work within the treatment plan provided by the dentist stating the treatment to be provided, the date of the next full mouth assessment and recall intervals at which the patient should be seen. The dentist can ask the dental hygienist or dental therapist to decide the recall intervals where appropriate. Dental therapists can work in all spheres of dental practice.

Dental hygienists and dental therapists

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Dental hygienists and dental therapists should have their own indemnity cover to protect them in the case of proceedings by the GDC and action by a patient. Dental defence organisations accept dental hygienists and dental therapists into membership. Dental technicians have to be registered with the GDC or be in formal training. Dental technicians do not work with patients, that is take impressions, or fit or adjust dentures. Clinical dental technicians are able to fit dentures to patients if instructed to do so by a dentist, but they cannot work without such a prescription. They are, however, permitted to provide full sets of dentures to edentulous patients without prescription. There is currently no training course available in the UK for dental technicians to become CDTs, but a number of UK dental technicians studied denturism at a Canadian college and, for such graduates, the FGDP has set up a conversion course. After passing this course, these individuals can register with the GDC as CDTs. If a patient prefers to be referred to a local CDT, dentists should cooperate as far as possible. We suggest that the CDTs registration is checked and that dentists should get to know their local CDT so that a working relationship can be built up. There is no compulsion on a dentist to refer a patient to a particular CDT, but dentists should respond to the patient or CDT in a courteous and timely way and act in the patients best interests, respecting their preferences as far as possible. Ensure that a full mouth examination has been undertaken and that the patient has given informed consent for the referral and/or treatment plan. CDTs must follow the GDCs Standards for dental professionals and the Clinical Dental Technicians Association also has a code of conduct for its members which can been seen at www.cdta.org.uk/index.php?option=com_content&task=view&id=47&Itemid=69. Dental nurses must be registered with the GDC or enrolled on an approved training course. They do not treat patients, but assist the dentist in the surgery. It is possible for dental nurses to undertake further training, for example in taking radiographs or in providing oral health education. They must ensure that they work within their competence. Clinical responsibility for their work remains with the dentist but the nurse may also be held accountable by the GDC. The National Examining Board for Dental Nurses accredits courses and provides certificates both for the primary qualification (national certificate or NVQ/SVQ 3 in dental nursing) and for the additional qualifications. Dental receptionists do not work in the surgery. Since registration for dental nurses became mandatory, receptionists cannot be asked to cover surgery duties in the event of absence of a dental nurse unless he/she is registered. A dentist asking the receptionist to do so would be subject to fitness-to-practise procedures. It is essential that all members of the dental team are adequately trained, registered and competent to perform their required duties. Once trained, skills and knowledge must be kept up-to-date. Dental nurses must be qualified and registered or in training towards a qualification. Courses for dental practice managers and dental receptionists are also available. All DCP groups have their own professional associations that provide courses, information and journals to their members. All registered DCPs are subject to mandatory CPD requirements. Postgraduate deaneries invite DCPs to appropriate courses and are also establishing programmes designed especially for them.
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Dental technicians and clinical dental technicians

Dental nurses

Dental receptionists

Training

Dental employers have a responsibility to allow their employees time off to attend appropriate training courses and to pay for or contribute to the cost of such training. Many practices attend courses as a team or arrange in-house training sessions. Terms and conditions of service Dental employers are obliged to comply with employment legislation covering conditions of employment, the minimum wage, dismissal, redundancy and discrimination. Detailed advice on employment legislation is contained in a series of BDA advice sheets and personal assistance is available from advisers in BDA Practice Support (practicesupport@bda.org; telephone 020 7563 4574. Dentists must take particular care to avoid breaching discrimination law since an adverse employment tribunal decision will lead to details of the case being passed to the GDC. Practices should have in place an equal opportunities policy that provides a procedure to deal with allegations of discrimination and sexual harassment. Dentists can find it difficult to compete in the local labour market for competent staff because of constraints in NHS funding. Careful thought should be given to pay and benefits packages to ensure that staff turnover is minimised and the quality of care and service to patients remains high. Staff management and appraisal A good staff appraisal scheme can help to deal with poor performance, reward good performance and increase motivation. The BDA provides a comprehensive guide to appraisal, available in the BDA Practice Compendium. Dental undergraduates receive little or no staff management training, although these issues are covered in the vocational training year. Communicating with and motivating staff are skills that are learned in practice. Providing a high standard of care and service to patients requires good management and administration by dentists and courses are available. The BDA also has a large amount of management information for use in dental practice. Contact the BDA's Information Centre and Professional and Advisory Services and use the BDA Practice Compendium. Also consider taking part in the BDA MasterClass management training programme. Checklist Dentists should ensure that their staff are properly trained and qualified to undertake the tasks that have been delegated to them Dentists are responsible for the acts and omissions of their staff Dentists must comply with employment legislation Training in the management of staff is important for dentists All dental care professionals must be registered with the GDC or enrolled on an approved training course Dental practices should follow a comprehensive equal opportunities policy.

