INSPECTION OF THE DIPLOMA IN DENTAL HYGIENE AND DENTAL THERAPY PROGRAMME

THE GREATER MANCHESTER SCHOOL FOR PROFESSIONS COMPLEMENTARY TO DENTISTRY SALFORD PRIMARY CARE TRUST

15, 16 JANUARY, 26 AND 27 MARCH 2007

REPORT OF THE INSPECTORS

MS B CHANA RDH RDT Dip DHE MR J CHOPE BDS BSc LDS MFGDP PROFESSOR P A HEASMAN BDS PHD MDS FDSRCPS DRDRCS DR S MORISON BA PGCE PHD MHEA

ACCOMPANIED BY MR P FEENEY BA PGCE MS R FUHR BA

OVERVIEW This is an innovative new programme, taught without a traditional dental hospital clinical base, in which all clinical teaching and learning is carried out in the community with the course tutors supervising students in these outreach locations. Students are exposed to a wide range and good volume of clinical cases. There is an excellent team spirit among staff and students and the School has developed strong collaborative arrangements with staff from Manchester University to teach specialist subjects. The programme is strongly supported by the Strategic Health Authority and, by producing locally recruited Dental care professionals (DCPs), the School plays a key role in meeting local dental health needs. Students’ exposure to dental team working is limited and dental nurse support is poor, with pairing of students for clinical sessions being the norm. The programme meets the curricular requirements and learning outcomes of Developing the Dental team. FOREWORD Purpose 1.

As part of its duty to protect patients and promote high standards, the General Dental Council (GDC) monitors the education of dental students and dental care professionals (DCPs) at institutions whose qualifications are approved by the GDC for registration. The aim is to ensure that these institutions provide high-quality learning opportunities and experiences and that students who attain a dental qualification are safe to practice.

GDC process 2.

The purpose of the inspection visit was to assess whether the Diploma in Dental Hygiene and Dental Therapy conforms to the GDC’s requirements for the training of dental hygienists and dental therapists and whether, on qualification, students with the Diploma in Dental Hygiene and Dental Therapy would be suitable for registration with the GDC as DCPs.

3.

This report sets out the findings of a two-day inspection visit to the Diploma in Dental Hygiene and Dental Therapy programme at the Greater Manchester School for Professions Complementary to Dentistry of the Salford Primary Care Trust (PCT), using the assessment principles and guidelines set out in Developing the Dental Team - Curricula Frameworks for Registrable Qualifications for Professionals Complementary to Dentistry (PCDs) as a benchmark. The report highlights the many areas of good practice, but also draws attention to areas where issues of improvement and development need to be addressed. The report is based on the findings of the inspection visit and on a consideration of supporting documents prepared by the School.

4.

A further inspection visit was made to the final examinations of the diploma programme in March 2007.

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5.

The School and PCT will be given the opportunity to correct factual errors and to submit its observations on each of the sections of the report. The combined report, together with the School’s and PCT's observations, will be considered by the GDC Education Committee and a decision made in respect of the sufficiency of the Diploma programme. The report and the observations will subsequently be published on the GDC website.

Introduction 6.

The inspection visit to the Diploma in Dental Hygiene and Dental Therapy programme at the Greater Manchester School for Professions Complementary to Dentistry took place on 15 and 16 January 2007. We were welcomed by Dr F Blinkhorn, Head of the School and Programme Director. During the inspection, we met clinical, teaching and administrative staff at the School. We also met with Trust managers, staff working in outreach centres and students on the Diploma programme. A full list of those we met appears in Annex One. We would like to thank all concerned for their help, courtesy and co-operation during the inspection visit.

7.

The Diploma in Dental Hygiene and The Diploma in Dental Therapy was provisionally approved by the GDC as a primary professional qualification in early 2005 and this inspection is the first visit by the GDC to the programme. This 27-month, full-time programme is a new programme which leads to the award of the Diploma in Dental Hygiene and The Diploma in Dental Therapy of the Royal College of Surgeons of England (RCS England).

8.

The GDC has not previously visited the Greater Manchester School for Professions Complementary to Dentistry.

Context 9.

The School is based in the headquarters building of the Salford Primary Care Trust (PCT) and is jointly funded by the SHA and the Trust. The funding was described by School managers as sufficient for the purposes of delivering the curriculum.

Student recruitment and selection 10.

