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This eBook is the lessons Colin Campbell has learned from his own GDC case; the problems he sees in the regulatory system & his potential solutions. 

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Introduction

My name is Colin Campbell

 

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I have been teaching in dentistry since 1994, the year I qualified as a dentist from the University of Glasgow. I began teaching dental students as a House Officer at Glasgow Dental Hospital and carried this on throughout my hospital career.

In 1997 I became a Fellow of the Royal College of Surgeons of Edinburgh and began teaching Vocational Dental Students in 1998. I placed my first dental implant in 1998 and began lecturing in implant dentistry in 2001. I became a Fellow of the International Team for Implantology in 2005 and have been heavily involved in the education of the dental team from dental students to postgraduate students and dental team members since. I have provided hundreds of lectures throughout the United Kingdom on implant dentistry to all types of groups and began designing my own courses related to implant dentistry for dental team members in 2002.

In 2007 I ran my first Live Skills implant course and formed The Campbell Academy in 2013. In 2013, running through to 2015, I was investigated by the General Dental Council (GDC).

 

This eBook is more than just the story of my case. It is the story of the journey the investigation has taken me on during and since. I have been privileged to speak to many people about this journey, some at very high level within dentistry in the UK.

The thoughts in this eBook are my opinion and are not intended to represent anyone else. It’s is one man’s view of where we are and where we could be.

 

I love being a dentist. I love the Dentistry profession.

 

I feel proud that I have been allowed to practice and want to continue to practice for years to come. But I want to practice within a profession with integrity and ethics, who look after each other but who similarly don’t tolerate members of the tribe who practice in a way which brings us into disrepute.

This eBook contains some of the lessons I feel can be learned from my case: the problems I see in the regulatory system in dentistry at the moment and some potential solutions.

A Description of My Case

In October 2013, I was referred to the General Dental Council (GDC) by a single patient who never once complained to the practice. Four days after the ‘brand launch’ of The Campbell Clinic, when we were looking forward to a new period in the business, I received a personal letter from the patient to the practice to inform me that they had complained to the GDC and that they (the patient) wished no contact from me of any kind. Two weeks later, I received a letter from the General Dental Council to say they were investigating the case. And so it began.

It was a process that ran for fifteen months, through to an Investigation Committee Hearing. I finally received a letter on 8th January 2015 to inform me that the case had been closed, with two points of advice.

Fifteen months: one GDC expert report, an Investigation Committee consisting of a dentist, a hygienist and a lay person, a charge sheet written by a Civil Servant which accused me of being misleading, deliberately misleading and dishonest. And hours, days, weeks and months of heartache and heartbreak, of broken confidence, shattered self esteem and fear.

My case details must be kept completely anonymous, but for the clinicians who are reading this I wanted to give some background.

The patient was referred to me by a very competent and capable General Dental Practitioner in 2012 and, as a result of occlusal issues and periodontal disease, was losing upper anterior teeth after already losing premolars in the upper right side. Specifically in the GDP’s letter he stated, “patient does not wish to wear a denture (understandably)”. Our standard assessment process was carried out. The case was discussed between myself and a very well qualified Restorative Dentist, where all aspects were taken into consideration including the occlusal aspects and periodontal disease. The patient underwent removal of the upper anterior teeth and hygiene treatment, together with diagnostics, including a CBCT scan which was reported and study models with diagnostic wax ups.

 

Case Details

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Surgical guides were used to provide placement of two dental implants in the upper anterior region with a GBR procedure and two implants in the upper right with an open sinus graft simultaneously.

During the open sinus graft procedure there was a tear in the membrane, which was repaired using Bio-Gide. The procedure proceeded unremarkably following that, after which the patient was discharged with a full explanation. It is important to point out here that, in my audited implant / sinus grafting cases (now over 200 with a 98% survival rate) a tear occurs in approximately 20 - 23% of cases. Sinusitis in those cases occurs in approximately 0.4% and more prolonged sinusitis has occurred in my career in one case. This case.

 

The patient suffered postoperative swelling which was more extensive than normal but was reassured that all was well as it was within normal ranges. When the patient returned approximately one month later, they were complaining of the symptoms of acute sinusitis and had been prescribed Amoxicillin by their GDP, which is appropriate for sinusitis treatment in our part of England, based on ENT advice.

