key: cord-1030777-359r4wtt authors: Ashiti, Shoukat title: The journey of an overseas dentist in the UK date: 2021-04-23 journal: Br Dent J DOI: 10.1038/s41415-021-2835-0 sha: 36925a0204cf3f65207d907034f6380da89eda74 doc_id: 1030777 cord_uid: 359r4wtt Registering as a dentist and working in the UK is a goal that many overseas dentists aspire to. Overseas-qualified dentists need to either pass a registration exam to be able to practise dentistry in the UK or, under certain circumstances, they can register through assessment. Additionally, temporary registration gives overseas-qualified dentists the opportunity to practise dentistry under supervision for up to five years. However, these routes are difficult and it could take a few years before a dentist is registered. These dentists have the academic route as well, but similar to the registration route, it is not easy and very competitive and expensive. Brexit and COVID-19 had their impact on the journey of these dentists and altered their plans to pursue their career in the UK. To sum up, the current system could probably be modified to be more in line with that of neighbouring countries. To my colleagues who have graduated from the UK or EU and are registered with the General Dental Council, please be aware that it is not an easy journey, requires a lot of money and time, and is an incredibly stressful time. Registering as a dentist and working in the UK is a goal that many overseas dentists aspire to. These dentists can be broadly grouped into two categories. The first group (group A) are overseas-qualified dentists who may have never been to the UK, or have been to the UK for non-dental career-related reasons such as a short-term visitor or spouse. The second group (group B) are overseas-qualified dentists who came to the UK to undertake a higher degree; that is, MSc or PhD. Both groups need to apply for and pass an exam to be able to practise dentistry independently in dental practices or hospitals in the UK, as they do in other countries worldwide. For many UK/European Union (EU)-qualified dentists, their awareness and knowledge of this is limited, or in some cases, unheard of. In this article, I will highlight the challenges an overseas-qualified dentist has to overcome to be able to register with the General Dental Council (GDC). I will also highlight some aspects of the Dentists Act (1984) 1 that might lead to inconsistencies between registration requirements of each non-UK-qualified dentist applying for GDC registration, and argue that the reasons behind these are unrelated to patients' best interests. Finally, I hope this article will give UK dentists, consultants and academics an insight into the journey and struggles of overseas dentists, who may even be one of their colleagues, trainees or students. For group A, the situation is not as bad as for group B, as they have not become attached to the country, people or the atmosphere in general, where they have witnessed great chances to pursue their clinical or academic career further. Furthermore, they need to accept the fact that to practise dentistry in the UK, the only way is to undertake the registration exams. However, what about Group B -what are the options available for them to be able to practise dentistry in the UK? First, Group B, as well as group A, can try to register by passing the recognised exams -either the Overseas Registration Exam (ORE) through the GDC or the Licence in Dental Surgery (LDS) by the Royal College of Surgeons. Both exams consist of two parts that are undertaken separately with a period of approximately five to six months between them. A candidate needs to pass part one to be able to sit part two. On the GDC website, it is not mentioned how often the ORE is held every year; however, according to past years, part one was held twice a year while part two was held three times in 2018 and 2019 with 100 candidates per exam. Conversely, the LDS part one is held at least once a year, 2 but part two is only held once a year. Raises awareness around the struggles overseas dentists face to register with the General Dental Council. Informs dentists about the option of temporary registration. The purpose of these exams is to test 'the clinical skills and knowledge of dentists from outside the European Economic Area (EEA) whose qualifications are not eligible for full registration with the GDC here in the UK. Candidates are expected to meet or exceed the standard of a "just passed" UK BDS graduate' . 3 Additionally: ' A candidate is expected to be able to show competence, knowledge and familiarity in the different aspects of dentistry' . 3 The booking process for both exams is online. The LDS is based on electronic random allocation and then candidates need to send the relevant supporting documents if they secure a place, whereas the ORE involves applicants sending very thorough documentation and certification before they are eligible to book a seat on the exam. The booking portal then opens for a fraction of a second as all the places are filled within this time. A dip in the internet connection or slightly slower internet speed means your chance of getting a seat is lost. Thus, for both exams, it seems to be based on luck and you can try for years and never have the chance to sit even part one. The booking system is very fair in that it gives both groups A and B the same chance to sit the exam, despite the fact that group B probably knows the UK's streets by heart, have learnt the culture and customs of the country, and understand