The programme aims to recruit ten students per year and there are currently no plans to increase cohort size. Minimum entry requirements are: five GCSE passes at grade C or above (including English and a science subject) plus a recognised dental nursing qualification and at least one post qualification certificate or two A-levels (It is desirable to have one science subject) or another relevant qualification such as a NVQ level 3. The majority of current students have a dental nursing background.

11.

Suitable applicants are interviewed before an offer of admission is made. The 2007 intake was selected from a total application of 91 candidates.

12.

At the time of the inspection, no student had dropped out or been excluded from the programme and there were currently 28 students on the programme representing three intakes.

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EDUCATIONAL ENVIRONMENT Clinical facilities 13.

This programme is unique in the United Kingdom in that no patients are treated within the School and all patient treatments are carried out in community clinics in and around Salford and Manchester. Students carry out clinical sessions at three clinics in the Salford area: the Mocha Parade Health Centre, the Lance Burn Health Centre and the Ordsall Health Centre. Students carry out clinical sessions at one clinic in the Manchester area: Cornerstone Centre. The centres provide DCP students with a full range of patients requiring a wide range of treatments.

14.

Clinical skills/operative techniques are taught in a fully-equipped phantom head room with 10 work stations. Plans are being developed to enlarge this area by extending into adjacent space. The phantom head room is well equipped and, in addition to the 10 workstations, has live and recorded video facilities linked to workstation VDUs. The clinical skills room is treated as a clinical area and students and staff observe rigorous cross-infection protocols aimed at instilling best practice from the outset of clinical learning.

Library, IT and teaching facilities 15.

The PCT Library holds a reasonable collection of texts for students and staff housed within the PCT building. The School library, co-located within the School, holds a good selection of texts, periodicals and health promotion materials. The PCT library also participates in the NHS inter-library loan scheme. There are PC terminals available for student use and we heard from students that there have been no problems accessing study materials or PCs.

16.

Classroom and meeting facilities as well as social spaces are adequate for the size of the student cohort and staff. Some expansion of teaching and common room space is planned for later this year.

Curricula 17.

The Diploma programme subjects are delivered through a combination of lectures, seminars, practical classes and clinical sessions. The following subjects and topics are common to all DCP disciplines and are described in Developing the Dental Team: • • • • • • •

18.

Biomedical sciences and oral biology Behavioural sciences, communication skills and health informatics Human disease Medical emergencies Law, ethics and professionalism Dental biomaterials science Health and safety and infection control

The following subjects and topics from Developing the Dental Team are specific to the curricula for dental hygiene and dental therapy:

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• • • • • • • • • • • • • • • • • • •

Oral disease Oral surgery Oral medicine Plaque-related dental disease Diseases of the periodontium Dental caries Oral pathology and oral microbiology Introduction to clinical work Gerodontology Dental implants Child dental health Paediatric dentistry Orthodontics Preventive dentistry Comprehensive oral care Dental radiography, dental radiology and imaging Pain and anxiety control Complementary and alternative medicine Elective studies

19.

All major topics described in Developing the Dental Team are adequately covered in the curriculum.

20.

The School enjoys a close working relationship with staff from the University of Manchester Dental School and senior staff from the Dental School provide teaching in a range of subjects such as restorative dentistry, periodontology, pain and anxiety, paediatric dentistry and clinical dental therapy topics.

Clinical experience 21.

The four centres provide DCP students with a full range of patients requiring a wide range of treatments. There appeared to be no difficulty in finding appropriate patients for students and the inspectors were pleased to note that student logbooks reflect a very good range of clinical experience.

22.

This programme is unusual in that no clinical work, other than clinical skills laboratory work, is carried out within the School setting. All clinical work with patients takes place in the four outreach clinics (see Paragraph 13 above) and a unique feature of this activity is that School staff supervise students working in the outreach clinics. This arrangement helps ensure consistency of teaching, clinical supervision and assessment. The inspectors were pleased to note this innovation.

23.

The inspectors were generally satisfied with the quality of facilities in the clinics used by students. However, at one clinic, the Ordsall Health Centre, the inspectors felt that the location and use of some of the radiography equipment did not encourage best practice. In this case, the patient sits in an ordinary waiting-room chair while the X-ray is taken and the chair had no head restraint or support. The operator is required to stand in the corridor, out of direct sight-line with the patient. While this arrangement complies with all regulations and there is no risk to patient or operator, the inspectors felt that, in a student learning environment, better facilities should be in use.