 

The patient was then seen again when the sinusitis symptoms were much reduced and very intermittent and appeared to be reducing entirely in nature. At this stage I wrote to the GDP to explain the complication that had occurred but that I felt it was resolving and no further action was required. This is generally the case when sinusitis occurs in open sinus grafting cases and resolution is generally complete.

When the patient was seen again six weeks later, they reported that they had had one other episode where the sinusitis symptoms had increased but had, of their own volition, sought General Medical Practitioner advice and was now taking Doxycycline. The patient said that the symptoms were reducing considerably again. I had a discussion with the patient at that stage where we discussed the fact that symptoms seemed to be continuing to reduce and I decided to review them through reconstruction.

The patient attended for reconstruction with a very experienced and highly qualified Restorative Dentist and all was well with no complaints of symptoms until the end of the reconstructive phase where the patient reported a return of their sinusitis symptoms. 

At this stage I felt it was prudent to refer the patient to the local Maxillofacial team which I did and expedited a referral including providing a free of charge CBCT scan for the patient to take to their appointment with the Maxillofacial surgeon.

 

As the patient lived a distance away, the Maxillofacial surgeon decided to refer to an ENT colleague closer to their home. At that stage we received no further contact from the clinicians treating the case and we left the case for a period of weeks before contacting the patient to ensure they were well.

When we contacted the patient at approximately eight weeks, after having heard nothing from the further referral from the ENT surgeon, I was horrified to discover that the patient had had a sinus washout which appeared not to have been successful and had then ended up in the care of another clinician, who had explained to the patient that the implants would need to be removed. At this point both myself and the patient’s GDP independently sought the advice of Consultant Maxillofacial surgeons providing full clinical information and detail including the CBCT scans from weeks before which showed that the implants were integrated and secure. The GDP had also re-torqued the crowns in position some time prior to this, which demonstrated that the implants were well integrated.

 

The patient proceeded with the remedial treatment to remove the implants and to have an open sinus washout and I am led to believe that the symptoms have resolved as a result of this.

 

The Complaint

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Following the patient asking me to provide no further contact to them, the patient then referred me to the General Dental Council with various degrees of complaints, including complaining about my teaching status in lecturing to dentists, the fact that we offer to provide finance at the practice (which they did not take up and we no longer provide) and also suggested I had withheld information in relation to the tear in the sinus. As is the case in disputes which occur in clinical care (and I have significant experience of this from Medico Legal work) there appears a litany of allegations against the clinician involved, many of which are difficult to understand.

I contacted my defence union, The Medical and Dental Defence Union of Scotland, who were excellent. I spoke to my Dental Advisor and the suggestion at that stage was to ‘keep your powder dry’ as the case will go to Investigation Committee Hearing.

 

The Process

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The information was collated, the patient’s complaint documented, the case notes collected, other case notes collected and any other relevant material. You can submit comments at that stage if you like but it is unlikely to stop the process in its tracks because no one clinical is looking at it. An expert report was then commissioned in my case, which was carried out by someone who is not on the Specialist Register in relation to detailed Oral Surgery procedures.

After initial discussions with my union and the submission of my case notes, which happened towards the end of October 2013, I received no other formal communication from the GDC until October 2014. A few days short of one year later, I received a letter informing me that my case had been passed to the Investigation Committee for a hearing in late 2014 and a list of charges related to the case. This bundle also contained a copy of the experts report for comment.

The only other actions to be undertaken in that year were to inform my Local Commissioners that I was under investigation and I was to be red flagged for further tendering processes.

 

The Investigation Committee Hearing

 

I received slightly short of one year following my initial GDC letter, a list of charges related to my GDC complaint and the referral to the Investigation Committee.

The Investigation Committee in my case consisted of one dentist, one hygienist and a layperson that chaired the panel. They sat in private to consider submissions from myself, the patient, case notes and evidence available from myself and other practitioners. During this process and following receipt of the Investigation Committee letter, a list of charges were drawn up by a caseworker for the GDC.

 

Inaccurancies

 

It’s fair to say that there were inaccuracies in the charge sheet, which in fact were dismissed by the Investigation Committee out of hand.

