The early intervention of mentors in the Fitness to Practise process

In the first of a mini-series of articles, Mabel Saw and Janine Brooks explore the role of those who support colleagues in difficulty

Introduction

We all know that despite our best of intentions, sometimes our performance slips and we end up with a patient complaint that could involve a Fitness to Practise (FtP) referral to the General Dental Council (GDC). Such complaints usually involve some kind of error on the registrant's part, perhaps a clinical error and/or an error in judgement or professionalism. This article explores some of the common pitfalls registrants face in the FtP process and how Development Advisers (DAs) and Mentors can act as guides to support and steer registrants in the right direction.

Anyone facing a FtP process with the GDC for the first time will realise that it is a very different world compared to the clinical settings that we are familiar with. The FtP process involves the GDC, indemnity organisations and legal teams. It is more a legal world than a dental world. So, while the indemnity advisers are also dental professionals and fluent in law, most registrants who find themselves in this position will have little or no knowledge of the legal process. Consequently, the experience can feel disorientating and bewildering.

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Demystifying the FtP process

Mentors can act as intermediaries in this alien world, bridging between the two different worlds of dentistry and law. While all dental Mentors are first and foremost dental professionals and so understand our clinical background, not all are familiar with the FtP journey. Consequently, registrants involved with potential FtP process will have to judiciously select a Mentor with the appropriate background to assist them along this journey. The GDC introduced the role of DA, in October 2021, specifically to work with registrants in difficulty. They replace the role that was undertaken by Dental Deaneries within Health Education England. This support was withdrawn from 1 April, 2022. While DAs are dental professionals and many are trained as Mentors, they are also familiar with the FtP process. They can help navigate through the potential hazards ahead and support registrants through the ups and downs of their journey. The role is prescribed and approved by the GDC and has an educational element alongside the skills of mentoring. Prospective DAs will need to provide their curriculum vitae (CV) for the GDC's approval before they can begin to support a registrant in difficulty.

It is worth pointing out that the GDC, as our regulator, is obliged to investigate every complaint that arrives in a fair and effective manner. From their perspective, it is very difficult to ascertain if a complaint has any substance until it has been investigated thoroughly. Although the GDC works within a tight timeframe, the process can take a long time, sometimes 2-3 years. The length of time can often have a negative impact on registrant's personal and professional lives, and on their physical and mental health.

Complaints that are made to the GDC are investigated through different stages, beginning with triage by case workers. In 2016, Case Examiners (CE) were introduced at the early stages of the FtP process. CEs continue the sifting process and decide if there is a real prospect that the allegations against a registrant can be proved and that, if proven, would suggest that the registrant's FtP has been impaired.¹ Part of their role is to fast track some of the cases and they have the authority to agree undertakings with registrants. Undertakings are formal pledges that registrants agree to carry out and their registration depends on compliance. CEs can sometimes stipulate that registrants work with DAs on specific issues as part of the undertakings. CEs have the authority to escalate the case to a Practice Committee hearing if the undertakings are not met.

CEs and the triage process have reduced the number of cases progressing to a Practice Committee (the highest escalation). Approximately 19% of initial complaints are referred to a Practice Committee. In 2021, this meant that 136 cases were heard at a Practice Committee. Despite this seemingly low percentage of cases, few of us would want to be caught in this position.²

Whilst the introduction of CEs helps to sift out inappropriate cases (for example, those that involve personal and malicious vendettas), it also means that most cases that are escalated tend to be more serious. This would be a nasty surprise for registrants who mistakenly believe that their complaints are straightforward. In reality, the vast majority of cases that are escalated to a Practice Committee hearing are rarely straightforward nor quick.

' Mentors can act as intermediaries in this alien world, bridging between the two different worlds of dentistry and law. While all dental Mentors are first and foremost dental professionals and so understand our clinical background, not all are familiar with the FtP journey.'

Common pitfalls

Registrants have the opportunity to work with DAs at different stages of the FtP process:

• Voluntarily at the very early stages of the complaint, often on the advice of indemnity or legal advisors

• Mandatory as part of undertakings from CEs and/or conditions imposed by a Practice Committee.³

While the option to work with DAs is voluntary at the early stages, I believe that this opportunity is often missed as it can be undervalued. Working with DAs at this point of the process could be pivotal to whether the case is escalated or not. I believe that the earlier the registrant works with a DA, the earlier they can develop their awareness, insight and reflective practice. This can help registrants move on and has the potential to de-escalate the case.

It is essential to engage with the GDC during the early stages of the FtP process. Yet, many registrants fail to do so for different reasons. Registrants are often understandably overwhelmed with a variety of emotions when confronted with the prospect of a GDC hearing. These emotions can range from fear, anger, resentment and a sense of injustice which in turn can translate as apathy and disillusionment with the whole profession. Consequently, their actions can come across as combative, aggressive or even indifferent. Although these emotions are natural and understandable, DAs are aware that registrants can remain stuck in this futile position. The reality is that the GDC view the failure or lack of engagement as a failure to respect the GDC's role as our regulator. This would almost certainly be viewed as an aggravating factor against the registrant. This is another reason why early intervention with a DA can be highly constructive in making a good start in the right direction and setting the right tone of response.