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Dental team working 24.

All students on the programme have the opportunity to work with dental hygiene and therapy students from Manchester University during their clinical sessions in the various outreach clinics. BDS dental students refer patients to the student hygienist/therapists, although this is done in the form of a written prescription with little face to face discussion of referred patients. Students also carry out some domiciliary visits with qualified dentists.

25.

At the time of this inspection, students had little experience of working with dental nurses and, instead, are paired in clinics and nurse for each other; although it is understood that greater dental nurse support is available later in the programme. The inspectors feel that students should gain more experience of working with dental nurses throughout their clinical training.

Management support 26.

There is strong management support from the PCT and from the North West SHA for this programme. SHA representatives said that the Greater Manchester School helps to address major health inequality in the Manchester area by training local DCPs to serve the local community. The SHA representatives said that they strongly supported the innovative approach taken by the PCT in developing the School.

Staff 27.

The teaching team at the School is well qualified both clinically and as professional teachers. Teachers on the programme are highly experienced clinicians and teachers. The teamworking among the teaching, management and administrative staff is exemplary and the inspectors were impressed by the dedication and professionalism of the staff. Students commented favourably on the quality and variety of teaching.

28.

External staff from other institutions who deliver specialist subject teaching were clearly well inducted and the inspectors heard from students and core staff that the inputs from contracted-in teachers were of a high standard and fitted well with the syllabus.

Staff development 29.

School staff are well supported by the PCT and by School management. The PCT provides training days and also sponsors staff to take a postgraduate qualification in teaching. The inspectors heard from a variety of staff that they feel encouraged to further develop. There are regular staff meetings and staff feel they have a voice within the School and are able to influence changes in the programme.

Student support 30.

Although there are less formal, structured student support systems at the School than is usual at universities, students reported that they feel well supported and receive personalised attention from helpful, experienced tutors who are able and willing to offer advice and guidance on any problem areas.

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The inspectors noted the highly positive comments from students about their tutors. 31.

Students also reported that there were functioning systems, both formal and informal, through which student opinions can be expressed and acted upon. Students gave several examples of curricular and workload issues which they had reported to the course leaders and which had been acted upon.

Assessment 32.

An appropriate range of summative and formative assessments are used throughout the course. None of these counts towards the final examination, but some are “gatekeeper” assessments which must be passed before students may progress to later stages of the course and final examination.

33.

The inspectors noted that there is little external scrutiny or benchmarking of internal assessments and feel that the involvement of an external examiner would be beneficial in assuring that internal assessments and marking are at an appropriate level and test an appropriate range and depth of knowledge. As a PCT-based institution, the inspectors observed that there is less internal and external scrutiny of the programme than would occur in a university where QAA and the university’s internal Quality Assurance (QA) would carry out quality audits.

34.

Students keep clinical portfolios and personal development plans. The portfolios encourage reflective learning and were up to date and comprehensive. There is a central, secure record of student assessment and progress within the School office.

FINAL EXAMINATION Overall structure 35.

The Final Examination for the Dental Hygiene and Dental Therapy Diploma programme at the Greater Manchester School of PCDs is set by the Royal College of Surgeons (England). The exam is made up of written and clinical components, with the students completing a total of three written exams and three clinical case presentations each. Each component of the exam is graded A-E. Viva assessments only take place if a student is on the borderline of pass and fail. The outcome of the viva is either a confirmed fail or ‘raise to pass’.

36.

There is no system of compensation between the written and clinical examinations, and if a student fails either of the two elements, they automatically fail the exam overall.

37.

In order to be eligible to sit the Final Examination, each student must pass the Intermediate exam (in December 2006 for this cohort), complete a project of approximately 5000 words, and demonstrate a history of satisfactory clinical performance throughout the course. All eight students in the current cohort were allowed to proceed to the Final Examination.

38.

The inspectors noted that uncertainty over the exact dates for the final examinations existed until only a few weeks before the examinations took place and feel that this uncertainty increases stress for all concerned.

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Written examination 39.

The written papers are made up of eight questions each, and students are required to select and answer six questions. Each question is marked out of 20, and each points total equates to one of the grades A-E. Once both of the internal examiners have blind marked the papers, they are submitted to the external examiners for moderation. There are two external examiners, and between them they see every written exam paper. The system seems to be working well, and this year the external examiners altered the marks for approximately 20 questions overall, all by one grade.