General anaesthesia and conscious sedation

General anaesthesia

There are stringent requirements for the provision of general anaesthesia and conscious sedation in dentistry. GDC requirements are contained in the annex to Standards for dental professionals. General anaesthesia, a procedure which is never without risk, should be avoided wherever possible. It must only be provided within a hospital setting which has critical care facilities. This means it cannot be provided within primary care. General anaesthesia may only be given by someone who is: on the specialist register of the General Medical Council as an anaesthetist a trainee working under supervision as part of a Royal College of Anaesthetists approved training programme, or

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a non-consultant career-grade anaesthetist with an NHS appointment under the supervision of a named consultant anaesthetist, who must be a member of the same NHS anaesthetic department where the non-consultant careergrade anaesthetist is employed. The anaesthetist should be supported by a health professional who is specifically trained and experienced in the necessary skills to help monitor the patients condition and to assist in an emergency. For settings which do provide general anaesthesia the recommendations set out in the Department of Health (England) publication A Conscious Decision a review of the use of general anaesthesia and conscious sedation in primary dental care (July 2000) and associated letters of advice from Chief Dental Officers in England, Northern Ireland, Scotland and Wales must be adopted. The Department of Healths (England) guidance document Conscious sedation in the provision of dental care was published in 2003 and lays down specific recommendations for all practitioners providing conscious sedation in general dental practice, community and hospital settings. It is a Standing Dental Advisory Committee (SDAC) report of an expert group on sedation for dentistry and is endorsed by the GDCs Standards for dental professionals. It underlines: 1. The importance of the referring dentist and the sedationist considering alternative methods of pain and anxiety control and discussing these with the patient before deciding that conscious sedation is appropriate 2. The need for both theoretical and practical training, continuing updating and clinical audit for the whole dental team is stressed as part of the clinical governance framework for ensuring the delivery of a high quality service, and 3. The necessity of having the appropriate equipment and drugs and ensuring that the equipment is properly maintained. The executive summary of the report is given below, but all practitioners and dental care professionals who offer sedation services are advised to make themselves aware of the full contents of the report. This is available from the BDA or Department of Health website. Executive summary Conscious sedation in the provision of dental care Department of Health (England) The effective management of pain and anxiety is of paramount importance for patients requiring dental care and Conscious Sedation is a fundamental component of this. Competently provided Conscious Sedation is safe, valuable and effective. It is absolutely essential that a wide margin of safety be maintained between Conscious Sedation and the unconscious state of general anaesthesia. Conscious Sedation must under no circumstances be interpreted as light general anaesthesia. A high level of competence based on a solid foundation of theoretical and practical supervised training, progressive updating of skills and continuing experience is the key to safe practice. Education and training must ensure that ALL members of the dental team providing treatment under Conscious Sedation have received appropriate supervised theoretical, practical and clinical training. Training in the management of complications in addition to regularly rehearsed proficiency in life support techniques is essential for all clinical staff. Retention and improvement of knowledge and skills relies upon regular updating.
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Conscious sedation

