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Advicesheet

B1Ethics in dentistry

© BDA March 2009 3

Advicesheet

Ethics in dentistry B1

This advice sheet provides detailed, practical advice and information on the

major aspects of ethics in dentistry. The sections are:

The duty of care and professional obligations 6

Professional regulation and registration 6

The patient’s best interests 6

Equal treatment and human rights 6

Professional competence and experience 7

Lifelong learning 7

Clinical audit, peer review and clinical governance 8

Professional indemnity/insurance 8

Revalidation 8

Checklist 9

Consent 9

Key definitions 9

The need for valid consent 10

Obtaining consent 10

Material risks 12

Consent under duress 13

Treatment at the patient’s request 13

Making claims 14

Battery 14

The age of consent 14

Children in care 15

Incompetent patients 15

Where consent is not obtainable 15

Clinical trials, research and lectures 17

Consent forms 18

Checklist 18

Confidentiality 19

What is personal health information 19

Data Protection Act 1998 20

Age of consent to disclosure 20

What information can be disclosed 21

Training and disciplinary procedures 24

Checklist 25

Model confidentiality policy 25

Data protection code of practice 27

contents page

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Dental records 29

Good record keeping practice 30

Storage, retention and disposal 31

Fair processing 32

Subject access 32

Third party access 33

Sale/transfer of records 34

Checklist 35

Patient care 35

Patient communication 35

Agreeing to provide care and treatment 36

Patient choice 37

Treatment planning 37

Health checks 37

Alternative therapies 37

Non-surgical cosmetic procedures 38

Tooth whitening 38

Medical emergencies 38

Misleading patients 38

Maintaining appropriate boundaries 39

Referral fees 39

Missed appointments 39

Debt collection 39

Handling complaints 40

Checklist 41

Professional relationships 41

Professional agreements 41

Duties of a dentist manager 41

Second opinions 42

Raising concerns 42

Specialist practice 43

Veterinary dentistry 43

The death of a dental practitioner 43

Checklist 44

Commercial interests 44

Financial interests 44

Advertising and canvassing 45

Shared arrangements with other health professionals 45

Buying, selling or closing a practice 45

Bodies corporate and limited liability partnerships 46

Practices owned by dental care professionals 47

Promotion of products and services 47

Private dental plans 47

Bankruptcy 48

Checklist 48

contents page

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Child protection 48

Types of abuse 48

Practical steps 49

Recording and reporting 50

Child protection policy 51

Criminal record checks 52

Further information 53

Checklist 53

The dental team 53

Vicarious responsibility 53

Dental hygienists and dental therapists 53

Dental technicians and clinical dental technicians 54

Dental nurses 54

Dental receptionists 54

Training 54

Terms and conditions of service 55

Staff management and appraisal 55

Checklist 55

General anaesthesia and sedation 55

General anaesthesia 55

Conscious sedation 56

Conscious sedation in Scotland 58

Alternative techniques 58

Consent 58

Checklist of ethical principles 59

Dentists’ Health Support Programme 61

BDA Benevolent Fund 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 [email protected] 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).

© BDA March 2009 6

This section gives an overview of the main obligations of a dentist and covers:

� Professional regulation and registration

� The patient’s 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 patient’s best interests and provide a high standard of

care and service. Acting in a patient’s best interests can be interpreted widely

but includes:

� Providing appropriate, necessary care and treatment to a high standard

� Not misleading patients

� Putting the patient’s 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 dentist’s duty of care and

professional obligations

Professional regulation and registration

The patient’s best interests

© BDA March 2009 7

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 patient’s and dentist’s

perceptions of what is an acceptable standard of care can differ, for example in

what constitutes a dental emergency.

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: [email protected] 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.

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.

Equal treatment and human rights

Professional competence and experience

Lifelong learning

© BDA March 2009 8

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 dentist’s 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

Clinical audit, peer review and clinical

governance

Professional indemnity/insurance

Revalidation

© BDA March 2009 9

questions remain, the GDC will be able to take further steps, for example an in-

practice assessment or a full assessment through the National Clinical

Assessment Service (NCAS).

� Always act in a patient’s best interests

� be familiar with the GDC’s 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.

The law on consent is subject to change and further specific advice should be

obtained from BDA Practice Support on 020 7563 4574 or [email protected].

This section gives general guidance on the dentist’s 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.

