A friendly favour, or fraud?

UNLIKE doctors, it is commonplace for dentists to treat family and friends. The General Dental Council (GDC) does not impose any restrictions on dentists doing so (unlike the General Medical Council), with the exception being guidance on drug prescribing.

In fact it is often quoted by dentists as a touchstone for probity and clinical excellence: “Would I carry out this treatment for my husband/wife/son/daughter…?”

Such treatments are often carried out for a reduced rate, or sometimes even for free. But as costs increase and as more practices are run by corporate bodies, there is a growing risk that dentists who carry out such “favours” could find themselves in professional difficulty – facing accusations of gross misconduct or even theft.

One recent case handled by MDDUS involved a dentist who decided to help out a practice dental nurse by making a crown free of charge. But when the practice owner found out, the dentist was severely reprimanded about her behaviour. Fortunately the matter was resolved when the dentist paid back the cost of the treatment to the practice.

In a similar case, one dentist was not so lucky and was reported to the GDC for alleged professional misconduct. These problems are sometimes compounded by a lack of care in record keeping and consent, which not only leads to additional criticism of the dentist on clinical grounds, but also adds to the sense that the treatment has been “covered up”.

These cases demonstrate the importance for dentists of taking a cautious approach before deciding to veer away from their practice’s usual policies and procedures. This is particularly relevant for associates or indeed any clinician who does not own the business.

Changing practices

Historically, practice owners have been content to allow associates considerable latitude in treating family and friends – often because they have been in relatively small, privately-owned businesses, where close relationships are common and valued.

But contemporary clinical dental practice has moved on. Private treatment is increasingly common, treatment costs are much higher in the NHS and private sector, practices are increasingly owned by corporates not individuals, and profit margins are tight.

Unilateral decisions by clinicians to provide treatment at reduced or no charge to the patient will represent a financial loss to the practice - a loss that can very easily be quantified. The clinician may well be prepared to forgo his/her percentage of the treatment fee for the benefit of friend or family. The practice may not and could be particularly aggravated if the dentist has in fact gained from the treatment through some ‘token of appreciation’ from the patient, undisclosed and unshared with the practice.

Secrets uncovered

Some dentists may believe that any “special arrangement” they have to provide treatment to a friend or family member need never trouble the practice’s senior management. It is true that certain incidences may not come to light for some time, perhaps not ever, but there are many ways in which something could be disclosed: a casual remark, an audit process or revenue investigation, a patient complaint (yes, I am afraid the patient might still complain), or whistleblowing by a genuinely concerned or perhaps disgruntled colleague.

The practice response

The practice response may vary. This is likely to be influenced by the number of occasions the “free” treatment has been provided, the costs involved, and crucially, the nature of the relationship between the clinician and practice owner. In its most benign form the clinician may face a mild admonishment, with a reminder of their professional and fiduciary responsibilities to the practice, and perhaps ground rules being set for circumstances when it is/is not appropriate for free treatment to be provided. An example might be treating a colleague in an emergency, allowing the most effective use of time and minimising disruption to the practice because of staff absence.

At the other end of the spectrum, such behaviour could be considered by the practice as theft: grounds for instant dismissal as gross professional misconduct by the practice, considered as dishonesty in terms of referral to NHS England, health boards, hospital trusts and the GDC, and a criminal matter in terms of referral to police. Clearly these are potentially very serious issues.

Isn’t this common practice?

The accused clinician is often surprised that the matter has been raised and is confused by developments, often genuinely outraged at any suggestion of dishonesty. Often the clinician holds the genuine belief that this is customary practice. They were allowed to do it in the last practice, they know of colleagues who do exactly the same, they thought there was tacit approval by the practice owners, or even a belief that there was a clear understanding and acceptance of it by the practice owner. In any case, an assumption was made that there was no reason not to. In corporates, clinicians may even have the agreement of the practice manager or senior clinician, without confirming the fact further up the line management system.

Potential resolutions

The clinician’s protestation may carry weight, particularly if there is an offer to make up the financial loss to the practice, but it may not. The practice may decide to deal with the matter in a particular way. The clinician may find they are suspended as an interim measure while an investigation is undertaken and may be dismissed. The practice may feel the matter can be closed at that point or may refer the clinician to the local area team/health board, to the GDC, or even the police.

Many years ago, in my first week working for a dental corporate, I was asked by one of the dental nurses to help her out with a filling. The appointment book was not fully up and running, and there was space. I was unused to working within a corporate environment. (I was used to owning the practice, being in charge.) I carried out the treatment, but it played on my mind. At the end of the morning, I charged the treatment through on the system. I went to the reception desk, paid the bill and asked the receptionist to save any embarrassment by saying nothing to the nurse about the transaction. It cost a few pounds, but I felt better, and I considered the lesson learnt as good value for money.

This may be just the opportunity to tell Auntie Dosie that you are obliged by the practice rules to charge for treatment, and so it is not really worth her travelling those extra miles to come see you in the practice.

Key points

• There is no impediment to treating friends and family in general dental practice, but be sure to check practice policy/associate agreements for more detailed guidance. Hospital trusts are likely to have very strict policies and guidance in place and so those working in a hospital setting should exercise particular caution.
• Communication, clarity, confirmation (in writing), and transparency are crucial.
• Be aware of the practice rules and do not make assumptions.
• Acting without authorisation could lead to accusations of dishonesty or other professional difficulties.
• Read this MDDUS advice article about the pitfalls of patient consent.

 

Mike Williams is a dental adviser at MDDUS