40.

The inspectors noted that the results of the written papers are collated and discussed before the clinical case presentations take place. This means that all of the examiners – internal and external – approach the clinical exam with an awareness of the students’ performance in the written component of the assessment. It was felt that this was not ideal, and that, if possible, the discussion of marks in the written papers should be postponed until after the clinical case presentations have taken place. This is particularly relevant when there is a small cohort of students sitting the exam, and anonymity is already so difficult to safeguard. Clinical case presentations

41.

Clinical case presentations took place over the course of two days, with each student presenting one adult restorative, one paediatric restorative, and one adult periodontal case. The examinations were carried out at two of the School’s outreach clinics: Mocha Parade and Lance Burn. These locations are close to the School and to each other, so the students were able to travel easily from one stage of the assessment to the next.

42.

The inspectors found the process to be carefully planned and well organised, and the management of the exams across two sites was impressive. The smooth running of the clinical case presentations, and the resulting calm atmosphere, was undoubtedly beneficial to the students.

43.

The environment in which students took their exams was generally good, with a dedicated, closed surgery space being used for the assessment. However, the inspectors noted some background noise, particularly at the Lance Burn clinic. The inspectors felt that addressing this issue would simply be a matter of ensuring that everyone at the clinic was aware that exams were taking place that day.

44.

The inspectors noted that a broad range of topics were covered in the clinical case presentations, with a good variety of patients. The mark sheet used for the clinical assessment ensured that students were questioned on the original condition of the patient, medical history, full details of the treatment plan, and consideration of future care.

45.

The procedure allowed a few minutes, before examination began, for the student to seat and settle their patient, and check for any recent developments in their condition. The external examiner always introduced him or her self before the assessment started. 30 minutes were dedicated to each presentation, with the last ten minutes of this being used for the examiners’ discussion of the student’s performance. Of the other 20 minutes,

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ten were allocated to questioning of the student by the external examiner, followed by five minutes of questioning by the internal examiner, and five minutes’ discussion and summing up by the student at the end. 46.

The students submitted a supporting document for each case presentation, which included details of the treatment plan they had devised, along with photos showing the patient’s condition and the work they had done. The external examiners commented that, although the standard of these documents was generally very high, they we rather longer than they needed to be. It was stated that this message should be passed on to future cohorts of students, so that any unnecessary additions to their w++orkload can be avoided. Arrangements for failed candidates

47.

One candidate from this first cohort failed the final examination. As this is a Royal College of Surgeons (England) exam, the Royal College’s resit regulations apply. In accordance with these, six months’ further training will be undertaken by failed candidates before they attempt the exam for a second time. The student will then be able to retake the exam at any School at which the exam is set. When approaching the resit, there is no retention of partial success from the original examination.

48.

While the rest of the students’ results were posted on the department notice board, the failed candidate was informed of the result privately. In accordance with the RCS regulations, an appeal can be made against the process of the examination, but not against any individual result. Examination Board meeting

49.

The Exam Board meeting was held immediately after the conclusion of the clinical case presentations. It was attended by both external examiners, all of the internal examiners, and a representative from the Royal College of Surgeons.

RECOMMENDATIONS The key areas for action identified by the inspectors are summarised below. Additional comments are contained within the body of the report. Figures in brackets refer to paragraphs in the body of the report. 1

To the GDC (To be determined by the Education Committee on consideration of this report)

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To the School •

Consider whether arrangements with BDS students can be coordinated to allow for more dental team working (24)

• Dental nurse support for students in clinics should be increased to avoid student pairing and to provide a student experience closer to professional working (25)

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• There should be a greater degree of external scrutiny over the programme (33) • Discussion of marks in the written papers should be postponed until after the clinical case presentations have taken place (40) • When case presentations are conducted in clinics while normal activities continue, other staff should be made aware that the assessments are taking place so that background noise can be kept to a minimum (43) 3

To the NHS agencies • Consider improvements to the X-ray facilities at clinics used by students so that they have the opportunity to experience best practice (23)

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To the Royal College of Surgeons of England • Consider whether detailed exam timetables could be finalised and schools informed at an earlier stage (38)