the UK patients' expectations. In other countries, dentists in group B have a greater chance than group A. For example, in Kuwait, the employer needs to submit a licence request letter to the Ministry of Health for the dentist to be able to sit the exam and obtain their registration, 4 while in Germany, it is different depending on the state where the request is submitted. However, most of them require a job offer or proof of residency in the state to be able to book an exam date. Some could argue that this is not fair and does not give equal chances for both group A and B; however, these systems are giving credit to other factors such as showing a commitment and attachment to the country. Furthermore, it can be argued that a dentist from group B can spend years in the UK trying to sit the exam. An example of these dentists are those who came to the UK and have been living independently or as a spouse, and have been trying to register as dentists; however, the system is failing them, as they are not lucky enough to book a place on the exam. These have assimilated to the UK way of life, have become attached to it and some of them are working as nurses, dental hygienists and dental therapists while trying to sit the ORE/ LDS. This long period of time to obtain GDC registration is creating an employment gap in their life career that is affecting their future employability. On the other hand, a dentist from group A can, by luck, book the part one exam, pass it, go back home and then return to sit part two. After all that, they might come to the UK, not like it and leave the country, hence never working here. It is worth mentioning that it takes a lot of paperwork for an overseas dentist to be able to submit their documents and be able to book the exam. For example, the GDC requests proof of clinical experience; however, they have specific forms that need to be completed by the referee, which can be time-consuming and challenging because most of these documents are coming from abroad. Furthermore, all documents need to be certified by a Notary Public, Commissioner of Oaths, Justice of the Peace, lawyer, solicitor, or an authorised official of an embassy or consulate, all of which adds up to be quite costly. Applicants who have left their home countries also face difficulties in that their application forms need to be signed by their referees, previous employers and university tutors, who are back home so are not easily contactable, or sometimes unfortunately no longer with us. According to the GDC website and route of registration page, an overseas-qualified dentist can sometimes obtain registration through an assessment process (not the exam) if they are considered to be an exempt person. However, how can a dentist become an exempt person? In the Dentists Act 1984, an exempt person is either a citizen of an EEA state or Switzerland, or a UK citizen who is seeking access, or an overseas citizen but 'by virtue of an enforceable EU right, entitled to be treated, for the purposes of access to and pursuit of the profession, no less favourably than a national of an EEA state or Switzerland' . 1 One could argue that this route of registration is potentially discriminatory and leads to inequalities between applicants depending on their nationality or their relationships rather than their clinical skills. This route is surely not the way that is for the best interests and safety of patients. If we have two dentists who both qualified from the same overseas university in the same year, but one of them holds an overseas passport and the other holds EEA or Swiss nationality, the former needs to sit the ORE/ LDS, pay around 3,700 GBP as exam fees, a further 1,000 GBP on course fees, and lose years and opportunities until he or she gets the chance to sit the exams. The latter, however, can prepare their documents, strengthen their CV and apply through assessment, and although this is not guaranteed, they stand a chance of obtaining registration. Now, looking at this case, the colour of the passport cannot make the dentist more or less safe to treat patients and thus this aspect of the system has not been set up with solely the patients' best interests in mind. Similarly, another dentist who has also qualified from an overseas university can register by assessment if he or she is a spouse of an EEA/Swiss citizen, again surely not for patient safety reasons. It seems unfair that a dentist has this option of registration based on their family's or partner's nationality. Interestingly, this does not apply if the overseas dentist is married to or is related to a UK citizen. An overseas dentist can practise dentistry in the UK through temporary registration, which can be renewed for up to five years. Temporary registration is 'only granted for the purposes of supervised training, teaching or research purposes in the UK' . 5 However, the UK, whose population is approximately more than 66.5 million, only has 23 temporary dental registrants at the time of writing this article. 6 Does that mean dentists are not interested to come to the UK and have dental training? Or does it mean that the UK is not giving these opportunities to overseas dentists, or is this route just too difficult? The GDC website states that there are six types of approved posts that overseas dentists can obtain temporary registration through; however, posts should be either in hospital or dental schools. 