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Consent

  • Q
    A patient has requested their dental x-rays because they want to have dental treatment abroad where it is cheaper. Can I give them to the patient?
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    28 April 2015

    We recommend you only allow the patient to take away copies of your radiography, retaining the originals yourself. The patient is of course entitled to copies but could be asked to pay for your reasonable charges incurred in producing them.

    You have obviously made the patient aware of the potential problems associated with seeking treatment abroad, especially the provision of follow-up care which may be necessary should the treatment not go according to plan. You cannot be held responsible for the outcome of another practitioner's work.

  • Q
    Can I post patient information on Facebook or Twitter when I am seeking advice from colleagues on the best way to treat a patient?
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    18 September 2014

    The new guidance specifically states (para 4.2.3) ‘you must not post any information about patients on social networking or blogging sites’ such as Facebook and Twitter. 

  • Q
    Can I take pictures of patients with a camera phone and send them to colleagues/specialists for an opinion or advice?
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    25 November 2014

    While it is tempting to capture various intra-oral situations with a handheld mobile camera phone, it is important to appreciate that the making of that image creates a record. This electronic record has the same quality of confidentiality as all other records and should be managed accordingly.

    Can you be sure that only the intended recipient will see the image? Unless there is encryption software on the phone, confidential material could be available to anyone who accesses the device especially if it is lost or stolen.

    The images, even on high resolution camera phones, may not be sufficient to make a diagnosis and may even lead to misleading advice being given. There is also the issue of storage since as a record it will require the same degree of permanence as other records. It cannot therefore simply be deleted.

  • Q
    Can I use my mobile phone to take clinical photos or images of radiographs for my own use or to obtain advice from colleagues?
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    18 September 2014

    It is important to ensure that the patient cannot be identified from any image taken, stored on or sent from your mobile phone. This includes the face or parts of the face or other details that will allow a viewer to identify the patient. The GDC expects registrants to obtain consent from their patient when taking such images either with a mobile phone or with a conventional camera.

  • Q
    Can you explain my responsibility to share patient records and information with a third party if an issue of child protection is raised?
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    18 September 2014

    If possible you should seek parental consent for the disclosure of any information about a child. If parental consent is not available, as is often the case in this type of situation, it may be appropriate to disclose the information requested on a public interest ground, or in the patient’s best interests.

    Each case must be judged on its own merits taking account of local child protection guidance, with which all clinicians should be familiar. If parental consent for disclosure cannot be obtained, for any reason, you should discuss the request with one of our dento-legal advisers via the member helpline.

  • Q
    How should I record a patient's consent for routine dental treatment? Does it have to be put in writing for the patient to sign?
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    07 July 2015

    The concept of consent arises when a patient seeks advice, care and treatment from a dentist and that dentist carries out an examination of the patient and provides them with details of the treatment required together with the options, benefits and risks as well as the cost of that treatment. This is an on-going conversation that is picked up at every stage of the treatment being provided.

    Most dental procedures are carried out without the need for written consent but it is important that a record is made (either by the dentist or dental nurse) of the conversation during which the patient gave their consent.

    When seeing a patient for a dental examination there is likely to be implied consent that the patient wishes the dentist to look in their mouth and therefore opens it to facilitate this. When carrying out more invasive treatment such as taking radiographs and providing fillings, the dentist should obtain the express consent of the patient for each procedure.

    Certainly when carrying out fillings patients should be informed of the various options which are available to them, the costs of the treatment as well as the risks of not having a particular treatment carried out.

    In the UK, consent only needs to be obtained in a written form signed by the patient, when the treatment is being provided under general anaesthetic or sedation.

    Some employers make it a contractual obligation to obtain the patient’s signature on a consent form for a variety of procedures as well as anaesthesia. The employee has an obligation to respond to the terms of their contract. Indeed in complex cases it is a sensible precaution to have some form of written consent. This would apply to treatment plans for extensive restorative work or for patients undergoing treatment which could pose a significant risk, such as the removal of a lower wisdom tooth.

    The signature on a consent form does not automatically imply the patient has provided their consent to the treatment. All it means is that the patient has signed their name and may not in fact have understood the treatment which the dentist had discussed with them.