 

On a more sinister note, there were three charges stating that my conduct had been misleading, deliberately misleading and dishonest. On reading this in October 2014 I was utterly heartbroken. For it to be suggested that I had deliberately mislead someone or been dishonest in my care was devastating and at this stage the defence union suggested to me that this case would go all the way to Fitness to Practice Hearing, based on those charges.

 

With the expert help from the MDDUS Solicitor and Dental Advisor, I was able to rebut every single charge and provide evidence, including four Consultant letters from people who had been involved in the case directly or indirectly. I was able to utterly refute the charges of being misleading, deliberately misleading and dishonest and submit my material to the Investigation Committee for consideration.

My response was then sent to the patient to allow them to respond, following which the patient’s response to my response is sent to me allowing me to respond to the patient’s response to my response! At that stage responses are closed. The material goes before the Investigation Committee.

 

The Outcome

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On the 8th January I received the letter (some weeks after my hearing) which said that the GDC had closed the case, with two items of advice for me including:

• Ensure all possible treatment options are discussed and noted in relation to implant treatments

• Ensure that any complications were fully explained to patients following treatment

 

Everything else was dismissed. Most notably, the charges of misleading, deliberately misleading and dishonest had been identified by the Investigation Committee as charges where they could not find any reason why they had been brought in the first place. It staggered me that charges of such gravity and severity can be entered into a Registrant’s charge sheet only to be put in front of an Investigation Committee who say they shouldn’t have been there in the first place.

Fitness to Practice Colin Campbell's case

 

Problems in the Regulatory System in Dentistry at the Moment

My experience, and the extensive research I have done since my own GDS case, has shown that there are a number of problems facing the process of regulation in the UK at the present time.

 

How Quickly a Complaint to the GDC escalates

 

The ease at which an individual patient (or clinician for that matter) can refer a clinician to the GDC and effectively catapult a complaint high up into the Fit To Practice process is causing enormous distress to dentists and enormous strain on resources of the GDC.

There are on average 4,000 ‘complaints’ in a year. Everyone is being investigated with the utmost rigour. This is an unsustainable situation. It must be addressed as quickly as possible lest the system collapses, the GDC entirely run out of money and are unable to charge anymore to dentists, and the dentists’ psychological health dramatically reduces.

 

The system must change. This will either come by the GDC becoming bankrupt and being sucked into a ‘super regulator’, or by people speaking to each other to resolve the system within the current framework before the framework is fixed.

 

Flawed Process

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There seems to be a worrying number of full Fitness to Practice (FTP) hearings, which are estimated to cost around £10,000 per day, which have led to verdicts of ‘no case to answer’. This is taking a registrant through a process similar to a criminal case with accusations, counter-accusations, huge and enormous psychological stress.

There is potential damage to their business and commercial activities, not to mention the huge collateral damage to their family life. All of this, and sometimes 10 and 11 days of a hearing to not only be found not guilty, and be told that there was no case to be brought in the first place. How many of these cases do we have to have before the numbers are released and full investigations into the process are undertaken to ensure that they are, in fact, fit for purpose?

 

Interim Orders Committee

 

The Interim Orders Committee (IOC) is the committee which assess potentially dangerous cases where patient safety was significantly at risk. They can sanction a Dentist prior to an investigation being carried out and before an Investigation Committee or full FTP hearing has been undertaken.

This is clearly a vital function to ensure immediate and decisive action is taken against dangerous practitioners. It is similar to being suspended on full pay in an employment situation except… there is no pay.

However, imagine a business owner who is suspended immediately from by an IOC, whose FTP hearing takes months to come through following an investigation, and then is found to be fit to practice. The business could be ruined and they could see themselves in financial ruin with no ability to generate income and a loss of goodwill for the practice.

I know this facility has to be in place for all our safety and peace of mind. But we must get this right.

The fact that an IOC can sit without representation from the Dentist is also something that needs revisiting.

 

Expert Witnesses

 

I think it is reasonable to state that many excellent expert witnesses have now decided not to work within the GDC expert framework for several reasons, not least the remuneration of the expert themselves. Some experts that I have spoken to have also complained that they have felt pressured into providing reports in a particular way. It’s clear on reading expert reports that some experts do not understand the neutrality of their position and therefore bias their reports towards the ‘prosecution’ instead of providing neutral evidence. Should it happen in a criminal case or a civil case, the expert would be liable to significant repercussions as a result of their biased participation in the case.