7 Therefore, it cannot be said that it is impossible to obtain a temporary registration, but it is very difficult. From a personal experience and after spending three years in a UK dental school, I found that most of my tutors, colleagues and dental students do not know much, if anything at all, about temporary registration. This means advertised jobs do not give the opportunity for temporary registrants to apply. Furthermore, the posts need to be supported by a GDC-registered consultant and the employer's human resources department, who are both unfamiliar with these posts because temporary registrants are scarce, thus making the process even more complicated. Additionally, as temporary registration is only allowed in hospitals, the NHS Jobs website is the most suitable website to find a post. However, jobs advertised here require full GDC registration to apply, which again does not give the opportunity for an overseas dentist to undertake further clinical training. On the contrary, in Ireland and Germany, a dentist can work in a practice under temporary registration as long as there is a dentist or consultant on the premises. As group B are undertaking postgraduate degrees in the UK, they are always surrounded by academics and researchers, and attend different scientific conferences. This academic atmosphere would in most cases motivate them to pursue further degrees; that is, PhD or trying to apply for a scholarship or a grant. The first option is either very expensive in comparison to the UK/EU rate fees, or they are not eligible to apply for a scholarship because of their nationalities (overseas passport). Furthermore, for the same reason, they are not eligible to apply for most of the grants that are offered by UK Research and Innovation (UKRI) or Wellcome Trust, for example. Another route is applying for grants that are offered for clinicians, and as they are dentists, they should be eligible; however, they need to have a job as a clinician in the UK, which takes them back to square one where they need GDC registration again. Furthermore, it is well known how competitive it is to win a grant or a scholarship. After the announcement of Brexit, the GDC announced that for dentists who qualified from the EU or Switzerland, 'registration arrangements after 31 December 2020 will depend on the outcome of negotiations taking place over the course of the transition period' . 8 Again, this shows that these regulations are not the way they are for the protection of patients or their best interests, as in both scenarios with Brexit or no Brexit, the clinical skills of the EU dentist have not changed, nor the syllabuses of EU dental schools. Therefore, because of political decisions and new agreements between countries, an EU-qualified dentist before 31 December 2020 only needs to submit evidence that they are EU/Swiss nationals and have completed an undergraduate training programme in dentistry at an EU/Swiss dental school to register with the GDC, while after that date, the same dentist will potentially face the same struggles as an overseas dentist. Furthermore, there is another group of dentists who can be categorised into a third group. These are EU/Swiss-qualified dentists who are UK nationals returning to the UK to live and work. Before 31 December 2020, they do not need to sit any exams to register, but after Brexit, again, they may end up in the same boat as overseas-qualified dentists. Also, one should consider that some of these dentists might be in their final years of their dental degree and perhaps if they knew that Brexit may affect their registration with the GDC, they may have not studied abroad in the first place. Thus, one must consider if this system of registration is really protecting patients from overseas dentists, or whether it is protecting the business of UK dentists, controlling the number of dentists in the country, or purely for immigration reasons. On the other hand, similar to the possible changes with the GDC after Brexit, UKRI have announced: 'UKRI will be opening up UKRI studentships to international students from AY 2021/22' , 9 which again demonstrates how science, research and education are not open for any keen student or brilliant clinician, nor under the control of academics and scientists, but rather controlled by political decisions and countries' agendas. The unprecedented circumstances following COVID-19 that have negatively impacted on everyone's lives have also put more pressure on group B dentists as the ORE/LDS exams have been postponed until further notice. Furthermore, many scholarships have been cancelled or suspended due to economy and financial pressures. To conclude, the current system could probably be modified to be more in line with that of neighbouring countries, where exam booking priority is given to dentists with job offers or to those where it is their first attempt at the exam, rather than them competing for exam places with people who have previously had their chance. To my colleagues who have graduated from the UK or EU and are registered with the GDC, if you work with an overseas dentist who managed to register with the GDC or is trying to, please be aware that it is not an easy journey, requires a lot of money and time, and is an incredibly stressful time. Dentists Act 1984 -53 Interpretation (F258) Issuing Professional Physician and Dentist Licences to Work in the Private Medical Sector General Dental Council. Temporary registration General Dental Council Brexit -information for dental professionals UKRI-funded postgraduate programmes to open to international students The author declares no conflicting interests.