    The best way of ensuring consent has been obtained is to check with the patient if they fully appreciate the details of what has been discussed and to make good notes within the clinical records of both the discussion and the patient’s response.

    Read our region-specific advice booklets on consent in the UK

  • Q
    I have CCTV cameras in my practice both for security reason as well as staff training purposes. What legal obligations apply to this material?
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    17 July 2014

    Having CCTV in dental practices does raise some interesting issues. The first is the issue of patient confidentiality, particularly if CCTV is utilised in clinical environments. While these devices do not usually record sound, they are liable to be considered an intrusion by patients who will have no control over what happens to the recordings. Even at the reception desk, patients will be easily identifiable from these recordings, which they may feel is an infringement on their right to have their confidentiality in a healthcare setting protected.

    If CCTV cameras are in use, it is important that patients are made aware of the fact and that signs are placed in suitably prominent positions to that effect. It may be sensible (or in some countries a legal requirement) to explain the purposes of the recordings, who will have access to them and how long they will be kept.

  • Q
    I run an implant referral practice and dentists sometimes ask if I will place implants for them so they can supply a coronal restoration. How should I deal with failures when the responsibility is shared?
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    04 August 2015

    UK dentists who place and restore implants are expected to follow the training pathways recommended by the General Dental Council and the Faculty of General Dental Practice (UK). When more than one clinician is involved in providing implant treatment, it is important that there is the ‘team leader’ with overall responsibility for the treatment, and that both clinicians can work together, complementing each other’s skills.

    Implants can and do fail, and the criteria for reimbursing or compensating the patient depend on many factors, such as the discussion during the consent process, the standard of care and the length of time the implant was viable. Other factors such as patient co-operation and subsequent treatment by the referring general dental practitioner may also be relevant. Any subsequent failure might involve both the original placement of the implant as well as the restorative element.

    Ideally there should be a good working relationship and close liaison between the two clinicians involved, on the understanding that one will be placing the implant and the other placing the restoration. To obtain patient consent there may need to be separate input from the clinician placing the implant as well as the clinician placing the restoration. Once the patient has given their consent, the treatment can be carried out. It would be prudent to advise the patient that the success of implants, like any other aspect of clinical dentistry, cannot always be guaranteed.

    When it comes to the apportionment of responsibility (including fees), this is something which should be discussed and decided between the clinicians involved, without the patient being involved or indeed compromised.

  • Q
    I treat anxious adult patients with RA and have recently been advised that they must always attend the surgery with an escort. Is this really the case?
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    27 August 2014

    The Department of Health guidance Conscious Sedation in the Provision of Dental Care states in section 15 that for an adult receiving nitrous oxide/oxygen inhalation sedation, the requirement that a responsible adult escort must accompany the patient home is less rigid and each patient must be assessed individually.

     Further into the document, at section 18.2 it advises that adult patients who have received nitrous oxide and oxygen inhalation sedation may leave unaccompanied at the discretion of the sedationist.

    It is important to ensure that pre- and post-operative assessments are recorded to support the decision to proceed with treatment and discharge without the presence of an accompanying responsible adult. If you ask your dental nurse or the receptionist to telephone the patient to see that they are safely home and comfortable after their treatment, you should also note their response in the record.

  • Q
    If a DCP is not working to a dentist’s prescription, what happens about consent?
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    11 May 2016

    You should always ensure that a valid consent has been obtained from the patient (and/or parent in the case of a minor), whether or not you are working to a prescription produced by a registered dentist. This is part of your duty of care to each and every patient you treat.

    In this situation the responsibility to obtain a valid consent is wholly yours and you would be legally, ethically and professionally accountable if you treat a patient without obtaining it. Members are referred to our Advice Booklet on this subject (a different version exists for members practising in Scotland) which can be downloaded here.