 

Lack of Appeal

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In my case the evidence was out before an Investigation Committee and although that committee was extremely strong in its words and actions in many aspects, it provided me with two lines of advice, and therefore a FTP history, with which I fundamentally and wholly disagree. I had no representation at the Investigation Committee hearing of any kind. I can see no deliberation or notes and have no right to appeal.

have to carry with me now a FTP history for the rest of my career, although confidential in theory, which I would have to declare for further job prospects.

 

Lack of Communication

 

There seems to be the lack of communication between the GDC and other dental bodies. Informal communication and discussion between the profession as a whole would surely help to lead to resolution of issues and problems associated with the FTP process. Any streamlining of the process at this stage would lead to a reduction in cost which could ultimately lead to a reduction in ARF and a much more positive feeling within the profession.

 

Lack of Self-Reflection

 

Too many dentists and clinicians are unable to self reflect. It takes a huge amount of strength to reframe your practice based on the results you receive from analysis which shows that you are in fact not performing ideally. Until as a practice, and in fact as a health care community, we are able to accept this we will have real difficulty in coming to terms with regulation.

 

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Lack of Performance Indicators

 

It is essential that the GDC sets and keeps performance indicators that it thinks are important for the protection of dentists and for the public to make sure that they’re not overbearing in their charge lists and that they are in fact proceeding to cases which have a realistic chance of a positive outcome on behalf of the patient, and therefore the patient.

Potential Solutions

Although there are many potential solutions, and there needs to be a larger conversation around the problems that have been highlighted through my own experience and my subsequent research, I have focused on two key areas as potential solution starting points.

 

A Move Towards Local Resolution

 

Currently, if a patient contacts the GDC with a complaint that can’t be managed by the Dental Complaints Service (DCS), it is escalated into the FTP process, investigated and potentially moves towards an Investigation Committee Hearing. This is madness when the vast majority of these cases could be managed locally.

 

My suggestion would be:

Panels of competent, trained and ethically responsible, clinicians and lay people who have a vested interest in stopping the process at local level if at all possible. These people would be trained mediators.

This service may be funded by the profession or taxes. This solution will save money for everybody in the long run.

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Taking my case as an example, I strongly believe, if a local resolution process had been in place, the patient would have received a much better outcome than they did from a GDC case. As it is, the patient may look on the case and see I have received no sanction whatsoever and the patient themselves has paid for remedial treatment.

 

Had there been Local Resolution, the patient could have had:

A dialogue between myself and the patient, with a third party mediator as required.

Their entire treatment costs refunded and their remedial treatment covered, as we would have arranged for treatment to be carried out.

A clear explanation from me as to why the situation had arisen.

The opportunity to feedback as to why they felt aggrieved, and how they felt we could improve our service.

 

The Statutory Issue

 

I understand there is a statutory framework currently in place would make this change difficult. But I think it is time we, at every level of our profession, called for change to improve the regulatory system we have, and to make it work for everyone.

 

Rethinking Standards

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In my own case, the phrase ‘gold standards in implant dentistry’ in relation to the FGDP standards was used in the expert report. This is utterly unacceptable; if we were to judge everyone against gold standards, then the GDC itself would fail and would in fact have to strike itself off. In my own case, the GDC lost radiographs, sent correspondence to the wrong address and passed by their own deadlines for reporting results of the Investigation Committee to me. It also seems clear that the faculty guidelines were used a considerable amount by the GDC in the past and these are not appropriate documents.

The GDC needs to have a secure framework, in which to judge practitioners who appear to have fallen short of what is expected of the profession and there needs to be minimum standards to relate to.

 

How Do We Create a Standard of Competence? 

 

The profession as a whole need to come together and produce some consensus conferences, where minimum standards for things such as case notes, consent, radiography reporting and similar could be laid down. We already have the mechanism for doing this, through the ITI Consensus Conferences. These standards could then be published widely so that everyone in the profession knew what they were, even published and adopted by the GDC, so that we would know the scale we were being measured against and how to ensure that we met those targets.

