Agony and Autonomy in the Shadow of Montgomery: An investigation into how General Dental Practitioners (GDPs) have negotiated the twin challenges of the new patient-centred standard of consent as laid down in Montgomery and the restrictions to care caused by COVID-19 from June 2020 onwards when treating adult patients suffering with acute dental pain

Since 2015 and the Montgomery ruling, the courts have informed healthcare workers in the UK of their duty "to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments". This legal standard for what constitutes sufficient information disclosure to allow consent to be classed as informed completed a swing from the previous paternalistic stance of the court to one based on a respect for the autonomy of each individual patient. Understanding the ramifications of this ruling and implementing the necessary changes to practice since then have represented a challenge to not just dentists but all healthcare workers.

From March 2020, the impact of the COVID-19 pandemic has had a dramatic impact on dentists in the UK who have faced unprecedented challenges to the provision of every aspect of dental care. Following the first national lockdown that ended in early June 2020, general dental practitioners (GDPs) could reopen their doors and carry out face-to-face dentistry for the first time in more than 10 weeks. The restrictions to care were significant and highly impactful on the provision of urgent dental care in particular.

The aim of this project was to give an informed contribution to our understanding of how GDPs perceive the impact of both the Montgomery ruling and the restrictions imposed upon them following their return to work in June 2020. To achieve this aim, I proposed the following objectives: to explore how much time GDPs routinely allocate for a typical urgent pain appointment; to evaluate how GDPs feel that COVID-19 restrictions have impacted their ability to gain appropriately informed consent for patients in severe, acute pain; and to investigate how GDPs feel that the Montgomery ruling has affected their consent process, with particular reference to how they would go about obtaining consent for a clinical scenario presented in the survey.

The views of GDPs across the UK were gained via a questionnaire-based survey that was distributed via a dental forum on the social media service provider Facebook. Drawing on data from 93 GDPs working in primary care in the UK, who responded to the survey, I was able to reveal the disproportionate impact of COVID-19 restrictions on those GDPs most reliant on NHS funding and the greater likelihood that these GDPs would offer shorter appointments and the lower likelihood that they would offer aerosol generating procedure (AGP) appointments for patients suffering with acute dental pain. The data also revealed that, overall, GDPs had a reasonable awareness and understanding of the Montgomery ruling and how it impacts on their consent processes for patients in pain although their perceived knowledge and actual knowledge were found to not always be consistent.

Drawing conclusions from these findings, the thesis seeks to explore the ramifications of this unequal impact on the provision of urgent dental care. When looking at the reduced ability of those practices most reliant on NHS funding to provide the conditions for optimal care, the thesis draws into question the courts' ubiquitous approach to consent, applying it equally, as it does, across all clinical settings. It also asks questions relating to how regulatory and authoritative bodies within dentistry offer guidance and advice regarding urgent care when the delivery of it differs from practice to practice. The thesis then seeks to offer solutions in the form of suggesting future research that can help us better understand the training needs of the profession and looks at how regulatory advice and legal rulings can better reflect the disparity in the ability of the profession to deliver optimal urgent care.