Operating chairs and patient trolleys must be capable of being placed in the headdown tilt position and equipment for resuscitation from respiratory and cardiac arrest must be readily available. Dedicated purpose-designed machines for inhalational sedation should be used. It is essential to ensure that hypoxic mixtures cannot be delivered. There should be adequate active scavenging of waste gases. All equipment for the administration of intravenous sedation including appropriate antagonist drugs must be available in the treatment area and appropriately maintained. Supplemental oxygen delivered under intermittent positive pressure together with back up must be immediately available. It is important to ensure that each exposure to Conscious Sedation is justified. Careful and thorough assessment of the patient ensures that correct decisions are made regarding the planning of treatment. A thorough medical, dental and social history should be taken and recorded prior to each course of treatment for every patient. There are few absolute contraindications for Conscious Sedation however special care is required in the assessment and treatment of children and elderly patients. Patients must receive careful instructions and written valid consent must be obtained. Fasting for Conscious Sedation is not normally required however some authorities recommend the same fasting requirements as for general anaesthesia. Recovery from sedation is a progressive step-down from completion of treatment through to discharge. A member of the dental team must supervise and monitor the patient throughout this period. The decision to discharge a patient into the care of the escort following any type of sedation must be the responsibility of the sedationist. The patient and escort should be provided with details of potential complications, aftercare and adequate information regarding emergency contact. The three standard techniques of inhalation, oral and intravenous sedation employed in dentistry are effective and adequate for the vast majority of patients. The simplest technique to match the requirements should be used. The only currently recommended technique for inhalation sedation is a titrated dose of nitrous oxide with oxygen and it is absolutely essential to ensure that a hypoxic mixture cannot be administered. The standard technique for intravenous sedation is the use of a titrated dose of a single drug; for example the current use of a benzodiazepine. Oral premedication with an effective low dose of a sedative agent may be prescribed. No single technique will be successful for all patients. All drugs and all syringes in use in the treatment area must be clearly labelled and each drug should be given according to accepted recommendations. Stringent clinical monitoring during the procedure is of particular importance and all members of the clinical team must be capable of undertaking this. Conscious Sedation for children must only be undertaken by teams which have adequate training and experience. Nitrous oxide / oxygen should be the first choice for paediatric dental patients. Intravenous sedation for children is only appropriate in a minority of cases. The management of any complication including loss of consciousness requires the whole dental team to be aware of the risks, appropriately trained and fully equipped. It is vitally important for the whole team to be prepared and regularly rehearsed.

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Attention must be given to risk awareness, risk control and risk containment. Evidence of active participation in continuing professional development (CPD) and personal clinical audit is an essential feature of clinical governance. The Scottish Dental Clinical Effectiveness Programme has produced specific guidance on the provision of sedation in Scotland. Conscious sedation in dentistry dental clinical guidance was published in May 2006 and evolved from the report by the English Department of Health summarised above. A full copy of the Scottish guidance is available at: www.scottishdental.org/cep/guidance/dentalsedation.htm In August 2007 the Royal College of Surgeons of England - Faculty of Dental Surgery and the Royal College of Anaesthetists produced new additional guidance encompassing the use of alternative conscious sedation techniques. Standards for Conscious Sedation in Dentistry: Alternative Techniques - A Report from the Standing Committee on Sedation for Dentistry can be accessed at www.rcseng.ac.uk/fds/docs/SCSDAT%202007.pdf Alternative techniques include: Any form of conscious sedation for patients under the age of 12 years* other than nitrous oxide/oxygen inhalation sedation Benzodiazepine + any other intravenous agent for example: opioid, propofol, ketamine Propofol either alone or with any other agent for example: benzodiazepine, opioid, ketamine Inhalational sedation using any agent other than nitrous oxide / oxygen alone Combined (non-sequential) routes for example: intravenous + inhalational agent (except for the use of nitrous oxide/oxygen during cannulation) *It is recognised that the physical and mental development of individuals varies and may not necessarily correlate with the chronological age. A dentist has a legal obligation to obtain the valid and voluntary consent of the patient to the treatment proposed. The nature of the treatment to be undertaken must therefore be explained clearly and in terms that the patient can understand. The patients comprehension is an essential element in the validity of consent and the onus is on the dentist to satisfy him or herself that the patient has understood the treatment to be carried out. Alternative treatments and methods of pain control which may be available, any material risks involved in each option and any aftercare or precautions which may be necessary form a vital part of the explanation leading to full patient comprehension. The patient must have the opportunity to ask questions and make a choice free from pressure. The duties of the referring dentist It is important that the referring dentist, as well as the treating dentist, obtains the patients agreement to the referral following a thorough and clear explanation of the risks involved and the alternative methods available. Consent Conscious sedation in Scotland