    Read our briefing document on Direct Access

  • Q
    I've been asked by a patient's new practice to supply some radiographs. Do I need written permission from the patient and what fee can I charge for the service?
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    21 April 2015
    Owing to the confidential nature of dental records, it is best practice to receive verbal or written consent from the patient and this can be documented. Radiographs can be copied and handed to the patient or posted by secure delivery. A reasonable copying charge could be applied, and it would be best practice to inform the patient of this beforehand. Digital images can be shared more readily than images taken on film and the copying charge can be reduced accordingly. Remember, care should always be taken when transmitting images digitally to ensure, for example, that emails and attachments are properly encrypted.
  • Q
    The practice owner has told me to economise the use of local anaesthetic by using it only in those cases where the patient will be in extreme pain. How can I decide what I should do?
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    13 January 2015

    Most patients have an expectation that their dentistry will either be pain-free or that any pain will be managed effectively. Therefore, the provision of a local anaesthetic for a given procedure will initially involve a discussion with the patient about the nature of the procedure being contemplated and what they may expect.

    This is an issue of consent. As a clinician, you should not impose your views and provide treatment without local anaesthetic simply because you have considered the matter (as requested by the practice owner) and concluded that the procedure will not be painful and does not require local anaesthetic. It is incumbent upon clinicians to respect patient autonomy and an individual’s right to make decisions about their treatment and this would extend to a decision about local anaesthetic.

    In any case, the patient’s medical history initially needs to be checked and updated before considering the type of local anaesthetic to be administered.

    Our advice booklet on consent is available here 
  • Q
    We are making a Facebook page for the practice. Are there any specific dos and don’ts that I need to be aware of?
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    27 August 2014

    Given the popularity of Facebook and its usefulness in the promotion of business, many dentists have been somewhat cautious in promoting themselves in this way, perhaps through fear of breaching the General Dental Council’s guidance.

    In reality, however, a Facebook page is no different to any web-based advertisement other than the fact that access to the page can be restricted. The contents of the Facebook page must conform to the GDC’s guidance and that of the Advertising Standards Authority; they must be legal, decent, honest and truthful. The contents of the page should not make any statements that cannot be substantiated, or would be regarded as misleading.

    It is quite possible to indicate to any patient who wishes to subscribe to the friends list that their name will be displayed on the website and will be visible to other members of the public. Their consent to this disclosure can then be obtained.

    For obvious reasons no other personal information should be displayed and certainly no indication of any treatment that has been provided for a patient unless they have provided their specific written consent.

    If a practice is considering whether a Facebook page is appropriate, it may wish to give thought to whether it will be possible for a ‘patient’ to use the Facebook page to post adverse comments that can be seen by other friends.

    Some disgruntled patients are seeking to use the internet as a forum to post their complaints. Thus if a practice is seeking positive reviews in this way, it may also receive negative comments. The practice may wish to consider how easy it would be to remove such comments. 

    With a little care, therefore, the use of a Facebook page to promote the practice should not necessarily cause the GDC any undue concern.

  • Q
    What could be considered to be 'a reasonable period of time' for a patient to think about their treatment options?
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    18 September 2014

    There is no definitive answer to this question because the consent process is ideally a detailed conversation between two individuals of sound mind. But the length of time needed for an individual patient to comprehend, weigh up and make an informed choice from their various treatment options will vary depending on the complexity of the treatment proposed and the risks and consequences of each procedure.

    Plastic Surgeons, when offering elective cosmetic procedures, are expected to leave a two-week interval between the consultation and the treatment visit. It might be prudent for dentists offering elective cosmetic treatments to work to a similar system.

    In the case of a patient seen in an emergency or on referral for the uncomplicated extraction of an infected/carious or broken tooth which is producing severe symptoms, any offer to press on with the procedure immediately means that the preceding consent process must be detailed.

    It should also include the offer of a less restrictive option, such as treating the cause of the pain but not extracting the tooth at the initial visit.

    The less well you know the patient, the greater the need for caution – but every patient needs sufficient time and opportunity to consider their options without feeling in any way pressured into making a decision before they have had sufficient time to consider.

    Such an idea may seem impractical in the real world situation of a busy surgery where you are confronted with a patient who has been fitted in without an appointment because of their acute pain. The law, however, views such situations dispassionately and with a forensic mind set. The time that patients are given to consider their options is very likely to become a key issue in a nerve damage case, when the patient could have/should have had longer to think about the risks involved. In such situations the contemporaneous notes of the conversation will be invaluable evidence that the standard has been met.