Some registrants see mentoring as having little or no value in the FtP process. Although mentoring could be simply described as having a conversation with a colleague, I believe that this description is too simplistic and runs the risk of belittling the skills of a trained mentor. The true skills of mentoring lie in supporting the mentee to reflect deeply in order to gain insights and self-awareness into the issues that led to the complaint (these are the golden nuggets that the FtP panel will look for). This might sound deceptively easy but experienced mentors will share that these are skills that have been honed through years of experience and training.

If registrants fail to see the value that mentoring can offer, it is too easy for them to question whether it is something that they can afford especially at a time when cashflow is often tight. Such an attitude focuses narrowly on the immediate short term. Mentoring is a professional relationship with goals and outcomes. The reality is that any complaint that reaches a Practice Committee stage has the potential to strip us of our professional registration which in turn threatens our professional and personal life. So, the question is not so much 'should I pay for a mentor?' but about 'how much do I value my professional life?' This shifts the focus from the immediate, narrow, short-term view to the bigger, long-term picture. For many of us, dentistry is inextricably linked to our identity and our status in life. When we adopt this 'helicopter' perspective, it is easier to view our professional life more as a journey than a destination. It is more of a marathon than a sprint.

One of the key skills of a DA is to help registrants create an effective Personal and Professional Development Plan (PPDP). Solicitors and legal advisors cannot offer any effective support in this area and registrants are expected to produce a realistic PPDP within a tight timeframe. In my experience, many dentists underestimate the degree of effort in formulating an effective PPDP. The GDC offers some basic guidelines in preparing our PDPs but few of us exploit this document to its full potential.⁴

Alongside the PPDP, another key objective for a DA is to support a registrant to produce a personal reflective statement. This statement reviews the index case or incident and reflects deeply on what happened, the factors that led to the incident and shows insight and self-awareness. Some dental professionals fail to see how reflection can improve us as clinicians; dentistry is, after all, purely about clinical work, isn't it? The fact is that the quality of this statement can determine the outcome of the whole case. It can make the difference between continuing sanctions or revoking sanctions. Consequently, spending time on this document is a necessary first step. Unfortunately, registrants commonly overlook the importance of this and subsequently many stumble at this point.

Some registrants consider working with DAs a sign of weakness, akin to asking for help. The reality is that we each need help at some point of our professional lives. We are only human and as such we are all exposed to the realities of juggling our different roles. Sometimes we cope. The bitter truth is that sometimes we struggle to cope. I don't believe that any of us can honestly claim that we have never needed help at any point in our lives. It is no shame to admit this. Indeed, it takes courage and honesty to confront this fact.

Some registrants fail to appreciate the seriousness of the allegations made against them. While it is easy to accept the seriousness of a case if it involves an adverse clinical event or when it affects patient safety, it is harder to understand the gravity of the allegation if it involves matters that are not seemingly a reflection of our clinical skills, like making an indiscrete comment on social media. One of the GDC's overarching duty is to maintain public confidence in the profession.⁵ This means that the GDC could act on any behaviour that could potentially undermine public confidence, even in the absence of any clinical issues.

' Registrants are often understandably overwhelmed with a variety of emotions when confronted with the prospect of a GDC hearing. These emotions can range from fear, anger, resentment and a sense of injustice which in turn can translate as apathy and disillusionment with the whole profession'

While our thoughts and comments made in public can be regarded as hearsay, comments made on social media have a tendency to be immortalised in public record. Consequently, the GDC could take a very harsh stance against unprofessional comments made on social media, even if this is in our own private time beyond the confines of the surgery. This is something that many registrants struggle to understand.

Our character is demonstrated throughout our lives, not just when in the surgery. Consequently, acting dishonestly or with lack of integrity outside the surgery can jeopardise our professional registration. This is because it is difficult to 'separate the performance of dentistry from the person performing it'.⁶

From the GDC's perspective, unless they investigate such comments made on social media, they are unable to verify if these were misguided, isolated comments made in the heat of the moment and so would not necessarily be a true reflection of the registrant's character. Alternatively, if they expose hidden aspects of a registrant's behaviour that could potentially harm patients or undermine the trust the public has in the profession. So, if a registrant makes sexually inappropriate comments on social media, does this mean that they could behave sexually inappropriately with their patients? The GDC would not know unless it investigates. Consider the alternative: if such a registrant were not investigated and the registrant went on to harm a patient in the surgery, the public would truly be horrified that the GDC had failed to investigate. This could adversely undermine public confidence in the profession.

Conclusion

DAs play a pivotal role throughout the FtP process but perhaps more so in the early stages. It is during the early stages that DAs could make a big difference, potentially de-escalating the case. They can help registrants see a wider perspective from the GDC's position and help challenge some of the common, and often wrong, assumptions that registrants tend to make. I discuss this further in my next article where I interview three registrants who share their experience working with mentors in issues relating to poor performance and professionalism. ◆