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 patient’s informed consent to sedation does not mean that

the patient has given specific consent to the treatment that will be carried out.

Checklist

Consent

Key definitions

© BDA March 2009 10

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 self-

determination. Any treatment or intentional physical contact with the patient

undertaken without valid consent may amount to assault and a breach of the

patient’s 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 GDC’s

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

patient’s 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.

The need for valid consent

Obtaining consent

© BDA March 2009 11

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 BDA’s 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

patient’s 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.

Express and implied consent

© BDA March 2009 12

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 dentist’s 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 patient’s 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.

© BDA March 2009 13

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 patient’s 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 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 patient’s prior authorisation and that third parties are not unduly influencing

the patient to consent.

Cases arise where patients ask a dentist to undertake treatment that is not in

their best interests and is against the dentist’s 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 patient’s best interests. Treatment should not be

Consent under duress

Treatment at the patient’s request

© BDA March 2009 14

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 child’s

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

child’s age, maturity and the proposed treatment. For example, a twelve year-

old 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” child’s consent to treatment.

Making claims

Battery

The age of consent

© BDA March 2009 15

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 child’s 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 child’s father and mother, where

they were married to each other at the time of birth; the child’s 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 child’s

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.

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.

Children in care

Incompetent patients

Where consent is not obtainable

© BDA March 2009 16

Notes must be made in the patient’s 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 patient’s 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.

© BDA March 2009 17

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 practice’s 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

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 patient’s 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.

Clinical trials, research and lectures

Consent forms

© BDA March 2009 18

� 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.

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

Checklist

© BDA March 2009 19

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 patient’s consent to anyone for any purposes other than the provision of

health care. This principle is included in the GDC’s 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 patient’s 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

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 dentist’s (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 patient’s

consent.

Removal of obvious identifying features from the information may not

necessarily remove the need to maintain confidentiality. The patient’s 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 patient’s

identity.

4. Maintaining confidentiality

What is personal health information?

© BDA March 2009 20

The 1998 Data Protection Act protects the confidentiality of sensitive personal

data (which includes information on the data subject’s 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 patient’s 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 child’s records, even if the child is under 16, and the dentist cannot discuss

the child’s treatment with the parents without the child’s consent. It is for the

dentist to judge whether a child is competent in the circumstances, taking into

account the child’s 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

© BDA March 2009 21

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 Act’s 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 patient’s ability to undergo a

particular dental procedure safely and the dentist wishes to discuss the best

approach with the patient’s 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 patient’s 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 GMP’s request for information about the

oral health status of a particular patient, information would not normally be

given about the patient’s personal circumstances. The consent of the patient

should be obtained. Similarly, if the GDP needs to know about a patient’s

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.

What information can be disclosed?

© BDA March 2009 22

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 researcher’s

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.

© BDA March 2009 23

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.

© BDA March 2009 24

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 dentist’s 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

© BDA March 2009 25

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.

� 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

practice’s 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 patient’s 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 Council’s rules for maintaining patient

confidentiality contained in Standards for dental professionals and Principles of

patient confidentiality.

Checklist

Model practice confidentiality policy

© BDA March 2009 26

“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 patient’s 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 patient’s 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 patient’s 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 patient’s 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.

© BDA March 2009 27

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 Practice’s 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.

© BDA March 2009 28

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 patient’s 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 dentist’s signature on his or her appointment card to

signify attendance

� Demonstrations of the practice’s 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 patient’s appointment record to a

patient’s employer without their consent

� Messages about a patient’s 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

© BDA March 2009 29

� 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 practice’s 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 practice’s 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 [ ].

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.

Dental records

© BDA March 2009 30

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 patient’s name, date of birth and unique

number

� Secured within the record folder if the record is manual.

A dental record should comprise:

� The patient’s 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

© BDA March 2009 31

� 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 recorder’s 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 patient’s 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).

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

Storage, retention and disposal

© BDA March 2009 32

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 child’s

interests, not their own. Where the child is capable of making a request for

Fair processing

Subject access

© BDA March 2009 33

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 patient’s 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.

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

Information about third parties

© BDA March 2009 34

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

patient’s 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 professional’s 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 vendor’s 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 dentist’s 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.

Sale and transfer of records

© BDA March 2009 35

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.

� 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.

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

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.

Checklist

Patient care

Patient communication

© BDA March 2009 36

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 dentist’s

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

© BDA March 2009 37

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).

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.