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Annex one People we met during the inspection visits Greater Manchester School for Professions Complementary to Dentistry Dr F Blinkhorn, Director and Head of School Mrs R Khan, Tutor in Dental Hygiene Mrs D Hunter, Tutor in Dental Hygiene Mrs E Taylor-Duxbury, Tutor in Dental Therapy Dr M Hardman, Principal Dental Tutor Mrs L Hopper, Principal Dental Tutor Mrs K O’Connor, Dental Nurse Mrs J Horrigan, School Manager Specialist subject lecturers Professor R Davies, Co-Director, Dental Health Unit, University of Manchester Mr N Grey, Co-Director Dental Health Unit, University of Manchester Professor A Blinkhorn, Director for Dental Outreach Programmes, University of Manchester Ms C Potter, Senior Clinical Teaching Fellow, University of Manchester North West Strategic Health Authority Mrs D Hough, Dental Workforce Development Lead for DCPs Salford Primary Care Trust Professor E Fairhurst, Chairman Students We met 8 students from the Diploma in Dental Hygiene and Dental Therapy Primary Care Outreach Clinics We met clinical, support, and management staff of the various outreach clinics we visited during the inspection Examinations During the final examinations, as well as internal examiners whom we had met during the programme inspection, we also met the external examiner, Ms E A Watts

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Comments on GDC report We have still not received Annex 1 Clinical experience Para 23 Ordsall We noted the inspectors’ comments regarding the radiography arrangements at Ordsall clinic and agree that the arrangement there complies with all regulations and that there is no risk to patient or operator. However whilst acknowledging the inspectors’ comments regarding the facilities we should like to point out that the students have the opportunity to attend four different clinics during the course of their training. The facilities available at the clinics do vary and although they all conform to all the regulations there are some restrictions, which are due to the space available at individual clinics. However on balance we feel that the learning experience that the students receive is extremely beneficial. Students take and process their own radiographs and we believe that the training and experience they receive prepares them for their future role as registered dental hygienists and therapists working in either hospital community or dental practice settings. We are aware that some of the clinics that we currently use as outreach clinics for our students have been established for some time and the premises are in need of updating, particularly with regard to the amount of space available. New clinical facilities have been commissioned and building work commenced. We do hope to have this facilities which will have very high quality resources and equipment will be in place by the end of 2008 Dental team working 25 We have noted the inspector’s comments regarding dental nurse support and would wish to re assure the inspectors that as the course progresses students do gain more experience of working with dental nurses. To date it has not been possible to guarantee the provision of dental nursing assistance on an individual basis for each student. Dental nurses are available at each clinic and where necessary, they assist the students. However it should be noted that most of our students are qualified dental nurses and all of them have spent some time working in a dental surgery. We do feel that working in pairs and having the opportunity to assist their colleagues increases their overall clinical experience and helps them to have a greater understanding of team working.

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Assessment 33 external scrutiny or benchmarking We fully accept the inspectors’ comments and agree that there appears to be less external scrutiny or bench marking than would be found in a more conventional university setting. As a school that is PCT based and not linked to a university, external scrutiny such as a QAA assessment is not available to us. However during our first year we invited a professor from a dental school to assist us with a review of the course. This review included an assessment of the quality of the course in terms of the overall coverage of the curriculum, the availability and quality of resources and the provision and quality of theoretical and clinical teaching and assessment. Comments and suggestions made by the external professor were noted and this guidance helped to formulate a robust in-house assessment of the course. The Intermediate examinations are scrutinised by an external assessor who is based in another dental training establishment and comments and suggestions regarding the assessment are reviewed and acted upon by the school director and staff. As the inspectors will be aware our examining body is the FGDP of the Royal College of Surgeons of England. The final examination is set and assessed by examiners appointed by the College. The examination system is therefore by its very nature external. It should be noted that we are currently trying to forge links with the University of Salford with a view to converting our current courses from a Diploma courses to a degree course. This is making slow but steady progress and we hope that this will eventually help us to establish a QAA link such as has been suggested by the inspectors. Clinical case presentations 46 Supporting documents for final case presentations We fully agree with the examiners comments and noted that they were re-iterated by the inspectors in the report. This was the first final examination that had been undertaken by students at the school and was the tutors and the director’s first experience of this particular style of final examination. Students have subsequently received additional guidance on the preparation of supporting documents and we now feel that a more succinct style of presentation has been achieved without compromising the high standard of supporting documentation, which was recognised by the inspectors.

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