    In the case described above it might be sensible to offer the emergency patient a seat in the waiting room whist they consider the various options. The next patient can be seen before the emergency patient returns to say which treatment option they would prefer.

  • Q
    What is ‘valid consent’? Is it different from ‘informed consent’?
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    17 August 2016

    The GDC has very sensibly adopted the term ‘valid consent’ which helps to avoid the incorrect perception that giving patients information (‘informed consent’) is sufficient to achieve a proper, valid consent. It isn’t.

    Valid consent is much wider than simply providing information, and it comprises a number of considerations, the most significant of which are briefly summarised below.

    • First you must determine that your patient has capacity to consent to treatment. ‘Capacity’ means the ability to use and understand information to make a decision.
    • Even when you apply the 'capacity' test and you consider the patient isn’t capable of consent then you may still be able to treat the patient provided that you act with their best interests in mind. If they are under 16, you will either need to involve parent(s) or assess whether the child’s capacity to consent can be considered as ‘Gillick’ competent.
    • Your next consideration is to establish what your patients wish to know about treatment, as well as telling them what you think they need to know. You should always respect your patients’ autonomy, it is their right to decide what happens to their body and they may decline your advice.
    • What would a reasonable person expect to be told about the proposed treatment? What facts are important and relevant to this specific patient? (What risks might be specific to this planned procedure)?
    • You may want to discuss why you think a proposed treatment is necessary; the risks and benefits of the proposed treatment; what might happen if the treatment is not carried out; and other forms of treatment, their risks and benefits, and whether or not you consider the treatment is appropriate.
    • Do I need to provide any information for the patient in writing? Has the patient expressed a wish to have written information for consideration before they consent? (Remember consent is viewed as an ongoing process and not just about a signature on a consent form).
    • Does the patient understand what treatment they have agreed to, and why? Have they been given an opportunity to have any concerns discussed, and/or have their questions answered?
    • Does the patient understand the costs involved, including the potential future costs, in the event of any possible complications?
    • Does the patient want or need time to consider these options, or to discuss your proposals with someone else? Can you/should you offer to assist in arranging a second opinion?

    Although not part of the consent process, you should also ask yourself whether you have made accurate records that are sufficient to demonstrate (or reconstruct) all the key communications between the patient and me?

    A full exploration of the subject of consent can be found in the dental advice booklet on consent that can be downloaded from the publications section of the website.

  • Q
    Why should I explain my infection control procedures to patients?
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    20 July 2016

    Patients are likely to be a lot more aware of infection control issues following the recent publicity surrounding a look back exercise involving 20,000 dental patients in the UK. If the cost of their dental care increases, patients are likely to be more critical in their choice of dental care provider. Choice and quality are two of the most important components of consumerism.

    Patients who have come to appreciate the steps that are being taken by a practice to ensure their safety will be far less likely to move to another practice where it is not immediately obvious that the same standards of infection control apply.

    Many of those patients who move from one practice to another never tell the original practice why they have left. They often have unspoken concerns and dissatisfaction and these can include doubts over infection control and the quality of care generally. A visible infection control policy and a willingness to explain to patients what is being done for their safety, and why, can address concerns and reinforce the patient’s decision to stay with the practice.

    A deliberately high-profile and visible commitment to infection control can also help to justify a patient’s perception of value, especially if they have just agreed to pay privately for their dental care.

    There are many different ways to get the point across – a poster in the waiting room or a page on your website can outline the basic principles. You can also reinforce the message every time you open bagged instruments from the steriliser or a new set of instruments by mentioning that they have just been sterilised. Disposable, single use items can also be pointed out to patients instead.

    It is paradoxical that patients may be questioning standards of cross infection control in dentistry at a time when they are generally higher and safer than ever before.

    Topics of inadequate infection control make good stories and help sell newspapers. Take the initiative and get your own story out there first.

    With the help of the rest of the dental team, share the evidence of your own infection control measures with patients before they even have to ask. Whether it is new gloves or the large quantity of disposable item that are used – each of these topics can be turned to a marketing advantage.