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.

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.

Patient choice

Treatment planning

Health checks

Alternative therapies

© BDA March 2009 38

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 patient’s dental treatment must be

provided separately to a registrant’s practice of dentistry. The practice of

alternative therapies must be advertised or otherwise publicised separately to a

registrant’s 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.

Non-surgical cosmetic procedures

Tooth whitening

Medical emergencies

Misleading patients

© BDA March 2009 39

The BDA is happy to check draft advertisements, leaflets and other literature to

ensure that they don’t 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.

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.

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.

Maintaining appropriate boundaries

Referral fees

Missed appointments

Debt collection

© BDA March 2009 40

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 co-

operate 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

© BDA March 2009 41

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

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

[email protected] 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.

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 decision-

making. 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 organisation’s 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.

Professional relationships

Professional agreements

Duties of a dentist manager

© BDA March 2009 42

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 patient’s 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 authority’s

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.

Second opinions

Raising concerns

© BDA March 2009 43

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.

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 dentist’s

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 dentist’s 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.

Specialist practice

Veterinary dentistry

The death of a dental practitioner

© BDA March 2009 44

� 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.

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 dentist’s 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.

Checklist

Commercial interests

Financial interests

© BDA March 2009 45

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 Authority’s 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.

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.

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.

Advertising and canvassing

Shared arrangements with other health professionals

Buying, selling or closing a practice

© BDA March 2009 46

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 company’s commercial interests must not influence the dentist’s 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

Bodies corporate and limited liability

partnerships

© BDA March 2009 47

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.

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.

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 in-

house 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.

Practices owned by dental care professionals

Promotion of products and services

Private dental plans

© BDA March 2009 48

Private dental plans should have no effect on a dentist’s 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.

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.

Bankruptcy

Checklist

Child protection

Types of abuse

© BDA March 2009 49

Emotional abuse is the persistent emotional maltreatment causing severe and

persistent adverse effects on the child’s 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 child’s 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 child’s basic physical and/or

psychological needs, likely to result in the serious impairment of the child’s

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 child’s basic emotional needs.

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 child’s reaction to other people

� The child’s reaction to dental examinations

� Any comments made by the child or parent/carer that give concern about

the child’s upbringing or lifestyle.

Practical steps

© BDA March 2009 50

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 child’s 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. Don’t 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

© BDA March 2009 51

A suitable child protection policy for a dental practice should affirm the

practice’s 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).

Child protection policy

© BDA March 2009 52

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

© BDA March 2009 53

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

[email protected]

www.disclosurescotland.co.uk

� Ensure the dental team in trained in child protection procedures

� Have a child protection policy

� Record and report cases

� Undertake criminal record checks

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

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 GDC’s 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.

Further information

Checklist

The dental team

Vicarious responsibility

Dental hygienists and dental therapists

© BDA March 2009 54

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 CDT’s 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 patient’s 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 GDC’s 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.

Dental technicians and clinical dental

technicians

Dental nurses

Dental receptionists

Training

© BDA March 2009 55

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.

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 ([email protected]; 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.

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.

� 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.

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

Terms and conditions of service

Staff management and appraisal

Checklist

General anaesthesia and conscious sedation General anaesthesia

© BDA March 2009 56

� 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 career-

grade 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

patient’s 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 Health’s (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 GDC’s 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.

Conscious sedation

© BDA March 2009 57

� 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.

© BDA March 2009 58

� 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 patient’s 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 patient’s agreement to the referral following a thorough and clear

explanation of the risks involved and the alternative methods available.

Conscious sedation in Scotland

Alternative techniques

Consent

© BDA March 2009 59

Dentists’ duties include

Obligations to patients

� Always to act in a patient’s best interests and put those interests before their

own or those of any colleague, organisation or business

� Respect a patient’s 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 patient’s human rights

� Comply with the Data Protection Act 1998 and give patients a copy of the

practice’s 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 dentist’s 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

Checklist of ethical principles

© BDA March 2009 60

� 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

dentist’s 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

© BDA March 2009 61

� 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.

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 dentist’s 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

Dentists’ Health Support Programme

© BDA March 2009 62

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 Fund’s 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: [email protected].

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

British Dental Association

l 64 Wimpole Street l London W1G 8YS l Tel: 020 7563 4563 l Fax: 020 7487 5232

l E-mail: [email protected] l www.bda.org l© BDA March 2009

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