 

The benefits of such a process would be that:

1. It shows the profession in a hugely proactive and standard driven light. It represents us very well and shows we can talk together and work together.

2. It allows clinicians to set the standards for experts to report upon. We will be able to show the experts who decide to work on the patient’s side for the GDC exactly where the guidance sits. This will make their job easier and more consistent.

 

What About a Super Regulator?

 

This idea came up in my discussions with people. The idea of a potential ‘super regulator’ – something the government has discussed before now. A regulator to cover all professions.

This is not in our interests and is not in the interests of the patient. You cannot commoditise regulation. It needs to be specific and bespoke for individual professions. To bundle together all professions from nursing to dentistry to veterinary skills and expect the people on the Council, or even the people assessing cases, to be able to understand the specifics of cases is madness.

 

We need a dentist as the Chairman of the GDC. We need a strong council to which the Chairman and the Chief Executive are completely responsible. We need cases filtered. We need a profession, which puts its hand up, stands up and is responsible for itself.

How I Have Applied What I Have Learnt

 

The process I have been through has naturally caused me to reflect on my practice, and to make some changes. The GDC would view this as a positive outcome – I have been encouraged to reflect on my practice. I would disagree with that view. I do not think the trauma I went through is proportional to any benefits from the reflection I have electively undertaken.

 

Fitness to Practice Colin Campbell's case

 

 

My Case Notes

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When I talk to people about my case, a recurring question is about whether my recording of patient experiences under my care has changed. The perhaps surprising answer to this is, not really. We already had an exceptional case note system in place. It just wasn’t 100%.

In the immediate aftermath of the case, I added a section onto my consent letter, which basically warns people that if they are unable to accept the fact that complications do occur they should postpone their treatment or have it somewhere else. I reviewed my warnings for sinus grafting cases, as my case was a sinus grafting case, but changed those very little, and perhaps, just for change’s sake.

Otherwise, I continued with exactly the same assessment of pro forma and a similar process of writing a consent letter. I was already in the habit of modifying this process in the practice on a regular basis, based on discussion between clinicians, both inside and outside the practice. I already had a system of information sharing for improvement.

 

Perhaps the biggest or only change is that I ensure my case notes are now written strategically.

 

What does this mean? They are written in such a way to protect me should a similar circumstance happen to me again. They are written from the point of view of someone who has been an expert in GDC cases but also a registrant under investigation. They are written from the point of view of someone who has extensive medico-legal experience. The sad thing about that is that they are now not written for the patient. We are not encouraged to write for the patient anymore. We have to write for ourselves. The risk is too high to have it any other way.

 

The slip towards defensive dentistry and defensive case note writing is awful, and it is only by standing up as a profession as a whole and writing guidelines on minimum case note requirements that we will ever change that.

 

My Change in Attitude

My attitude has changed because of my experiences. This means two things:

  • Firstly, I have much less patience with people who I see are detrimental to the profession as a whole and who should in fact be held to task by the regulators but appear not to be. I have become more and more vocal and proactive in trying to seek solutions to this within the profession. There are some quick, dramatic things we can do as a group of ethical and empathic practitioners which can freeze people like that out and I believe it is our duty to do that.
  • Secondly, my attitude to empathic and ethical practitioners who have a strong grasp of 'Prethics' has grown even stronger. I am much more inclined to help support and develop people with these values to allow them to benefit patients in the longer term. I have spent countless amounts of hours talking to people, answering emails and working towards a solution for regulation in dentistry behind the scenes because that attitude altered and changed. I have become less selfish, less inward facing and more open.

 


 

I want to finish this eBook by telling you about a positive to come out my experience being investigated by the GDC. That is, The Campbell Academy, in its current form. This came directly as a result of the GDC case. The ethos and mission of the Academy is in keeping with the change in attitude I have had towards my colleagues. This has been a huge positive step and definitely one of the positives I was able to take out of a terrible experience.

I recognise through my own experience, and the experiences I have heard since through my research, that the profession is far from perfect. I am able to be a part of training empathic and ethical practitioners, and to work towards a solution for regulation in dentistry.

 

Thank you for reading,

Colin Campbell

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