Alternative techniques

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Checklist of ethical principles

Dentists duties include Obligations to patients Always to act in a patients best interests and put those interests before their own or those of any colleague, organisation or business Respect a patients dignity and choices Treat patients politely and with respect Only undertake procedures for which they have the necessary training competence and experience Obtain and keep up appropriate professional indemnity/insurance cover Obtain valid consent that is informed and specific Confidential personal information about patients must only be disclosed with the consent of the patient and in particular circumstances Respect a patients human rights Comply with the Data Protection Act 1998 and give patients a copy of the practices data protection code of practice Not provide excessive or unnecessary treatment Maintain appropriate professional boundaries Patients must be treated fairly and reasonably and not misled about the treatment they will receive, the contractual basis on which it is provided or its cost Where dentists offer patients treatment under private dental plans, the scope of care to be provided by the plans should be clear and their terms should not interfere with the contract and relationship between dentist and patient Where a patient makes a complaint, try to resolve it using the practice complaints procedure Not discriminate on the grounds of sex, race, religion, gender reassignment or disability Refer a patient for further advice and treatment if it transpires that the task in hand is beyond the dentists own skills or experience Not intimidate child patients and only use physical restraint in the most exceptional circumstances Arrange for the completion of treatment when leaving a practice Train staff in patient confidentiality and use a comprehensive practice confidentiality policy Include breaches of confidentiality in staff disciplinary procedures as an offence which would result in summary dismissal. Professional practice Notify the GDC promptly of any change in registered address or practising name Registration with the GDC must be renewed every year and a dentist must ensure that dental care professionals whom they engage are registered Read communications from the General Dental Council promptly and retain GDC guidance for reference Undertake the required amounts of continuing postgraduate education, together with clinical audit and peer review Comply with ASA advertising guidelines Comply with current health and safety legislation and infection control procedures Have a registered DCP who is trained in emergency procedures in the room when a patient is being treated Promote oral health among patients Only provide or refer a patient for general anaesthesia where there is no suitable alternative Ensure that where a patient receives either general anaesthesia and sedation, GDC rules are followed

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Ensure that the dental team is regularly trained in resuscitation techniques Keep comprehensive clinical records for at least eleven years after treatment has finished or for children up to age 25, whichever is the longer Not refer patients to colleagues in return for a fee Where treatment is offered that does not amount to dental treatment, the dentist must have appropriate indemnity cover and be fully trained and competent to provide the treatment Ensure that staff are properly trained and qualified to undertake the tasks that have been delegated to them Are responsible for the acts and omissions of staff Where a patient is referred to another practitioner a comprehensive referral letter should be sent. Patients have the right To a high standard of dental care To a free choice of general dental practitioner To a prompt referral for a second opinion where this is necessary or the patient has requested it To change dentist To be fully informed of the treatment that is necessary, alternatives and material risks as well as the nature of the contract (NHS/private) and the cost of treatment To a written treatment plan and estimate where a new course of NHS treatment is planned or expensive or extensive treatment is required To be provided with an itemised bill on request To be notified of the terms (NHS/private) and the probable cost of specific items of treatment if referred to another practitioner To have a complaint dealt with sympathetically and promptly by the practice in the first instance To be informed in writing if they are ceasing to be entitled to NHS dental care at the practice To access to information held about them If offered alternative therapies as part of their treatment, to know at the outset any additional cost. Professional relationships Agreements between dentists must always be written down. The BDA is happy to comment on drafts Transfer of dental records depends on the agreement between associate and practice owner and the wishes of the patient Dentists must act in a professional manner towards colleagues Where a professional colleague, because of poor performance, health or other unprofessional conduct may be putting patients at risk a dentist has a duty to raise a concern with an appropriate body to protect patients Not to place young colleagues under pressure to achieve target earnings which may compromise their clinical standards and put pressure on them not to act in their patients best interests Where a patient has been referred, undertake the treatment that is set out in the referral letter, except where it is not in accordance with the treating dentists clinical judgement. In this case the matter should be discussed with the referring dentist. Legal responsibilities Comply with employment legislation Follow a comprehensive equal opportunities policy and not discriminate on the grounds of sex, race, disability, religion or gender reassignment If practising within the NHS comply with the terms of their contract

