In the second part of her exclusive interview, new Chief Dental Officer for England, Sara Hurley, talks to news editor David Westgarth about the GDC, judging the success of contract reform, antibiotics and students
You have discussed the need for a collaborative approach across the board. Given the profession's views toward the GDC, the collective sense of anger over their handling of the ARF hike in 2014 and the fact they are considered the worst of all the healthcare regulators.... Do you see the GDC being one of those involved?

As a profession we deliver ordinary dentistry extraordinarily well, moreover we do it very safely. Although I appreciate that with organisations like the Dental Protection Society reporting that the likelihood of a UK dentist facing some kind of regulatory challenge is much greater than for any other dentist anywhere else in the world, this places the profession's relationships with our regulators under considerable strain and impacts on the profession's image and relationship with our patients and the public.
I recognise the profession's frustrations but I also recognise the GDC's on-going reflection on their relationship with the profession and the reforms to the GDC fitness to practise processes. In particular, I sense a tangible appetite for early resolution of less serious cases and engagement with both NHS-England and CQC to de-conflict investigations, avoid duplication and step back from cases that lie elsewhere for resolution.
I recognise the profession's frustrations but I also recognise the GDC's on-going reflection...
I understand that the profession would say it's still too early to confidently state that we have a seismic shift, but certainly looking down the road I envisage a greatly improved relationship with our regulators. They are a necessary feature of the dental care landscape so yes they are part of the collaboration; indeed I am impressed by the collaborative approach of both the GDC and CQC to the work being developed by the Tripartite Regulatory Board, with all the key stakeholders getting round the table and asking 'is this really adding value?'.
I guess that leads us on nicely to CDO collaboration with the Department of Health (DH) and the process of contract reform... How you will judge the success of the prototypes?
We all recognise the current care and remuneration model is unbalanced and there is a clear desire to shift our goals towards prevention. The legacy characteristics of remuneration based on activity may have stood our forefathers in good stead in the early years of NHS dentistry but they are clearly no longer applicable, it was a model of its time that has had its time.
Acknowledging that the DH contract reform process commenced well before my arrival on the scene, I am fully aware of the various drivers and aspirations of all stakeholders. From my perspective, success will be a dental contract that improves access to care and, critically, a contract that recognises and facilitates the ability of the dental team to develop longer term relationships with patients in order to support an individual in taking charge of their health and preventing dental disease. The profession has expressed a desire for a contract that draws on the NHS England General Medical Practice model of registration and capitation, but for the NHS England Dental Practice contract I am keen to ensure that we also add in a value to recognise the practice's commitment to prevention and quality of care where dental treatment does become necessary.
In terms of the prototypes, DH have advised that we should expect the first datasets by the end of 2017 and that they will be looking for evidence of improved access as a primary measure of success.
From my point of view I want to know if patients and the profession are satisfied that there is a viable contract which allows delivery of a model of preventative care, a contract which is sufficiently future-proofed to meet the complex and technically demanding treatment challenges presented by the maturing heavy metal generation, to quote Jimmy Steele, as well as creating the conditions to realise the aspiration of a generation of children caries free and all those in between; if not what do we need to further evolve the prototypes?
With regard to the prototypes, my first measure of success would be that we will have a wealth of learning acquired from the 100 practices DH has signed up to test out the next phase of potential contract arrangements. From each performer I want to know does the prototype either allow or not allow you to fulfil your vision of providing a prevention pathway to the patient, provide me with the evidence that says what worked, what didn't work and what your recommendations are to evolve the prototypes. I do not envisage the current prototypes as the be all and end all, a next step not the last step.
I foresee further evolution based on the prototype outcomes and evidence and as a consequence we may have to sacrifice some momentum as the price for building a robust evidence set and ensuring thorough evaluation if we are to achieve the optimal contract conditions and terms of service.
One area that dentistry can lead on is the over-prescribing of antibiotics. How do you intend to drive the profession forward on this?
We all recognise the necessity of engaging with the Government's five year AMR Strategy to conserve and steward the effectiveness of existing treatments. Although dental prescribing represents only a small percentage of overall prescribing in England, the fact is that 66.4% of the dental prescription items are antibacterial drugs.
No one across the profession can have failed to acknowledge the particular risks around the prescribing of broad-spectrum antibiotics but, during 2014, HSCIC advise that dental prescribing in England accounted for more than 20% of all the prescription items of clindamycin. So clearly we need to get our house in order, certainly with increasing concerns about the volume of antibiotics prescribed by dentists and what appears to be a dental prescribing habit for drugs like clindamycin, which are associated with the causal factors in healthcare acquired infections, particularly Clostridium difficile associated disease.

In terms of driving the profession forward on this, given the profession's declared commitment to AMR and the number of influential dental groups tackling this very issue, I would be surprised that this initiative should require any significant drive from me as CDO. It is the right thing to do and the profession is already actively engaged but I remain poised to assist. What I have, in some small way, managed to do is initiate a corralling and connecting of the various groups and as a consequence we have secured the profession a place in the vanguard of AMR activity, starting with an understanding of prescribing trends and what drives them. The jurisdiction for this initiative sits with PHE and I am grateful to Sandra White taking the lead on AMR supported by the sterling efforts of the BDA and FGDP (UK) who have rightly offered to take a pivotal role in collating information and in disseminating findings to the profession.
We have talked a lot about the future. With that in mind, how do you see your relationship with students starting their degrees now and qualifying now?
I was very fortunate to visit Peninsula Dental School in October and met with students in their very first weeks of their first term as well as those in their final year. The Peninsula concept of developing the integrated dental team from the outset is evident as is a focus on the art of dental care, their approach is hallmarked by an energy and commitment that is infectious. Remaining engaged with this dynamic group will not be an onerous task. With this in mind I have an aspiration for the CDO Executive Team, myself, Janet Clarke and Eric Rooney, to look at how we may best maintain links with the schools, Young Dentist Associations and the DFT cohorts as we endeavour to connect with those that have both aspiration and leadership potential.
So if I was to be your plus one to a graduation ceremony and I asked the students there what they thought of the last five years and the CDO they're about to work with, what do you hope they will say?
Clearly we need to get our house in order in relation to prescribing clindamycin...
Firstly, I would be honoured to be invited – we'd all be marking the end of five years' of personal and professional development. But conscious that my words today will no doubt be revisited by you in five years' time, I offer and hope that it is not a too grandiose an aspiration to think that within the next five years, together with Janet, Eric, the BDA, Royal College Faculties, the whole gamut of representative dental bodies and associations, that we will have collaboratively set the conditions for an integrated oral healthcare system that actively engages and retains high quality professionals.
I would hope that the graduates would acknowledge that we as a profession grasped all the opportunities to influence and shape the evolution of the NHS Dental Contact. For those electing to work in partnership with NHS England, it is seen as an attractive prospect within a viable reformed contract, enabled and managed through an agreed framework of national standards for commissioning and regulation.
I would hope that the new graduates would be excited by the prospect of joining a profession that is using technology and informatics far more effectively to collect and share data and critically we are demonstrating our effectiveness in proactively supporting improvements in oral health for all. That we have continued with our themes of Inform, Integrate and Improve and that our 'value added' as a profession is fully recognised.
Finally I would hope that the new graduates all anticipate and desire the prospect of clinical leadership and that amongst them will be a future CDO England.
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When David met Sara Part 2. Br Dent J 219, 477–478 (2015). https://doi.org/10.1038/sj.bdj.2015.880
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DOI: https://doi.org/10.1038/sj.bdj.2015.880
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