Above suspicion

A RECENT English court case highlighted dentistry’s need for probity and honesty. The dentist involved was criticised by the judge who, in jailing her for six and a half years, described her actions as “calculated, blatant and persistent dishonesty”. The jury heard how she had submitted claims for treating more than 100 patients who were dead and made duplicate claims for others. Investigators from NHS Protect said she had forged more than 28,000 documents to support her “bogus claims”. An extreme example and luckily a very rare one.

Dentists not only need to behave honestly; like Caesar’s wife they have to be above suspicion. The public trust and look up to dentists. The other side of the coin is they expect us to behave differently. We are expected to put patients first and not be influenced by the needs of our bank manager. However, the slippery slope to court or the General Dental Council is one which is all too easy to follow if we are not careful.

The damage of high-profile court cases is not just to the individual but also to the profession itself. Each such case or journalistic exposé gradually erodes public trust in dentists. If this was to become widespread we move from being a profession to being a trade. Retaining that trust is vital.

There are many temptations in general practice. The pressures of running a business are considerable. On many occasions your business head will be in conflict with your professional self. It is easy to justify “bending the rules”. We complain of the government or the Department of Health treating us unjustly through low fees or poor pay rises. The temptation is to redress the balance, to “game” or to “pad” claims. No one gets hurt, do they? If successful the temptation is to do more, leading us ever more quickly down that slippery slope.

“Doing the right thing even when no one is watching” (to quote CS Lewis) is a succinct practical definition of “ethical”. Certainly as a dentist for much of the time you will not be being watched. You are trusted to behave honestly. There will be no lecturer, VDP/FD trainer or DRO looking over your shoulder.

There are of course many grey areas both ethically and legally in the practice of dentistry. For example, do you discuss all treatment options whether or not you make money from them? Do you use unbalanced advertising material? Is your tone and body language unbiased when discussing options? Do you always give a written treatment plan with costs? Do you inform patients that nearly 20 per cent of crowned teeth become non-vital within five years and that veneers remove between nine and 30 per cent of the tooth? Or, as a recent Which? investigation reported, do you only give the hard sell for tooth whitening? It is easy to let financial pressures influence your discussions with patients in the consent process.

It is even easier to “misinterpret” regulations. one of the oldest grey areas is the claiming of fees for sealant restorations (preventive resin restorations). In both Scotland and England there is an increased fee associated with these restorations.

The fundamental difference between the two is the diagnosis, and the treatment, of caries. Clinically they appear the same. Only you, your dental nurse and possibly the patient know what was actually done. Your decision on what fee to claim is down to your ethics. And who will know? The answer is – you will, and you will have to live with it. it is easy to think that if it worked once, why not do it again?

There are many other grey areas: misleading patients as to what is available on the NHS, changing dates on record cards to avoid time bars, splitting courses of treatment to avoid prior approval or to increase the UDAs claimed, or carrying out one visit periodontal treatments and claiming increased fees.

It is all too easy to think that no one will notice or check, or that “everyone does it”. Dentists are trusted to put patients first and claim appropriately. However, this trust only goes so far. There are deterrents. Your claiming patterns will be monitored statistically and compared to others in the same health board/Trust or even street. Your record cards can be reviewed for the record of what and how you treated the patient. in the sealant restoration example, did you chart the decay? What materials did you use? Did you use local anaesthetic? Did you carry out an enamel biopsy? What does your nurse think about what you are doing? Dental care professionals have an ethical duty to whistleblow.

Meanwhile in Scotland a counter fraud charter has been signed by the BDA and NHS Counter Fraud Services which is designed to combat fraud and promote ethical conduct.

The vast majority of dentists are honest, ethical and empathise with their patient. Do not forget to do the right thing “even when no one is watching” because it is easier than you think to slide down the slippery slope to professional difficulties.

Dick Birkin is Secretary of the Dental Law and Ethics Forum and acts as an expert witness to the GDC on regulations and record keeping