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Keep up to date with his responsibilities under a wide range of relevant legislation including: Data Protection Act 1998 Health and Safety at Work Act 1975 Ionising Radiations Regulations 1998 Dentists Act 1984 (as amended) Medicines Act 1988 Misuse of Drugs Act 1971 Employment Rights Act 1996 Disability Discrimination Act 1998 Working Time Regulations 1998 Supply of Goods and Services Act 1982 Consumer Credit Act 1974 Consumer Protection Act 1987 Medical devices regulations Human Rights Act 1998.

Dentists Health Support Programme

Established in April 1986 as the Sick Dentist Scheme, the Dentists Health Support Programme is designed to help the dentist who is in need of but not seeking - medical attention and whose condition is considered to compromise well-being, the safety and welfare of patients and the reputation of the profession. It is designed both to protect patients and to help dentists who may be at risk of formal complaint to the GDC. Whilst the majority of cases are alcohol/drug related, this is not always the case. The Dentists Health Support Programme can be contacted by calling the helpline number below. This line can be used by any dentist who has a problem or by someone (a colleague, staff, family member or a friend) who knows a dentist who might have a problem. The scheme is entirely confidential and callers are assured that their identity will not be disclosed to the dentist at any time. The caller will be put in contact with a Regional Referee in the appropriate geographical area or with the Co-ordinator of the Programme. Regional Referees are usually retired or semi-retired dentists who are trained and willing to make time to help colleagues in trouble. The Regional Referee will contact a Special Referee and help establish whether there is a problem. Special Referees are recovered alcohol/drug addicts who have received specialised training. The Referees discuss and investigate the case in a careful and confidential manner. If necessary, the sick dentist will be visited by both referees who will discuss the problem, offer help and, with the dentists agreement, make suitable arrangements for the provision of treatment and such other help as is necessary. The key role of the Regional Referee is to provide practical help and advice in dealing with practice problems and support for the family - both very important. The management of the practice may have deteriorated and the dentist may have to be absent from the practice and from home while receiving treatment. If you know of a dentist who might be helped by the Dentists Health Support Programme, call the following confidential number, which is also widely advertised in the dental press. Names and addresses of Regional Referees may also be available from GDPC representatives and LDC Secretaries. Tel: 01327 262 823

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Who does the Fund help? The Fund cares for all dentists in the UK and their families at times of need, not just members of the Association. Dentistry is a stressful profession, and some people find it difficult to cope with the pressures, suffering mental or physical breakdown. Others retire in apparently comfortable circumstances, but find after twenty or thirty years that their savings and pensions have dwindles considerably. People of all ages are cared for, whenever need arises. How does it help? The Fund helps many people every year, supplementing their income or paying the occasional bill they cannot manage. Grants help people replace items such as washing machines, beds and refrigerators, and pay for television licences. The Fund enables people to enjoy life, gives a Christmas grant to every beneficiary and occasionally pays for holidays. Some people only need help in the short term, and may be offered a loan (usually interest-free) to see them through the difficult time. The valuable team of visitors provides friendship and support for those who require it. Many deserving cases do not come to the Funds attention. If you know of someone you think could benefit from the Fund's assistance, please encourage him or her to contact the Fund's Welfare Manager, Mrs Sally Atkinson. Her address is 64 Wimpole Street, London W1G 8YS, telephone number: 020 7486 4994 (24 hour answerphone) and email: dentistshelp@btconnect.com. Every enquiry is considered in absolute confidence. Can I help the Fund? Yes! You can help in many ways. You can give money regularly to the Fund through a tax-efficient covenant system. You can leave a bequest to the Fund in your will. You can also tell colleagues and their families about the work of the Fund, particularly when you think its help might be needed. The Fund is truly grateful for the generous support received from members of the profession as, without it, it could not continue its work.

BDA Benevolent Fund

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British Dental Association 64 Wimpole Street l London W1G 8YS l Tel: 020 7563 4563 l Fax: 020 7487 5232 l E-mail: enquiries@bda.org l www.bda.org l BDA March 2009